Diagnosis and etiology of poststroke depression: A review

Table 1 Diagnostic criteria for poststroke depression in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases, eleventh revision

	DSM-5	ICD-11
Fully specified name	Depressive disorder due to another medical condition	Mood syndrome due to health condition not classified under mental and behavioral disorders
Diagnostic criteria
(1) Symptoms	One of following symptoms:	Prominent depressive, manic, or mixed mood symptoms
	(1) Prominent and persistent period of depressed mood
	(2) Markedly diminished interest pleasure in all activities
(2) Medical conditions (stroke)	Evidence from the history, physical examination, or laboratory findings	Evidence from the history, physical examination, or laboratory findings
(3) Etiological relation	(1) A temporal association between the onset, exacerbation, or remission of the general medical condition and that of the mood disturbance	(1) The medical condition is known to be capable of producing the symptoms
	(2) Features that are atypical of primary Mood Disorders (e.g., atypical age at onset or course or absence of family history)	(2) The course of the mood symptoms (e.g., onset, remission, response of the mood symptoms to treatment of the etiological medical condition) is consistent with causation by the medical condition
	(3) Evidence from the literature that suggests that there can be a direct association between the general medical condition in question
	(4) The development of mood symptoms can provide a useful context in the assessment of a particular situation
(4) Exclusion	(1) Adjustment disorder, with depressed mood, in which the stressor is a serious medical condition	(1) Delirium, dementia, another mental disorder (e.g., adjustment disorder, depressive disorder, bipolar I disorder)
	(2) Delirium	(2) Secondary catatonia syndrome
	(3) Medication-induced depressive disorder	(3) Effects of a medication or substance, including withdrawal effects
(5) Stress or impairment	Social, occupational, or other important areas of functioning	Sufficiently severe to be a specific focus of clinical attention
(6) Specifiers	(1) With depressive features: Full criteria are not met for a major depressive episode	(1) With depressive symptoms
	(2) With major depressive-like episode: Full criteria are met for a major depressive episode	(2) With manic symptoms
	(3) With mixed features: Symptoms of mania or hypomania are also present but do not predominate in the clinical picture	(3) With mixed symptoms
		(4) With unspecified symptoms

DSM-5: The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders; ICD-11: The International Classification of Diseases, eleventh revision.

Table 2 Rating scales for depression associated stroke

Tools	Type of tool	Cut off points	Total score
CESD[25]	Self-report	≥ 16: Depression	60
PHQ-9[26]	Self-report	0-4: No depression	27
		5-9: Mild depression
		10-14: Moderate depression
		15-19: Moderately-severe depression
		20-27: Severe depression
PHQ-2[27]	Self-report	≥ 3: Depression	6
GDS-30[28]	Self-report	≥ 11: Depression	30
GDS-15[17]	Self-report	0-4: Normal	15
		5-8: Mild depression
		9-11: Moderate depression
		12-15: Severe depression
HADS[31]	Self-report	0-7: Normal	21
		8-10: Mild
		11-14: Moderate
		15-21: Severe
BDI[29]	Self-report	0-13: Normal	63
		14-19: Mild depression
		20-28: Moderate depression
		29-63: Severe depression
PSDS[34]	Self-report	0-4: Normal	24
		5-9: Moderate depression
		≥ 10: Severe depression
HAMD[23]	Observational	0-9: Normal	52
		10-13: Mild depression
		14-17: Mild to moderate depression
		> 17: Moderate to severe depression
MADRS[30]	Observational	0-6: Normal	60
		7-19: Mild depression
		20-34: Moderate depression
		> 35: Severe depression
SADQ[32]	Observational	≥ 14: Depression	63
SADQ-H[33]	Observational	Not mentioned	63

CES-D: Center for Epidemiological Studies Depression Scale; PHQ-9: Patient Health Questionnaire-9; PHQ-2: Patient Health Questionnaire-2; GDS-30: Geriatric Depression Scale-30 items; GDS-15: Geriatric Depression Scale-15 items; HAMD: Hamilton Depression Rating Scale; MADRS: Montgomery-Åsberg Depression Rating Scale; HADS: Hospital Anxiety and Depression Scale; SADQ: Stroke Aphasic Depression Questionnaire; SADQ-H: Stroke Aphasic Depression Questionnaire - Hospital version; PSDS: Post Stroke Depression Scale.

Table 3 Comparison of etiology for poststroke depression

	Inflammation	Abnormal neurotrophic response, glutamate excitotoxicity	Brain network dysfunction, lesion location	Cerebral small vessel disease	Decreased levels of monoamines	Psychosocial factors
Mechanism	Extracellular, intracellular	Extracellular, intracellular	Extracellular	Extracellular	Extracellular	Environmental, interpersonal
Main study subjects	Animals	Animals	Human	Human	Human	Human
Study samples	Smaller	Smaller	Larger	Larger	Larger	Larger
Study design	Experimental, comparative	Experimental, comparative	Comparative, systematic review	Comparative, cohort study	Comparative, cross sectional	Cohort study, systematic review
Linked to depressive symptoms in study	Not yet	Not yet	Yes	Not yet	Yes	Yes
Role in major depression	Significant	Significant	Less significant	Significant	Significant	Significant
Role in poststroke depression	Significant, within 6 months after stroke	Significant, within 6 months after stroke	Significant, within 6 months after stroke	Significant, within 6 months after stroke	Significant, within 6 months after stroke	Significant, impact is greater after 6 months