In the United States, roughly 795,000 new or recurrent strokes occur annually. According to the American Heart Association, about 6.6 million American adults have had a stroke and, by the year 2030, this figure is expected to grow by 3.4 million.1 Despite rehabilitative efforts to provide poststroke physical, cognitive, and psychological therapy, the development of poststroke depression is often overlooked and the condition undertreated. When not treated effectively, poststroke depression is associated with the following:
- reduced participation in rehabilitation
- decreased functional recovery and increased functional dependence2
- poorer recovery of cognitive function3
- increased 12- and 24-month mortality rates4, 5
- prolonged institutional care6
- a shorter interval to ischemic stroke recurrence7
Poststroke depression is a multifaceted phenomenon requiring careful nursing assessment and management. This article seeks to familiarize nurses with poststroke depression, its prevalence, risk factors, and common manifestations. It discusses assessments nurses can use to identify depression in patients who have had a stroke and describes related nursing interventions.
UNDERSTANDING POSTSTROKE DEPRESSION
Depression is one of the most common neuropsychological consequences of stroke. Pooled data from 61 studies that included more than 25,000 participants with a clinical diagnosis of stroke suggest that roughly 31% of stroke survivors experience depression within the five years following stroke.8 The onset of depression following stroke varied among studies in this meta-analysis, with frequency ranging from 5% within five days to 84% at three months.8 Depression may manifest in a variety of ways, including but not limited to the following signs and symptoms9:
- persistent feelings of sadness, hopelessness, or emptiness
- diminished pleasure or interest
- sleep disturbances (insomnia or hypersomnia)
- excessive fatigue
- poor concentration
- changes in appetite or weight
- recurrent thoughts of death or suicide, or suicidal plans or attempts
- observable agitation or feelings of being slowed down
- feelings of worthlessness or inappropriate guilt
Poststroke depression is characterized by the same symptoms, and research suggests that when such somatic symptoms as sleep disturbance, fatigue, appetite or weight changes, and poor concentration occur in patients following stroke, they should be evaluated as potential clinical manifestations of depression, rather than simply as consequences of stroke.10 As Folstein and colleagues demonstrated in the late 1970s, depression is far more common in patients who have had a stroke than in patients with comparable physical limitations due to orthopedic injuries.11
ETIOLOGY OF POSTSTROKE DEPRESSION
The mechanisms underlying the development of poststroke depression remain elusive. Many believe poststroke depression to be a form of vascular depression, a phenomenon resulting from small vessel ischemia at the microvascular level.12 Mast and colleagues, however, found that patients with poststroke depression and those with vascular depression demonstrated different symptom patterns, clinical correlates, and prevalence rates, suggesting that the two syndromes are unique, each associated with distinct levels of vascular disease.13
Proposed mechanisms to explain the relationship between stroke and depression focus on the role of social isolation, inflammatory signaling, hypothalamic–pituitary–adrenal (HPA) axis dysfunction, and autonomic nervous system dysregulation.14-16 In addition to regulating immune responses, the HPA axis and autonomic nervous system regulate the body's response to stress. Such stressors as depression (and its sequelae) or stroke stimulate the HPA axis, triggering an immune response and activating the sympathetic nervous system, which in turn creates a state of chronic inflammation. This chronic inflammatory state in turn contributes to increasing susceptibility to such inflammatory disease states as stroke.14
RISK FACTORS FOR POSTSTROKE DEPRESSION
Researchers continue to explore risk factors for poststroke depression, though its development is definitively linked to the following characteristics14, 17-21:
- greater stroke severity
- higher levels of physical impairment
- a personal history of depression or anxiety
- a family history of depression
- social isolation
- limited social support
- low levels of serum vitamin D
In addition, it's been hypothesized that women,22 people with diabetes,18 or non-Hispanic white people23 may be at higher risk for poststroke depression, but further research is needed to substantiate these claims.
Greater loss in function, autonomy, and communication may raise the risk of severity of poststroke depression.17, 24-26 The extent of physical impairment as measured by dependence in performing activities of daily living is more predictive of poststroke depression than any other factor. When De Ryck and colleagues performed an 18-month prospective study of 125 patients following stroke, they found that every unit increase in patient activity as measured by the Stroke Impact Scale was associated with a 5% decrease in the risk of poststroke depression.24 In a study of 368 patients enrolled within two weeks of stroke onset, Wei and colleagues found that patients with both motor and sensory dysfunction at admission were significantly more likely to have poststroke depression than patients with motor or sensory dysfunction alone.26 In addition to apraxia, speech and language dysfunction are more prevalent in patients with poststroke depression than in patients who are not depressed following stroke.17 Cognitive impairment, especially executive dysfunction, is also strongly related to poststroke depression.25
Social support and social utilization. Development and severity of poststroke depression have been found to be significantly and inversely correlated with social support.20 Similarly, patients who demonstrate a low degree of social utilization or community participation are more likely to develop poststroke depression.21, 26
In collaboration with other members of the health care team (physicians; social service workers; and physical, occupational, and speech therapists), nurses should assess patients’ social support, living situation, and need for services, encouraging patients to use the resources available to them, and urging caregivers to become involved in patient care as soon as possible following stroke. Patients and caregivers should be asked detailed questions about postdischarge care, including the following:
- home accessibility, including bathroom access and setup
- scheduling of primary caregivers
- financial concerns
- meal preparation
- assistance with medication administration
- physician appointments
- management of chronic conditions (such as hypertension and diabetes) that may have precipitated the stroke
- strategies for maximizing functional independence
- plans for maintaining social interaction with friends for both patient and caregiver
- respite care for caregivers
Recommendations for achieving best outcomes should be outlined by the health care team and reinforced with the patient and caregiver. Caregivers should be taught how to help patients with bathing, dressing, and using assistive devices, but they also may need advice on caring for themselves and their own psychological well-being. In a 12-month longitudinal study that included 399 caregiver–stroke survivor pairs, caregiver emotional distress was associated with patients’ poststroke depression, but not with patients’ physical disability.27
In addition to providing caregivers with information that helps them manage patients’ poststroke depression, nurses can remind caregivers that participating in respite programs that allow them to engage in valued activities can improve their own well-being and that of the patient. Individualized teaching coupled with realistic goal setting can minimize the severity of the patient's depression and reduce caregiver burden.
SCREENING PATIENTS FOR POSTSTROKE DEPRESSION
In 2013, the Joint Commission announced that care certification for comprehensive stroke centers would require institutions to routinely screen stroke survivors for depression prior to discharge.28 Many of the tools used to screen for general depression have also been used to screen for poststroke depression. Additionally, several researchers have focused on designing scales and tools with the specific purpose of predicting a patient's risk of developing depression in the immediate poststroke period. In selecting the best screen or predictive tool to use for this purpose in a particular clinical setting, as well as for use in ongoing assessment, nurses must consider such factors as patient characteristics and the time required to complete and score the assessment (see Table 1 29-36). Although patients with aphasia or other cognitive or language deficits are at higher risk for poststroke depression, some screening and assessment tools are inappropriate for use in this population.
Screening nonaphasic patients. Ideally, patients should be screened for depression as soon as possible after a stroke; for nonaphasic patients who have experienced ischemic stroke or intracerebral hemorrhage, it's often feasible to conduct such screening within the acute care setting.37, 38 To screen for poststroke depression in a timely manner within the confines of a limited acute care hospital stay, de Man-van Ginkel and colleagues developed a clinical predictive model that uses information from the patient's medical history, psychiatric history, and the “dressing” item from the Barthel Index.37 This model—the Post-Stroke Depression Prediction Scale (DePreS)—is a valid tool for predicting risk of poststroke depression in a hospital setting within one week of a stroke.37 Using this scale, a medical history of hypertension or angina, a history of depression or other psychiatric disorders, and dependency on help in dressing are predictive of poststroke depression. While immediate assessment is imperative, ongoing assessment is also necessary, especially in patients who demonstrate persistent emotional lability, lack motivation, or fail to progress in the rehabilitative process. In the inpatient setting, screening should be performed daily. Before discharge, nurses should teach caregivers the signs and symptoms of poststroke depression, impressing on them that depression can delay patient progress, increase caregiver burden, and raise the risk of stroke recurrence.
Several depression screening tools, which require no specialized training, can be used by nurses in the clinical setting to identify poststroke depression with accuracy in patients who do not have aphasia.39 Before administering a self-rating scale, nurses should assess their patients’ ability to read and understand the scale. If a patient is unable to read but able to understand the questions, the nurse can read the questions aloud to the patient and score the results.
It's been suggested that self-rating instruments may be more useful than ratings provided by family caregivers, as proxies often score patients as more severely depressed than patients would score themselves, and their scoring is potentially confounded by their own depression.40 But caregivers are often well positioned to identify symptoms of poststroke depression that patients hide from their health care providers. For this reason it's important for nurses to seek information about the patient's mood and behavior from both the patient and the caregiver, recognizing both the potential insights and the potential biases caregivers may provide.41
Screening aphasic patients. There are limitations to the meaningful use of depression rating scales in aphasic patients, as most require language skills. The challenge of verifying understanding in aphasic patients may undermine the validity of the assessment.34
A review of six depression screening instruments available for use in patients with stroke-related aphasia found that only three have acceptable feasibility in the clinical setting: the 10-item Stroke Aphasic Depression Questionnaire, the hospital version of the 10-item Stroke Aphasic Depression Questionnaire, and the Signs of Depression Scale.34 However, most patients’ limited acute care hospital stay immediately following stroke makes it difficult to use these instruments in the immediate poststroke period.37 In such cases, nurses may use the DePreS to predict risk of poststroke depression.
Pharmacologic management of poststroke depression includes traditional antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), which may be used prophylactically—not only to prevent depression following stroke, but also to improve motor function and (because of their antiplatelet properties) reduce the risk of subsequent vascular disease.42, 43 Additionally, the use of fluoxetine (Prozac, Sarafem) or nortriptyline (Pamelor) has been shown to improve stroke-related cognitive deficits44 and increase survival after stroke, in patients both with and without a diagnosis of poststroke depression.45
Five major classes of drugs are used to treat poststroke depression: SSRIs, serotonin–norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and atypical antidepressants (see Table 2 46, 47). Each class of drugs works in a unique way to increase the availability of monoamine neurotransmitters at the synaptic junction, which alleviates the severity of depression. The SSRIs, SNRIs, and atypical antidepressants, such as bupropion (Wellbutrin and others) and mirtazapine (Remeron), are the first-line therapy choices. Because of the less favorable toxicity profile of TCAs and MAOIs, these drugs are typically reserved for those who respond poorly to first-line therapy.48
A thorough patient history and ongoing nursing assessment are key to identifying the best treatment for patients with poststroke depression and to managing both the depression and any adverse pharmacologic effects. Common adverse effects of antidepressants include weight gain, central nervous system (CNS) stimulation or sedation, sexual dysfunction, anticholinergic effects, orthostatic hypotension, and gastrointestinal upset.47 Since a common manifestation of poststroke depression is excessive fatigue, an SSRI, such as fluoxetine, or an atypical antidepressant, such as bupropion—both of which are known to stimulate the CNS—may be prescribed in patients with overwhelming fatigue and no known risk of seizure. The atypical antidepressant mirtazapine, which has sedative effects, may be used by patients with insomnia. Bupropion, which is known for increasing libido, may be a good choice for patients whose poststroke depression has caused sexual dysfunction. The SNRI duloxetine (Cymbalta) is indicated for chronic pain in addition to depression, and the TCAs are used off label to manage chronic pain.47
It is essential to be familiar with the unintended—and potentially adverse—effects of antidepressants and to reinforce the patient's understanding of them. It's also important to inform patients that, while antidepressant effects may begin within one to three weeks of initiating treatment, the full effects of the drugs may not be felt until week 12. Understanding this timeline will help patients manage their expectations and remain alert for changes in their response to the drugs. Patients should be advised not to discontinue antidepressant therapy abruptly, but rather to taper off the medications slowly under the supervision of their health care provider.
Although pharmacologic antidepressant therapy is effective in treating poststroke depression, it is not without risks. Of special concern for patients who have had a stroke is the elevated risk of hemorrhage and hemorrhagic stroke in patients taking SSRIs.49, 50
Nonpharmacologic management. Strategies such as motivational interviewing, life review therapy, behavioral–psychosocial support programs, and structured physical exercise, used in conjunction with usual care, including antidepressant therapy, have been shown to improve symptoms of poststroke depression.51-57
Motivational interviewing is a talk-based therapy designed to help patients modify their behaviors by strengthening their motivation for and commitment to specific goals.58 Following stroke, this intervention may be used to encourage both self-efficacy and optimism.57 The interviewer asks open questions, listens reflectively to the patient, offers advice with permission, and provides affirmation and support. Motivational interviewing requires training, but nurses who frequently care for patients with poststroke depression may find it worthwhile, as this therapy can improve patient outcomes. Motivational interviewing can begin soon after a stroke (in one study, the process was initiated within the first week) and sessions can be completed in 30 to 60 minutes.57
Life review therapy. The “life review” was first described by Butler in the 1960s as a naturally occurring process through which older adults reminisce about past experiences and unresolved issues.59 According to Butler, the life review may contribute to depression or produce serenity and wisdom. Based on this idea, life review therapy seeks to help patients use the life review process to tap the insights and knowledge they've acquired throughout life to help them cope with their current struggles. In a small study of 14 patients recovering from stroke in a rehabilitation center, three one-hour life review therapy sessions led by the nurse researcher resulted in significantly lower levels of depression and higher levels of life satisfaction among the seven patients in the intervention group compared with the seven in the control group.52 Despite the small sample size, the study supported the feasibility of administering life review therapy in a rehabilitation setting. Nurses administering life review therapy may use each session to focus on a particular period in the patient's life (childhood, adolescence, or adulthood) or on major milestones (personal or professional achievements, important relationships, birth of children, or personal losses).
Behavioral–psychosocial support programs have been shown to reduce poststroke depression symptoms in both the short and the long term.54, 55 In a randomized controlled trial of 101 patients recovering from a stroke that had occurred within the past four months, Mitchell and colleages demonstrated the efficacy of a nurse-delivered behavioral–psychosocial intervention as an adjunct to usual care, which included antidepressant therapy as prescribed by the stroke care or primary care provider.54, 55 All patients received information about stroke recovery and depression. Those in the intervention group met with the nurse interventionist individually (though they could opt to have a family member or caregiver join the sessions) nine times over eight weeks. During the sessions, patients were taught individualized problem-solving strategies and ways to identify and overcome negative thought patterns. The goal of treatment was to increase the patients’ experience of pleasant social and physical activities to counteract depressive symptoms. Severity of depression in the intervention group was significantly reduced at one year, compared with that in the control group, and significantly more patients in the intervention group were in remission both immediately following treatment and at one year.54, 55
This study highlights the importance of recognizing depressive symptoms and developing a plan for altering maladaptive behavior and negative thought patterns. Nurses can teach patients and caregivers how to recognize symptoms and develop effective methods for controlling them. They can help patients discover ways to maximize their functional capacity within the confines of their poststroke disabilities and to identify pleasant activities and social interactions in which they can realistically participate, thereby countering the adverse effects of social isolation.
Physical activity. Moderate physical activity, defined for adults with disabilities as 150 minutes of moderate physical activity per week, 75 minutes of vigorous aerobic activity per week, or an equivalent combination of the two,60 has been shown to lower the risk of depressive symptoms and major depressive symptoms by 74% and 89%, respectively.51 Nurses can encourage physical activity among patients who have had a stroke by reinforcing its importance in poststroke recovery. Structured exercise has been found to reduce depressive symptoms and improve quality of life in patients with poststroke depression, while lessening stroke-related impairment and functional limitations in both depressed and nondepressed patients recovering from stroke.53, 56
Further research is required to identify all the mechanisms underlying the development of poststroke depression. While vitamin D deficiency has been recognized as a risk factor,19, 61, 62 studies on the effect of vitamin D supplementation have been disappointing, with the supplement having neither improved nor worsened depressive symptoms in seven randomized controlled trials.63
Because of the nature of aphasia, currently available screening tools for depression in aphasic patients have not yet been proven valid and reliable.34 More research is needed to develop valid and reliable means of screening patients with poststroke aphasia. Nursing research on the impact and feasibility of providing motivational interviewing and life review therapy within the clinical setting to patients with poststroke depression may be beneficial in generating strategies to help patients develop coping styles. Likewise, it would be helpful to test empirically whether early recognition in the acute care setting of risk factors for poststroke depression could serve a preventive purpose.
1. Writing Group Members, et al Heart disease and stroke statistics—2016 update: a report from the American Heart Association Circulation 2016 133 4 e38–e360
2. Matsuzaki S, et al The relationship between post-stroke depression and physical recovery J Affect Disord 2015 176 56–60
3. Murata Y, et al Does cognitive impairment cause post-stroke depression? Am J Geriatr Psychiatry 2000 8 4 310–7
4. Ellis C, et al Depression and increased risk of death in adults with stroke J Psychosom Res 2010 68 6 545–51
5. House A, et al Mortality at 12 and 24 months after stroke may be associated with depressive symptoms at 1 month Stroke 2001 32 3 696–701
6. Kotila M, et al Post-stroke depression and functional recovery in a population-based stroke register: the Finnstroke study Eur J Neurol 1999 6 3 309–12
7. Sibolt G, et al Post-stroke depression and depression-executive dysfunction syndrome are associated with recurrence of ischaemic stroke Cerebrovasc Dis 2013 36 5-6 336–43
8. Hackett ML, Pickles K Part I: frequency of depression after stroke: an updated systematic review and meta-analysis of observational studies Int J Stroke 2014 9 8 1017–25
9. American Psychiatric Association, editor. Diagnostic and statistical manual of mental disorders.
5th ed. Washington, DC: American Psychiatric Association; 2013.
10. de Man-van Ginkel JM Clinical manifestation of depression after stroke: is it different from depression in other patient populations? PLoS One 2015 10 12 e0144450
11. Folstein MF, et al Mood disorder as a specific complication of stroke J Neurol Neurosurg Psychiatry 1977 40 10 1018–20
12. Alexopoulos GS, et al ‘Vascular depression’ hypothesis Arch Gen Psychiatry 1997 54 10 915–22
13. Mast BT An examination of the post-stroke and vascular depression hypotheses among geriatric rehabilitation patients [dissertation] 2002 Detroit Wayne State University
14. Friedler B, et al One is the deadliest number: the detrimental effects of social isolation on cerebrovascular diseases and cognition Acta Neuropathol 2015 129 4 493–509
15. Li W, et al Systematic hypothesis for post-stroke depression caused inflammation and neurotransmission and resultant on possible treatments Neuro Endocrinol Lett 2014 35 2 104–9
16. Spalletta G, et al The etiology of poststroke depression: a review of the literature and a new hypothesis involving inflammatory cytokines Mol Psychiatry 2006 11 11 984–91
17. De Ryck A, et al A prospective study on the prevalence and risk factors of poststroke depression Cerebrovasc Dis Extra 2013 3 1 1–13
18. De Ryck A, et al Risk factors for poststroke depression: identification of inconsistencies based on a systematic review J Geriatr Psychiatry Neurol 2014 27 3 147–58
19. Kim SH, et al Relationship between serum vitamin D levels and symptoms of depression in stroke patients Ann Rehabil Med 2016 40 1 120–5
20. Taylor-Piliae RE, et al Predictors of depressive symptoms among community-dwelling stroke survivors J Cardiovasc Nurs 2013 28 5 460–7
21. White JH, et al Predictors of depression and anxiety in community dwelling stroke survivors: a cohort study Disabil Rehabil 2014 36 23 1975–82
22. Poynter B, et al Sex differences in the prevalence of post-stroke depression: a systematic review Psychosomatics 2009 50 6 563–9
23. Jia H, et al Racial and ethnic disparities in post-stroke depression detection Int J Geriatr Psychiatry 2010 25 3 298–304
24. De Ryck A, et al Psychosocial problems associated with depression at 18 months poststroke Int J Geriatr Psychiatry 2014 29 2 144–52
25. Robinson RG The clinical neuropsychiatry of stroke
. 2nd ed. Cambridge: New York: Cambridge University Press; 2006.
26. Wei C, et al Factors associated with post-stroke depression and fatigue: lesion location and coping styles J Neurol 2016 263 2 269–76
27. Cameron JI, et al Stroke survivor depressive symptoms are associated with family caregiver depression during the first 2 years poststroke Stroke 2011 42 2 302–6
29. de Man-van Ginkel JM An efficient way to detect poststroke depression by subsequent administration of a 9-item and a 2-item Patient Health Questionnaire Stroke 2012 43 3 854–6
30. Healey AK, et al A preliminary investigation of the reliability and validity of the Brief Assessment Schedule Depression Cards and the Beck Depression Inventory-Fast Screen to screen for depression in older stroke survivors Int J Geriatr Psychiatry 2008 23 5 531–6
31. Kroenke K, et al The PHQ-9: validity of a brief depression severity measure J Gen Intern Med 2001 16 9 606–13
32. Kroenke K, et al The Patient Health Questionnaire-2: validity of a two-item depression screener Med Care 2003 41 11 1284–92
33. Sagen U, et al Screening for anxiety and depression after stroke: comparison of the Hospital Anxiety and Depression Scale and the Montgomery and Asberg Depression Rating Scale J Psychosom Res 2009 67 4 325–32
34. Van Dijk MJ, et al Identifying depression post-stroke in patients with aphasia: a systematic review of the reliability, validity and feasibility of available instruments Clin Rehabil 2016 30 8 795–810
35. Williams LS, et al Performance of the PHQ-9 as a screening tool for depression after stroke Stroke 2005 36 3 635–8
36. Zigmond AS, Snaith RP The hospital anxiety and depression scale Acta Psychiatr Scand 1983 67 6 361–70
37. de Man-van Ginkel JM In-hospital risk prediction for post-stroke depression: development and validation of the Post-stroke Depression Prediction Scale Stroke 2013 44 9 2441–5
38. Karamchandani RR, et al Early depression screening is feasible in hospitalized stroke patients PLoS One 2015 10 6 e0128246
39. Salter K, et al The assessment of poststroke depression Top Stroke Rehabil 2007 14 3 1–24
40. Berg A, et al Assessment of depression after stroke: a comparison of different screening instruments Stroke 2009 40 2 523–9
41. Klinedinst NJ, et al Stroke survivor and informal caregiver perceptions of poststroke depressive symptoms J Neurosci Nurs 2012 44 2 72–81
42. Flaster M, et al Poststroke depression: a review emphasizing the role of prophylactic treatment and synergy with treatment for motor recovery Top Stroke Rehabil 2013 20 2 139–50
43. Pompili M, et al Suicide in stroke survivors: epidemiology and prevention Drugs Aging 2015 32 1 21–9
44. Chollet F, et al Fluoxetine for motor recovery after acute ischaemic stroke (FLAME): a randomised placebo-controlled trial Lancet Neurol 2011 10 2 123–30
45. Jorge RE, et al Mortality and poststroke depression: a placebo-controlled trial of antidepressants Am J Psychiatry 2003 160 10 1823–9
47. Vallerand AH, et al Davis's drug guide for nurses
. 15th ed. Philadelphia: F.A. Davis Company; 2017.
48. Qaseem A, et al Nonpharmacologic versus pharmacologic treatment of adult patients with major depressive disorder: a clinical practice guideline from the American College of Physicians Ann Intern Med 2016 164 5 350–9
49. Hackam DG, Mrkobrada M Selective serotonin reuptake inhibitors and brain hemorrhage: a meta-analysis Neurology 2012 79 18 1862–5
50. Smoller JW, et al Antidepressant use and risk of incident cardiovascular morbidity and mortality among postmenopausal women in the Women's Health Initiative study Arch Intern Med 2009 169 22 2128–39
51. Aaron SE, et al Lower odds of poststroke symptoms of depression when physical activity guidelines met: National Health and Nutrition Examination Survey 2011–2012 J Phys Act Health 2016 13 8 903–9
52. Davis MC Life review therapy as an intervention to manage depression and enhance life satisfaction in individuals with right hemisphere cerebral vascular accidents Issues Ment Health Nurs 2004 25 5 503–15
53. Lai SM, et al Therapeutic exercise and depressive symptoms after stroke J Am Geriatr Soc 2006 54 2 240–7
54. Mitchell PH, et al Living well with stroke: design and methods for a randomized controlled trial of a psychosocial behavioral intervention for poststroke depression J Stroke Cerebrovasc Dis 2008 17 3 109–15
55. Mitchell PH, et al Brief psychosocial-behavioral intervention with antidepressant reduces poststroke depression significantly more than usual care with antidepressant: living well with stroke: randomized, controlled trial Stroke 2009 40 9 3073–8
56. Smith PS, Thompson M Treadmill training post stroke: are there any secondary benefits? A pilot study Clin Rehabil 2008 22 10-11 997–1002
57. Watkins CL, et al Motivational interviewing early after acute stroke: a randomized, controlled trial Stroke 2007 38 3 1004–9
58. Cheng D, et al Motivational interviewing for improving recovery after stroke Cochrane Database Syst Rev 2015 6 CD011398
59. Butler RN The life review: an interpretation of reminiscence in the aged Psychiatry 1963 26 65–76
61. Han B, et al Low serum levels of vitamin D are associated with post-stroke depression Eur J Neurol 2015 22 9 1269–74
62. Yue W, et al Association of serum 25-hydroxyvitamin D with symptoms of depression after 6 months in stroke patients Neurochem Res 2014 39 11 2218–24
63. Shaffer JA, et al Vitamin D supplementation for depressive symptoms: a systematic review and meta-analysis of randomized controlled trials Psychosom Med 2014 76 3 190–6
For 21 additional continuing nursing education activities on the topic of stroke, go to www.nursingcenter.com/ce.