Western Journal of Nursing

Research
http://wjn.sagepub.com/

Natural Patterns of Change in Poststroke Depressive Symptoms and

Function
Niloufar Hadidi, Ruth Lindquist, Diane Treat-Jacobson and Kay Savik
West J Nurs Res 2011 33: 522 originally published online 21 October 2010
DOI: 10.1177/0193945910382426
The online version of this article can be found at:
http://wjn.sagepub.com/content/33/4/522

Published by:
http://www.sagepublications.com

On behalf of:

Midwest Nursing Research Society

Additional services and information for Western Journal of Nursing Research can be found
at:
Email Alerts: http://wjn.sagepub.com/cgi/alerts
Subscriptions: http://wjn.sagepub.com/subscriptions
Reprints: http://www.sagepub.com/journalsReprints.nav
Permissions: http://www.sagepub.com/journalsPermissions.nav
Citations: http://wjn.sagepub.com/content/33/4/522.refs.html

Downloaded from wjn.sagepub.com at LEVY LIBRARY BOX 1102 on June 5, 2011

382426
didi et al.Western Journal of Nursing Research
The Author(s) 2011

WJN33410.1177/0193945910382426Ha

Reprints and permission: http://www.

sagepub.com/journalsPermissions.nav

Natural Patterns of
Change in Poststroke
Depressive Symptoms
and Function

Western Journal of Nursing Research

33(4) 522539
The Author(s) 2011
Reprints and permission: http://www.
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0193945910382426
http://wjn.sagepub.com

Niloufar Hadidi1,2, Ruth Lindquist1,

Diane Treat-Jacobson1, and Kay Savik1

Abstract
The objective of this study was to evaluate patterns of change in depressive symptoms and function in ischemic stroke patients 0 to 3 months
poststroke. Twenty-three newly diagnosed ischemic stroke patients were
enrolled in a study with nonrandomized prospective longitudinal design
to assess function and depressive symptoms on admission, 2 weeks,
1 month, and 3 months poststroke in a tertiary care acute rehabilitation
center in the Midwest. Participants mean age was (69 11.9), Mini Mental
State Exam (MMSE 23), and NIH Stroke Scale (M = 2.8, SD = 2.3), and thus
cognitively intact. Results suggest that the dominant pattern emerging for
function (Functional Independence Measure) and depressive symptoms
(Center for Epidemiologic Studies Depression Scale) showed significant
improvement relative to baseline at 2 weeks poststroke and reached a
plateau thereafter. The results may suggest that as stroke survivors
gain independence in accomplishing activities of daily living, their moods
improve as well.

University of Minnesota, Minneapolis

University of Minnesota Medical Center, Minneapolis

Corresponding Author:
Niloufar Hadidi, PhD, RN, FAHA, ACNS-BC, Assistant Professor, University of Minnesota,
School of Nursing, 5-140 Weaver-Densford Hall, 308 Harvard Street S.E., Minneapolis,
MN 55455
Email: hadi0001@umn.edu

Downloaded from wjn.sagepub.com at LEVY LIBRARY BOX 1102 on June 5, 2011

523

Hadidi et al.
Keywords
stroke, depressive symptoms, function, rehabilitation

Each year about 795,000 people experience a new or recurrent stroke (American
Heart Association, 2010). According to a recent systemic review of literature,
among stroke patients in acute rehabilitation setting, the prevalence of depression rages from 19.3% for major depression to 18.5% for minor depression
(Robinson, 2003). Diagnosing depressive symptoms poststroke is a difficult
task due to the wide range of symptoms that are associated with the volume
and specific areas of the brain involved. Poststroke depression (PSD) is often
manifested by fatigue, changes in appetite, sleep, or loss of interests; furthermore, the diagnosis is complicated by aphasia, anosognosia, and adverse cognitive consequences of stroke. Thus, symptoms of stroke may be confused by
symptoms of depression and the assessment of PSD is made more difficult by
stroke effects. In addition to PSD, functional disability is a common consequence of stroke. Disability is an important area of assessment used to
evaluate stroke outcome.
The International Classification of Functioning by the World Health
Organization considers disability from the perspective that every individual
can experience a decline in health and as a result experience disability, thus
changing the focus from the cause to the impact of disability. It recognizes that
disability is a universal human experience and takes into account the social
aspect of disability (World Health Organization [WHO], 2010). Impairment,
caused by deficits in primary neurologic functions, results in disability, which
is manifested by the reduced ability to perform functional activities such as
dressing, walking, and elimination.
Although approximately 14% of stroke survivors achieve a full recovery
in physical function, between 25% and 50% require at least some assistance
with activities of daily living, and half experience severe long-term effects
such as partial paralysis. Consequently, activity intolerance is common among
stroke survivors, especially in the elderly (Rusin, 1990; Verdelho, Henon,
Lebert, Pasquier, & Leys, 2004). A large number of stroke survivors are left
with significant physical, cognitive, and psychological impairments. These
impairments may result in inability of persons experiencing stroke to live
independently in the community. They may require substantial assistance
with activities that are basic to independent functioning in everyday life. In a
recent literature review, a combination of demographic variables (including
age), risk factors, clinical examination findings (including motor strength),

Downloaded from wjn.sagepub.com at LEVY LIBRARY BOX 1102 on June 5, 2011

524

Western Journal of Nursing Research 33(4)

laboratory test results, and imaging studies impact outcome (mostly mortality)
from the acute phase of stroke care (Demchuk et al., 2000).

Poststroke Depression and

Poststroke Functional Disability
Poststroke depression and poststroke functional disability are intimately
linked in studies describing outcomes of stroke. In fact, poststroke functional
disability has been considered to be predictive of depression following stroke
in some literature (Cassidy, OConner, & OKeane, 2004). Parikh and colleagues (1990), investigated the impact of depression on recovery of activities of daily living over 2-year follow-up on 63 stroke patients, and suggested
that there is different pattern of recovery between the depressed and nondepressed group during acute rehabilitation. This highlights the importance of
recovery pattern poststroke. In a recent review of literature by Johnson,
Minarik, Nystrom, Bautista, and Gorman (2006), 24 of the 30 studies that
investigated the relationship between physical disability and PSD found a
significant association between the two. However, research on the relationship between depressive symptoms and functional outcome in stroke patients
has resulted in inconsistent findings. In a recent study by Cassidy et al.
(2004) on 50 stroke patients 3 to 12 months poststroke, one of the major
findings was that depression was unrelated to the extent of functional disability after stroke. Indeed, the relationship between depressive symptoms and
functional impairment is rather complex and poorly understood (Tanner &
Gerstenberger, 1988). Furthermore, this relationship is not only time dependent (Sinyor et al., 1985; Verdelho et al., 2004) but also complicated by the
types and magnitude of depressive symptoms being studied. Contradictory
findings hinder our understanding of the mechanisms and causal flow regarding the coexistence of depressive symptoms and functional impairment.
Although some studies have found no correlation between severity of depressive symptoms and degree of functional impairment (Feibel & Springer,
1982; Folstein, Folstein, & McHugh, 1975), others have found that patients
with the greatest functional impairments had the most severe depressive
symptoms (Astrom, Adolfsson, & Asplund, 1993; Lipsey, Robinson, Pearlson,
Rao, & Price, 1983).
Few research studies have investigated the relationship between function
and depressive symptoms poststroke and factors impacting their relationship
over time. A clearer understanding of this phenomenon may provide insight
and assist clinicians in early identification of high-risk patients who most

Downloaded from wjn.sagepub.com at LEVY LIBRARY BOX 1102 on June 5, 2011

525

Hadidi et al.

likely will benefit from treatment interventions. It is anticipated that this

could benefit patients by leading to improved quality of life, shorter hospital
stay, reduced health care costs, and reduced mortality.

Purpose
The purpose of this study was to investigate the natural patterns of change
and the relationship between PSD (depressive symptoms) and functional
status 0 to 3 months poststroke.

Method
Design
A prospective longitudinal design was used to determine potential changes
in depressive symptoms and function poststroke (0-3 months) and to assess
whether any relationship existed between the two. Time was considered an
independent variable whereas dependent variables were depressive symptoms and function. Participants completed measures at baseline, 0.5 months/
2 weeks, 1 month, and 3 months. All measures at baseline and 2 weeks were
obtained by in-person assessment, while for the last 2 times, measures were
obtained over telephone. The advantage of using a longitudinal design is to
reveal the time patterns that reflect changes within individuals.

Participants
All patients who were admitted to a 1,850-bed tertiary care institution
located in Minneapolis, Minnesota, with an approximate average annual
number of stroke patients of 140 with a diagnosis of ischemic stroke were
potentially eligible for study participation.
Inclusion criteria were that participants had to (a) have a first-time diagnosis of ischemic stroke within the last 48 hours; (b) be 45 years of age;
(c) have a Mini Mental State Exam 23; and, (d) be able to read and write
English. There were no restrictions based on patients gender, race, or socioeconomic status.
Exclusion criteria were (a) a diagnosis of hemorrhagic stroke or TIA;
(b) severe aphasia as identified by speech pathologist; (c) medical instability
requiring transfer to critical care; and (d) documented history of psychiatric
illness including depression/depressive disorder.

Downloaded from wjn.sagepub.com at LEVY LIBRARY BOX 1102 on June 5, 2011

526

Western Journal of Nursing Research 33(4)

This study was reviewed and approved by the Institutional Review Board
at the University of Minnesota as well as Nursing Research Council of the
organization that research was conducted.

Measures
Demographic measures and chart review. A demographic data form was
developed by this researcher to collect information including race, education,
marital status, socioeconomic status, and income level. A chart review was
completed for each patient to obtain medical history, cardiovascular-related
comorbidities (i.e., coronary artery disease, peripheral vascular disease, history
of coronary artery bypass graft, etc.,) lesion location (based on CT scan), age,
living conditions, and past medical history.
Depressive symptoms. Depression instruments were chosen for this study
based on a review of the literature and the psychometric properties of the
instruments. Since no instrument has been reliably shown to measure depressive symptoms in the stroke population, two instruments were used in an effort
to more accurately evaluate depressive symptoms in this study. The instruments
are further elaborated below.
Geriatric Depression Scale, shortened 15-item version (GDS) is a selfreport instrument with 15 yes/no questions. It is a screening instrument
designed to identify persons with potential clinical depression according to
the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; Almeida
& Almeida, 1999). The 15-item version of the longer 30-item GDS was
developed by Sheikh and Yesavage (1986) and currently is the version most
commonly used. The scores on this version range from 0 to 15, with a score
of 5 as a designated cutoff point for a positive screen based on the number of
depressive symptoms endorsed by the respondents. It has demonstrated
excellent sensitivity of 85% and specificity of 74% (Andersen, Vestergaard,
Riis, & Lauritzen, 1994; Andresen, Malmgren, Carter, & Patrick, 1994b). The
advantages of using this scale in stroke patients are the relative ease of answering questions (not asking the patient to recall from memory), measuring
change over time, and the demonstrated validity in its over-the-phone administration. In a comparison of six depression rating scales in geriatric stroke
patients, the authors found that Cronbachs for GDS was 0.90, with sensitivity of 88% and specificity of 64% (Agrell & Dehlin, 1989).
Center for Epidemiologic Studies Depression Scale (CES-D), 10-item version measures the number and severity of depressive symptoms. The instrument has been validated with healthy older adults and in stroke population.

Downloaded from wjn.sagepub.com at LEVY LIBRARY BOX 1102 on June 5, 2011

527

Hadidi et al.

The questionnaire assesses perceived mood and level of functioning within

the past seven days. It has 10 items with responses ranging from all of the
time (5-7 days/week), occasionally or moderate amount of time (3-4 days/
week), some or little of the time (1-2 days/week), and rarely or none of the
time (less than 1 day/week). Scores range from 0 to 30 with a score of 10 or
greater considered a positive screen for depression. It takes a few minutes
to administer. Documented test-retest item correlation has been found to
range from r = .21 to r = .84, with overall score correlation of r = .71 (comparable to 20-item CES-D; Andresen, Malmgren, Carter, & Patrick, 1994a).
Function measures. The Functional Independence Measure (FIM) was
selected based on a review of the literature on measurement of functional
impairment in stroke populations. The FIM is a widely used disability measure that assesses physical and cognitive disability in terms of burden of care.
It is used to monitor patients progress and to assess the outcome of rehabilitation. The FIM contains 18 items with 13 items covering motor functioning
and five covering social-cognitive functioning. The motor section of the tool
covers independence in self-care, sphincter control, mobility, and locomotion.
Three cognitive items cover social interaction, problem solving, and memory
(McDowell & Newell, 1996). Seven-point ordinal ratings represent gradations of independence and reflect the amount of assistance a patient requires.
For each item, two levels of independent functioning distinguish complete
independence from modified independencewhen the activity is performed
with some delay, safety risk, or with an assistive device. Two dependent levels
refer to the provision of assistance: modified dependence is when the assistant provides less than half the effort required to complete the task, and complete dependence is when the assistant provides more than half the effort.
Finer gradations can be made within each level. A tool score sums the individual ratings; higher scores indicate more independent function: scores
range from a low of 18 to a maximum of 126.
In a study by Dodds and colleagues on validation of FIM in rehabilitation
patients, a majority with diagnosis of stroke, they found that FIM had high
internal consistency (discharge FIM = 0.93). Furthermore, FIM registered
significant functional gains during rehabilitation (33% FIM score improvement, p < .001), as do many other functional status indicators (Dodds, Martin,
Stolov, & Deyo, 1993).
Cognitive measure. Mini Mental State Examination (MMSE) is a widely
used method for assessing cognitive mental status. The MMSE has been
widely used as a research tool to screen for cognitive disorders in epidemiological studies and cognitive changes in clinical trials. It assesses orientation,
attention, immediate and short-term recall, language, and the ability to follow
simple verbal and written commands (Cockrell, 1988). Test-retest reliability

Downloaded from wjn.sagepub.com at LEVY LIBRARY BOX 1102 on June 5, 2011

528

Western Journal of Nursing Research 33(4)

has been demonstrated to be 0.89 and concurrent validity 0.98; it takes

5 minutes to complete (Folstein, Folstein, & McHugh, 1975). Scores range
from 0 to 30. Any score over 27 (out of 30) is effectively normal. Below this,
20 to 26 indicate mild dementia; 10 to 19 moderate dementia; and below 10
severe dementia. For the purpose of this study, a score of 23 was established as the cutoff point in the screening for inclusion of participants in the
study. Lower scores would reflect difficulty with orientation, attention, immediate and short-term recall, language, and the ability to follow simple verbal
and written commands (Cockrell, 1988).
Stroke Severity Scale. National Institute of Health Stroke Scale or NIHSS
(15-item version) is a valid and reliable measure of impairment resulting from
stroke and allows clinicians and researchers to quantify both the extent of
neurological recovery that occurs during acute management and medical rehabilitation and the relationships between disease, impairment, disability, and
handicap (Heinemann, 1997, p. 1174). It assesses the severity of impairments
in level of consciousness, ability to respond to questions and obey simple commands, papillary response, gaze deviation, extent of hemianopsia, facial palsy,
resistance to gravity in the weaker limb, limb ataxia, sensory loss, visual neglect,
dysarthria, and aphasia severity. The actual NIHSS scores ranges from 0 to 23,
with a higher score indicating more impairment. Muir and colleagues demonstrated that a cut point of 13 on the NIH Stroke Scale predicted 3-month poor
functional outcome with a 0.71 sensitivity, a specificity of 0.90, and an overall accuracy of 0.83 (Muir, Weir, Murray, Povey, & Lees, 1996). In the past,
this tool has documented sensitivity of 0.72 and specificity of 0.89, interclass
correlation coefficient of 0.82 (Kasner et al., 1999).

Procedure
Twenty three subjects were recruited at an acute rehabilitation center based
on study inclusion and exclusion criteria. All instruments were administered
by the principal investigator. Following the consent process, the MMSE was
administered to determine further eligibility in the study. Furthermore, the
NIH stroke scale was administered to determine the severity of neurological
impairment. The MMSE, demographic information form, and NIHSS were
completed only at baseline. At baseline and subsequent time intervals (2 weeks,
1 and 3 months) CES-D, GDS, FIM were administered.

Analysis
Sample size. The minimum sample size of n = 23 needed to address the
specific aims was calculated based on the following: (a) estimates of the

Downloaded from wjn.sagepub.com at LEVY LIBRARY BOX 1102 on June 5, 2011

529

Hadidi et al.

standard deviation in functional outcome derived from a review of literature

(23.9), (b) detectable difference of 11.9 , repeated measures ANOVA, (c) =
.05, (d) power = 80%, (e) subject assessments repeated over four time
periods.
Appropriate descriptive statistics on demographics as well as all scored-on
measures were performed to understand the characteristics of the population.
Categorical data were summarized using frequencies, interval data using mean
and standard deviation for normally distributed data, and medians and ranges
for nonnormal data. Significant differences at the three time points were
assessed using repeated measures analysis of covariance for the FIM, GDS,
and CES-D with a priori contrasts between each successive time period tested.
Function as measured by the FIM and depressive symptoms as measured
by the CESD and GDS were collected at four time points, baseline, 2 weeks,
1 and 3 months. Random coefficient models were used for analysis which is
appropriate for longitudinal data. These allow modeling rates of change individually. Random coefficient models accommodate correlated and nonhomogeneous residuals in the model, typical in repeated measures. This type of
model also allows for discontinuity in rates of change.
The first step in the analysis was to graph each participants scores for
FIM, CES-D, and GDS to identify different individual patterns of change in
the measures over time. Graphs revealed definite inflection points at 2 weeks
for CES-D and FIM. Level 1 modeling assessed if there were significant differences in starting points (intercept), differences in change over time (slopes
before and after the inflection point), and/or significant unexplained variance. A discontinuity point was introduced at 2 weeks for both outcomes.
This was accomplished by splitting time into two components and computing a rate of change for each component. An unstructured covariance model
was chosen which is appropriate for correlated random coefficient models.
Appropriateness of the model and covariance structure was assessed based
on various goodness-of-fit statistics; the Akaike Information Criteria, Bayesian
Information Criteria, and the Wald statistic for nonnested models. Analysis
was performed using SPSS v.14 and SAS v.9.

Results
Demographics
The 23 stroke patients (12 men and 11 women) who participated in the study
were similar with respect to their demographic characteristics (see Table 1).
Participants were predominantly White, married, retired, and earning less
than US$25,000. The average age was 69 years (ranging from 48-94 years),
with average length of stay of 10.5 days. A majority had education either at
Downloaded from wjn.sagepub.com at LEVY LIBRARY BOX 1102 on June 5, 2011

530

Western Journal of Nursing Research 33(4)

Table 1. Participant Demographics and Baseline Medical Characteristics

Variable

M (SD)

Number of cardiovascular-related comorbidities

Number of children
NIH Stroke Scale (0-23)
Mini Mental State Exam (0-30)
Variable
Gender
Male
Lesion location
Right
Ethnicity
White
American Indian
African American
Race
Non-Hispanic
Marital status
Single
Married
Employment
Full-time
Part-time
Homemaker
Retired
Other
Education
Less than 9th grade
High school graduate (or equivalency)
Some college or associate degree
Bachelors degree or higher
Living arrangement
Living alone
Living with someone
Tobacco use
Yes

5.2 (2.3)
1.6 (1.6)
2.8 (2.3)
28.1 (2.2)
n (%)
12 (52.2)
13 (56.5)
21 (91.3)
1 (4.3)
1 (4.3)
23 (100)
11 (47.8)
12 (2.2)
5 (21.7)
2 (8.7)
3 (13)
12 (52.2)
1 (4.3)
1 (4.3)
9 (39.1)
8 (34.8)
5 (21.7)
7 (30.4)
16 (70.0)
8 (84.8)

high school level or some college education. Although an equal number of

participants were single as were married, most lived with someone. Patients
were recruited over a 1-year period.

Downloaded from wjn.sagepub.com at LEVY LIBRARY BOX 1102 on June 5, 2011

531

Hadidi et al.
Table 2. Tests of Within-Subjects Contrasts for FIM and CES-D (n = 23)

Baseline 2-Weeks
Measure M (SD) M (SD)

1-Month
M (SD)

FIM

117.9
(11.4)
3.9
(2.7)

CES-D

94.0
(19.3)
6.6
(4.4)

111.6
(16.8)
4.4
(4.0)

2 Weeks 1 Month
Baseline vs. vs.
vs.
3-Month 2-Week 1 Month, 3 Months,
M (SD)
F (p)
F (p)
F (p)
118.6
(12.1)
2.8
(2.3)

20.6
(< .001)
0.1
(.04)

9.8
0.2 (.70)
(.005)
4.1
1.2 (.10)
(.59)

Note: Analysis of covariance.

A majority of participants were not severely affected by stroke as evidenced by NIH Stroke Scale scores (M = 2.8, SD = 2.3) with range of participant scores from 2 to 9, with a possible range 0 to 23. The NIH stroke
scale administered at baseline was strongly associated with function at baseline (p = .008), but not associated with depressive symptoms (p = .46).
All patients had to have a minimum score of 23 on the Mini Mental State
Exam to have been included in the study. The mean score on this measure was
28.1 with SD of 2.2. These scores indicate that most participants were cognitively intact. Most of the difficulties observed were in short-term memory and
mathematical abilities. The mean number of cardiovascular-related comorbidities
abstracted from the charts was 5.2 (SD = 2.3). A majority of participants did not
smoke at the time of their stroke although most had a history of smoking.
Tests of within-subject changes over time for successive time periods (baseline vs. 2 weeks, 2 week vs. 1 month, and 1 month vs. 3 months) of the FIM
and the CES-D were tested using repeated measures ANCOVA. The FIM
scores for participants at 2 weeks were significantly improved compared to
baseline, and the FIM scores at 1 month were significantly improved compared
to 2 weeks. The CES-D scores were only significantly different between baseline and 2 weeks, demonstrating a considerable improvement (see Table 2).

Sample of Individual Graphs

A matrix of all participants graphs representing change over time in the FIM,
and CES-D are included to illustrate observed patterns of change in individual participants (see Figure 1).
In viewing the graphs for the FIM over time, a dominant pattern emerged.
Function improved significantly at Time 2 (2 weeks) and reached a plateau
thereafter. For a few participants, there was another inflection point at Time 3
(1 month) at which point there was another increase in function. Overall, the

Downloaded from wjn.sagepub.com at LEVY LIBRARY BOX 1102 on June 5, 2011

532

Western Journal of Nursing Research 33(4)

Figure 1. Patterns of depressive symptoms and function in 23 participants 0 to 3

months poststroke
Note: Participants 11 and 12 expired after Time 2, and participant 22 missing Time 4.

graphs of function as measured by the FIM and depressive symptoms as measured by CES-D were similar in change pattern. Thus, as functional outcome
improved, depressive symptoms as measured by the CES-D decreased. This
did not hold true for the GDS. The changes in the GDS over time did not
reflect any pattern, nor did they correspond to changes in other variables
(CES-D or FIM). Based on this observation, the GDS was eliminated from
further analysis. Instead, CES-D scores were used in subsequent multi
variate analysis.
Level 1 analysis of the mixed modeling with the FIM as a measure of
function is presented in Table 3 and Figure 2. On average, subjects started
at an average score of 92.9 and their FIM score increased by an average of
16 points by 2 weeks. There was significant change in slopes (change per
month) from 2 weeks to 3 months resulting in a slope of 3.2 points per month

Downloaded from wjn.sagepub.com at LEVY LIBRARY BOX 1102 on June 5, 2011

533

Hadidi et al.
Table 3. Measurements of Function (FIM) and Depression (CES-D) Over Time

FIM
CES-D

Baseline M (SD)

2-Week M (SD)

1-Month M (SD)

3-Month M (SD)

92.9 (19.4)

107.2 (21.1)

117.0 (11.9)

118.6 (12.1)

7.1 (4.7)

5.3 (5.0)

3.9 (2.7)

2.8 (2.3)

Scores

Note: FIM = Functional Independence Measure; CES-D = Center of Epidemiological

StudiesDepression.

120
100
80
60
40
20

FIM
CES-D

10
0
0.0

0.5

1.0

1.5
2.0
Months

2.5

3.0

Figure 2. Level 1 analysis of the mixed modeling

on the FIM. There was significant variance between subjects for the baseline
(p < .001), baseline to 2 weeks (p = .004) and 2 weeks to 3 months (p = .005),
meaning that subjects presented with different levels of function and did not
change homogenously. There was also a significant correlation between
Slope 1 (change from baseline to 2 weeks) and Slope 2 (change from 2 weeks
to 3 months; p = .009). This indicates that subjects started out at different
levels of the FIM, had significantly different rates of change from baseline to 0.5
months and also from 0.5 months to 3 months. Change from baseline to 2 weeks
(or 0.5 months) affected change in individual scores from 2 weeks to 3 months.
Thus, if a participant had a significant change in his/her functioning from
baseline to 2 weeks, that rate of change affected the rate of change from
2 weeks (0.5 months) to 3 months. Level 1 modeling with the CES-D showed
that participants on average started at a score of 7.1 and by 2 weeks, their
CES-D score decreased by an average of 2 points (see Table 3). The slope of
change was .8 CES-D points per month after two weeks. There was a
significant (p = .03) variance at baseline; meaning that participants had

Downloaded from wjn.sagepub.com at LEVY LIBRARY BOX 1102 on June 5, 2011

534

Western Journal of Nursing Research 33(4)

different depression scores at baseline. There was no significant variance

between participants from baseline to 2 weeks (p = .32) or 2 weeks to 3 months
(p = .41), meaning participants were homogenous in their depression score
changes over those time periods. This indicated that although participants
had different levels of CES-D scores at baseline, participants changed but
not differently.

Discussion
Patterns of Depressive Symptoms and Function
In reviewing the longitudinal graphs, pattern of score changes on the CES-D
were similar to those of function; change in functional ability and depressive
symptoms were inversely related, whereas GDS did not demonstrate any
similarity to FIM or CES-D. In a study conducted by Tang and colleagues
with 127 acute stroke patients, the investigators utilized the GDS 15-item
version with the depression evaluation from the DSM IV as a benchmark for
validation of GDS (Tang et al., 2004). The results showed that the GDS
identified PSD with a sensitivity of 89%, and a specificity of 73%. However,
although the negative predictive value was high, at 98%, the positive predictive value was just 37%, meaning that there would have been a substantial
number of false positive results. The authors concluded that although GDS
appears to be a sensitive instrument, due to its low positive predictive value,
studies should not solely rely on this instrument to identify depressed stroke
patients (Tang et al., 2004).
In assessing function over time with repeated measures analyses, Table 2
reveals that function improved significantly from baseline to 2 weeks, as well
as from 2 weeks to 1 month. However, changes in physical function did not
achieve significance from 1 month to 3 months follow-up; confirming patients
stability in improvement at 1 month poststroke. A majority of the study sample had discontinued rehabilitation by 3 months poststroke.
Robinson-Smith, Johnston, and Allen (2000) evaluated 63 stroke patients
1 and 6 months poststroke to determine the relationship of self-care selfefficacy to functional independence and stroke and depression after stroke
using the CES-D and FIM for measurement of depression and function respectively. Their results indicated that at 1 month, FIM had significant relationship to depression (p = .02), but this relationship was not supported at 6 months
poststroke (p = .45). The FIM also improved significantly from admission to
1 month after stroke (M of 84, SD = 14 on admissions, to a M of 106,
SD = 16 at discharge).

Downloaded from wjn.sagepub.com at LEVY LIBRARY BOX 1102 on June 5, 2011

535

Hadidi et al.

Acute rehabilitation is required when a patients intensity of interventions

cannot be met in any other setting. Once patients achieve the goal of independence in ADLs and little is achieved by staying longer, they are discharged.
Once discharged, patients are often required to follow-up with outpatient
rehabilitation therapy with differing frequency based on their level of functioning. By the end of 3 months, rehabilitation programs usually slow and
there are fewer available resources for reimbursement. This leads to frustration of stroke survivors and their families, because the progress is not complete yet and patients become isolated (Ostwald, Davis, Hersch, Kelley, &
Godwin, 2008). Continued participation in rehabilitation shown to contribute
to patients progress toward achieving independence.
Depressive symptoms as measured by the CES-D improved significantly
from baseline to 2 weeks only. This improvement was similar to improvement in function from baseline to 2 weeks. Depressive symptoms, however,
remained stable after 2 weeks and was under the cutoff score of 10. Several studies using the CES-D as a measure for depressive symptoms have demonstrated
an association of depression with disability late in life (Barberger-Gateau
et al., 1992; Beekman, Deeg, Braam, Smit, & Van Tilburg, 1997; Black,
Markides, & Miller, 1998). Few studies have examined the pattern of change
longitudinally.
Tests of within-subject contrasts for progressive time periods (Baseline
vs. 2 weeks, 2 weeks vs. 1 month, and 1 month vs. 3 months) of the FIM and
CES-D using a repeated measure ANCOVA suggest that with respect to
function, the FIM at baseline versus 2 weeks was significantas was 2 weeks
versus 1 month. However, with respect to depressive symptoms, CES-D was
significantly different only between baseline and 2 weeks. This suggests that
function changed significantly from baseline to 2 weeks and up to 1 month
and remained stable thereafter. The pattern of depressive symptoms also
changed significantly from baseline to 2 weeks; however, the change was not
as significant as function from 2 weeks to 1 month and 3 months. Considering
average length of stay in acute rehabilitation to be 2 weeks, the significant
change in function from baseline to 2 weeks may be related to the impact of
intense rehabilitation during that time. Furthermore, it is not clear how much
of patients improvement is attributable to spontaneous recovery following
stroke. The improvement in depressive symptoms and function may suggest
that as stroke survivors gain independence in accomplishing activities of
daily living and observe the significant progress they have made, their moods
improve as well. Due to small sample size, one may infer that both measures
improve immediately poststroke.

Downloaded from wjn.sagepub.com at LEVY LIBRARY BOX 1102 on June 5, 2011

536

Western Journal of Nursing Research 33(4)

This study is one of the few longitudinal studies describing patterns of

depressive symptoms and function in acute ischemic stroke patients over
time. The results of this study have several implications for research and
practice in acute rehabilitation. First, it is imperative that once patients have
become stable after stroke, they are encouraged to participate in aggressive
rehabilitation programs. Families and stoke survivors need to be informed of
how neuroplasticity applies to an injured brain and how exercising the brain
may cause development of new neuro pathways and thus new learning to
regain lost function. Furthermore, concurrent examination of changes in patterns of depressive symptoms and function revealed a possibility that as independence in activities of daily living is increased, not only function may be
restored, but that gain in independence is associated with positive changes in
mood and depressive symptoms. It was determined that function and depressive symptoms follow a similar pattern of change over time. It must be noted
that this does not suggest causality between the function and depressive
symptoms. Therefore, follow-up after discharge from acute rehabilitation is
also essential in regaining independence in activities of daily living and
improving cognitive skills and speech. Rehabilitation programs and support
groups need to be sensitive in their development of educational programs for
patients and families to inform them of the importance of the signs and symptoms of depression and their relationship with function and critical role of
early interventions.
Acknowledgment
The authors wish to thank the acute rehabilitation staff at the University of Minnesota
Medical Center for their time and effort, without whose support this research would
not have been possible.

Authors Note
The research was presented in part at the Annual Meeting of The Gerontological
Society of America, November 24, 2008, National Harbor, MD.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the authorship
and/or publication of this article.

Funding
The author(s) received no financial support for the research and/or authorship of this
article.

Downloaded from wjn.sagepub.com at LEVY LIBRARY BOX 1102 on June 5, 2011

537

Hadidi et al.
References

Agrell, B., & Dehlin, O. (1989). Comparison of six depression rating scales in geriatric
stroke patients. Stroke, 20, 1190-1194.
Almeida, O. P., & Almeida, S. A. (1999). Short versions of the geriatric depression
scale: A study of their validity for the diagnosis of a major depressive episode
according to ICD-10 and DSM-IV. International Journal of Geriatric Psychiatry,
14, 858-865.
American Heart Association. (2010). Heart and stroke statistics update. Dallas, TX:
Author.
Andersen, G., Vestergaard, K., Riis, J., & Lauritzen, L. (1994). Incidence of poststroke depression during the first year in a large unselected stroke population
determined using a valid standardized rating scale. Acta Psychiatrica Scandinavica, 90, 190-195.
Andresen, E. M., Malmgren, J. A., Carter, W. B., & Patrick, D. L. (1994a). Screening for depression in well older adults: Evaluation of a short form of the CES-D
(Center for Epidemiologic Studies depression scale). American Journal of Preventative Medicine, 10, 77-84.
Andresen, E. M., Malmgren, J. A., Carter, W. B., & Patrick, D. L. (1994b). Screening
for depression in well older adults: Evaluation of a short form of the CES-D
(Center for Epidemiologic Studies depression scale). American Journal of Preventive Medicine, 10(2), 77-84.
Astrom, M., Adolfsson, R., & Asplund, K. (1993). Major depression in stroke patients:
A 3-year longitudinal study. Stroke, 24, 52-57.
Barberger-Gateau, P., Chaslerie, A., Dartigues, J. F., Commenges, D., Gagnon, M.,
& Salamon, R. (1992). Health measures correlates in a French elderly community
population: The PAQUID study. Journal of Gerontology, 47(2), S88-S95.
Beekman, A. T., Deeg, D. J., Braam, A. W., Smit, J. H., & Van Tilburg, W. (1997).
Consequences of major and minor depression in later life: A study of disability,
well-being and service utilization. Psychological Medicine, 27, 1397-1409.
Black, S. A., Markides, K. S., & Miller, T. Q. (1998). Correlates of depressive
symptomatology among older community-dwelling Mexican Americans: The
Hispanic EPESE. Journals of Gerontology Series B: Psychological Sciences &
Social Sciences, 53, S198-S208.
Cassidy, E. M., OConner, R., & OKeane, V. (2004). Prevalence of post-stroke
depression in an Irish sample and its relationship with disability and outcome
following inpatient rehabilitation. Disability and Rehabilitation, 26(2), 71-77.
Cockrell, J. R. (1988). Mini mental state examination (MMSE). Retrieved September
18, 2010, from http://www.leukemia-net.org/content/e58/e525/e5012/e5352/

Downloaded from wjn.sagepub.com at LEVY LIBRARY BOX 1102 on June 5, 2011

538

Western Journal of Nursing Research 33(4)

Demchuk, A. M., Tanne, D., Hill, M. D., Kasner, S. E., Hanson, S., Grond, M., et al.
(2001). Predictors of good outcome after intravenous tPA for acute ischemic stroke.
Neurology, 57, 474-480.
Dodds, T. A., Martin, D. P., Stolov, W. C., & Deyo, R. A. (1993). A validation of the
functional independence measurement and its performance among rehabilitation
inpatients. Archives of Physical Medicine & Rehabilitation, 74, 531-536.
Feibel, J. H., & Springer, C. J. (1982). Depression and failure to resume social activities
after stroke. Archives of Physical Medicine & Rehabilitation, 63, 276-277.
Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-mental state: A
practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189-198.
Heinemann, A. W. (1997). Measurement properties of the NIH stroke scale during
acute rehabilitation. Stroke, 28, 1174-1180.
Johnson, J. L., Minarik, P. A., Nystrom, K. V., Bautista, C., & Gorman, M. J. (2006).
Poststroke depression incidence and risk factors: An integrative literature review.
Journal of Neuroscience Nursing, 38, 316-327.
Kasner, S. E., Chalela, J. A., Luciano, J. M., Cucchiara, B. L., Raps, E. C.,
McGarvey, M. L., et al. (1999). Reliability and validity of estimating the NIH
stroke scale score from medical records. Stroke, 30, 1534-1537.
Lipsey, J. R., Robinson, R. G., Pearlson, G. D., Rao, K., & Price, T. R. (1983). Mood
change following bilateral hemisphere brain injury. British Journal of Psychiatry,
143, 266-273.
McDowell, I., & Newell, C. (1996). Measuring health: A guide to rating scales and
questionnaires. New York: Oxford University Press.
Muir, K. W., Weir, C. J., Murray, G. D., Povey, C., & Lees, K. R. (1996). Comparison
of neurological scales and scoring systems for acute stroke prognosis. Stroke, 27,
1817-1820.
Ostwald, S. K., Davis, S., Hersch, G., Kelley, C., & Godwin, K. M. (2008). Evidencebased educational guidelines for stroke survivors after discharge home. Journal of
Neuroscience Nursing, 40, 173-179.
Parikh, R. M., Robinson, R. G., Lipsey, J. R., Starkstein, S. E., Fedoroff, J. P.,
& Price, T. R. (1990). The impact of poststroke depression on recovery in
activities of daily living over a 2-year follow-up. Archives of Neurology, 47,
785-789.
Robinson, R. G. (2003). Poststroke depression: Prevalence, diagnosis, treatment, and
disease progression. Biological Psychiatry, 54, 376-387.
Robinson-Smith, G., Johnston, M. V., & Allen, J. (2000). Self-care self-efficacy,
quality of life and depression after stroke. Archives of Physical Medicine and
Rehabilitation, 81, 460-464.

Downloaded from wjn.sagepub.com at LEVY LIBRARY BOX 1102 on June 5, 2011

539

Hadidi et al.

Rusin, M. J. (1990). Stroke rehabilitation: A geropsychological perspective. Archives

of Physical Medicine and Rehabilitation, 71, 914-922.
Sheikh, J. I., & Yesavage, J. A. (1986). Geriatric Depression Scale (GDS): Recent
evidence and development of a shorter version. Clinical Gerontology, 5, 165 -173.
Sinyor, D., Amato, P., Kaloupek, D., Becker, R., Goldenberg, M., & Coopersmith, H.
(1985). Post-stroke depression: Relationship to functional impairment, coping
strategies, and rehabilitation outcome. Stroke, 17, 1102-1107.
Tang, W. K., Chan, S. S., Chiu, H. F., Wong, K. S., Kwok, T. C., Mok, V., et al.
(2004). Can the Geriatric Depression Scale detect poststroke depression in Chinese
elderly? Journal of Affective Disorders, 81, 153-156.
Tanner, D. C., & Gerstenberger, D. L. (1988). The grief response in neuropathologies
of speech and language. Aphasiology, 2, 79-84.
Verdelho, A., Henon, H., Lebert, F., Pasquier, F., & Leys, D. (2004). Depressive
symptoms after stroke and relationship with dementia: A three-year follow-up
study. Neurology, 62, 905-911.
World Health Organization. (2010). International classification of functioning, disability, and health (ICF). Retrieved September 18, 2010, from http://www.who
.int/classifications/icf/en/

Downloaded from wjn.sagepub.com at LEVY LIBRARY BOX 1102 on June 5, 2011