title: The triad of pain, fatigue and depression in ischemic stroke patients: the Bergen Stroke Study.
abstract: BACKGROUND
  Many patients with cerebral infarction suffer from symptoms such as pain, fatigue and depression. Most studies focus on single symptoms, but these symptoms often occur together. Whereas symptom clusters have been studied in cancer patients, little is known about different symptom clusters in patients with cerebral infarction. The aim was to evaluate clusters of co-occurring symptoms in the long term. We hypothesized that patients with cerebral infarction display distinct symptom clusters. Furthermore, we hypothesized that multiple co-occurring symptoms have an adverse effect on patients.
  
  
  METHODS
  All consecutive patients with acute stroke (the index stroke) admitted to the Stroke Unit, Department of Neurology, Haukeland University Hospital, between February 2006 and July 2008, were prospectively registered in a database. Prior risk factors (including diabetes mellitus, hypertension, smoking, coronary heart disease, atrial fibrillation and prior stroke), prior depression and stroke severity (modified Rankin Scale (mRS) score on day 7) were registered. Patients with cerebral infarction were sent a questionnaire including a visual analogue pain scale (VAS), Fatigue Severity Scale (FSS), depression subscale of the Hospital Anxiety, Depression Scale (HADS-D) and Barthel Index at least 6 months after stroke onset.
  
  
  RESULTS
  The questionnaire was returned by 328 patients (response rate 60%). All three symptoms were reported by 10.1%. Pain and fatigue among nondepressed patients were reported by 19.6%. Pain and depression among nonfatigued patients were reported by 2.0%. Depression and fatigue, and no pain were reported by 4.4%. Single symptoms were reported by 31% whereas 33% reported no symptoms. VAS, FSS and HADS-D score severity increased with the number of co-occurring symptoms. Logistic regression analyses showed that two or three symptoms (versus no symptoms) was associated with high mRS score on day 7 (p = 0.02), prior stroke (p = 0.002), prior diabetes mellitus (p = 0.005) and prior depression (p < 0.001).
  
  
  CONCLUSIONS
  Symptom clusters are frequent in patients with cerebral infarction. Fatigue was associated with pain and depression whereas there was little association between depression and pain in nonfatigue patients, indicating distinct symptom clusters. The severity of symptoms increased with the number of co-occurring symptoms.
authors.affiliation: Department of Neurology, Haukeland University Hospital, Bergen, Norway. halvor.naess@haukeland.no
authors.forename: Halvor
authors.initials: H
authors.lastname: Naess
authors.forename: Lene
authors.initials: L
authors.lastname: Lunde
authors.forename: Jan
authors.initials: J
authors.lastname: Brogger
mesh_terms: D000368:Aged; D000928:Antidepressive Agents / Q000627:therapeutic use; D002545:Brain Ischemia / Q000150:complications*; D002544:Cerebral Infarction / Q000150:complications; D003863:Depression / Q000209:etiology*; D005221:Fatigue / Q000209:etiology*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016014:Linear Models; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009664:Norway; D010146:Pain / Q000209:etiology*; D010147:Pain Measurement; D011569:Psychiatric Status Rating Scales; D012307:Risk Factors; D020521:Stroke / Q000150:complications*; D011795:Surveys and Questionnaires; D014057:Tomography, X-Ray Computed
chemical_list: D000928:Antidepressive Agents