<clinical_study>
  <!-- This xml conforms to an XML Schema at:
    https://clinicaltrials.gov/ct2/html/images/info/public.xsd -->
  <required_header>
    <download_date>ClinicalTrials.gov processed this data on September 20, 2023</download_date>
    <link_text>Link to the current ClinicalTrials.gov record.</link_text>
    <url>https://clinicaltrials.gov/ct2/show/NCT03761303</url>
  </required_header>
  <id_info>
    <org_study_id>rTMS-PSD</org_study_id>
    <nct_id>NCT03761303</nct_id>
  </id_info>
  <brief_title>rTMS as an add-on Therapy in Patients With Post-stroke Depression</brief_title>
  <official_title>Investigation of the Efficacy of Repetitive Transcranial Magnetic Stimulation (rTMS) as an add-on Therapy in Patients With Post-stroke Depression (PSD)</official_title>
  <sponsors>
    <lead_sponsor>
      <agency>BDH-Klinik Hessisch Oldendorf</agency>
      <agency_class>Other</agency_class>
    </lead_sponsor>
  </sponsors>
  <source>BDH-Klinik Hessisch Oldendorf</source>
  <oversight_info>
    <has_dmc>No</has_dmc>
    <is_fda_regulated_drug>No</is_fda_regulated_drug>
    <is_fda_regulated_device>No</is_fda_regulated_device>
  </oversight_info>
  <brief_summary>
    <textblock>
      About 50% of all stroke patients develop post-stroke depression (PSD). A meta-analysis has&#xD;
      shown that rTMS treatment can reduce depressive symptoms in PSD patients. In addition to rTMS&#xD;
      alone for the improvement of depression, the question arises as to whether a combination&#xD;
      therapy of rTMS plus antidepressant medication can achieve a stronger or longer-term effect&#xD;
      in PSD patients. Unfortunately, there are currently no trials of combination therapy with&#xD;
      rTMS and drug therapy in PSD patients. Therefore, this study will investigate whether&#xD;
      combination therapy of antidepressant and rTMS can provide additional relief of depressive&#xD;
      symptoms compared to antidepressant and sham rTMS therapy. It is assumed that the additional&#xD;
      active rTMS achieves a faster normalization of affect and drive than with a sham rTMS, so&#xD;
      that the patients benefit from neurorehabilitation measures earlier and more sustainably.&#xD;
    </textblock>
  </brief_summary>
  <detailed_description>
    <textblock>
      Depression is one of the most common forms of mental illness. According to studies by the&#xD;
      World Health Organization (WHO), the World Bank and the European Brain Council [1],&#xD;
      depression is the leading disease in Europe and Germany since the early 1990s.&#xD;
&#xD;
      Besides drug or psychotherapeutic treatment, repetitive transcranial magnetic stimulation&#xD;
      (rTMS) is currently being used as a new non-invasive therapy for depression. The rTMS applies&#xD;
      an electromagnetic coil to the patient's head, creating a magnetic field. Impulses emanating&#xD;
      from the coil trigger a multitude of reactions at the point of stimulation which, for&#xD;
      example, can alter the metabolism, lead to a release of neurotransmitters and a change in&#xD;
      gene expression [2-3]. Pulses with a frequency ≤1Hz lead to a reduction of the excitability&#xD;
      of the neurons and to an inhibition of cortical activity. In contrast, frequencies ≥5 Hz&#xD;
      increase the excitability of neurons and increase cortical activity [4-5].&#xD;
&#xD;
      A large number of studies has already shown that rTMS in depressive patients leads to an&#xD;
      improvement in depressive symptoms and has been shown to have an antidepressant effect [6].&#xD;
      In the United States, rTMS has been approved by the Food and Drug Administration (FDA) since&#xD;
      2008 as a treatment for patients with depression who do not respond to antidepressant drug&#xD;
      therapy. The FDA recommends a high-frequency (10Hz) rTMS on the left dorsolateral prefrontal&#xD;
      cortex (DLPFC) five days a week for four to six weeks [7]. The stimulation of the DLPFC is&#xD;
      based on the valence hypothesis that the right hemisphere specializes in the processing of&#xD;
      negative emotions and the left hemisphere is specialized in the processing of positive&#xD;
      emotions [8] and the DLPFC controls emotional processing [9-10]. Activation of the left DLPFC&#xD;
      is therefore associated with the processing of positive emotions [11].&#xD;
&#xD;
      About 50% of all stroke patients develop post-stroke depression (PSD) [12]. A meta-analysis&#xD;
      has shown that rTMS treatment can reduce depressive symptoms in PSD patients [13]. In&#xD;
      addition to rTMS alone, it is unkown if a combination therapy of rTMS plus antidepressant&#xD;
      medication can achieve a stronger or longer-term antidepressive effect in PSD patients.&#xD;
      Unfortunately, there are currently no trials of combination therapy with rTMS and drug&#xD;
      therapy in PSD patients. Previous studies with depressive patients provide both results that&#xD;
      suggest an additional effect of combination therapy [14-19] and results that found no&#xD;
      difference between drug-only therapy and combination with rTMS [20-24]. The comparability of&#xD;
      the studies is difficult due to the heterogeneity of the study designs. However, it is&#xD;
      noticeable that a younger age (&lt;50 years), an intervention duration of rTMS of four weeks, a&#xD;
      higher dose of the antidepressant, an inter-train interval (interval between the trains) of&#xD;
      &lt;30 seconds and a total number of pulses of &lt;1250 per day, associated with positive effects.&#xD;
      However, further studies are needed that address the issue of an additional effect of&#xD;
      combination therapy. In addition, a neurological disease was considered to be an exclusion&#xD;
      criterion in some of the studies performed [14-15; 20; 23]. It is therefore questionable&#xD;
      whether the study results can be transferred to PSD patients.&#xD;
&#xD;
      Therefore, this study will investigate whether combination therapy of antidepressant and rTMS&#xD;
      can provide additional relief of depressive symptoms compared to antidepressant and sham rTMS&#xD;
      therapy. It is assumed that the additional active rTMS achieves a faster normalization of&#xD;
      affect and drive than with a sham rTMS, so that the patients benefit from neurorehabilitation&#xD;
      measures earlier and more sustainably.&#xD;
    </textblock>
  </detailed_description>
  <overall_status>Withdrawn</overall_status>
  <why_stopped>
    No eligible patients could be recruited.&#xD;
  </why_stopped>
  <start_date type="Actual">May 1, 2018</start_date>
  <completion_date type="Anticipated">November 1, 2022</completion_date>
  <primary_completion_date type="Anticipated">November 1, 2021</primary_completion_date>
  <phase>N/A</phase>
  <study_type>Interventional</study_type>
  <has_expanded_access>No</has_expanded_access>
  <study_design_info>
    <allocation>Randomized</allocation>
    <intervention_model>Parallel Assignment</intervention_model>
    <intervention_model_description>All patients will receive standard antidepressant therapy with 15 mg escitalopram (Selective Serotonin Reuptake Inhibitor) per day during the study. The dose of escitalopram is increased in all included patients from 5mg/day (day 1-3), over 10mg/day (day 4-6) to 15mg/day (from day 7).&#xD;
Patients in the experimental group (active rTMS stimulation) receive active 10 Hz rTMS stimulation over the left dorsolateral prefrontal cortex (DLPFC) over a period of 20 days, seven days a week (20 sessions). The comparison group receives a duration of equal long sham-stimulation.&#xD;
For transcranial magnetic stimulation, the Stimulator &quot;PowerMAG Research 100&quot; (Mag &amp; More, Munich, Germany) is used with a cooled double coil (PMD70-pCool).</intervention_model_description>
    <primary_purpose>Treatment</primary_purpose>
    <masking>Double (Participant, Investigator)</masking>
    <masking_description>The randomization of the patients is carried out by a non-medical employee. This co-worker maintains a randomly generated randomization list, indicating to the particular study code (e.g., TMS-PSD-001; TMS-PSD-002), whether to perform an active or sham treatment. The employee pulls a number from an envelope before beginning the intervention of each enrolled patient and then looks at the list to identify the particular group assignment. There will always be randomization packages of ten patients each. Once these are used up, a new list and a new envelope with study codes are prepared.&#xD;
In addition, the &quot;real&quot; and the placebo coils are coded before starting studies (eg &quot;A&quot; and &quot;B&quot;). Only the uninvolved employee is the assignment to the real - or placebo coil known. The uninvolved employee randomly assigns the study code containing the information on which coil to use (&quot;A&quot; or &quot;B&quot;). In this way a blinding of performing physician, patient and the evaluating scientist is guaranteed.</masking_description>
  </study_design_info>
  <primary_outcome>
    <measure>Changes of Hamilton Depression Rating Scale [HAM-D; 17 Item Version]</measure>
    <time_frame>For the clinical assessment of the severity of depression, the HAM-D is collected at the following times: day -7; baseline (day 1 before rTMS stimulation); day 2, day 8, day 15 and day 22).</time_frame>
    <description>The primary endpoint is the change in the HAM-D score. A decrease of at least 50% from baseline on day 29 is considered clinically significant. From this, the responder rate is determined.</description>
  </primary_outcome>
  <secondary_outcome>
    <measure>HAM-D score ≤8 Points</measure>
    <time_frame>baseline (day 1 before rTMS stimulation); day 22</time_frame>
    <description>A HAM-D score of ≤8 points is considered a decline in depression and is used to record the remission rate. It is expected that the decrease in the HAM-D from baseline (baseline) to the end of the study (day 22) in the active rTMS group is significantly greater than in the sham rTMS group.</description>
  </secondary_outcome>
  <secondary_outcome>
    <measure>HAM-D score (day -baseline)</measure>
    <time_frame>baseline (day 1 before rTMS stimulation); day 36</time_frame>
    <description>To analyze the long-term effect the HAM-D score will evaluated at day 36 (follow up). It is expected that the decrease in the HAM-D score from baseline to the follow-up (day 36) is significantly greater in the active rTMS group than in the sham rTMS group.</description>
  </secondary_outcome>
  <number_of_arms>2</number_of_arms>
  <enrollment type="Actual">0</enrollment>
  <condition>Post-stroke Depression</condition>
  <arm_group>
    <arm_group_label>active rTMS</arm_group_label>
    <arm_group_type>Active Comparator</arm_group_type>
    <description>Patients in the intervetion group (active rTMS stimulation) receive active 10 Hz rTMS stimulation over the left dorsolateral prefrontal cortex (DLPFC) over a period of 20 days, seven days a week (20 sessions).</description>
  </arm_group>
  <arm_group>
    <arm_group_label>sham rTMS</arm_group_label>
    <arm_group_type>Sham Comparator</arm_group_type>
    <description>Patients in the control group receive sham rTMS stimulation over the left dorsolateral prefrontal cortex (DLPFC) over a period of 20 days, seven days a week (20 sessions).</description>
  </arm_group>
  <intervention>
    <intervention_type>Device</intervention_type>
    <intervention_name>active rTMS</intervention_name>
    <description>The rTMS coil is applied tangentially to the head surface above the left DLPF (corresponding to position F3 of the international 10-20 system). For the stimulation intensity, the motor rest threshold of the patient is determined. The motor rest threshold is defined as the minimum intensity that triggers an EMG response with an amplitude&gt; 50 μV in the first right interosseus dorsalis muscle in at least 5 out of 10 cases. The stimulation intensity within the rTMS therapy is 80 percent of the motor rest threshold. In one session, 1,000 pulses are applied in 10 trains at a frequency of 10 Hz (1 train = 100 pulses in 10 s). Between the individual trains there is an inter-train interval of 28 seconds. The total duration of a session is 5:52 minutes. In total, the patient recieve 20 sessions.</description>
    <arm_group_label>active rTMS</arm_group_label>
  </intervention>
  <intervention>
    <intervention_type>Device</intervention_type>
    <intervention_name>sham rTMS</intervention_name>
    <description>Patients in the intervetion group (active rTMS stimulation) receive active 10 Hz rTMS stimulation over the left dorsolateral prefrontal cortex (DLPFC) over a period of 20 days, seven days a week (20 sessions).</description>
    <arm_group_label>sham rTMS</arm_group_label>
  </intervention>
  <eligibility>
    <criteria>
      <textblock>
        Inclusion Criteria:&#xD;
&#xD;
          -  first insult&#xD;
&#xD;
          -  Post-stroke Depression (17 item version of the Hamilton Depression Rating Scale&#xD;
             [HAM-D]&gt; 18 points)&#xD;
&#xD;
          -  capacity to consent&#xD;
&#xD;
        Exclusion Criteria:&#xD;
&#xD;
          -  insufficient cardiorespiratory stability&#xD;
&#xD;
          -  previous depression or previous use of antidepressants&#xD;
&#xD;
          -  pre-stroke psychological illnesses (eg psychosis, bipolar disorder)&#xD;
&#xD;
          -  severe cognitive impairment&#xD;
&#xD;
          -  aphasia&#xD;
&#xD;
          -  lefthanded&#xD;
&#xD;
          -  decreased seizure threshold or history of epileptic seizures&#xD;
&#xD;
          -  taking medicines that lower the seizure threshold (local anesthetics, cortisone,&#xD;
             alcohol, neuroleptics)&#xD;
&#xD;
          -  hemorrhages and cerebral edema (e.g., subarachnoid haemorrhage, intracerebral&#xD;
             hemorrhage, subdural hematoma, epidural hematoma)&#xD;
&#xD;
          -  fresh and healed head wounds near the area to be stimulated&#xD;
&#xD;
          -  missing bone cover (relief spread)&#xD;
&#xD;
          -  colonization with a germ requiring isolation (e.g., MRSA, 3MRGN, 4MRGN)&#xD;
&#xD;
          -  recent myocardial infarction or higher grade cardiac arrhythmias&#xD;
&#xD;
          -  contraindications to rTMS: Metallic or magnetic implants containing iron, cobalt or&#xD;
             nickel (e.g., pacemakers, brain pacemakers, automatic insulin pumps, electrodes,&#xD;
             plates, clips, implanted hearing aids, dental implants, metal endoprostheses, metal&#xD;
             parts, or metal fragments in the body).&#xD;
&#xD;
          -  pregnancy&#xD;
&#xD;
          -  no consent for study participation by the patient&#xD;
      </textblock>
    </criteria>
    <gender>All</gender>
    <minimum_age>18 Years</minimum_age>
    <maximum_age>N/A</maximum_age>
    <healthy_volunteers>No</healthy_volunteers>
  </eligibility>
  <location>
    <facility>
      <name>Institute for rehabilitative Research, BDH-Clinic Hessich Oldendorf</name>
      <address>
        <city>Hessisch Oldendorf</city>
        <state>Lower Saxony</state>
        <zip>31840</zip>
        <country>Germany</country>
      </address>
    </facility>
  </location>
  <location_countries>
    <country>Germany</country>
  </location_countries>
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  <verification_date>December 2019</verification_date>
  <study_first_submitted>November 30, 2018</study_first_submitted>
  <study_first_submitted_qc>November 30, 2018</study_first_submitted_qc>
  <study_first_posted type="Actual">December 3, 2018</study_first_posted>
  <last_update_submitted>December 13, 2019</last_update_submitted>
  <last_update_submitted_qc>December 13, 2019</last_update_submitted_qc>
  <last_update_posted type="Actual">December 17, 2019</last_update_posted>
  <responsible_party>
    <responsible_party_type>Principal Investigator</responsible_party_type>
    <investigator_affiliation>BDH-Klinik Hessisch Oldendorf</investigator_affiliation>
    <investigator_full_name>Dr. rer. nat. Simone B. Schmidt</investigator_full_name>
    <investigator_title>Postdoctoral Researcher</investigator_title>
  </responsible_party>
  <keyword>rTMS</keyword>
  <keyword>Escitalopram</keyword>
  <keyword>add-on therapy</keyword>
  <condition_browse>
    <!-- CAUTION:  The following MeSH terms are assigned with an imperfect algorithm            -->
    <mesh_term>Stroke</mesh_term>
    <mesh_term>Depression</mesh_term>
    <mesh_term>Depressive Disorder</mesh_term>
  </condition_browse>
  <patient_data>
    <sharing_ipd>No</sharing_ipd>
  </patient_data>
  <!-- Results have not yet been posted for this study                                          -->
</clinical_study>


download date: ClinicalTrials.gov processed this data on September 20, 2023
link text: Link to the current ClinicalTrials.gov record.
url: https://clinicaltrials.gov/ct2/show/NCT03761303
org study id: rTMS-PSD
nct id: NCT03761303
lead sponsor: 
has dmc: No
is fda regulated drug: No
is fda regulated device: No
About 50% of all stroke patients develop post-stroke depression (PSD). A meta-analysis has
      shown that rTMS treatment can reduce depressive symptoms in PSD patients. In addition to rTMS
      alone for the improvement of depression, the question arises as to whether a combination
      therapy of rTMS plus antidepressant medication can achieve a stronger or longer-term effect
      in PSD patients. Unfortunately, there are currently no trials of combination therapy with
      rTMS and drug therapy in PSD patients. Therefore, this study will investigate whether
      combination therapy of antidepressant and rTMS can provide additional relief of depressive
      symptoms compared to antidepressant and sham rTMS therapy. It is assumed that the additional
      active rTMS achieves a faster normalization of affect and drive than with a sham rTMS, so
      that the patients benefit from neurorehabilitation measures earlier and more sustainably.
Depression is one of the most common forms of mental illness. According to studies by the
      World Health Organization (WHO), the World Bank and the European Brain Council [1],
      depression is the leading disease in Europe and Germany since the early 1990s.

      Besides drug or psychotherapeutic treatment, repetitive transcranial magnetic stimulation
      (rTMS) is currently being used as a new non-invasive therapy for depression. The rTMS applies
      an electromagnetic coil to the patient's head, creating a magnetic field. Impulses emanating
      from the coil trigger a multitude of reactions at the point of stimulation which, for
      example, can alter the metabolism, lead to a release of neurotransmitters and a change in
      gene expression [2-3]. Pulses with a frequency ≤1Hz lead to a reduction of the excitability
      of the neurons and to an inhibition of cortical activity. In contrast, frequencies ≥5 Hz
      increase the excitability of neurons and increase cortical activity [4-5].

      A large number of studies has already shown that rTMS in depressive patients leads to an
      improvement in depressive symptoms and has been shown to have an antidepressant effect [6].
      In the United States, rTMS has been approved by the Food and Drug Administration (FDA) since
      2008 as a treatment for patients with depression who do not respond to antidepressant drug
      therapy. The FDA recommends a high-frequency (10Hz) rTMS on the left dorsolateral prefrontal
      cortex (DLPFC) five days a week for four to six weeks [7]. The stimulation of the DLPFC is
      based on the valence hypothesis that the right hemisphere specializes in the processing of
      negative emotions and the left hemisphere is specialized in the processing of positive
      emotions [8] and the DLPFC controls emotional processing [9-10]. Activation of the left DLPFC
      is therefore associated with the processing of positive emotions [11].

      About 50% of all stroke patients develop post-stroke depression (PSD) [12]. A meta-analysis
      has shown that rTMS treatment can reduce depressive symptoms in PSD patients [13]. In
      addition to rTMS alone, it is unkown if a combination therapy of rTMS plus antidepressant
      medication can achieve a stronger or longer-term antidepressive effect in PSD patients.
      Unfortunately, there are currently no trials of combination therapy with rTMS and drug
      therapy in PSD patients. Previous studies with depressive patients provide both results that
      suggest an additional effect of combination therapy [14-19] and results that found no
      difference between drug-only therapy and combination with rTMS [20-24]. The comparability of
      the studies is difficult due to the heterogeneity of the study designs. However, it is
      noticeable that a younger age (<50 years), an intervention duration of rTMS of four weeks, a
      higher dose of the antidepressant, an inter-train interval (interval between the trains) of
      <30 seconds and a total number of pulses of <1250 per day, associated with positive effects.
      However, further studies are needed that address the issue of an additional effect of
      combination therapy. In addition, a neurological disease was considered to be an exclusion
      criterion in some of the studies performed [14-15; 20; 23]. It is therefore questionable
      whether the study results can be transferred to PSD patients.

      Therefore, this study will investigate whether combination therapy of antidepressant and rTMS
      can provide additional relief of depressive symptoms compared to antidepressant and sham rTMS
      therapy. It is assumed that the additional active rTMS achieves a faster normalization of
      affect and drive than with a sham rTMS, so that the patients benefit from neurorehabilitation
      measures earlier and more sustainably.
allocation: Randomized
intervention model: Parallel Assignment
intervention model description: All patients will receive standard antidepressant therapy with 15 mg escitalopram (Selective Serotonin Reuptake Inhibitor) per day during the study. The dose of escitalopram is increased in all included patients from 5mg/day (day 1-3), over 10mg/day (day 4-6) to 15mg/day (from day 7).
Patients in the experimental group (active rTMS stimulation) receive active 10 Hz rTMS stimulation over the left dorsolateral prefrontal cortex (DLPFC) over a period of 20 days, seven days a week (20 sessions). The comparison group receives a duration of equal long sham-stimulation.
For transcranial magnetic stimulation, the Stimulator "PowerMAG Research 100" (Mag & More, Munich, Germany) is used with a cooled double coil (PMD70-pCool).
primary purpose: Treatment
masking: Double (Participant, Investigator)
masking description: The randomization of the patients is carried out by a non-medical employee. This co-worker maintains a randomly generated randomization list, indicating to the particular study code (e.g., TMS-PSD-001; TMS-PSD-002), whether to perform an active or sham treatment. The employee pulls a number from an envelope before beginning the intervention of each enrolled patient and then looks at the list to identify the particular group assignment. There will always be randomization packages of ten patients each. Once these are used up, a new list and a new envelope with study codes are prepared.
In addition, the "real" and the placebo coils are coded before starting studies (eg "A" and "B"). Only the uninvolved employee is the assignment to the real - or placebo coil known. The uninvolved employee randomly assigns the study code containing the information on which coil to use ("A" or "B"). In this way a blinding of performing physician, patient and the evaluating scientist is guaranteed.
measure: Changes of Hamilton Depression Rating Scale [HAM-D; 17 Item Version]
time frame: For the clinical assessment of the severity of depression, the HAM-D is collected at the following times: day -7; baseline (day 1 before rTMS stimulation); day 2, day 8, day 15 and day 22).
description: The primary endpoint is the change in the HAM-D score. A decrease of at least 50% from baseline on day 29 is considered clinically significant. From this, the responder rate is determined.
measure: HAM-D score ≤8 Points
time frame: baseline (day 1 before rTMS stimulation); day 22
description: A HAM-D score of ≤8 points is considered a decline in depression and is used to record the remission rate. It is expected that the decrease in the HAM-D from baseline (baseline) to the end of the study (day 22) in the active rTMS group is significantly greater than in the sham rTMS group.
measure: HAM-D score (day -baseline)
time frame: baseline (day 1 before rTMS stimulation); day 36
description: To analyze the long-term effect the HAM-D score will evaluated at day 36 (follow up). It is expected that the decrease in the HAM-D score from baseline to the follow-up (day 36) is significantly greater in the active rTMS group than in the sham rTMS group.
arm group label: active rTMS
arm group type: Active Comparator
description: Patients in the intervetion group (active rTMS stimulation) receive active 10 Hz rTMS stimulation over the left dorsolateral prefrontal cortex (DLPFC) over a period of 20 days, seven days a week (20 sessions).
arm group label: sham rTMS
arm group type: Sham Comparator
description: Patients in the control group receive sham rTMS stimulation over the left dorsolateral prefrontal cortex (DLPFC) over a period of 20 days, seven days a week (20 sessions).
intervention type: Device
intervention name: active rTMS
description: The rTMS coil is applied tangentially to the head surface above the left DLPF (corresponding to position F3 of the international 10-20 system). For the stimulation intensity, the motor rest threshold of the patient is determined. The motor rest threshold is defined as the minimum intensity that triggers an EMG response with an amplitude> 50 μV in the first right interosseus dorsalis muscle in at least 5 out of 10 cases. The stimulation intensity within the rTMS therapy is 80 percent of the motor rest threshold. In one session, 1,000 pulses are applied in 10 trains at a frequency of 10 Hz (1 train = 100 pulses in 10 s). Between the individual trains there is an inter-train interval of 28 seconds. The total duration of a session is 5:52 minutes. In total, the patient recieve 20 sessions.
arm group label: active rTMS
intervention type: Device
intervention name: sham rTMS
description: Patients in the intervetion group (active rTMS stimulation) receive active 10 Hz rTMS stimulation over the left dorsolateral prefrontal cortex (DLPFC) over a period of 20 days, seven days a week (20 sessions).
arm group label: sham rTMS
criteria: 
gender: All
minimum age: 18 Years
maximum age: N/A
healthy volunteers: No
facility: 
country: Germany
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responsible party type: Principal Investigator
investigator affiliation: BDH-Klinik Hessisch Oldendorf
investigator full name: Dr. rer. nat. Simone B. Schmidt
investigator title: Postdoctoral Researcher
mesh term: Stroke
mesh term: Depression
mesh term: Depressive Disorder
sharing ipd: No