I visited my friend’s place recently after he had called me over to talk to his father, who had recently suffered a large vessel stroke. During my interaction, I noticed my friend’s father frequently breaking down. He was of the view that he had become a burden on his son.
The current World Health Organisation definition of stroke is to rapidly develop clinical signs of focal (or global) disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin.
The word ‘stroke’ was first introduced to medicine by William Cole in a 1689 essay entitled ‘A Physico-Medical Essay Concerning the Late Frequencies of Apoplexies’. Before Cole, the common term used to describe very acute non-traumatic brain injuries was ‘apoplexy’. It originated with Hippocrates circa 400 BC.
Stroke is associated with substantial neuropsychiatric morbidity including cognitive impairment, dementia, personality change, and mood disorders. Disability stemming from stroke is a mixture of physical, mental, and emotional manifestations. Neuropsychiatric features may be a result of the damage sustained by the brain or may be a function of the individual’s reaction to the handicaps imposed on them.
Robert Gaupp, a disciple of the noted German psychiatrist Emil Kraeplin, was the first to characterise forms of depression related to what he called “arteriosclerotic brain disease”. Later, Martin Roth suggested an association between atherosclerotic disease and depression, and in 1977 M.F. Folstein showed that depression was significantly more common among stroke survivors.
What are the clinical features of post-stroke depression?
There are several reasons outlined in the genesis of post-stroke depression. They include the location of the stroke, genetic factors, the availability of social support, and personality factors. The sudden onset of disability may trigger an emotional response. Brain injury and neurochemical changes may produce changes in the mood. Post-stroke depression as a result of a stroke is strongly associated with impairment in the activities of daily life. The individual may have a family history of depression or may have had a depressive episode prior to the stroke.
When diagnosing post-stroke depression, a clinician will have to rule out other pathologies that may mimic depression. Some stroke symptoms in hospitalised patients overlap with depressive symptoms, including weight loss, fatigue, and altered sleeping patterns. The clinician will need to look for other symptoms such as dysphoria, loss of pleasure in previously pleasurable activities (anhedonia), feelings of guilt or worthlessness, impaired concentration, inability to make decisions, and suicidal thoughts. Speech difficulties occur in about 30% of stroke patients, posing a major challenge to an accurate diagnosis of depression in stroke patients.
Classificatory systems, while far from perfect, have certain criteria for diagnosing post-stroke depression. For example, the DSM-5 describes post-stroke depression as a depressive disorder caused by another medical condition. This is defined as a “prominent and persistent period of depressed mood or markedly diminished interest and pleasure in all, or almost all, activities that predominates in the clinical picture”. As well, the depressive disorder should be “the direct pathophysiological consequence of another medical condition”.
A 2014 study estimated the frequency of post-stroke depression to be 31%. In fact, while many other studies have prepared different estimates, the majority zeroes in on a prevalence of around 30%. Gender is not a significant risk factor for post-stroke depression, although some studies have identified the sex as such.
How is post-stroke depression treated?
The treatment of post-stroke depression should ideally involve biological, psychological, social, and rehabilitation paradigms. Such holistic and comprehensive care may not always be feasible in resource-constrained settings.
Small studies have indicated the efficacy of cognitive behavioural therapy in reducing depressive symptoms in stroke patients. Some studies have considered novel technologies such as virtual reality and reported beneficial effects for individuals with post-stroke depression.
Behavioural activation therapy is based on prolonging the frequency of pleasant and enjoyable events, and this has shown some promising results. Similarly, reminiscence therapy, which is routinely employed in dementia, involves recalling prominent life events and pleasurable memories to enhance belonging. Researchers have shown that it can reduce the burden of depressive symptoms following a stroke. Brain stimulation modalities, such as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) among others, have also been shown to be effective in relieving post-stroke depression.
Along with the aforementioned interventions, psychiatrists also use antidepressants to treat post-stroke depression. There is sufficient and reliable evidence to show that these drugs can treat the condition efficaciously. But when doing so, the psychiatrist must carefully consider the type of antidepressant to be administered, and regularly monitor the individual.
The psychiatrist must also discuss the benefits and possible risks before initiating antidepressant therapy in individuals with post-stroke depression. There is also evidence to initiate antidepressant therapy prophylactically in stroke patients to prevent the onset of depression.
Stroke is a common condition associated with significant morbidity. A common neuropsychiatric sequel of stroke is the occurrence of post-stroke depression. If left untreated, post-stroke depression can lead to a poor quality of life and further impair the individual’s life.
With the right treatment approaches, a full remission of depressive symptoms is possible. Stroke-ready hospitals and stroke physicians should work closely with neuropsychiatrists to facilitate better patient outcomes.
Stigma and lack of awareness regarding post-stroke depression can result in patients getting over-investigated and yet being under-treated. Evidence-based biological, psychological and social interventions delivered by psychiatrists can vastly improve the quality of life of patients. The aphorism “prevention is better than cure” should be readily applied to stroke and post-stroke depression.
Dr. Alok Kulkarni is a senior interventional neuropsychiatrist at the Manas Institute of Mental Health and Neurosciences at Hubli in Karnataka. He received the IMH Marshall Fellowship in Mood Disorders from the University of British Columbia, Vancouver.
