Depression in Stroke

Hafiz Husnain Javed (1), Nauman Ashraf MD
1 - Shaikh Khalifa Bin Zayed Al-Nahyan Medical and Dental College, Lahore
2 -

Introduction

  • Depression is a common illness that severely limits psychosocial functioning and diminishes quality of life.
 
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Depression after stroke is common, and it impacts on recovery and it is often undetected

Clinical Features

They are more specific to brain injury
  • Mood swings are more severe in patients having right hemisphere lesions
  • Diurnal moods
  • Indifference reaction
  • Emotional lability
  • Catastrophic reactions
  • Hyperemotionalism
  • Disinhibition
  • Unawareness of illness (anosognosia)

Factors elevating depression after stroke

  • Difficulties with emotional expression (aprosody)
  • Living alone
  • Few social contacts outside the immediate family
  • Lack of significant other

Prevalence of Depression in Stroke

  • There is no significant difference between sexes in depression in stroke
  • There are at least 500,000 new ischemic stroke patients in US
  • Out of which 150,000 develop depression
  • The mean prevalence of major depression is 14.1% and minor depression is 9.1%
  • The greater risk of developing depression after stroke is in first few months after stroke
  • Depression develop in 33% of all stroke survivors on follow up
  • It is greater in 34% in long term phase of recovery after stroke
  • However, in acute phase of stroke is noted as well
    • It is 36% in hospital admitted patients
    • It is 30% in patients who are doing rehabilitation

Association with anxiety

  • 26% of men and 39% of women had an associated anxiety disorder, mainly agoraphobia
 
Table 1: Stroke lesions and Depression features
Feature
Right hemi-sphere
Left hemi-sphere

Middle Cerebral Artery Stroke

  • In right middle cerebral artery stroke, there is absence of striking cognitive deficits, reduced emotional awareness.
  • So, it is difficult to diagnose depression in right middle cerebral artery stroke.
  • However, in left middle cerebral artery stroke, depression is easily recognized.

Diagnosis

According to DSM-5, depression in stroke have following features for at least two or more than following weeks :
  • Depressed mood
  • Loss of interest
  • Loss of pleasure
  • Insomnia
  • Fatigue
  • Feeling guilt
  • Functional dependency

Management

Pharmacological

Anti-depressants

All types of antidepressant have been used however, SSRI are most effective and have some clinical data to improve functional recovery.
  • Selective serotonin reuptake inhibitors (SSRIs)
    • Fluoxetine 40 mg Daily
    • Other include fluvoxamine sertraline, citalopram and paroxetine
  • Tricyclic antidepressants
    • Nortriptyline 100mg/day for 12 weeks,
  • Monoamine oxidase inhibitors (MAOIs)

Side effects

  • Seizures
  • Falls
  • Delirium
  • Gastro intestinal disturbances

Non-Pharmacological Management

  • Cognitive Behavioral Therapy
  • Motivational interviewing
  • Electroconvulsive therapy

Prevention of post-stroke depression [Controversial]

  • Prevention with prophylactis use has been discused however remains to be contraversial
    • Escitalopram (for 1 year post stroke)
      • 5 mg/day for patients over age 65
      • 10 mg/day for patients ages 65 and under

Progression of Depression

  • In 1/3 of patients depression persist during or after one year of life

Prognosis

  • Patients having anxious depression have poor prognosis
  • Patients with severe symptoms have poor prognosis

Sequelae of depression

  • Greater morbidity and dependency
  • Higher use of drugs
  • Increase intake of alcohol
  • Increased use of healthcare resources
  • Poor compliance with treatment of co‐morbid conditions recovery
  • In-hospital depression that impair recovery

Apathy after stroke

  • Apathy is defined as a decrease in goal directed behavior attributable to loss of motivation
  • The frequency of apathy following stroke is 20-25%
  • It may present with or without depression after stroke.
  • Post stroke apathy is associated with older age, poor cognitive status, low functional status after stroke, as well as lesions of the posterior limb of the internal capsule.

Conclusion

  • Depression is a common consequence after stroke
  • Is associated with excess disability, cognitive impairment, and mortality
  • It can be treated by use of anti-depressants, cognitive behavioral therapy and psychotherapy

Further Reading

  • Robinson, R. G., & Jorge, R. E. (2016). Post-stroke depression: a review. American Journal of Psychiatry173(3), 221-231.
  • Gaete, J. M., & Bogousslavsky, J. (2008). Post-stroke depression. Expert review of neurotherapeutics8(1), 75-92.

Bibliography

  • Aström, M., Adolfsson, R., & Asplund, K. (1993). Major depression in stroke patients. A 3-year longitudinal study. Stroke24(7), 976-982.
  • Hackett, M. L., Yapa, C., Parag, V., & Anderson, C. S. (2005). Frequency of depression after stroke: a systematic review of observational studies. Stroke36(6), 1330-1340.
  • Williams, L. S. (2005, December). Depression and stroke: cause or consequence?. In Seminars in neurology (Vol. 25, No. 04, pp. 396-409). Published 2005 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.
  • Burvill, P. W., Johnson, G. A., Jamrozik, K. D., Anderson, C. S., Stewart-Wynne, E. G., & Chakera, T. M. H. (1995). Prevalence of depression after stroke: the Perth Community Stroke Study. The British Journal of Psychiatry166(3), 320-327.
  • Hackett, M. L., Anderson, C. S., House, A., & Xia, J. (2008). Interventions for treating depression after stroke. Cochrane Database of Systematic Reviews, (4).
  • Schwartz, J. A., Speed, N. M., Brunberg, J. A., Brewer, T. L., Brown, M., & Greden, J. F. (1993). Depression in stroke rehabilitation. Biological psychiatry33(10), 694-699.
  • Robinson, R. G. (2003). Poststroke depression: prevalence, diagnosis, treatment, and disease progression. Biological psychiatry54(3), 376-387.
  • Gaete, J. M., & Bogousslavsky, J. (2008). Post-stroke depression. Expert review of neurotherapeutics8(1), 75-92.
  • Lenzi, G. L., Altieri, M., & Maestrini, I. (2008). Post-stroke depression. Revue neurologique164(10), 837-840.
  • Mayo, N. E., Fellows, L. K., Scott, S. C., Cameron, J., & Wood-Dauphinee, S. (2009). A longitudinal view of apathy and its impact after stroke. Stroke40(10), 3299-3307.
  • Jorge, R. E., Starkstein, S. E., & Robinson, R. G. (2010). Apathy following stroke. The Canadian Journal of Psychiatry55(6), 350-354.
  • Paradiso, S., Anderson, B. M., Ponto, L. L. B., Tranel, D., & Robinson, R. G. (2011). Altered neural activity and emotions following right middle cerebral artery stroke. Journal of Stroke and Cerebrovascular Diseases20(2), 94-104.
 
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