Depression in Stroke

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


  • Depression is a common illness that severely limits psychosocial functioning and diminishes quality of life.
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
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.


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




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


  • 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.


  • 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.


  • 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.
"If anyone saved a life, it would be as if he saved the life of all mankind"
"If anyone saved a life, it would be as if he saved the life of all mankind"
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