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Post-Stroke Depression
by Marc Sadowsky, M.D. Division of Neuro-Behavioral Medicine
Depression following stroke is a relatively common occurrence, and identification and treatment can help patients take better advantage of rehabilitation opportunities and thereby facilitate their recovery.
Although the frequency of stroke is declining with improved treatment for hypertension, the American Heart Association estimates that there will be 400,000 new stroke victims each year, and a significant percentage of these will experience depression in addition to their physical and cognitive impairments.
Investigators have found that the rate of post-stroke depression varies from 25-50%, with most meeting criteria for major depression and the remainder for minor depression. Longitudinal studies indicate that those with major depression generally experience remission after one year while those with minor depression may have symptoms up to three years after their stroke.
Symptoms of Depression
Depressive symptoms include depressed mood, sleep disturbance, appetite disturbance, increased irritability, decreased energy and motivation, inability to enjoy previously pleasurable activities, and suicidal ideation. A study comparing stroke patients with depression and elderly depressed patients who had not suffered a stroke found that both groups experienced the same type of depressive symptoms, the only difference being that stroke patients experienced more psychomotor retardation.
Interestingly, there does not appear to be a strong relationship between the magnitude of physical impairment and depression. This has led researchers to uncover other factors which might be etiologically related to post-stroke depression.
Stroke Research and Depression
Much of this research has been focused on finding possible correlation between lesion location in the brain and depression. There appears to be a higher rate of depression among those patients with a left anterior hemisphere lesion, with increasing rates associated with more anterior lesions. There is also a higher rate of depression among those having left basal ganglia strokes (caudate and/or putamen).
Those at risk for post-stroke depression include patients with subcortical atrophy. For those patients with a right hemispheric lesion, family history of psychiatric illness is a risk factor.
Treatment
Patients often respond to standard treatment using antidepressants and occasionally psychostimulants. The drugs of choice are often the selective serotonin reuptake inhibitors (SSRIs), which include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and fluvoxamine (Luvox). Although the initial treatment trials demonstrated success with nortriptyline for post-stroke depression, we generally avoid the use of tri-cyclic antidepressants b because of their less favorable side effect profile, particularly their anticholinergic effects, which can lead to delirium.
Psychostimulants, particularly methylphenidate (Ritalin), are used also, and have the advantage of more rapid onset of action than SSRIs. They are also associated with few side effects in the elderly.
Conclusion
Post-stroke depression should not be viewed as a "natural" consequence of stroke about which little can be done. Identification and treatment of post-stroke depression can play an important role in enabling patients to derive full advantage of rehabilitation, giving them the best chance of regaining functions that have been robbed by stroke.
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