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.
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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.
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 both3
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.
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.
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.
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.
Disclaimer: The information and references contained
herein are intended solely for the information.
It should not be used for treatment purposes, but rather for
discussion with the patient's own physician.
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