Post-stroke Depression delays Recovery

Post-stroke depression (PSD) is considered as the most important and most common neuro-psychiatric outcome of stroke. As many as half of stroke survivors will become depressed according to Dr. James Castle, a neurologist at Stanford University. Others estimate, though, that one-third of stroke victims suffer major depression.

The bottom line is that depression can wreak havoc on chances for survival and recovery of cognitive abilities and motor skills. Currently, there is a debate to determine whether post-stroke depression is caused by biological mechanisms related to stroke, or if PSD is simply the result of social and psychological distress.

A number of studies clearly provide evidence that biological mechanisms do play a significant role on the development of post-stroke depression:

1. Stroke patients show a higher rate of depression compared to orthopedic patients with disabilities of comparable severity
2. Some studies reported a link between post-stroke mania and right orbital frontal, basotemporal, basal ganglia lesions
3. It has been shown that patients with anosognosia who are unaware of their disability still develop post-stroke depression
4. Several studies showed an association with specific lesions (left anterior and basal ganglia lesions and lesions close to frontal pole) and occurrence of post stroke depression

Diagnosing Depression
Brain damage or brain lesions caused by stroke can be identified using medical imaging study such as an MRI (magnetic resonance imaging). Dr. Robert Robinson, a psychiatrist at the University of Iowa, explains that when the brain is injured, stroke survivors may lose the ability to feel positive emotions, possibly leading to post-stroke depression. Dr. Robinson has conducted several researches about post-stroke depression and has observed that since the depression is not diagnosed correctly, “most patients who suffer depression after a stroke DO NOT receive treatment for it”.

What happens if PSD is not treated?
If PSD remains untreated “it can go on for up to 3 years after a stroke”.  This, in turn, may delay the stroke victim’s physical as well as cognitive or intellectual recovery. In contrast, stroke survivors who were treated for depression, according to a study published in Stroke journal, showed an improvement in the survivor’s mood thereby improving recovery in regular daily activities compared to those whose depression remain untreated. In addition, people who suffer PSD tend to be less open to making lifestyle changes to prevent a second stroke. They also have a tendency to resist or defy rehabilitation interventions that will hasten their recovery.

This is stated more clearly by Dr. Mark Huang, a professor of rehabilitation at the Rehabilitation Institute of Chicago. According to Dr. Huang, “Survivors who are depressed may not find the motivation to work in rehabilitation. They feel discouraged and hopeless. They may feel fatigued, sleep poorly and don’t eat well”.

Therefore, post-stroke depression can increase the chances of a second stroke which in turn, can be more fatal than the first one.

Symptoms of PSD
The National Institute of Neurological Disorders and Stroke (NINDS) website lists some signs of clinical depression, an emotional disorder most commonly experienced by stroke survivors:

• Radical change in eating patterns which may lead to sudden weight loss/gain
• Loss of pleasure in hobbies and activities that were once enjoyed, and life in general
• Frequent crying episodes
• Sleep disturbances
• Fatigue and lethargy
• Social withdrawal
• Irritability and restlessness
• Self-loathing
• Suicidal thoughts and suicidal attempts
• Overwhelming sense of hopelessness

If a stroke survivor has had several if not all of these symptoms for more than two weeks, he should be evaluated by a qualified psychiatrist to determine the right combination of treatment modalities.

What to do to help people with PSD?
Dr. Huang asserts that depressed survivors need treatment if they are not progressing in rehabilitation, because “their thinking skills are also affected by depression. They have a hard time concentrating in rehabilitation. Their attention to detail is affected as well. Treating depression can improve thinking skills. The rehab team needs to be on the lookout for depression. They need to notice the survivor’s mood and participation level.”

Dr. Robinson agrees and explained it was the family’s responsibility “to make sure that stroke survivors do not simply explain away their depression and deny they need treatment just because it is ‘understandable’.” The patient should consult a psychologist or psychiatrist as soon as depression is suspected. If the patient is afraid to get help, or refuses to undergo testing because he is ashamed, help him to understand that a diagnosis of depression is not something to be embarrassed about. It does not mean that he is “crazy” or that he needs to be locked-in in a psychiatric facility.

It is important that the patient gets over his initial fear and that the family assures the patient of their full support. Social support is crucial for survivors dealing with depression.  A 2002 study in Topics of Stroke Rehabilitation found that depression was related to lower levels of support. Survivors typically find support among family, friends, a stroke support group, a psychologist, or a combination of all these sources.  Attending a peer support group can also help.

Aside from consulting a psychiatrist and finding a stroke support group, there are other practical approaches to dealing with depression.

Diet

1. Eating foods rich in Omega-3 can improve and uplift your mood whether you’ve been diagnosed with depression or not. Eating 2 servings of salmon, tuna and trout per week or taking fish oil supplements may help as these are all good sources of Omega 3.
2. Adding folic acid to a prescription antidepressant may help the medication be more effective. Foods rich in folic acid are dried beans, peas, lentils, oranges, whole-wheat products, asparagus, broccoli and spinach.
3. Eating foods rich in B-vitamin or taking supplements. B-vitamins are found in whole unprocessed foods. B vitamins are particularly concentrated in meat such as turkey and tuna, in liver and meat products. Good sources for B vitamins include whole grains, potatoes, bananas, lentils, chili peppers, beans, nutritional yeast, brewer’s yeast, and molasses.

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