A stroke occurs when the blood supply to the brain is stopped. Strokes can cause loss of speech and understanding language, and weakness and/or numbness in the face, arms and legs. It is not surprising that depression often comes afterwards.1 The severity of the stroke can influence the severity of depression.
If the psychological symptoms of depression are treated in conjunction with the physical symptoms associated with the stroke, the chance of recovery is much greater.
How Common Is Depression After a Stroke?
Strokes can at least initially create some degree of loss of independence. There are obvious concerns about the speed and degree of recovery. In addition, the daily therapies required to treat stroke complications are intense and require much focus, patience, and energy. Patients can feel overwhelmed by these dynamics in the midst of adjusting to the consequences of the stroke. If there was a pre-existing diagnosis of depression prior to the stroke it is more likely to be present post stroke.
Here are additional facts regarding post stroke depression (PSD):
- “Post-stroke depression occurs in one in three patients and more than half of all cases are neither diagnosed or treated.”1
- “Women were more likely to have a history of and be on medication for depression at the time of stroke than men.” However “sex differences of depression after first stroke was not significant overall.”2
- If aphasia occurs post stroke which is the ability to understand or produce speech there is a higher incidence of depression. It can also impact the ability to read and write. This compromises the effectiveness of psychological therapy.
- Symptoms of depression generally occur three to six months after the onset of the stroke.
- Another research study noted “functional recovery of non-treated depressed patients was poorer than the non depressed and the depressed but treated patients.”3
- Treatment of depression for both the patient and the caregiver or close loved ones aides the patient’s more successful recovery from stroke. Spouse’s or significant others play a prominent role in the recovery of a stroke patient.
- Vani Rao, MD reports “a significant decline in depression to about 50% of initial rates in one year. Spontaneous remission can occur one to 2 years post stroke.” He goes on to report the “duration of major PSD is 9 months to 1 year.” 4
Most Common Signs & Symptoms of Depression
The diagnosis of depression post stroke can be complicated due to language and cognitive impairments. Depression from a stroke can also occur from biochemical changes in the brain post stroke. Symptoms of stroke such as loss of energy, loss of appetite, inability to focus, and increased or decreased sleep, mimic symptoms of depression. The origins of PSD are a combination of biological and psychosocial factors like family support, marital status, and social status.
Here are some of the most common symptoms to watch for regarding post stroke depression:
- Lack of energy or willingness to participate in physical, occupational and/or speech therapy.
- Emotional liability or rapid changes in mood can be due to stroke. However, ongoing sadness or apathy can be a symptom of depression if it lasts more than a few weeks.
- Suicidal thoughts
- Feelings of hopelessness, and pessimism, that extend beyond a few weeks signals possible depression.
- Ongoing restlessness and irritability
- Feelings of sadness that are ongoing and don’t diminish in intensity or get worse.
- Wanting to sleep all the time or not sleeping at all.
- These depressive symptoms appear 3 months post stroke or longer.
- Ongoing social isolation.
- Loss of interest in things that were pleasurable prior to the stroke.
Risk Factors for Depression After a Stroke
As mentioned earlier the severity of the stroke can have a direct relationship to the degree and length of depression. The resulting level of handicap directly correlates with the depressive reaction. The loss of independence causing more significant disability is a much larger emotional challenge for someone suffering a stroke.
The quality of life contributes to the level of life satisfaction people experience. There is a higher level of uncertainty living in a post stroke world when the degree of recovery is unknown. Another risk factor is if the patient had a previous medical condition prior to the stroke.
A 2017 research study addressed these additional risk factors regarding post stroke depression and came up with these conclusions:
- “A history of mental illness was the highest ranking modifiable risk factor.”
- “Prevention of PSD requires social and family participation.”5
- “Female gender was a significant risk. Hormonal changes perhaps play a role in the occurrence of PSD.”5
Diagnosing Depression After Stroke
Complicating factors for diagnosing depression after a stroke have been addressed earlier. Stroke patients can display, “flat affect” which looks like a reduction in emotion. It can appear that they are feeling no emotions. This can mistakenly be seen as depression.
Observations from family members and other loved ones can offer invaluable tools for healthcare professionals who are trying to make a determination regarding post-stroke depression. Their knowledge of the personality and behaviors of the patient prior to the stroke can be very important in making an accurate diagnosis.
Psychiatrists and other mental health professionals use a tool called the Diagnostic and Statistical Manual of Mental Health Disorders (DSM) to diagnose mental health disorders. It categorizes criteria and symptoms for all known mental health illnesses. If patients with PSD meet five of the nine symptoms listed for depression, and not attributed to direct complication of stroke, they can receive a diagnosis of depression.
There are also assessment tools and tests that psychologists use to gain further insights about the presence of depression or other mental health symptoms in stroke patients. They are also used to determine if there are any cognitive or language impairments imposed post stroke.
Strokes can cause another symptom called pseudobulbar affect. People display sudden episodes of laughing or crying without any apparent cause or reason. If there are many tearful episodes it may be mislabeled as depression. The sudden start and stopping of these episodes provides clues to healthcare professionals that they may not be caused by depression. If this type of behavior is seen it should be more closely examined.
How to Get Help for Depression
There are several avenues of help to pursue for those that experience depression after a stroke. The best place to start is with the doctor that treated the stroke. It may be your physician who specializes in rehabilitation medicine. You might have worked with a neurologist as the head of the treatment team. Tell the doctors about your concerns regarding the possibility of depression and get their feedback and recommendations about psychiatric help.
These doctors can prescribe anti-depressant medications that will help alleviate the depressive symptoms. Your primary care physician is also a good resource. Especially if this doctor has been treating you prior to the stroke. This previous relationship will help the doctor detect mood or behavioral changes that may indicate depression.
If the person who has the stroke does not have serious communication or cognitive impairment then seeing a therapist is another excellent place to get help. Look for a therapist who has expertise in working with people who have had medical illnesses causing loss of body function and major lifestyle changes. Because the significant other is such an important part of the team to rehabilitate stroke patients they should be involved in therapy as well. Individual and couples or family counseling are potential options. The stroke symptoms and altered lifestyle can impact family members as well and the therapist may recommend family therapy.
Finally, support groups for stroke patients and their family members is another great resource. You may find them at the hospital that did stroke treatment. Talking to other stroke survivors and family members who have a shared personal understanding of the lifestyle changes created by a stroke can be extremely helpful for stroke patients, their significant others, and other family members. You can find stroke support groups online as well if going in person is not an option. Peer support can have a powerful therapeutic component.
When to Seek Treatment for Post Stroke Depression
It is very important to get treatment for depression as soon as possible if it appears to be present. Especially if it is interfering with the physical rehabilitation process. The Journal of Neuropsychiatry published a research article about stroke and depression which indicated “early identification of depression and proper treatment are of paramount importance for decreasing morbidity and disability associated with it.”6
The combination of coping with the limitations caused by the stroke and experiencing some loss of independence and needing a caregiver can trigger a cascade of feelings. They can include feelings of loss, anxiety, fear, anger, frustration and depression. Acting quickly when these symptoms arise can help reduce the severity of the psychological reaction and improve the chances for a more positive physical post-stroke recovery.
How Depression After a Stroke Is Treated
It is critical to determine the cause of the post stroke depression. The American Heart Association/ American Stroke Association advises “PSD resulting from biological causes could potentially respond better to pharmacological therapy whereas PSD resulting from psychosocial causes could respond more favorably to psychotherapy and social support interventions.”7 Treatment for depression post stroke frequently includes a combination of medication and counseling if the patient is able to participate in therapy sessions.
Treatment options for people experiencing depression after a stroke include:
Therapy
Cognitive therapy is frequently used helping people recognize negative behavior and thoughts and offering coping strategies. Group, individual, and family therapy can all prove beneficial for both the patient, caregiver, and other loved ones. Therapy can also focus on issues around grief, loss, and lifestyle changes in relation to the disabilities created by the stroke.
Medications
The Stroke Foundation reports, “Anti-depressants are very useful in the treatment of moderate to severe depression. Your doctor may prescribe antidepressant medication along with psychological treatments.”8
Self-Care
Doctor approved exercise is very important for stroke patients. It has the dual purpose of improving mental and physical health. There is also sometimes a tendency for stroke patients to self isolate. Limits on mobility may be an issue for some. Other stroke patients are reluctant to be around others if they have limitations on their communication, or other stroke related disabilities.
It is important for caregivers to encourage loved ones who are stroke survivors to interact with others. If the individual is reluctant to spend time with people perhaps caregivers can set up a scenario where socialization is done with a limited number of people that the individual is more comfortable with. It is equally important for caregivers and significant others to have the opportunity to interact with friends and family so they are not isolated and alone.
What to Ask Your Doctor When Seeking Treatment
It is crucial to maintain communication with both the physician and the psychiatrist, especially with a post stroke depression diagnosis. Both the physiological and the psychological aspects of the illness need to be closely monitored. Treatment for stroke patients is not a one size fits all scenario.
Stroke recovery varies between people and depression can hinder this process. In addition the psychological healing will be closely intertwined with the physical rehabilitation progress after the stroke.
When seeking treatment for the depression consider asking your doctor the following questions:
- What type of depression do I have?
- What is its relationship to my stroke? How does my stroke impact my depression?
- How will my depression impact my recovery from my stroke?
- If you are prescribing medications for me what is its purpose and side effects? How does it interact with the other medication I am on? How long will I need to be on medication?
- Do you recommend medication, counseling, or both for me and why?
- How does my depression impact my sleep, appetite, and energy level?
- What kind of lifestyle changes should I make that will help alleviate my depression?
- How long should I anticipate that my depression will last?
- How long will I need treatment from you?
Tips for Caregivers
The recovery time from post stroke depression will vary. Depending on the degree of disability caregivers may need to supply physical support as well as emotional support to their loved ones. The toll can be both physical and emotional for caregivers. If loved ones need to help stroke patients with mobility, standing up, or self care tasks, that can cause physical stress for caregivers.
Caregivers should pay attention to their body. Don’t try to do physical tasks you are not able to do. Don’t ignore aches and pains in your body. Be sure you get training from physical and occupational therapists on the safest ways to assist loved ones in their activities of daily living and with mobility.
The emotional state, mood, and attitude of caregivers directly impacts the stroke survivor’s recovery. Caregivers need to try to be optimistic but must be realistic in terms of their expectations of physical and emotional recovery of a loved one with PSD. Communication is key. That includes communication between the patient and caregiver about feelings relating to the stroke and how it affects your relationship and lifestyle.
It also is recommended that caregivers have somebody to talk to as they face the uncertainty of the future recovery of the person they are taking care of. If the stroke has impeded mobility then there can be more isolation and lack of social support.
Self-Care for Caregivers
Here are five tips for caregivers to help improve your self care:
1. Make a Plan
Make a plan to allow yourself breaks for respite care. Identify a trusted person or healthcare professional that can come in regularly so you can recharge yourself emotionally and physically.
2. Encourage Independence
Encourage the stroke survivor to do as much as they can for themselves. If you set up a dynamic where you are doing things for them that they can do it will actually hinder their recovery from the stroke and rob them of the chance to see the progress they are making. This will also impede their recovery from the depression.
3. Educate Yourself
Educate yourself about strokes and depression. Consult doctors and other healthcare professionals to help you create realistic expectations about what both you and the stroke survivor should and should not be doing. Consult the treatment team about anticipated progress or challenges to help you emotionally prepare for the future.
4. Manage Grief
Address the feelings of loss and grief you will experience in relation to the changed condition of your loved one and the resulting lifestyle changes. Get the counseling and support you need to work through these changes. Therapy will help to learn new coping mechanisms. Investigate individual counseling, support groups, and chat rooms for family members and caregivers.
5. Be Active
Maintain a level of physical activity and exercise to promote your well being. If you jogged, did yoga, or meditated, don’t let those activities fade away. You need to promote your physical and mental well being to preserve your overall health. Eat well and get as much sleep as you can. It will help make you a better caregiver and enhance your overall health.
Additional Resources for Depression After a Stroke
If you or someone you love is dealing with depression after a stroke, the following resources may be helpful:
- American Stroke Association: They offer information on local support groups you can join and online support groups for both stroke survivors and caregivers.
- Stroke Foundation: They offer information, support, and referrals for patients and caregivers focusing on coping with stroke and depression. Call 1-800-787-653 (1-800-STROKE)
- Substance Abuse and Mental Health Services Hotline (SAMHSA): Call 1-800-662-4357 (HELP) This is a government run national hotline open every day 24 hours a day. They offer referrals to local support groups and community based organizations that offer mental health counseling.
