What is post-stroke depression and how can we address it? | Explained Premium

Understanding post-stroke depression, its diagnosis, treatment, and impact on quality of life by Dr. Alok Kulkarni, a neuropsychiatrist.

I visited my friend’s place recently after he had called me over to talk to his father, who had recently suffered a large vessel stroke. During my interaction, I noticed my friend’s father frequently breaking down. He was of the view that he had become a burden on his son.

The current World Health Organisation definition of stroke is to rapidly develop clinical signs of focal (or global) disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin.

The word ‘stroke’ was first introduced to medicine by William Cole in a 1689 essay entitled ‘A Physico-Medical Essay Concerning the Late Frequencies of Apoplexies’. Before Cole, the common term used to describe very acute non-traumatic brain injuries was ‘apoplexy’. It originated with Hippocrates circa 400 BC.

Stroke is associated with substantial neuropsychiatric morbidity including cognitive impairment, dementia, personality change, and mood disorders. Disability stemming from stroke is a mixture of physical, mental, and emotional manifestations. Neuropsychiatric features may be a result of the damage sustained by the brain or may be a function of the individual’s reaction to the handicaps imposed on them.

Robert Gaupp, a disciple of the noted German psychiatrist Emil Kraeplin, was the first to characterise forms of depression related to what he called “arteriosclerotic brain disease”. Later, Martin Roth suggested an association between atherosclerotic disease and depression, and in 1977 M.F. Folstein showed that depression was significantly more common among stroke survivors.

There are several reasons outlined in the genesis of post-stroke depression. They include the location of the stroke, genetic factors, the availability of social support, and personality factors. The sudden onset of disability may trigger an emotional response. Brain injury and neurochemical changes may produce changes in the mood. Post-stroke depression as a result of a stroke is strongly associated with impairment in the activities of daily life. The individual may have a family history of depression or may have had a depressive episode prior to the stroke.

When diagnosing post-stroke depression, a clinician will have to rule out other pathologies that may mimic depression. Some stroke symptoms in hospitalised patients overlap with depressive symptoms, including weight loss, fatigue, and altered sleeping patterns. The clinician will need to look for other symptoms such as dysphoria, loss of pleasure in previously pleasurable activities (anhedonia), feelings of guilt or worthlessness, impaired concentration, inability to make decisions, and suicidal thoughts. Speech difficulties occur in about 30% of stroke patients, posing a major challenge to an accurate diagnosis of depression in stroke patients.