The Silent Struggle: Shedding Light on Post-Stroke Depression

The current World Health Organisation's meaning of stroke is to rapidly develop signs of focal (or global) disturbance of cerebral function, lasting more than 24 hours or leading to death, with no clear reason other than that of vascular origin.

The word 'stroke' was first introduced to medicine by William Cole in a 1689 essay named '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 around 400 BC.

Stroke is associated with substantial neuropsychiatric morbidity including cognitive impairment, dementia, personality change, and mood disorder. Disability stemming from stroke is a mixture of physical, mental, and emotional manifestations. Neuropsychiatric features may be a consequence 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 describe forms of depression related to what he called "arteriosclerotic brain disease". Later, Martin Roth recommended an association between atherosclerotic disease and depression, and in 1977 M.F. Folstein showed that depression was significantly more common among stroke survivors.

Clinical features of post-stroke depression:

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

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

Classificatory systems, while far from perfect, have certain criteria for diagnosing post-stroke depression. For instance, the DSM-5 describes post-stroke depression as a depression disorder caused by another medical condition. This is defined as a "prominent and persistent period of depressed mood or markedly diminished interest and pleasure in all, or almost all, activities that predominate in the clinical picture". As well, depressive disorder should be "the direct pathophysiological result of another medical condition".

A recent study estimated the frequency of post-stroke depression to be 31%. While many other studies have prepared various estimates, the majority zeroes in on a prevalence of around 30%. Gender is not a significant risk factor for post-stroke depression, although a few studies have identified the sex as such.

Treatment for post-stroke depression :

The treatment of post-stroke depression should ideally involve biological, psychological, social, and rehabilitation paradigms. Such holistic and comprehensive care may not generally be feasible in resource-constrained settings.

Small studies have indicated the efficacy of cognitive behavioral therapy in reducing depressive symptoms in stroke patients. Some studies have considered novel technology, such as virtual reality, and reported beneficial effects for people with post-stroke depression.

Behavioral activation therapy is based on prolonging the frequency of pleasant events, and this has shown a few promising results. Also, reminiscence therapy, which is routinely employed in dementia, involves recalling prominent life events and pleasurable memories to enhance belonging. Researchers have shown that it can reduce the burden of depressive symptoms following a stroke. Brain stimulation modalities, such as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) among others, have also been shown to be effective in relieving post-stroke depression.

Along with the previously mentioned interventions, psychiatrists also use antidepressants to treat post-stroke depression. There is sufficient and reliable proof to show that these drugs can treat the condition efficaciously. But, while doing so, the psychiatrist should carefully consider the type of antidepressant to be administered and consistently monitor the person.

The psychiatrist should also discuss the benefits and possible risks before initiating antidepressant therapy in people with post-stroke depression. There is also evidence to initiate antidepressant therapy prophylactically in stroke patients to prevent the onset of depression.

Stroke is a common condition associated with significant morbidity. A common neuropsychiatric sequel of stroke is the occurrence of post-stroke depression. If left untreated, post-stroke depression can lead to a poor quality of life and further impair the individual's life.

With the right treatment approaches, a full remission of depressive symptoms is possible. Stroke-ready hospitals and stroke physicians should work closely with neuropsychiatrists to facilitate better patient outcomes.

Stigma and lack of awareness regarding post-stroke depression can result in patients getting over-investigated and yet being under-treated. Evidence-based biological, psychological, and social interventions delivered by psychiatrists can vastly improve the quality of life of patients. The aphorism "prevention is better than cure" should be readily applied to stroke and post-stroke depression.