Post-Stroke Depression
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Psychiatric Complications of Stroke
Many of the studies addressing post-stroke depression (PSD) have arrived at different conclusions. Pseudodepressive mood disorders are often classified simply as depression.
These pseudodepressive manifestations, which occur shortly after a stroke, include emotionalism, catastrophic reaction, pathological crying, anxiety, apathy, and loss of psychic self-activation.4
Some of the studies lump together acute and chronic complications of stroke; for example, mania or mania-like states and catastrophic reactions are seen early in the course of stroke, whereas depression is usually a chronic manifestation.
The Lausanne Emotion in Acute Stroke Study4 examined at the various emotional manifestations following stroke in over 300 patients and found that overt sadness was the most common manifestation (72%), followed by disinhibition (56%), lack of adaptation (44%), emotional withdrawal (40%), crying (27%), anosognosia (24%), passivity (24%), and aggressiveness (11%).
Depression is the main mood disorder seen in the nonacute phase. It is difficult to assess for features of depression, such as lack of interest, lack of pleasure in activities, or loss of self-esteem in patients in intensive care units; hence, it is more appropriate to speak of sadness or behavioral changes in the acute phases than of clinical depression.
Depression following stroke shows important clinical differences from “endogenous depression,” as patients have much more reactive diurnal mood variation and emotionalism, show an absence of guilt, and are rarely suicidal, despite the fact that they are also disabled from a physical point of view. However, the death rate is increased in patients who are depressed following a stroke.5-10
Post-stroke depression has a negative impact on functional outcome, and there is a strong correlation between development of depression, social functioning, and overall quality of life for stroke survivors. This is complicated by the fact that depression can lead to a worse functional outcome and vice versa. Depression also causes a significant increase in the risk of death following a stroke, with cardiac causes being more implicated than other causes.
Various subjective and objective measures have been used in different studies in the assessment of PSD. Among them are the Montgomery-Asberg Depression Rating Scale (MADRS), Hamilton Depression Rating Scale (HDRS), Zung Self-Rating Depression Scale, Center for Epidemiological Studies Depression (CES-D) scale, and the Diagnostic and Statistical Manual of Mental Disorders, third and fourth editions (DSM-III and DSM-IV).
Risk Factors
Increased incidence of PSD is associated with female sex,11 family history or past history of psychiatric problems (particularly depression),12 subcortical lesions,13 younger age,14 impaired social support (especially from spouse), negative life events,15 and living at home within 1 month of a stroke. A positive correlation between the level of functional impairment and PSD has also been noted, particularly within 1 month following stroke. Patients with high neuroticism scores have a higher rate of developing PSD than those with low neuroticism scores.16
Depression is also associated with dementia and more severe strokes, particularly in vascular territories that supply limbic structures. Reliance on nonsomatic rather than somatic symptoms would result in the most accurate diagnosis of depression after ischemic stroke.17
Site of brain lesion
A number of studies have examined the relationship between depression and laterality of brain lesion.
References
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