by Susan Fralick-Ball, Psy.D.,
Bryn Mawr Rehab Psychology Associates

Depression following a stroke is becoming recognized as a major complication in the overall recovery of this population. Twenty-five to sixty percent of all stroke patients have PSD. There are two types of depression most prevalent: major post-stroke depression (deeply linked from the brain stem through the underlying and outer structures in the brain) and minor post-stroke depression (not necessarily linked with a lesion or bleed location). Each can last up to two or more years following a stroke and minor PSD can become a major PSD if left untreated.

Post-Stroke Depression is often associated with damage to the deep areas of the frontal and parietal lobes, often the sites of direct or indirect damage from blood clots or active bleeding leading to the cause of the stroke. These areas in the brain are centers for certain types of emotional and behavioral control, organized and planned thinking, and the will to stay engaged and active in life activities. Disruption in these behaviors may lead to prolonged responses and functional improvements in rehabilitative therapy and transition to home or long term care.

Some of the clinical signs of PSD are the same for other forms of depression and include:

• Sense of hopelessness that disrupts one’s ability to function
• Sleep disturbances
• Radical change in eating patterns leading to weight loss/gain or malnutrition
• Lethargy
• Social withdrawal
• Irritability
• Fatigue
• Self-loathing or poor self esteem
• Suicidal thoughts

PSD patients have lower functional status, increased impairment in thinking and higher mortality rates than stroke patients without depression. Female stroke patients tend to experience more PSD than do men, yet the symptoms of PSD are very often overlooked in males or assumed to be part of their basic personality and therefore go untreated. Additionally, the symptoms of depression are similar to those of dementia, although true dementia is progressive and irreversible.

Quality of life after stroke can be significantly hampered by PSD. Stroke with aphasia (difficulty with speech and communication) and significant impairments in thinking are highly correlated with major PSD after 3 three months. Additionally, PSD increases over time for aphasic patients and is likely to increase the instability of cognitive deficits. PSD for married stroke patients is a major factor in low quality of life. Sexual function and satisfaction are lower for both the stroke patient and spouse. Those who develop PSD in the acute stroke period are more likely to die during first few years post-stroke, generally due to the ongoing apathy, eating problems, and loss of personal will to live and be engaged in normal daily activities.

Treatment of PSD is only given to one third to one half of all stroke survivors. Assessment of PSD can be problematic since there is no generally accepted standard for diagnosis of depression after a recent stroke; however, rating scales are readily available for use by medical professionals. Unfortunately, most of the rating scales have symptoms reported by the patient, and PSD patients tend to underreport or be unaware of their depressive symptoms. Treatment of PSD also improves mental impairments imposed by stroke (for example, orientation, memory, language, and hand-eye coordination). Standard treatment includes individual and/or group psychotherapy and antidepressant medication to boost or replace lost neurochemicals in the brain. Many prescribed antidepressant medications are helpful to alleviate the symptoms of PSD, and may include, but are not limited to tricyclics such as Elavil or Pamelor, or SSRI’s such as Paxil, Zoloft, Celexa, or Prozac.

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