Depression is one of the most common psychiatric complications following a stroke. It remains undiagnosed in up to 80 per cent of cases, and is associated with negative functional, social and quality-of-life outcomes. Although a significant proportion of cases resolve spontaneously in the immediate post-stroke period, particularly in the first 4 to 6 weeks, Drs Rao Attoti and Louise Shaw discuss the benefits of early recognition and treatment.

troke is the third most common cause of death in western countries and the single biggest cause of severe disability. Each year there are 110,000 new patients experiencing strokes in England and Wales, and about 30,000 patients experiencing recurrent strokes¹. The incidence of stroke increases with age and it is estimated that 5 per cent of health and social service's resources are used for immediate and continuing care of people who have had stroke². The true impact of stroke, be it on the patient, health services, carers or society is almost impossible to gauge. In addition, depression is a common psychiatric complication and it has been estimated that mood disorders affect between 18 and 78 per cent of patients in the first year after stroke^3,4 which is double that expected in the general elderly population. It is also double that expected for a population with similar disability other than due to stroke⁵.

Psychiatric complications on stroke outcomes

One of the important influences on post-stroke rehabilitation is the presence of psychiatric problems, which can have a significant, negative impact on outcomes. Timely recognition and appropriate treatment of post-stroke psychiatric problems has been shown to improve outcomes, making early recognition in the immediate post-stroke period very important^6,7. Depression, mania, bipolar disorder, anxiety, catastrophic reactions and pathological crying are among the neuropsychiatric complications that can occur after a stroke. Of all these, depression is by far the most common⁸. In addition to the negative impact on functional outcome, post-stroke neuropsychiatric complications can also negatively affect the social functioning and overall quality of life of stroke survivors⁶. In spite of the evidence for improved functional, social and quality of life outcomes, the detection and treatment of depression and other psychiatric problems in the immediate post-stroke period remains very poor.

Post-stroke depression

How common is it?

The incidence of post-stroke depression (PSD) is reported to be between 18 and 65 per cent in different studies. The risk of PSD is greatest in the first 2 years, especially in the first 2 to 6 months after a stroke. The wide variation in incidence is thought to be due to different selection criteria, different environments in which post-stroke patients are assessed, a difference in the time of assessment since the onset of stroke and difficulties in accurately diagnosing depression in patients with cognitive or communication problems after a stroke. In spite of the fact that PSD is very common and has a significant negative influence on outcomes, as many as 80 per cent of cases remain undiagnosed. Various subjective and objective measures have been used in different studies in the assessment of post-stroke patients with depression. Among them are the Montgomery Asberg Depression Rating Scale (MADRS), Hamilton Depression Rating Scale, Zung Self Rating Depression Scale (SDS), Centre for Epidemiological Studies Depression Scale (CES-D), the Wakefield self-assessment depression inventory and the Diagnostic and Statistical Manual 3 and 4 criteria. The variability in results between studies highlights the limitations of these scales.

Who is affected?

Increased incidence of PSD has been shown to be associated with female sex, family history or past history of psychiatric problems including depression, and living at home within one month of stroke. A positive correlation between the level of functional impairment and PSD has also been noted, particularly one month following a stroke. Lack of motivation, withdrawal, poor progression in rehabilitation, loss of appetite, and sleep disturbance are some of the features that should alert professionals caring for stroke patients to the presence of PSD. Members of the multidisciplinary team are often the first to note symptoms of depression in hospitalized patients with post-stroke and all team members should see it as part of their role to monitor patients for PSD. Currently, there are no satisfactory clinically proven methods of detecting depression in people with defective cognition and communication which makes assessment difficult.

PSD and the site of brain lesion

A number of studies have looked into the relationship between depression and the laterality of brain lesion. Some of the earlier studies showed that left-sided lesions are associated with increased incidence of PSD⁹. Another study¹⁰ concluded that the proximity of the lesion to the inferior frontal region of the hemisphere, irrespective of the side, is associated with increased incidence of PSD. A review of 25 studies that examined the relationship between PSD and lesion laterality, noted that 14 of them showed no predisposition to any particular side, 8 of them showed increased predisposition to the left hemisphere and 3 studies showed increased predisposition to the right hemisphere¹¹. There is still no consensus as to whether there is any relation between depression and the side or site of the brain lesion. Some studies have suggested that the relation is identifiable in the acute stages of the stroke, which is not demonstrable later on.

Recognizing PSD

Recognition of the condition in the immediate post-stroke period is very important and one study has shown that depressed patients following a stroke have greater impairment of activities of daily living than non-depressed patients. In this study, the finding is independent of all other factors that influence post-stroke physical disabilities¹². It has also been shown that post-stroke patients followed up for 6 months who showed remission of symptoms of PSD also showed improved recovery in activities of daily living⁷. Patients also showed improved physical ability with remission of depressive symptoms underscoring the fact that depression leads to increased disability in post-stroke patients. As there is a high rate of spontaneous improvement in the first four to six weeks, it would be sensible to wait until then to eliminate the possibility of acute reactive depression. If symptoms persist after the initial six weeks period it is unlikely they will resolve spontaneously and treatment is indicated.

Treatment of PSD

A significant proportion (up to 50 per cent in some studies) of post-stroke depression resolves spontaneously, raising the possibility that a reactive element is the cause of depression, particularly in the immediate post stroke period. The later the onset of depression after a stroke, the less likely it is that it will improve spontaneously. Initial trials of antidepressants in PSD involved using Tricyclic antidepressants (TCAs) like nortriptyline¹³. Even though there was a significant improvement in the symptoms of depression, the frequency of side-effects was higher than normal, and stroke patients appeared more susceptible to the side-effects of tricyclics than patients without stroke. With the introduction of Selective Serotonin Reuptake Inhibitors (SSRIs), the likelihood of treating depression without the side-effects associated with TCAs became a reality. This led to trials involving citalopram¹⁴ and fluoxetine¹⁵ in patients with PSD. Citalopram in particular was shown to be effective in relieving symptoms of PSD in up to 65 per cent of patients, especially after 7 weeks from the onset of a stroke.

The number of randomized trials on treatment of post stroke depression are few. Tricyclic antidepressants are undoubtedly the choice in central post stroke pain (CPSP) and if the depressive symptoms are associated with CPSP, it makes sense to use TCAs instead of SSRIs. Overall, the treatment should also be guided by the response and the side effect profile.

Conclusion

Depression following stroke is very common, yet under diagnosed. It has a negative influence on functional, social and quality of life outcomes and effective treatment of depression is shown to improve these outcomes. More effort though should be put towards improving awareness of PSD in health professionals involved in looking after stroke patientsl

Dr Rao Attoti is a Specialist Registrar in Geriatrics and Dr Louise Shaw is a Consultant Geriatrician, Older People's Unit, Royal United Hospital, Combe Park, Bath

References

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