post stroke depression

Dr.Sherif Saad Osman, M.D.

Consultant of Psychiatry

1Posr Stroke Depression


Post Stroke Depression

Posr Stroke Depression 3

4

Initial Impact◦ Shock

◦ Denial

◦ Loss and grief

◦ Anxiety and

depression

20-25% experience

psychological

symptoms

If these reactions last too long, they can have an negative effect on the illness

Must adjust to:◦ Symptoms of the disease◦ Stress of Treatment◦ Feelings of vulnerability◦ Loss of Control◦ Threat to self-esteem◦ Financial Concerns◦ Changes in family

structure

Posr Stroke Depression

5

Must adjust to:◦ Increased stress

◦ Change in the nature of the relationship

◦ Change in family structure/roles

◦ Lost income all have impact

Different issues for different relationships◦ Adult children of ill

parents

◦ Spouse of ill person

◦ Parents of ill children

Posr Stroke Depression

A variety of emotional and behavioural disorders may develop following cerebrovascularlesions.

The DSM-IV categorizes post-stroke depression as a “mood disorder due to general medical conditions” with the specifiers of:

(a) depressive features;(b) major depressive-like episodes; (c) manic features; or (d) mixed features.


Five or more of the following present during two week period and representing a change in function, one symptom must be

either depressed mood or loss of interestDepressed mood most of the day for most days.Marked reduction in interest or pleasure in most

activities Significant weight loss or gain, significant

increase or decrease in appetite Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness; inappropriate guiltReduced ability to think or concentrateRecurrent thoughts of death or suicide


The most associated with stroke are:

*

“depressed mood or loss of interest and at least 2 but fewer than 4 symptoms of major depression.”


Depression is often observed in patients with severe physical illnesses.

PSD has less emphasis on feelings of low self-esteem, guilt and self-blame, while hypochondrial concerns, lethargy and behaviour disturbances are most characteristic


Three possible explanations

Coincidental

relationship

physical

consequences

neurotransmitter

imbalance


Poor functional recovery – may delay recovery by 2 years.

Poor social outcomes.

Reduced quality of life.

Reduced rehabilitation treatment efficiency.

Increased cognitive impairment.

Increased mortality .

Stroke & Depression


Social

Psycho

Bio

Bio-psycho-social model


Depression is a common complication post-stroke affecting approximately one-third of patients.


The mean prevalence of depression among in-patients in acute or rehabilitation settings was 19.3% and 18.5% for major and minor depression respectively while, among individuals in community settings, mean prevalence for majorand minor depression was reported to be 14.1% and 9.1%.

Among patients included in outpatient studies, mean reported prevalence was 23.3% for major depression and 15% for minor depression (Robinson 2003).

Overall mean prevalence ranged from 31.8% in the community studies to 35.5% in the acute and rehabilitation hospital studies


The mean prevalence in acute or rehabilitation settings was: 19.3% for major depression, and 18.5% for minor depression while,

In community settings mean prevalence for major depression was 14.1% and 9.1% for minordepression .

Among patients included in outpatient studies, mean reported prevalence was 23.3% for major depression and 15% for minor depression (Robinson 2003).

Overall mean prevalence ranged from 31.8% in the community studies to 35.5% in the acute and rehabilitation hospital studies


Estimates of prevalence may be affected by the time from stroke onset until assessment.

Sub acute phase may be in a period of transition >>>>attempting to adjust.

In fact, the highest rates of incident depression have been reported in the first month following stroke.


While the incidence of major depression post-stroke may decrease over the first 24 months following stroke, minor depression tends to persist or increase over the same time period.

0

10

20

30

40

50

60

70

80

90

100

Inpt. 1 y 2 y

Maj.

Dep.

0

10

20

30

40

50

60

70

80

90

100

Inpt. 1 y 2 y

Min.

Dep.


Approximately one-half of individuals identified as experiencing depression during the acute phase post stroke, continued to experience depression at 18 months; however, more women than men were identified in the acute phase while more men than women were identified as depressed at 18 months post stroke


female sex,

past history of depression or psychiatric illness,

social isolation,

functional impairment, and

cognitive impairment.


There remains a wide diversity of findings in studies looking at the relationships between stroke location and depression.

Not all studies have confirmed this relationship and more recent meta-analyses have failed to establish a definitive relationship between the site of the brain lesion and depression


PSD most often with:- left cortical and basal ganglia lesions (the

closer to left frontal pole the more likely is severe, major depression),

right posterior pole (produces minor depression),

less so with subcortical lesions, and least with cerebellar brain stem lesions.

Apathy and paradoxical cheerfulness are associated with right anterior lesions.


Detection and diagnosis of post-stroke depression is often inconsistent.

Compliance with guidelines for screening is poor.

Identified barriers to routine screening include time pressures and concerns about

screening tools.


Low Barthel Index score

Age <68 years

Crying in first few days◦ Pathological crying (not associated with PSD)

◦ Emotionalism (41% developed PSD)

◦ Catastrophic reaction (63% developed PSD)

Activity ScoreFEEDING

0 = unable

5 = needs help cutting, spreading butter, etc., or requires modified diet

10 = independent

BATHING

0 = dependent

5 = independent (or in shower)

GROOMING

0 = needs to help with personal care

5 = independent face/hair/teeth/shaving (implements provided)

DRESSING

0 = dependent

5 = needs help but can do about half unaided

10 = independent (including buttons, zips, laces, etc.)

BOWELS

0 = incontinent (or needs to be given enemas) 5 = occasional accident 10 = continent

BLADDER

0 = incontinent, or catheterized and unable to manage alone 5 = occasional accident 10 = continent

TOILET USE

0 = dependent

5 = needs some help, but can do something alone

10 = independent (on and off, dressing, wiping)

TRANSFERS (BED TO CHAIR AND BACK)

0 = unable, no sitting balance

5 = major help (one or two people, physical), can sit

10 = minor help (verbal or physical)

15 = independent

MOBILITY (ON LEVEL SURFACES)

0 = immobile or < 50 yards

5 = wheelchair independent, including corners, > 50 yards

10 = walks with help of one person (verbal or physical) > 50 yards

15 = independent (but may use any aid; for example, stick) > 50 yards

STAIRS

0 = unable

5 = needs help (verbal, physical, carrying aid)

10 = independentTOTAL

(0–100):

Pathological crying linked to infarct in basis of pontis and corticobulbarpathways and occurs in response to mood incongruent cues.

Emotionalism is crying that is congruent with mood (sadness) but patient is unable to control crying as they would have before stroke.

Catastrophic reaction is crying or withdrawal reaction triggered by a task made difficult or impossible by a neurologic deficit (e.g. moving a hemiplegic arm)

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Clinical interview and history

Collateral information from family and caregivers

Observational standardized screening measure

Self-reports standardized screening measure when appropriate

Poor functional recovery – may delay recovery by 2 years.

Poor social outcomes.

Reduced quality of life.

Reduced rehabilitation treatment efficiency.

Increased cognitive impairment.

Increased mortality .

Stroke & Depression


Depression post stroke is associated with functional ability and may have a negative impact on recovery.

Although patients with post-stroke depression may experience significant recovery, functional ability will remain at a lower level than non-depressed patients, despite rehabilitation interventions.

Goodwin and Devanand (2008) demonstrated that co-occurrence of stroke and depression is associated with greater physical limitations than either condition on its own.

Physical impairment and post-stroke depression appear to act upon each other, and each influences the recovery of the other.


Early attention to issues of social withdrawal or impaired social functioning may help deter later depression and provide an opportunity for patients to resume pre-stroke activities.

Post-stroke depression impacts negatively upon social activity and vice versa.


Post-stroke depression appears to have a negative impact on cognition; however, the relationship between depression and cognitive impairment post stroke is poorly understood.


The presence of mental health disorders post stroke, including depressive symptomatology, has been associated with an increased risk for mortality.

Further study to clarify the association between psychological distress and mortality is required.


There is strong (Level 1a) evidence that early initiation of antidepressant therapy, in non-depressed stroke patients is associated with reduced risk for the development of post-stroke depression.

While treatment over a period of one year was associated with significant reduction in risk, further study is required to assess both duration of treatment and optimal timing for the initiation of therapy.

Early initiation of antidepressant therapy in non-depressed individuals is effective in preventing post-stroke depression.


There is strong (Level 1a) evidence that ongoing individualized contact and support provided via various care provision models is associated with less deterioration of mood and/or mental health state following stroke.

Ongoing, individualized contact and support may reduce the risk for deterioration of psychological health following stroke.


There is strong (Level 1a) evidence that heterocyclic antidepressants improve depression post stroke. Side effects in elderly patients mean that these medications should be used with caution in that population.

SSRI antidepressants are effective in the treatment of post-stroke depression.

There is moderate (Level 1b) evidence that reboxetine, a noradrenaline reuptake inhibitor, is effective in reducing retarded post-stroke depression.

There is limited (Level 2) evidence suggesting that venlafaxine, an SNRI, is a safe and effective treatment for post- stroke depression. Randomized controlled trials are required.

There is moderate (Level 1b) evidence that methylphenidate is more effective than placebo in improving depression and improving functional recovery. Methylphenidate (a psychostimulant) appears to be effective in treating depression post-stroke and has an earlier onset of action than traditional antidepressants

The herbal medicine Free and Easy Wanderer Plus may be effective in the treatment of PSD. Further research is required.


Active care management in conjunction with antidepressant therapy may improve response to treatment.

Pharmacologic treatment of post-stroke depression is associated with improved functional recovery.

Treatment with antidepressants following stroke improves long-term survival.


Electroconvulsive therapy may be a safe and effective treatment for post-stroke depression.

Repetitive transcranial magnetic stimulation is an effective and well-tolerated treatment for post-stroke depression in patients for whom pharmacotherapy is ineffective


12/15/2014Bridging The Gap 37

post stroke depression

Health & Medicine

posr stroke depression

posr stroke depressionthe

minor depression

symptoms of major depression

mean prevalence of depression

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major depressionfive

loss of energyfeelings