Some facts: there are approximately 500,000 strokes that occur in the United States. Of those strokes, about 70 to 80 percent of patients survive the stroke. Of those patients who survive the stroke, depression occurs in approximately 40 to 50 percent of patients. Major depression occurs in about 20 percent of patients. Major depression is the most severe form of clinical depression that we recognize in neuropsychiatry. Another, about 20 percent of patients, will develop minor depression. There are some, approximately 10 to 20 percent of patients, who develop either major or minor depression some months or even a year after the onset of the stroke. Most depressions occur within the acute period after the stroke, but there are some depressions, that are delayed in onset and occur during the first year of poststroke recovery. The issue of poststroke depression has gained worldwide interest in the past 10 years. There has been a general agreement about the prevalence of both major and minor depression after stroke. Depression is one of the major impediments to full physical and mental recovery from stroke.

Do most stroke sufferers end up suffering depression?

Approximately 50 percent will become depressed at some time during the first two years after the stroke. The majority of patients, approximately 40 percent, will develop depression within the first one to two months after the stroke. There is another number of 10 to 20 percent of patients who will develop depression at some later time during the first two years.

What type of rehab can help with stroke depression?

By rehab, I assume what is meant is the usual types of rehabilitation therapy such as physical therapy, speech therapy, and occupational therapy. These do not specifically treat depression after a stroke. The treatment for poststroke depression that has received the most scientific study has been the use of antidepressant medications. Both Nortriptyline and Citalopram have been demonstrated in controlled studies to be effective in treating poststroke depression.

Is stroke patients' depression caused by the physical damage to the brain or do the individuals already have a history of depression before the stroke?

Most patients do not have a history of depression prior to the stroke. Approximately 20 percent will have a prior history, but the majority have never had a prior depression. There is a debate in the literature about the cause of depression after stroke. The debate generally centers around whether the depression is caused by biological factors provoked by the brain injury or whether the depression is a secondary psychological response to the physical, cognitive, and social impairments produced by the stroke. There is evidence in the scientific literature that supports both of these views. My own research has focused in large part on the biological mechanisms that may be involved in depression, because I believe that studying patients with poststroke depression can give us insights into the biological mechanisms causing depression in patients without brain injury.

How can a family member or caregiver help the stroke patient with their depression?

The first thing that a caregiver or a family member can do is to make sure that the stroke victim sees a professional for evaluation and potential treatment of the depression. Many doctors, as well as family members, tend to explain depression as an understandable response to the loss and impairment that is produced by the stroke. Depression, however, can be effectively treated regardless of whether or not they may be experiencing a psychological response to the impairments. That is why it is so important for family members and caregivers to make sure that the stroke victim does not simply explain away their depression and deny that they need treatment because it is an understandable depression. There are very effective treatments, and patients should be taken to a professional who is familiar with this disorder because it will not only improve the patient's mental state--that is, their mood--but it will also improve their physical recovery and their cognitive or intellectual recovery from the stroke. Our recent studies have demonstrated that both physical and intellectual impairments are significantly improved when a poststroke depression is successfully treated with an antidepressant medication.

Can stroke patients be treated with antidepressants or is that a dangerous idea?

No, it's not a dangerous idea to treat stroke patients with antidepressants. The treating doctor needs to be careful, depending on the antidepressant being used and the other illnesses that the stroke victim may have. For example, in patients who have heart block, a medication such as Nortriptyline, which has been shown to be a very effective treatment for poststroke depression, can be dangerous. If Nortriptyline is used in somebody with heart block, a cardiologist needs to be involved in treatment so if heart block occurs, a pacemaker or other treatment can be used appropriately. Most of the new antidepressants, however, have relatively few contraindications, and most patients, even those with additional medical illnesses such as heart disease, are able to take them. Our recent study demonstrated that Prozac was not an effective treatment for poststroke depression but a similar medication, Citalopram, which is also an SSRI medication, is effective in treating poststroke depression. Although there are cautions that must be used whenever an antidepressant medication is administered to a patient with poststroke depression, there are medications that can be used safely and effectively to treat not only the depression but, as I mentioned previously, the physical and intellectual impairment produced by the stroke.

What are some of the symptoms of a stroke?

A stroke is a loss of blood supply to a region of the brain, caused usually by the formation of a clot within an artery in the brain or by a blood clot, usually from the heart, breaking off and traveling up the artery into the brain. Those are called thromboembolic strokes. There are also strokes due to bleeding inside the brain, called hemorrhagic strokes. The symptoms of a stroke are a reflection of where that thromboembolic blockage to the blood supply has occurred. The most common place for a stroke to occur is in the distribution of the middle cerebral artery. The middle cerebral artery supplies much of the frontal, temporal, and parietal lobes of the brain as well as the subcorticol basoganglia. The symptoms produced by middle cerebral artery blockage include a loss of ability to move the arm or the leg on the opposite side of the body. So, if the left side of the brain suffers a stroke, the right side of the body shows physical weakness. Another common symptom of stroke is loss of sensation, that is, sensation on the opposite side of the body. A feeling of numbness on the right side of the body may be the result of a left middle cerebral artery infarction or blockage. Another common symptom that occurs with stroke is loss of language ability. Language is predominantly localized to one side of the brain, which we refer to as the dominant hemisphere. In the great majority of patients, the dominant hemisphere is the left hemisphere. If a stroke occurs in the dominant hemisphere in the frontal area of the brain, the patient will lose the ability to produce language. If a stroke occurs in the posterior portion of the dominant hemisphere where the temporal and parietal lobes come together, the patient will lose the ability to comprehend language that is spoken to them. If a patient loses the ability to comprehend language and to produce language with a very large middle cerebral artery stroke, we refer to that as a global aphasia. There are quite a number of other symptoms that may be produced by stroke, including the ability to see on one side of the body, the ability to swallow or to move the tongue in a normal way, and quite a number of other symptoms that are really beyond the scope of this limited discussion.

Is an older person who suffers from a stroke more likely also to become depressed?

It is interesting that although one might expect that an older person suffering a stroke would be more likely to become depressed, we have consistently found in our studies that younger stroke victims are more likely to become depressed than older stroke victims. There are some investigators who have found that older patients were more likely to develop depression, but I think it is fair to say that based on all of the literature, which has been produced around the world, that at least older patients are not at increased risk for developing depression after a stroke.

What are some of the signs of depression?

In patients who have had a stroke, the symptoms of depression are very similar to the symptoms found in patients without brain injury. The symptoms of depression include a sad mood, loss of interest or enjoyment in usual activities, loss of energy, difficulty with concentration, decreased appetite with weight loss, sleep disturbance (particularly waking during the middle of the night and having difficulty getting back to sleep), a feeling of self-blame or guilt, feelings of hopelessness about the future, a slowing of the thought process with slowing of movement and thinking, and thoughts of death or suicide. Patients who demonstrate several of these symptoms that last for more than two weeks--and, if the symptoms of the depression interfere with their desire or willingness to undertake their usual social activities--are very likely to have a clinical depression and should be seen by a neuropsychiatrist for evaluation of their depression.

What is the difference between an aneurysm and a stroke, if there is a difference?

An aneurysm is a weakness in the wall of an artery. If it occurs within the brain, it is called a cerebral aneurysm. Aneurysms can occur in arteries in any part of the body, but cerebral aneurysms are ones that can cause a stroke. A cerebral aneurysm causes a stroke if the weakness in the wall of the artery becomes so severe that the artery breaks and blood flows out of the artery into the brain. This blocks off a portion of the brain from its normal blood supply and causes an accumulation of blood within the substance of the brain. We call that kind of stroke a hemorrhagic stroke. That kind of stroke is different than the stroke that I talked about previously which is called a thromboembolic stroke. The aneurysm causes a bleed within the brain or a hemorrhagic stroke, and a thromboembolism causes a blockage of the blood supply with no bleeding into the substance of the brain.

Is it safe to take anti-depression medication if the patient is also on stroke medication?

It depends on what somebody means by stroke medication. Usually stroke medication refers to anticoagulant medication. If somebody is taking Coumadin, his or her bleeding time needs to be evaluated after beginning the antidepressant. But, just taking an anticoagulant does not prevent somebody from taking an antidepressant after a stroke.

How are most people trying to beat the depression associated with having a stroke?

I think the answer to that question is that most people don't try to beat the depression. There are several studies in the scientific literature that have demonstrated that most patients who suffer depression after a stroke do not receive treatment for their depression. So, I think the answer to the question is that most patients and families simply suffer through these severe depressions without seeking help. The depression, without being treated, will on the average continue for approximately nine months. In the scientific literature, there are at least five studies, which have examined the duration of depression after stroke. Although the majority of studies have found that the average length of duration of depression is about 9 to 12 months, in several studies, investigators have found that poststroke depressions can go on for up to three or more years after the stroke. It is very important for both family members and treating physicians to recognize the occurrence of depression after a stroke. One of our studies, published in 1993, found that patients who suffered a depression following stroke were 3 1/2 times more likely to die following the stroke than patients who were nondepressed. This finding was replicated by Dr. Morriss in Australia in a completely different population of patients. This suggested that the identification and treatment of depression will not only improve physical and intellectual recovery from stroke, but it may also increase the likelihood that a patient will survive their stroke.

Can folic acid prevent strokes?

I don't know the answer to that. I don't know whether there is any scientific evidence that folic acid will prevent strokes. If there is any, I'm not aware of it.

Is there a reasonable length of time a post-stroke patient remains on antidepressants?

That is an important question that has not been fully resolved by the scientific research. At the present time, my practice is to leave a patient on an antidepressant following a stroke for at least one year. Patients who stop taking their medication within the first year or after the first year following stroke are vulnerable to developing another depression. No researcher thus far has examined the likelihood of developing a depression when somebody has a depression after a stroke, receives adequate antidepressant treatment, and remains well for six months. Nobody knows what the likelihood that patient will develop another depression within the next 5 or 10 years. I do know, however, from having treated a large number of patients with depression after stroke that there are patients who do develop recurrent depression after a stroke. At the present time, someone who has had one episode of depression after a stroke should remain on antidepressant for at least one year and if they stop the antidepressant, they should be cautious to ensure or to have their family members observe them for possible recurrence of depression.

I think that depression following stroke is one of the most under-recognized complications of a stroke. It is a very common occurrence following this kind of brain injury and can produce a very severe emotional disorder which, without treatment, will last on average nine months to a year. There are treatments that have been demonstrated in the scientific literature to be effective for the treatment of poststroke depression, and we have recently demonstrated that these treatments will not only improve the patient's emotional state, but also improve their physical and intellectual recovery from stroke. Because of the tremendous impact that depression can have both in preventing the normal recovery from stroke as well as the potential of the treatment of depression to improve the outcome of stroke, these depressive disorders should be recognized by both families and physicians of stroke victims to make sure that patients can receive appropriate evaluation and, if indicated, treatment for their depressive disorder.