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