Poststroke Depression (PSD)

1. Poststroke Depression (PSD) Frank McDonald Consultation-Liaison Psychologist Townsville General Hospital Queensland, Australia July 2000

2. Overview • 3 Prevalence of Poststroke Depression (PSD) • 4 Who is at greater risk? • 5-7 When and why should you consider the diagnosis? • 8-9 Other emotional reactions to stroke • 10-11 Differential diagnosis and motivation problems • 12-13 Causes – biological most common • 14-18 Management of PSD – determine what is organic and what is not and treat accordingly • 19 Take-home message • 19 References and web address for this presentation

3. Prevalence • Depression is common after stroke either as a direct biologic effect of the brain damage or as a reaction to disabling illness • Reported in 11 to 68 percent of patients - depending on research criteriafor ‘depression’ • More common as rehab progresses than in acute phase • At the time of initial in-hospital evaluation of 103 pts (Robinson et al. 1983, 1987). • 26% - major depression • 20% - minor depression • Total 46% received a diagnosis of depression • Increases at 6/12 follow up to • 34% - major depression • 26% - minor depression • Total 60% • Figures change after 1 to 2 years. See slide 7.

4. Who is at greater risk? • PSD most often with left cortical and basal ganglia lesions (the closer to left frontal pole the more likely is severe, major depression) and 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. • Other influences: • More severe ADL impairment (correlates with longer course of depression) • Pre-existing cortical atrophy • History of stroke • Family or premorbid history of affective illness (Robinson et al., 1981,1982,1983,1984; Starkstein et al., 1988, 1989)

5. When should you consider the diagnosis? • When the patient persistently appears depressed and gives evidence of: • diminished interest in activities • loss of energy • loss of appetite • sleep disturbances • an agitated state • expresses feelings of worthlessness • impaired concentration • suicidal thoughts • A helpful marker for PSD is lack of motivation in physiotherapy (Ross and Rush, 1981). Though see ‘Differential Diagnosis’ slide 11. • Changes from pre-stroke behaviours observed by family members and a history of previous depression may provide valuable clues. • (Engage a suitably qualified mental health professional to secure the diagnosis of depression and to assess other emotional and cognitive effects of stroke.)

6. Why should you consider the diagnosis? • Depression may adversely affect both participation in rehabilitation and long-term outcomes and may compound cognitive dysfunction (Bolla-Wilson, Robinson, Starkstein, et al., 1989). • Documented effects include • a 3.4 times higher 10-year mortality than that of nondepressed patients (Morris, Robinson, Andrzejewski, et al., 1993) • longer lengths of stay in inpatient rehabilitation programs (Schubert, Burns, Paras, et al., 1992) • greater disability in ADL (Parikh, Robinson, Lipsey, et al., 1990; Schubert, Taylor, Lee, et al., 1992) • higher rates of discharge to an institution (Cushman, 1988) • lower levels of social activities (Gordon, Hibbard, Egelko, et al., 1985) • sexual functioning problems (Monga, Lawson, and Inglis, 1986).

7. Why should you consider the diagnosis? (cont’d) • Pharmacological treatment can shorten the course of major and minor depression, reduce needless suffering and so ease recovery Psychotherapy/supportive care may have an added positive effect • The high risk period for PSD is 2 years after the stroke. Left untreated, major depression can last from 9 to 12 months, or up to 2 years in a minority of patients • Minor depression left untreated has a chronic course of about two years • Nortriptyline (Allegron) used in patients w/o certain heart disease, may aid recovery, e.g. enhance ADL, better than SSRI (Prozac) which was no better than a placebo (Robinson, 2000a) • Treating PSD aids cognitive recovery. Mini-mental scores mean increase = 12% (Nortriptyline vs. placebo) (Robinson, 2000b)

8. Other emotional reactions to stroke • More common emotional responses are: • an immediate sense of powerlessness, then grief or anger over the losses of functions and social roles due to stroke • anxiety “What will become of me?” “Am I going to die?” “ How will others see me?” are common questions of patients. • altered body image and self-esteem • emotional lability • impulsive behaviours • Emotional disturbances such as apathy, mania (see slide 9), delusions, hallucinations, personality changes, and obsessive-compulsive disorders occur in patients with strokes (but are relatively rare). Treatment relies on behavioural approaches or medications.

9. Other emotional reactions to stroke (cont’d) • The effectiveness of pharmacological treatment has been well demonstrated for pathologic laughing and crying after stroke (Robinson, Parikh, Lipsey, et al., 1993). • Poststroke anxiety • Nearly half (23/47) of one series of patients with PSD had co-morbid anxiety symptoms (Starkstein et al.1990) • Poststroke (secondary) mania • Rare. Starkstein and Robinson (1992) saw only 3 in 300 consecutive stroke patients. Does occur though, especially in right hemisphere lesions. But also other locations within the cerebrum e.g. the limbically connected basotemporal cortex. • Diagnosis of depression depends primarily on a clinical interview. Recognition of this and other problems is important so that precautions can be taken to protect patient safety, treatment with behavioural approaches or medications can be given, and appropriate nursing interventions offered.

10. Differential diagnosis and motivation problems • Sometimes patients thought to be depressed by ward staff actually have aprosodia – a disorder of the affective components of language including gesturing - and do not mount appropriate affective responses to the treatment team. Classified and assessed like aphasia (e.g. motor,sensory, comprehension.)

11. Differential diagnosis and motivation problems (cont’d) • Sometimes poor motivation, apathy etc reflects problems other than depression. Assessment of motivation is complex and imprecise. • Apparent motivational problems may actually reflect communication deficits or lack of clarity in instructions by staff. • Poor motivation may indeed be due to modifiable causes such as depression, but also incongruence between the patient's goals and those of the rehabilitation program, or a failure of the rehabilitation team to make clear the connection between interventions and goals that are valued by the patient. • Motivation may also be affected by neurological deficits that lead to hypoarousal, apathy, or a lack of awareness of disabilities.Mood or memory disorders are especially likely to be denied by patients (Anderson and Tranel, 1989; Hibbard, Gordon, Stein, et al., 1992).

12. Causes • Depression in stroke can have many etiologies. • a normal reaction to the losses caused by a stroke • an exacerbation of pre-existing depressive personality features or separate pre-existing depressive disorder • a specific psychiatric disorder such as Major Depression • a medical condition (e.g. hypothyroidism or Addison's disease) • a medication (sedatives,antihypertensives) • organic brain damage

13. Causes (cont’d) • Evidence from U. Iowa Psychiatry Dept head Robert Robinson’s group is heavily weighted toward an intrinsic biological contribution to depressive syndromes. • Specifically, stroke can injure the brain’s catecholamine pathways, drastically reducing release of neurotransmitters (which are akin to a car engine’s transmission fluid), with depression likely. (Folstein et al.1977, Robinson et al. 1983,1985) • A common reaction to depression seen in stroke, and also seen in other medical conditions, is that it is to expected. “Of course he is depressed, it’s only natural after a stroke.” As a result of this faulty logic evidence-based appropriate treatment is withheld, courting consequences listed in slide 6.

14. Management of PSD • Effective treatment depends on an accurate diagnosis. • The first step is to ensure that the patient is receiving the best possible care for other disabilities and that depressive symptoms are not due to medications (e.g. sedatives) or environmental factors (e.g. interruption of sleep habits or dissatisfaction with rehabilitation) • Mild symptoms of depression will often respond to greater attention and encouragement from staff or family, simple changes in the environment, or active participation in therapeutic activities

15. Management of PSD (cont’d) • More severe depression may respond to antidepressant medications or psychotherapy (cognitive, interpersonal, or behavioural). • No controlled studies have examined the effectiveness of psychotherapy specifically in patients with depression due to stroke. The effectiveness of medications has been demonstrated in three small randomised controlled trials and is supported by numerous uncontrolled studies (Andersen, Verstergaard, and Lauritzen, 1994; Lipsey, Robinson, Pearlson, et al., 1984; Reding, Orto, Winter, et al., 1986). • Once the acute phase has passed and the patient is stabilised, the nurse and other health team members need to determine which behaviours are the result of brain damage and which are not e.g. outburst of tears - ?organic crying, ?motor discharge or ?sad thoughts

16. Management of PSD (cont’d) • To aid dealing with depression, reassurance about the availability of physical, psychological and practical assistance is in order, as well as positive feedback on progress made. • Point out increases in self-responsibility e.g.more dexterous use of knife and fork, praise physical transfers from bed. • Never reprimand expressions of depression. • Educate family and patient about ‘out of the blue’ emotional changes – normalise these. • Encourage open expression of feelings. Provide for the release of various feelings e.g. humiliation about loss of elimination functions. Offset with information on retraining and its usual course and outcomes • If families have continued trouble with excessive emotionality they may need to verbalise plans for dealing with outbursts next time they occur (Lambert and Lambert, 1985)

17. Management of PSD (cont’d) • To aid the stroke patient and family deal with their senses of powerlessness and anxiety, the nurse can identify and encourage coping mechanisms used by both. “How did the individual deal with previous stresses, such as illness?” “What are the individual’s physical and mental strengths?” “Family strengths?” • Utilise these creatively to help the person feel he or she has something positive to offer. E.g. if the person was a good cook have him or her put recipes into written form for others; avid readers could proof read some texts from their workplace (Lambert and Lambert,1985)

18. Management of PSD (cont’d) • Communication defects can be a major source of distress. When communicating with the patient: • Provide a variety of auditory and visual stimuli • speak directly to the person • encourage pt to look at speaker use simple one-word commands and gestures • Normal tone of voice but slower pace than usual • Brief, simple sentences. • Allow response time • Provide with pencil and paper. Allows drawing of object wanted.Alternatively book of pictures of items needed • Be patient as person attempts to comprehend and communicate. (Lambert and Lambert,1985) Pass these strategies on to family members

19. Take-home message • Maintain a high index of suspicion for Poststroke Depression – around 25-35% will develop a clinical depression by 6/12 • Establish the cause - organic or otherwise - of depressive symptoms and manage accordingly • Main drug alternatives for major depression are SSRI’s and tricyclic antidepressants (in cases where it is safe, the latter may be the superior choice. See slide 7.) • Minor depression may respond to encouragement and support, information and simple environmental changes References: These are available from the author. This presentation can be downloaded from my web page. www.users.bigpond.com/fmcdonald