Mental Health Disorders Following Stroke

Original Editor - Stacy Schiurring based on the course by Srishti Banerjee
Top Contributors - Stacy Schiurring, Jess Bell, Ewa Jaraczewska and Kim Jackson

Introduction

The Global Burden of Disease report published in 2019 estimated that stroke (cerebrovascular accident or CVA) is the second leading cause of death, and the third leading cause of death and disability combined. There is growing interest in the effect stroke has on the development of mental health disorders. Mental health issues are also a leading cause of disability worldwide, with depression and anxiety topping the list of global mental health diagnoses.

Mental health disorders are common, but often overlooked, following a stroke. These disorders can greatly affect a stroke survivor's quality of life, treatment outcomes and functional status, burden of care, and mortality rates. Three major mental health disorders common after stroke include: (1) poststroke depression, (2) poststroke anxiety, and (3) post-traumatic stress disorder. Other associated disorders and concerns include psychosis, mania, and suicidal ideation.

Recent evidence has shown that mental health disorders following stroke are associated with decreased patient functional outcomes and lowered quality of life. However, they continue to be under-diagnosed and treated. With the exception of poststroke depression, other mental health disorders lack reliable and high-quality evidence for clinical practice. Further research is needed to develop protocols or guidelines for diagnosing, treating, or preventing mental health disorders following stroke.

This article will overview three common mental health disorders following stroke, the pathophysiological changes that occur after stroke and may contribute to these mental health concerns, and the clinical features of these conditions.

Poststroke Depression

To learn more about depression in general, please read: Depression (optional).

Poststroke depression (PSD) occurs in one-third of stroke survivors at any time following their initial injury. At one year after injury, approximately 33% of stroke survivors experience PSD, 25% experience it at 5 years, and 23% past 5 years post-stroke injury. There appears to be no significant difference in the occurrence of PSD within the first year after injury based on patient placement at a hospital, rehabilitation setting, or in the general population. An early study on PSD by Folstein et al. found depression to be more common in stroke survivors compared to patients with a similar level of "motor disability" of orthopaedic origins.

A formal diagnosis of PSD requires careful assessment of presenting symptoms, including timing of onset. PSD diagnoses may be assisted by the use of screening tools validated for use in stroke.

According to the Canadian Stroke Best Practices

All patients who experience stroke are at high risk for PSD.

"Depression following stroke: The DSM5 (The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) category that applies is mood disorders due to another medical condition such as stroke with depressive features, major depressive-like episode, or mixed-mood features. It is often associated with large vessel infarction.

• A patient who is a candidate for this diagnosis would present with depressed mood or loss of interest or pleasure along with four other symptoms of depression (e.g., weight loss, insomnia, psychomotor agitation, fatigue, feelings of worthlessness, diminished concentration, suicidal ideation) lasting two or more weeks.
• Several mechanisms, including biological, behavioural, and social factors, are involved in its pathogenesis.
• Symptoms usually occur within the first three months after stroke (early onset depression following stroke); however, may occur at any time (late onset depression following stroke). Symptoms resemble those of depression triggered by other causes, although there are some differences - people who have experienced a stroke with depression following stroke experience more sleep disturbances, vegetative symptoms, and social withdrawal."

PSD consists of both (1) post-stroke depressive symptoms and (2) post-stroke depressive disorder:

• Post-stroke depressive symptoms develop in parallel with the stroke, possibly due to direct brain injury or acute psychosocial response to the stroke event
  • relatively short duration (approximately 12 weeks)
• Post-stroke depressive disorder is an endogenous depression prompted by the stroke event or sequelae, most commonly occurring six months post-stroke injury
  • lasts an average of 39 weeks

Pathophysiological Changes Related to PSD

Recent research suggests that PSD has underlying biological causes and is not only a psychological reaction to a new medical condition and level of ability.

According to a 2022 literature review by Frank et al., the pathophysiology of PSD is complex and unknown, but it involves mechanisms such as:

1. Dysfunction of the monoamine
   • this theory suggests that ischaemic lesions in the brain interrupt biogenic amine-containing axons, "which ascend from the brainstem nuclei as it extends to the cerebral cortex")
2. The glutamatergic systems
   • dysfunctions in glutamatergic neurotransmission are known to play a role in a number of psychiatric conditions
3. The Gut-brain axis
4. Neuroinflammation
   • neuroinflammation can lead to a dysregulated immune system, which has been linked by Tubbs et al. to infectious disease and psychiatric disorders

Other physiological factors which can affect a person's likelihood of developing PSD can include: (1) genetic variations, (2) white matter disease, (3) cerebrovascular deregulation, (4) altered neuroplasticity and (5) lesion location.

Optional additional reading: for more in-depth information on the effects of neuroinflammation and neurodegeneration in the brain after a stroke, please read this 2021 research article by Stuckey et al.

Clinical Features of PSD

• Anhedonia is a core symptom and feature of depression. It is the "near-complete absence of enjoyment, motivation, and interest." Clinical features can include limitations in the ability to (1) experience pleasure, (2) approach-related motivated behaviour, and (3) learn how to match expectations to the environment.
• Lack of interest or lack of pleasure in activities which were previously enjoyable to the patient
• Lack of energy
• Reduced concentration
• Psychomotor retardation (slowing or impairment) is a long-established symptom of depression which has significant clinical and therapeutic implications for treatment. Signs of psychomotor impairment include (1) slowed speech, (2) decreased movement, and (3) impaired cognitive function.
• Anorexia
• Changes in sleep patterns: insomnia versus hypersomnia
• Guilt
• Low self esteem
• Suicidal ideation
• Apathy (please see the Differential Diagnosis section below for more information)

Predictors for the Development of PSD

Consistent predictors of PSD development supported by research:

1. Physical disability
2. Stroke severity
3. Depression present prior to stroke
4. Cognitive impairment

Other less consistent factors identified as predictors include:

1. Lack of family and social support after stroke
2. Anxiety after stroke
3. Older age
4. Female sex
5. Diabetes mellitus
6. Stroke subtype
7. Education level
8. Living alone
9. Previous stroke

PSD Differential Diagnosis

PSD is the most common mental health disorder identified in stroke survivors. However, there are a number of other potential diagnoses which may require a skilled clinician to perform a differential diagnosis. Below is a non-exhaustive list of other mental health disorders found in stroke survivors.

Differential Diagnosis	Description	Clinical Features	Prevalence	Clinical Pearls
Poststroke Apathy	A "multidimensional syndrome of diminished goal-directed behavior, emotion, and cognition" Apathy can be diagnosed as an independent syndrome or as a symptom of PSD or dementia	Psychiatric symptoms: disinhibition, declining cognitive function, aberrant motor behaviours Emotional properties: indifference, neutral mood, usually without suicidal ideation Flat affect with lack of eye contact	29-40% of stroke survivors demonstrate symptoms of apathy	Can be difficult to distinguish from PSD
Poststroke Anxiety (PSA)	According to the Canadian Stroke Best Practices: "Anxiety disorders occur when symptoms become excessive or chronic" "Anxiety has been defined both by consideration of the presence and severity of symptoms using validated screening and assessment scales ... or by defining syndromes using diagnostic criteria (e.g., panic disorders, general anxiety disorder, social phobia)" PSA is closely associated with anxiety prior to stroke	Fear and avoidance of stressful situations Worry Irritability Restlessness Physiological arousal: increased heart rate, dizziness, tense muscles, tingling/numbness in hands and feet, headache, chronic muscle spasm, and joint pain Insomnia Can have poor rehabilitation prognosis due to self-restrictive behaviours	Up to 20% one-month post-stroke Increases up to 24% six-months post-stroke Usually seen in the chronic phase of stroke
Poststroke Fatigue (PSF)	Debilitating and long-lasting condition Has been defined as "a sensation of exhaustion during or after usual activities, or a feeling of inadequate energy to begin these activities"	Subjective feeling of physical or mental weariness Lack of energy independent of exercise or prior activity, with abnormal, transitional, and chronic characteristics that lead to difficulty maintaining even routine activities	29–68% of stroke survivors demonstrate symptoms of poststroke fatigue	Differential diagnosis is indicated: depressed mood presents with fatigue symptoms such as fatigue and loss of energy accompany PSD
Poststroke Psychotic Disorder (PSPD)	PSPD refers to a variety of psychiatric syndromes in the acute, rehabilitation, and sequelae stages of stroke Typically presents with a slow and fluctuating course that may quickly progress post-stroke	Includes a complex of many symptoms which hinder functional ability and quality of life Symptoms can include: hallucination, delusion, delirium PSPD will generally develop into dementia	At least 30% of stroke survivors demonstrate symptoms of neuropsychic disorders Approximately 4.86% of stroke survivors have delusions or hallucinations secondary to stroke
Post Traumatic Stress Disorder (PTSD) in Stroke	A stress-related disorder which comprises of a cluster of four symptoms: (1) intrusion, (2) avoidance, (3) negative alteration in cognition and mood, (4) alteration in arousal and activity	Continuous flashbacks and memories associated with stroke Persistent avoidance of triggering situations such as IV placement, repeat hospitalisation, imaging procedures Increase in reactivity Irritability Anger Outbursts Agitation More common for patients in inpatient settings	25% PTSD one year post-stroke

Resources

Clinical Resources

• Poststroke Depression Fact Sheet for patient education (American Stroke Association)
• Canadian Stroke Best Practices

Optional Additional Video

If you would like to learn more about PSD diagnosis, please view this hour-long video presentation from the American Stroke Association at the International Stroke Conference.