Mental Health Disorders Following Stroke: Difference between revisions
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# Cognitive impairment | # Cognitive impairment | ||
'''Other less consistent factors | '''Other less consistent factors identified as predictors include:'''<ref name=":3" /> | ||
# Lack of family and social support after stroke | # Lack of family and social support after stroke | ||
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# Previous stroke | # Previous stroke | ||
'''Preventative measure:''' | |||
Talking about the clinical course of PSD, the South of London Stroke Registry has defined that PSD begins about within one year following stroke and the recovery rate with the patients who encounter post-stroke depression is quite affected by post-stroke depression, and the recovery is moderate in about 15 to 57% of these patients. The chances of recurrence are about 38% at two years, and about 100% at about 10 to 15 years following stroke. It is interesting to note that post-stroke depression increases the mortality up to five years and this is very common in young patients, young in sense, individuals with less than 65 years of age because They are more independent and after stroke, they are quite more dependent on their caregivers which hamper the psychological health of these patients. And this is independent of any other factors such as smoking, alcohol, or other comorbidities, or social support. So this data is independent of all those things. So that was about post-stroke depression. | |||
For videos and podcast: https://www.stroke.org/en/about-stroke/effects-of-stroke/emotional-effects-of-stroke/depression-and-stroke | |||
== PSD Differential Diagnosis == | == PSD Differential Diagnosis == | ||
Source: Zhao FY, Yue YY, Li L, Lang SY, Wang MW, Du XD, Deng YL, Wu AQ, Yuan YG. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6899404/#B79 Clinical practice guidelines for post-stroke depression in China]. Brazilian Journal of Psychiatry. 2018 Feb 1;40:325-34. | Source: Zhao FY, Yue YY, Li L, Lang SY, Wang MW, Du XD, Deng YL, Wu AQ, Yuan YG. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6899404/#B79 Clinical practice guidelines for post-stroke depression in China]. Brazilian Journal of Psychiatry. 2018 Feb 1;40:325-34. | ||
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!'''Clinical Features''' | !'''Clinical Features''' | ||
!'''Prevalence''' | !'''Prevalence''' | ||
!''' | !'''Clinical Pearls''' | ||
|- | |- | ||
|'''Poststroke Apathy''' | |'''Poststroke Apathy''' | ||
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* can be difficult to distinguish from PSD<ref name=":2" /><ref name=":4" /> | * can be difficult to distinguish from PSD<ref name=":2" /><ref name=":4" /> | ||
|- | |- | ||
|'''Poststroke Anxiety''' | |'''Poststroke Anxiety'''(PSA) | ||
| | | | ||
* PSA is closely associated with anxiety prior to stroke<ref name=":4" /> | |||
* Four types: (1) generalised anxiety, (2) . social anxiety, (3) phobia, (4) panic disorders or panic attacks<ref name=":1" /> | |||
| | | | ||
* fear<ref name=":4" /> and avoidance of stressful situations<ref name=":1" /> | |||
* worry<ref name=":4" /> | |||
* irritability<ref name=":4" /> | |||
* restlessness<ref name=":4" /> | |||
* '''Physiological arousal''': increased heart rate, dizziness, tense muscles, tingling/numbness in hands and feet, headache, chronic muscle spasm, and joint pain<ref name=":1" /> | |||
* insomnia<ref name=":1" /> | |||
* Can have poor rehab prognosis due to self restrictive behaviours<ref name=":1" /> | |||
| | | | ||
* up to 20% 10month post-stroke | |||
* increases up to 24% 6-months post-stroke<ref name=":1" /> | |||
* usually seen in the chronic phase of stroke<ref name=":4" /> | |||
| | | | ||
|- | |- | ||
|'''Poststroke Fatigue''' | |'''Poststroke Fatigue'''(PSF) | ||
| | |PSF is a subjective feeling of physical or mental weariness and lack of energy independent of exercise or prior activity, with abnormal, transitional, and chronic characteristics that lead to difficulty maintaining even routine 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 | |||
| | | | ||
|Differential diagnosis is indicated: | |||
* depressed mood presents with fatigue | |||
* symptoms such as fatigue and loss of energy accompany PSD<ref name=":4" /> | |||
|- | |- | ||
|'''Poststroke Psychotic Disorder''' | |'''Poststroke Psychotic Disorder'''(PSPD) | ||
| | | | ||
* PSPD refers to many types of psychiatric syndromes in the acute, rehabilitation, and sequelae stages of stroke | |||
* Although usually with a slow and fluctuating course that may rapidly worsen when aggravated by a stroke or improve due to compensating collateral circulation, | |||
|Includes a complex of many symptoms which hinder functional ability and quality of life. | |||
Symptoms can include: | |||
* hallucination | |||
* delusion | |||
* deliriumPSPD will generally develop into dementia <ref name=":4" /> | |||
| | | | ||
| | | | ||
|- | |- | ||
|'''Post Traumatic Stress Disorder in Stroke''' | |'''Post Traumatic Stress Disorder 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<ref name=":1" /> | |||
| | | | ||
* 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<ref name=":1" /> | |||
|25% PTSD one year post-stroke<ref name=":1" /> | |||
| | | | ||
|} | |} | ||
== Resources == | == Resources == | ||
*bulleted list | *bulleted list |
Revision as of 04:08, 17 July 2023
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Introduction[edit | edit source]
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[1]. There is growing interest and research around the effect stroke has on the development of mental health discorders. Mental health issues are a leading cause of disability worldwide[2], with depression[2][3] and anxiety[2] topping the list of global mental health diagnoses.
Mental health disorders are common, but often overlooked, following a stroke. These disorders can greatly affect the stroke survivors quality of life, treatment outcomes and functional status, burden of care, and morality rates[4]. Three major mental health disorders common after stroke include: (1) poststroke depression, (2) poststroke anxiety, and (3) post traumatic stress disorder[4]. Other associated disorders and concerns include psychosis, mania[4], and suicidal ideation[5].
This article will overview three common mental health disorders following stroke, discuss the pathophysiological changes which occur after stroke with may contribute to these mental health concerns, outline clinical features, and give a basic overview preventative measures from a multidisciplinary team perspective.
Poststroke Depression[edit | edit source]
To learn more about depression in general, please read this article (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 will experience PSD, 25% at 5 years, and 23% past 5 years post-stroke injury. There appears to be no significant difference of PSD occurrence within the first year after injury based on patient placement at hospital, rehabilitation setting, or out in the general population[6]. An early study on PSD by Folstein found depression to be more common in stroke survivors compared to patients with a similar level of "motor disability" of orthopeadic origins[7].
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[8].
According to the Canadian Stroke Best Practices[edit | edit source]
All patients who experience stroke are at high risk for PSD[9].
"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[10].
- 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."[9]
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)[11]
- 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[11]
[edit | edit source]
Recent research and evidence suggests that PSD has underlying biological causes and is not only a psychological reaction to a new medication condition and level of ability[6].
According to a 2022 literature review, the pathophysiology of PSD is complex and the exact mechanisms are unknown. It involves systemic body reactions to include (1) dysfunction of monoamine which stem from ischemic lesions in the brain and has effects from the brainstem to the cerebral cortex, (2) the glutamatergic systems which play a role in the occurrence of varied psychiatric conditions and abnormalities, (3) the gut-brain axis, and (4) neuroinflammation[12]. Neuroinflammation can lead to a dysregulated immune system, which can been linked by Tubbs et al. to infectious disease and psychiatric disorders[13]. Other physiological factors which can effect a person's likelihood of developing PSD can include: (1) genetic variations, (2) white matter disease, (3) cerebrovascular deregulation, (4) altered neuroplasticity[14] and (5) lesion location[6].
Optional additional reading: for more in-depth information on the effects of neuroinflammation and neurodegeneration in the brain after a stroke, please read this research article published in 2021.
Clinical Features of PSD[edit | edit source]
- Anhedonia is a core symptom and feature of depression. It is the "near-complete absence of enjoyment, motivation, and interest." Clinical feature 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[4][15].
- Lack of interest or lack of pleasure in activities which were previously enjoyable to the patient[4]
- Lack of energy[4]
- Reduced concentration[4]
- Psychomotor retardation a long established symptom of depression which has significant clinical and therapeutic implications for treatment. Signs of psychomotor retardation include (1) slowed speech, (2) decreased movement, and (3) impaired cognitive function[4][16].
- Anorexia[4]
- Changes in sleep patterns: insomnia versus hypersomnia [4]
- Guilt [4]
- Low self esteem [4]
- Suicidal ideation [4]
- Apathy [4](please see Differential Diagnosis section below for more information)
Predictors for the development of PSD[edit | edit source]
Research supported consistent predictors of PSD development:[6]
- Physical disability
- Stroke severity
- Depression present prior to stroke
- Cognitive impairment
Other less consistent factors identified as predictors include:[6]
- Lack of family and social support after stroke
- Anxiety after stroke
- Older age
- Female sex
- Diabetes mellitus
- Stroke subtype
- Education level
- Living alone
- Previous stroke
Preventative measure:
Talking about the clinical course of PSD, the South of London Stroke Registry has defined that PSD begins about within one year following stroke and the recovery rate with the patients who encounter post-stroke depression is quite affected by post-stroke depression, and the recovery is moderate in about 15 to 57% of these patients. The chances of recurrence are about 38% at two years, and about 100% at about 10 to 15 years following stroke. It is interesting to note that post-stroke depression increases the mortality up to five years and this is very common in young patients, young in sense, individuals with less than 65 years of age because They are more independent and after stroke, they are quite more dependent on their caregivers which hamper the psychological health of these patients. And this is independent of any other factors such as smoking, alcohol, or other comorbidities, or social support. So this data is independent of all those things. So that was about post-stroke depression.
For videos and podcast: https://www.stroke.org/en/about-stroke/effects-of-stroke/emotional-effects-of-stroke/depression-and-stroke
PSD Differential Diagnosis[edit | edit source]
Source: Zhao FY, Yue YY, Li L, Lang SY, Wang MW, Du XD, Deng YL, Wu AQ, Yuan YG. Clinical practice guidelines for post-stroke depression in China. Brazilian Journal of Psychiatry. 2018 Feb 1;40:325-34.
Differential Diagnosis | Description | Clinical Features | Prevalence | Clinical Pearls |
---|---|---|---|---|
Poststroke Apathy |
|
|
29-40% of stroke survivors demonstrate symptoms of apathy[9] | |
Poststroke Anxiety(PSA) |
|
|||
Poststroke Fatigue(PSF) | PSF is a subjective feeling of physical or mental weariness and lack of energy independent of exercise or prior activity, with abnormal, transitional, and chronic characteristics that lead to difficulty maintaining even routine activities |
|
Differential diagnosis is indicated:
| |
Poststroke Psychotic Disorder(PSPD) |
|
Includes a complex of many symptoms which hinder functional ability and quality of life.
Symptoms can include:
|
||
Post Traumatic Stress Disorder 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[4] |
|
25% PTSD one year post-stroke[4] |
Resources[edit | edit source]
- bulleted list
- x
or
- numbered list
- x
References[edit | edit source]
- ↑ Feigin VL, Brainin M, Norrving B, Martins S, Sacco RL, Hacke W, Fisher M, Pandian J, Lindsay P. World Stroke Organization (WSO): global stroke fact sheet 2022. International Journal of Stroke. 2022 Jan;17(1):18-29.
- ↑ 2.0 2.1 2.2 Pan American Health Organization. Mental health problems are the leading cause of disability worldwide, say experts at PAHO Directing Council side event. Available from: https://www3.paho.org/hq/index.php?option=com_content&view=article&id=15481:mental-health-problems-are-the-leading-cause-of-disability-worldwide-say-experts-at-paho-directing-council-side-event&Itemid=0&lang=en#gsc.tab=0 (accessed 12/July/2023).
- ↑ United Nations. UN health agency reports depression now ‘leading cause of disability worldwide’. Available from: https://news.un.org/en/story/2017/02/552062 (accessed 12/July/2023).
- ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18 4.19 4.20 4.21 4.22 Banerjee, S. Stroke. The Role of Rehabilitation Professionals in Mental Health Disorders Following Stroke. Physioplus. 2023.
- ↑ Chun HY, Ford A, Kutlubaev MA, Almeida OP, Mead GE. Depression, anxiety, and suicide after stroke: a narrative review of the best available evidence. Stroke. 2022 Apr;53(4):1402-10.
- ↑ 6.0 6.1 6.2 6.3 6.4 Towfighi A, Ovbiagele B, El Husseini N, Hackett ML, Jorge RE, Kissela BM, Mitchell PH, Skolarus LE, Whooley MA, Williams LS. Poststroke depression: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2017 Feb;48(2):e30-43.
- ↑ Folstein MF, Maiberger R, McHugh PR. Mood disorder as a specific complication of stroke. Journal of Neurology, Neurosurgery & Psychiatry. 1977 Oct 1;40(10):1018-20.
- ↑ Chun HY, Ford A, Kutlubaev MA, Almeida OP, Mead GE. Depression, anxiety, and suicide after stroke: a narrative review of the best available evidence. Stroke. 2022 Apr;53(4):1402-10.
- ↑ 9.0 9.1 9.2 9.3 9.4 Canadian Stroke Best Practices. Post Stroke Depression. Available from: https://www.strokebestpractices.ca/recommendations/mood-cognition-and-fatigue-following-stroke/post-stroke-depression (accessed 13/July/2023).
- ↑ DSM-5 293.83; Robinson and Jorge, AJP, Volume 173, Issue 3, March 01, 2016, PP. 221-231.
- ↑ 11.00 11.01 11.02 11.03 11.04 11.05 11.06 11.07 11.08 11.09 11.10 11.11 Zhao FY, Yue YY, Li L, Lang SY, Wang MW, Du XD, Deng YL, Wu AQ, Yuan YG. Clinical practice guidelines for post-stroke depression in China. Brazilian Journal of Psychiatry. 2018 Feb 1;40:325-34.
- ↑ Frank D, Gruenbaum BF, Zlotnik A, Semyonov M, Frenkel A, Boyko M. Pathophysiology and current drug treatments for post-stroke depression: A review. International Journal of Molecular Sciences. 2022 Dec 1;23(23):15114.
- ↑ Tubbs JD, Ding J, Baum L, Sham PC. Immune dysregulation in depression: Evidence from genome-wide association. Brain, Behavior, & Immunity-Health. 2020 Aug 1;7:100108.
- ↑ Robinson RG, Jorge RE. Post-stroke depression: a review. American Journal of Psychiatry. 2016 Mar 1;173(3):221-31.
- ↑ Cooper JA, Arulpragasam AR, Treadway MT. Anhedonia in depression: biological mechanisms and computational models. Current opinion in behavioral sciences. 2018 Aug 1;22:128-35.
- ↑ Buyukdura JS, McClintock SM, Croarkin PE. Psychomotor retardation in depression: biological underpinnings, measurement, and treatment. Progress in Neuro-Psychopharmacology and Biological Psychiatry. 2011 Mar 30;35(2):395-409.