Mental Health Disorders Following Stroke: Difference between revisions

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<div class="editorbox"> '''Original Editor '''- [[User:Stacy Schiurring|Stacy Schiurring]] based on the course by [https://members.physio-pedia.com/instructor/srishti-banerjee// Srishti Banerjee]<br>
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== Introduction ==
== Introduction ==
So as we know that stroke, or cerebrovascular accident, is particularly characterised by sensory and motor difficulties and which presents as hemiplegia or hemiparesis, leading to difficulty in balance, gait, activities of ADL. (Activities of Daily Living) So now what happens is that we address all of these difficulties, but the mental health aspect remains overlooked. So, as a result of which, what happens that the patient performs poorly in all of these other interventions. And it is very important to identify that this poor performance is because some psychological issues are present which are not been assessed or treated. So psychiatric disorders are very common complications following stroke and which are associated with low quality of life, worsening of treatment outcomes, also increasing the burden on the caregivers, and deterioration of the functional status of the patient.  
The [https://www.healthdata.org/gbd 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.<ref>Feigin VL, Brainin M, Norrving B, Martins S, Sacco RL, Hacke W, Fisher M, Pandian J, Lindsay P. [https://world-stroke-academy.org/media/uploads/2022/02/World-Stroke-Organization-WSO-Global-Stroke-Fact-Sheet-2022.pdf World Stroke Organization (WSO): global stroke fact sheet 2022. International Journal of Stroke]. 2022 Jan;17(1):18-29.</ref> 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,<ref name=":0">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).</ref> with depression<ref name=":0" /><ref>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).</ref> and anxiety<ref name=":0" /> topping the list of global mental health diagnoses.  


So neuropsychiatric disorders following stroke also increase the mortality. In this course, I will be talking about three major neuropsychiatric disorders or mental health issues following stroke: post-stroke depression, post-stroke anxiety, and post-traumatic stress disorder. (PTSD) In addition to this some rare disorders, which are not that prevalent, are psychosis and mania. And it can be present in combination of any of these.
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.<ref name=":1">Banerjee, S. Stroke. The Role of Rehabilitation Professionals in Mental Health Disorders Following Stroke. Physioplus. 2023.</ref> Three major mental health disorders common after stroke include: (1) poststroke depression, (2) poststroke anxiety, and (3) post-traumatic stress disorder.<ref name=":1" /> Other associated disorders and concerns include psychosis, mania,<ref name=":1" /> and suicidal ideation.<ref name=":6">Chun HY, Ford A, Kutlubaev MA, Almeida OP, Mead GE. [https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.121.035499 Depression, anxiety, and suicide after stroke: a narrative review of the best available evidence]. Stroke. 2022 Apr;53(4):1402-10.</ref> 


== Post-Stroke Depression ==
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.<ref>Zhang S, Xu M, Liu ZJ, Feng J, Ma Y. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7360525/ Neuropsychiatric issues after stroke: Clinical significance and therapeutic implications]. World journal of psychiatry. 2020 Jun 6;10(6):125.</ref> 
'''Description''':  


Firstly, talking about post-stroke depression or PSD. It is one of the most important neuropsychiatric complications following stroke because it is associated with worsening of treatment outcomes, which leads to social withdrawal of the patient, leads to increase in disability, affects sleep, and cognitive impairments.  Also, it increases the burden on the caregivers.  
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.  


'''Prevalence''':
== Poststroke Depression ==
'''To learn more about depression in general, please read: [[Depression]]''' (optional).


So it has been found that 33% of stroke survivors show symptoms of PSD and up to 40% of these patients, they remain symptomatic at least for about one year following stroke.  
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.<ref name=":3">Towfighi A, Ovbiagele B, El Husseini N, Hackett ML, Jorge RE, Kissela BM, Mitchell PH, Skolarus LE, Whooley MA, Williams LS. [https://www.ahajournals.org/doi/10.1161/str.0000000000000113 Poststroke depression: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association]. Stroke. 2017 Feb;48(2):e30-43.</ref> An early study on PSD by Folstein et al.<ref>Folstein MF, Maiberger R, McHugh PR. [https://scholar.google.com/scholar?output=instlink&q=info:jJcDkCMRA-YJ:scholar.google.com/&hl=en&as_sdt=0,44&scillfp=17356804565716228823&oi=lle Mood disorder as a specific complication of stroke]. Journal of Neurology, Neurosurgery & Psychiatry. 1977 Oct 1;40(10):1018-20.</ref> found depression to be more common in stroke survivors compared to patients with a similar level of "motor disability" of orthopaedic origins.        


'''Pathophysiological changes/NT''':  
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.<ref name=":6" />        <blockquote>
=== According to the [https://www.strokebestpractices.ca/recommendations/mood-cognition-and-fatigue-following-stroke/post-stroke-depression Canadian Stroke Best Practices] ===
'''All patients who experience stroke are at high risk for PSD.'''<ref name=":2" />


'''Clinical Features:'''  
"'''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.<ref>DSM-5 293.83; Robinson and Jorge, AJP, Volume 173, Issue 3, March 01, 2016, PP. 221-231.</ref>


So moving on, clinical features. First and foremost is a depressed mood. The second is anhedonia. Anhedonia is the term which is used to refer a depressed mood. Also with lack of interest or lack of interest or lack of pleasure in activities which were previously enjoyable to the patient, recreational activities the patient used to enjoy but now does not. Lack of energy. Reduced concentration. Now these things are very important when we are going on for cognitive rehabilitation for the patient because this reduced concentration is going to affect the cognitive rehabilitation part. Lack of energy is going to affect your motor rehabilitation part. Then the next is psychomotor retardation. So psychomotor retardation is associated with slow speech, slow movement, and impaired cognition. So this is all going to have a lot of effect on physical therapy and occupational therapy interventions. The next is anorexia. That is lack of appetite which eventually leads to weight loss. Then insomnia. Some patients also present with hypersomnia, that is excessive sleep. Guilt. The patient is continuously guilty that they're dependent on caregivers. There is low self esteem and suicidal thoughts.  
* 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."<ref name=":2">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).</ref>
</blockquote>


Post-stroke depression has been divided into three major categories. So the first category is that the patient should have at least five of the previously described clinical features for about two weeks or more. So the patient's fall in category one. Category two is that the patient meets some of the previously mentioned clinical features, but they do not have major depressive episodes. So that is what it is. And they have these features on and off, but no major depressive episodes. The last one is, there is a combination of depression with mania.
'''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)<ref name=":4">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.</ref>
* '''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<ref name=":4" />


'''Preventative measure:''' 
=== 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.<ref name=":3" /> 


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.
According to a 2022 literature review by Frank et al.,<ref name=":7">Frank D, Gruenbaum BF, Zlotnik A, Semyonov M, Frenkel A, Boyko M. [https://www.mdpi.com/1422-0067/23/23/15114 Pathophysiology and current drug treatments for post-stroke depression: A review]. International Journal of Molecular Sciences. 2022 Dec 1;23(23):15114.</ref> the pathophysiology of PSD is complex and unknown, but it involves mechanisms such as:<ref name=":7" />


== Post-Stroke Anxiety ==
# Dysfunction of the monoamine
'''Description''':  
#* 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"<ref name=":7" />)
# The glutamatergic systems
#* dysfunctions in glutamatergic neurotransmission are known to play a role in a number of psychiatric conditions
# The [[Gut Brain Axis (GBA)|Gut-brain axis]]
# [[Neurogenic Inflammation|Neuroinflammation]]
#* neuroinflammation can lead to a dysregulated immune system, which has been linked by Tubbs et al.<ref>Tubbs JD, Ding J, Baum L, Sham PC. [https://www.sciencedirect.com/science/article/pii/S2666354620300739 Immune dysregulation in depression: Evidence from genome-wide association]. Brain, Behavior, & Immunity-Health. 2020 Aug 1;7:100108.</ref> to infectious disease and psychiatric disorders


These patients have a very poor prognosis because they tend to restrict themselves. Because of the anxiety, they tend to restrict themselves a lot and this hampers their social participation sometimes also their participation in the rehabilitation. Now what happens is that anxiety or post-stroke anxiety is of three types. The first is generalised anxiety. The next is social anxiety. That is when the patient is among a group of people. The next is phobia, particular fears. And the next, the last one, is panic disorders or panic attacks.  
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 After Stroke|neuroplasticity]]<ref>Robinson RG, Jorge RE. [https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2015.15030363 Post-stroke depression: a review.] American Journal of Psychiatry. 2016 Mar 1;173(3):221-31.</ref> and (5) lesion location.<ref name=":3" />


'''Prevalence''':  
'''''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 [https://www.mdpi.com/1422-0067/22/23/13101 research article] by Stuckey et al.<ref>Stuckey SM, Ong LK, Collins-Praino LE, Turner RJ. [https://www.mdpi.com/1422-0067/22/23/13101 Neuroinflammation as a key driver of secondary neurodegeneration following stroke?] Int J Mol Sci. 2021 Dec 3;22(23):13101.</ref> 


Now talking about post-stroke anxiety, which is a very common psychological complication, and the prevalence is up to 20% in the first month of stroke, and which increases up to 24% six months following stroke.
=== Clinical Features of PSD ===


'''Pathophysiological changes/NT''':
* '''[[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.<ref name=":1" /><ref>Cooper JA, Arulpragasam AR, Treadway MT. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5828520/ Anhedonia in depression: biological mechanisms and computational models]. Current opinion in behavioral sciences. 2018 Aug 1;22:128-35.</ref>
* '''Lack of interest''' or '''lack of pleasure''' in activities which were previously enjoyable to the patient<ref name=":1" />
* '''Lack of energy'''<ref name=":1" />
* '''Reduced concentration'''<ref name=":1" />
* '''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.<ref name=":1" /><ref>Buyukdura JS, McClintock SM, Croarkin PE. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3646325/ Psychomotor retardation in depression: biological underpinnings, measurement, and treatment]. Progress in Neuro-Psychopharmacology and Biological Psychiatry. 2011 Mar 30;35(2):395-409.</ref>
* [[Anorexia Nervosa|'''Anorexia''']]<ref name=":1" />
* '''Changes in sleep patterns''': insomnia versus hypersomnia<ref name=":1" />
* '''Guilt'''<ref name=":1" />
* '''Low self esteem'''<ref name=":1" />
* '''Suicidal ideation'''<ref name=":1" />
* '''Apathy'''<ref name=":1" /> (please see the [[Mental Health Disorders Following Stroke#PSD Differential Diagnosis|Differential Diagnosis section]] below for more information)


'''Clinical Features:'''  
==== Predictors for the Development of PSD ====
'''Consistent predictors of PSD development supported by research:'''<ref name=":3" />


Now, clinical features, it is very interesting to note that patients with post-stroke anxiety show a lot of physiological features. So there is a physiological arousal which is manifested as increase in heart rate, dizziness, tense muscles, tingling and numbness in hands and feet, headache, chronic muscle spasm, and joint pain. The next is sleep disturbances, particularly insomnia. Avoidance of stress is basically avoiding particular stressors, right? The stressors can be different for different patients, like sometimes going to a social gathering or sometimes doing a particular motor activity, which the patient is not able to do and the patient is stressed while doing that. That is avoidance of stress, avoidance of that particular stressor. Then disruption in cognition. The patient has quite flight of thoughts. There is a persistent worry, like the patient is continuously worried and these worries are associated with unpredictable outcomes of stroke, which are not actually going to happen, but the patient is quite worried that, what if this happens? What if that happens? Right? So avoiding crowded places and even avoiding sexual intercourse, the patient is anxious about these things. The patient is very anxious about going out alone. Also, being at home alone. So the patient is quite anxious about these things. Travelling in public transport. Now, one of the major feature, or contributing feature, of all of these clinical features is that the patient has a continuous anxiety that the stroke will reoccur. There is a reoccurrence of stroke. The patient continuously worries that the stroke is going to happen again. So that is what is associated with post-stroke anxiety.
# Physical disability
# Stroke severity
# Depression present prior to stroke  
# Cognitive impairment


'''Preventative measure:'''  
'''Other less consistent factors identified as predictors include:'''<ref name=":3" />


== Post-Traumatic Stress Disorder in Stroke ==
# Lack of family and social support after stroke
'''Description''':
# Anxiety after stroke
# Older age
# Female sex
# Diabetes mellitus
# Stroke subtype
# Education level
# Living alone
# 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.
{| class="wikitable"
|+
!'''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<ref name=":2" />
|
* '''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<ref name=":4" />
|
* 29-40% of stroke survivors demonstrate symptoms of apathy<ref name=":2" />
|
* Can be difficult to distinguish from PSD<ref name=":2" /><ref name=":4" />
|-
|'''Poststroke Anxiety''' (PSA)
|According to the Canadian Stroke Best Practices:
* "Anxiety disorders occur when symptoms become excessive or chronic"<ref name=":2" />
* "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)"<ref name=":2" />
* PSA is closely associated with anxiety prior to stroke<ref name=":4" />
|
* 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 rehabilitation prognosis due to self-restrictive behaviours<ref name=":1" />
|
* Up to 20% one-month post-stroke
* Increases up to 24% six-months post-stroke<ref name=":1" />
* Usually seen in the chronic phase of stroke<ref name=":4" />
|
|-
|'''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"<ref name=":5">Alghamdi I, Ariti C, Williams A, Wood E, Hewitt J. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8948505/#:~:text=Post%2Dstroke%20fatigue%20has%20a,mortality%20rates%20is%20well%2Destablished.&text=This%20condition%20has%20been%20reported,–68%25%20of%20stroke%20survivors. Prevalence of fatigue after stroke: a systematic review and meta-analysis]. European stroke journal. 2021 Dec;6(4):319-32.</ref>
|
* 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<ref name=":5" />
|Differential diagnosis is indicated:


The next is post-traumatic stress disorder. So DSM-V, that is Diagnostic and Statistical Manual of Mental Health Disorders, fifth edition defines post-traumatic stress disorder as a stress-related disorder which comprises of a cluster of four symptoms. The first is intrusion, the next is avoidance, negative alteration in cognition and mood, and alteration in arousal and activity. So the patient has a feeling of intruding and intrusion, right. And the patient continuously in this intrusive feeling, the patient has continuous flashbacks and memories associated with stroke, that I was admitted, and I had so much of IV (intravenous) lines. Or when the patient had stroke there was a loss of consciousness, or what the patient actually felt while having a stroke attack, or following the hospitalisation and the course. So that is intrusion. Avoidance and negative alterations are associated with these things. A psychological trauma is a key feature of PTSD. And now what happens is when we talk about psychological trauma, the patients, the inpatients, are more prone to this because they're hospitalised, a lot of tests are going on. They're going for an MRI, there are different type of lines, catheters, the patient is completely dependent. So these create a psychological trauma to the patient.
* depressed mood presents with fatigue 
* symptoms such as fatigue and loss of energy accompany PSD<ref name=":4" />
|-
|'''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<ref name=":4" />
|
* Includes a complex of many symptoms which hinder functional ability and quality of life


'''Prevalence''':  
* Symptoms can include: hallucination, delusion, delirium


Now, it has been found that one out of four patients develop PTSD following one year of cerebrovascular vascular accident or stroke.
* PSPD will generally develop into dementia<ref name=":4" />
|
* At least 30% of stroke survivors demonstrate symptoms of neuropsychic disorders
* Approximately 4.86% of stroke survivors have delusions or hallucinations secondary to stroke<ref>Agrawal R, Verma S, Vatsalya V, Halappanavar M, Oraka K. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7888683/#:~:text=Neuropsychiatric%20symptoms%20following%20stroke%20occur,or%20hallucinations%20secondary%20to%20stroke. Dilemma of treating psychosis secondary to stroke]. Cureus. 2021 Jan 18;13(1).</ref>
|
|-
|'''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<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" />
|
|}


'''Pathophysiological changes/NT''':  
== Resources ==
 
'''Clinical Features:'''
 
Now, the clinical features of PTSD is, first and foremost, the intrusive symptoms that the patient has dreams, memories or flashbacks of the stroke, followed by hospitalisation, or any bad memory or any difficult memory associated with stroke keeps on coming back to the patient. Persistent avoidance of any particular stimulus that the patient is afraid of. Negative alteration in cognition and mood. All of this is physiologically associated with alteration arousal state of the patient, and the patient is always reactive. There is an increase in reactivity, which is followed by irritability, and anger, and outbursts, and the patient is very much agitated because of this. Now this was all about PTSD.


'''Preventative measure:'''
==== Clinical Resources ====
* [https://www.stroke.org/-/media/Stroke-Files/Support-Group-Resources/Post-Stroke-Depression-Fact-Sheet.pdf Poststroke Depression Fact Sheet] for patient education (American Stroke Association)
* [https://www.strokebestpractices.ca/recommendations/mood-cognition-and-fatigue-following-stroke/post-stroke-depression Canadian Stroke Best Practices]


== Resources  ==
==== Optional Additional Video ====
*bulleted list
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.
*x
or


#numbered list
{{#ev:youtube|DJm11NBthgY|500}} <ref>YouTube. Stroke Connection at ISC: Stroke and Depression: A Practical Approach to Diagnosis and Treatment. Available from: https://www.youtube.com/watch?v=DJm11NBthgY [last accessed 16/July/2023]</ref>
#x


== References  ==
== References  ==
<references />
<references />
[[Category:Plus Content]]
[[Category:Course Pages]]
[[Category:Stroke]]

Latest revision as of 19:23, 15 August 2023

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

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 in the effect stroke has on the development of mental health disorders. Mental health issues are also 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 a stroke survivor's quality of life, treatment outcomes and functional status, burden of care, and mortality 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]

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.[6]

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[edit | edit source]

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.[7] An early study on PSD by Folstein et al.[8] 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.[5]

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]

Pathophysiological Changes Related to PSD[edit | edit source]

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.[7]

According to a 2022 literature review by Frank et al.,[12] the pathophysiology of PSD is complex and unknown, but it involves mechanisms such as:[12]

  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"[12])
  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.[13] 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[14] and (5) lesion location.[7]

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.[15]

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 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.[4][16]
  • 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 (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.[4][17]
  • Anorexia[4]
  • Changes in sleep patterns: insomnia versus hypersomnia[4]
  • Guilt[4]
  • Low self esteem[4]
  • Suicidal ideation[4]
  • Apathy[4] (please see the Differential Diagnosis section below for more information)

Predictors for the Development of PSD[edit | edit source]

Consistent predictors of PSD development supported by research:[7]

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

Other less consistent factors identified as predictors include:[7]

  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[edit | edit source]

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[9]
  • 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[11]
  • 29-40% of stroke survivors demonstrate symptoms of apathy[9]
  • Can be difficult to distinguish from PSD[9][11]
Poststroke Anxiety (PSA) According to the Canadian Stroke Best Practices:
  • "Anxiety disorders occur when symptoms become excessive or chronic"[9]
  • "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)"[9]
  • PSA is closely associated with anxiety prior to stroke[11]
  • Fear[11] and avoidance of stressful situations[4]
  • Worry[11]
  • Irritability[11]
  • Restlessness[11]
  • Physiological arousal: increased heart rate, dizziness, tense muscles, tingling/numbness in hands and feet, headache, chronic muscle spasm, and joint pain[4]
  • Insomnia[4]
  • Can have poor rehabilitation prognosis due to self-restrictive behaviours[4]
  • Up to 20% one-month post-stroke
  • Increases up to 24% six-months post-stroke[4]
  • Usually seen in the chronic phase of stroke[11]
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"[18]
  • 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[18]
 Differential diagnosis is indicated:
  • depressed mood presents with fatigue
  • symptoms such as fatigue and loss of energy accompany PSD[11]
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[11]
  • 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[11]
  • At least 30% of stroke survivors demonstrate symptoms of neuropsychic disorders
  • Approximately 4.86% of stroke survivors have delusions or hallucinations secondary to stroke[19]
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[4]
  • 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[4]
  • 25% PTSD one year post-stroke[4]

Resources[edit | edit source]

Clinical Resources[edit | edit source]

Optional Additional Video[edit | edit source]

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.

[20]

References[edit | edit source]

  1. ↑ 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. ↑ 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).
  3. ↑ 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. ↑ 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 Banerjee, S. Stroke. The Role of Rehabilitation Professionals in Mental Health Disorders Following Stroke. Physioplus. 2023.
  5. ↑ 5.0 5.1 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. ↑ Zhang S, Xu M, Liu ZJ, Feng J, Ma Y. Neuropsychiatric issues after stroke: Clinical significance and therapeutic implications. World journal of psychiatry. 2020 Jun 6;10(6):125.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 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.
  8. ↑ 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.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 9.6 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).
  10. ↑ DSM-5 293.83; Robinson and Jorge, AJP, Volume 173, Issue 3, March 01, 2016, PP. 221-231.
  11. ↑ 11.00 11.01 11.02 11.03 11.04 11.05 11.06 11.07 11.08 11.09 11.10 11.11 11.12 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.
  12. ↑ 12.0 12.1 12.2 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.
  13. ↑ 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.
  14. ↑ Robinson RG, Jorge RE. Post-stroke depression: a review. American Journal of Psychiatry. 2016 Mar 1;173(3):221-31.
  15. ↑ Stuckey SM, Ong LK, Collins-Praino LE, Turner RJ. Neuroinflammation as a key driver of secondary neurodegeneration following stroke? Int J Mol Sci. 2021 Dec 3;22(23):13101.
  16. ↑ 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.
  17. ↑ 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.
  18. ↑ 18.0 18.1 Alghamdi I, Ariti C, Williams A, Wood E, Hewitt J. Prevalence of fatigue after stroke: a systematic review and meta-analysis. European stroke journal. 2021 Dec;6(4):319-32.
  19. ↑ Agrawal R, Verma S, Vatsalya V, Halappanavar M, Oraka K. Dilemma of treating psychosis secondary to stroke. Cureus. 2021 Jan 18;13(1).
  20. ↑ YouTube. Stroke Connection at ISC: Stroke and Depression: A Practical Approach to Diagnosis and Treatment. Available from: https://www.youtube.com/watch?v=DJm11NBthgY [last accessed 16/July/2023]
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