Mental Health Disorders Following Stroke

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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 and research around the effect stroke has on the development of mental health discorders. Mental health issues are 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 the stroke survivors quality of life, treatment outcomes and functional status, burden of care, and morality 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.

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

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. 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.

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 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.

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. Neuroinflammation can lead to a dysregulated immune system, which can been linked by Tubbs et al. to infectious disease and psychiatric disorders. 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 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 research article published in 2021.

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 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.
• Lack of interest or lack of pleasure in activities which were previously enjoyable to the patient
• Lack of energy
• Reduced concentration
• 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.
• Anorexia
• Changes in sleep patterns: insomnia versus hypersomnia
• Guilt
• Low self esteem
• Suicidal ideation
• Apathy (please read below for more information on this topic)

Predictors for the development of PSD

Research supported consistent predictors of PSD development:

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

Other less consistent factors that have been 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

Make into table

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	How differs from PSD
Poststroke Apathy
Poststroke Anxiety
Poststroke Fatigue
Poststroke Psychotic Disorder
Post Traumatic Stress Disorder in Stroke

Post-stroke apathy

Post-stroke apathy is so similar to PSD that it is difficult to distinguish them. The differentiation could depend on varying psychiatric symptoms, emotional properties, or facial expressions. In psychiatric symptomatology, apathy is related to disinhibition, declining cognitive function, and aberrant motor behaviors, while depression is associated with anxiety, agitation, and irritability.83 Regarding emotional properties, apathetic patients are indifferent, have a neutral mood, and are usually without suicidal ideation,84 but depressed patients show a clearly negative mood. With respect to facial expression, apathetic patients often present a flat affect and lack of eye contact, while most depressed individuals have a typical expression of sadness, with emotion in their eyes.

Post-stroke anxiety (PSA)

PSA is usually seen in the chronic phase of stroke, with the incidence rising over time,85 while most PSD occurs in the acute stage. Although the occurrence of PSD is loosely linked to prior history of depression, it is rather strongly influenced by the stroke itself; however, PSA is closely associated with prior anxiety.86PSD patients mostly show a constantly depressed mood and loss of interest, accompanied by somatic or mental anxieties such as worrying, tension, and palpitation, which are all attributable to depressive mood. In comparison, PSA patients present fear, tension, worry, irritability, or restlessness.

Post-stroke 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.87 It is necessary to differentiate PSF from PSD when depressed mood presents in fatigue and when symptoms such as fatigue and loss of energy accompany PSD.

Post-stroke psychotic disorder (PSPD)

PSPD refers to many types of psychiatric syndromes in the acute, rehabilitation, and sequelae stages of stroke. It is reportedly a complex of many symptoms, including hallucination, delusion, and delirium, which hinders functional outcome and quality of life.88 Although usually with a slow and fluctuating course that may rapidly worsen when aggravated by a stroke or improve due to compensating collateral circulation, PSPD will generally develop into dementia despite its various clinical presentations.

Apathy, a related diagnosis, is defined as 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. 29-40% of stroke survivors demonstrate symptoms of apathy.

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

Post-Stroke Anxiety

Description:

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.

Prevalence:

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.

Pathophysiological changes/NT:

Clinical Features:

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.

Preventative measure:

Post-Traumatic Stress Disorder in Stroke

Description:

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.

Prevalence:

Now, it has been found that one out of four patients develop PTSD following one year of cerebrovascular vascular accident or stroke.

Pathophysiological changes/NT:

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:

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