ATrain Education

 

Continuing Education for Health Professionals

Stroke: Emergency Care and Rehabilitation

Module 16

Psychosocial Issues and Depression

A significant number of people struggle with psychological and psychosocial issues and depression following a stroke. Many will require mental health treatment to address depression, anxiety, frustration, or anger.

These psychiatric comorbidities have a powerful influence over both quality of life and functional outcomes. In a sample of more than 50,000 ischemic stroke patients, those patients diagnosed with depression or other mental health concerns had an increased risk of death 3 years post stroke, even after the influences of other chronic conditions were statistically controlled (Han et al., 2014).

Post Stroke Depression

Post stroke depression has both physical and psychological components and it is thought that about one-third of all people who have had a stroke will develop depression (Hackett et al., 2008). The presence of depression is significantly and independently associated with the presence of cognitive impairment in stroke survivors 1 year following the stroke event (Teasell, McClure, Salter, Murie-Fernandez, 2014). Women are at a higher risk than men for experiencing depression, and people who have had difficulties with depression prior to stroke are more likely to have a resurgence of their depressive symptoms post stroke.

Depression, grief, and sadness have an enormous impact on stroke survivors and their caregivers. People who were accustomed to living independently suddenly become reliant on others—either voluntary or hired. This results in physical, psychological, and financial adjustments that must be made to their day-to-day life. Therapy and other forms of counseling can help people regain some level of independence and gradually adjust to changes induced by the stroke (Hackett et al., 2008).

Several factors may affect the risk and severity of depression after a stroke, including:

  • Area of the brain where stroke damage occurred
  • Personal or family history of depression or other mood or anxiety disorders
  • Level of social isolation before the stroke (NIMH, 2011)

Diagnosis of depression after stroke is the same as depression at other times. Consider a diagnosis of depression if symptoms last for more than two weeks. Warning signs include:

  • Deep, ongoing sadness or anxiety
  • Loss of interest in activities that were once enjoyable
  • Lack of motivation, difficulty making decisions
  • Poor concentration, difficulty remembering details
  • Low self-esteem, feelings of worthlessness, helplessness
  • Sleep difficulties, sleeping all the time, difficulty falling asleep or staying asleep
  • Overeating or loss of appetite

Some people who are depressed may also be unable to modulate their emotions. They may laugh or cry inappropriately or become volatile. Pre-existing drug or alcohol problems may resurface or become exacerbated, making it more difficult to participate in rehabilitation activities.

Recovery from depression takes time, but treatments can be effective. At present, the most common treatments for depression include:

  • Cognitive behavioral therapy (CBT)
  • Selective serotonin reuptake inhibitors (SSRIs) such as citalopram (Celexa), sertraline (Zoloft), and fluoxetine (Prozac)
  • Serotonin and norepinephrine reuptake inhibitor (SNRI) such as venlafaxine (Effexor) and duloxetine (Cymbalta) (NIMH, 2011)

People recover better from a stroke if they receive good support and comprehensive care. In the long term, they cope more successfully if their treatment is well-organized with a well-coordinated team identifying and meeting needs as they arise. Stroke recovery also requires that the individual be highly motivated in order to adhere to a plan of care. Early identification and referral when depression is suspected helps to ensure that patients receive the support and understanding needed to adjust to sudden and overwhelming changes to their life (Han et al., 2014).

To address this intersection of neurology and neuropsychology, the National Institute of Neurological Disorders and Stroke–Canadian Stroke Network (NINDS-CSN) developed a vascular cognitive impairment (VCI) half-hour assessment protocol. The assessment is used to monitor proactively stroke patients’ cognitive, psychiatric, and functional outcomes during outpatient followup. In this model, neuropsychologic assessments are integral to supporting stroke patients’ quality of life and increasing patient satisfaction with stroke-related healthcare services. Acknowledging this, recent standards called for routine, standardized cognitive and mood assessment in both clinical practice and research with stroke patients (Han et al., 2014).

Changes in Identity

The sudden and dramatic onset of cognitive changes such as aphasia following stroke is associated with major disruptions of a person’s quality of life. The psychosocial adjustment process is complicated and protracted, and people with aphasia are especially prone to psychosocial problems such as anxiety and depression, disruptions related to identity, changes in their relationships with significant others, reduced social networks and social isolation and exclusion, unemployment, and loss of leisure activities. The emotional and psychosocial factors have a marked impact on recovery, the psychosocial adjustment process, and the response to rehabilitation (Bronken et al., 2013).

In particular, aphasia has a profound effect on a person’s identity. It affects occupational identity, family relationships and roles, and social identity. In a number of semi-structured interviews with 12 post stroke survivors with aphasia, these themes were touched on again and again. All participants were employed fulltime prior to their strokes and none had been able to return to their previous jobs (Musser et al., 2015).

Participants spoke about the difficulty they had accepting the loss of an occupational identity and their struggle to find some kind of work they could do. Participant “J” narrated the difficulty he had accepting that he could not return to work, describing his experience of driving to his office repeatedly and trying to engage in his previous occupation. Participant “S,” whose stroke was more recent, was still trying to come to terms with his options for employment and income. Both participants expressed the sense of displacement they felt when they were abruptly forced to retire from their professions (Musser et al., 2015).

Many participants, once they had received a certain amount of rehabilitation, were eager to engage in some kind of meaningful activity. Several became hospital volunteers or peer visitors to other stroke patients; they were able to draw on their own experiences in a way that they felt would be helpful to others. One participant, “B,” who had previously worked as a computer programmer, responded enthusiastically to the subject of volunteering at the hospital. “B” and his partner framed his volunteer work in terms of an earlier aspiration to be a physician. This reclaiming of an occupational identity helped him to embrace a sense of meaning in his daily activities (Musser et al., 2015).

While the changes in occupational identity were often individually experienced, the shifts in relationships and family roles were often jointly negotiated by the participant and other people, their partner or children. Participants and their partners spoke of changes in the dynamic of their relationship as the result of aphasia. In some cases, the balance of responsibilities in the relationship shifted. While the participants spoke about the impact of aphasia on their occupation, “J’s” wife characterized the experience in terms of this shift in balance and roles. She acknowledged feeling overwhelmed by the change (Musser et al., 2015).

Participants and their partners also talked about the changes they experienced in their sense of themselves in their broader social lives: their level of independence and their ability to meet and talk to new people. They discussed the impact of the aphasia on their friendships and social support, especially in terms of the partner. “V’s” wife noted his difficulty meeting and talking to people. She describes him as friendly and talkative before the stroke, a personal style that she feels has since changed. Here, she reflects that his aphasia makes it much harder for him to relate to people in the way he did before and results in his withdrawing more at social events and enjoying them less. Previously, “V” knew himself as someone who enjoys being around others; now, he is more self-conscious and avoids situations where he might have to introduce himself or talk to acquaintances. As “V’s” wife notes, while his stroke has changed his ability to interact with others, the more profound change is in “V” himself—his desire to be social and his social identity (Musser et al., 2015).

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