Depression after a stroke

Photo of an older couple at the park (PantherMedia / Dieter Möbus)

Some people develop depression after a stroke. It is important to diagnose and treat it. Good medical treatment and nursing care are crucial, along with support from family and friends.

Grief and sadness are normal shortly after a stroke. But about one third of all people who have a stroke later develop depression that requires treatment. Women may have a slightly higher risk than men of becoming depressed following a stroke.

Depression is not always noticed and treated properly after a stroke. The condition is also called "post-stroke depression" (PSD).

Why can depression occur following a stroke?

It is not exactly clear whether the causes of depression after a stroke are mainly physical or psychological. After all, a stroke damages the brain, and brain damage can also affect people's emotions. But depression can also be a reaction to physical and mental limitations and the sudden loss of independence. This is known as reactive depression.

Depression normally occurs within the first few weeks after a stroke. During that time, people have to come to terms with the fact that they could have died, and have to recover physically. In the medium to long term, some people will have to get used to disabilities and how they affect their daily lives as well as their relationships with friends and family. This can take a while, and sometimes that is the very cause of depression in some people.

Depression is more common after a major stroke than after a mild one, and is also more likely in people who have already suffered from depression. The severity of a person's depression often depends on how physically or mentally limited they are in daily life. Studies have shown that a person's social environment, living arrangements and the support they get can also influence the likelihood of developing depression. Good treatment and social support can help reduce the risk of depression developing following a stroke.

Sometimes depression goes away after a while without treatment. Most people do need treatment to get over the illness, though.

How can you tell if someone is depressed after a stroke?

It is important to know the difference between depression and the feelings of sadness caused by a stroke. Strokes often lead to paralysis on one side of the body. That can seriously affect a person's ability to move or lead an independent life. Everyday activities like eating and washing may be difficult without the help of others. On top of this, people may have problems with body awareness because they have little or no feeling in the paralyzed side of their body. Difficulties with speech or understanding could be a further burden. Not being able to communicate properly can be very depressing. Some people may just appear depressed to others because they are unable to express their emotions as easily as they could before their stroke. So, depression after stroke can be tricky to detect.

It is diagnosed in the same way as "normal" depression. The symptoms are:

  • Deep sadness
  • Loss of interest
  • Listlessness
  • Poor concentration
  • Low self-esteem
  • Sleep problems

If several of these symptoms occur together and last for more than two weeks, it could be a sign of depression. It is important to seek medical advice if you think that it might be depression. People with depression often don't talk about how they feel. They may also be unable to express themselves clearly enough because of problems with speech. That's why it's so important that the people around them – doctors and carers, as well as friends and family – look out for signs of depression.

Sometimes people who are depressed are overly emotional. They might have less control over how they express their emotions after a stroke, and find that they suddenly start crying – or even laughing – for no apparent reason. They may also generally have more mood swings and react very emotionally.

How are patients and those close to them affected by depression?

Being depressed can slow down recovery after a stroke. Whether or not stroke-related disabilities improve depends on various factors, including how actively a person participates in their therapy. For example, certain physical exercises can help to improve movement on the paralyzed side of the body. But this often takes a long time, and can require a lot of patience and motivation. People with depression find it more difficult to motivate themselves. They may not be able to work as hard to restore their health as people who aren't depressed. As a result, it could take them longer to recover, or their physical and mental abilities may even get worse.

People who are caring for somebody who has had a stroke can also develop depression, especially if the care gets too much for them. It is more difficult for people with depression to give somebody who has had a stroke the help they need. This can be an additional burden. So looking after the carers is not only important for them and other family members, but also for the person who had the stroke.

What treatment options are available?

Depression is often treated with medication (antidepressants) and / or psychological interventions such as counseling or psychotherapy. The treatment options include support, learning about your thought patterns, stress management techniques and relaxation strategies. Some people also use complementary therapies, such as massage or herbal products with ingredients like St. John's wort (hypericum). Research suggests that a targeted exercise program can reduce the symptoms of depression. Programs involving regular strength training or endurance sports are two examples.

Antidepressants

Studies show that antidepressants can help people who have developed depression following a stroke. They may also have a positive effect on physical recovery. The following two groups of antidepressants have been studied the most: Selective serotonin re-uptake inhibitors (SSRIs) and tricyclic antidepressants. They are among the most frequently prescribed drugs for treating depression.

The medication doesn't have an immediate effect. But the symptoms usually begin to improve within the first six to eight weeks. Some people also find that they start to feel better after a while without taking antidepressants. Generally speaking: The more severe the depression, the greater the benefit of medication. But there is no guarantee of success. Depression may not go away despite taking medication, or it may return.

Antidepressants can also have side effects, including drowsiness, cramps, bleeding and digestion problems. But there isn't enough research to say how often such side effects are experienced by people who have had a stroke. Because walking can be difficult or only possible with a walking aid after a stroke, it is especially important to pay attention to side effects that influence coordination. Dizziness and drowsiness can increase the risk of falling, for example. There isn't enough research on the effects of antidepressants in people with specific problems such as trouble speaking or understanding.

Antidepressants can also interact with other medication and affect how it works. For those and other reasons, doctors carefully monitor people who take antidepressants following a stroke. They may need to stop taking the medication or switch to other medication.

Psychological and psychotherapeutic support

Professional support is a key element in treating depression, and might also be advisable for people who have had a stroke. Psychiatrists, psychologists and trained counselors in hospitals or rehabilitation clinics can help people to come to terms with their condition and the changes in their lives. But there aren't any good-quality studies in this area. Help can also be found at centers for psychosocial support.

Medication and psychological therapy are not the only options for preventing and treating depression. Everyday support from relatives or professional carers can play an important role in the recovery process and in coping with disabilities. The more support people receive, the more successful their rehabilitation after a stroke is likely to be. In turn, good physical recovery can have a positive effect on mental health.

How can you help people with depression?

People recover better from a stroke if everybody involved gives their full support. Research has shown that people cope more successfully in the long term if treatment is very well organized, and nurses, doctors, physiotherapists and people close to them actively participate in their care. Occupational therapy in particular can help to regain certain physical abilities. This involves practicing daily activities like washing, getting dressed and doing things around the house. Successful rehabilitation therapy requires a lot of motivation, but it can make an important difference to people's lives after a stroke.

Simple words of encouragement and advice usually don't help to motivate people who are depressed.  A lot of empathy and patience are needed when trying to help them. What's more, people with depression can be prone to mood swings. And depression can take many different forms. For example, older people tend to experience more pain than younger people.

Looking after a family member who has had a stroke can be a major challenge, but there is a lot of help available. Information centers and self-help groups, for instance, can provide patients and their families with help concerning nursing care, finances and psychosocial issues. Many cities and local authorities have special centers that provide information on nursing care, free of charge. Close friends and family members can also attend courses to learn basic nursing techniques, among other things.