Depression after 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 that develops after a stroke 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. This can also affect their relationships with friends and family. Adjusting to this may take a while, and sometimes that is the very cause of depression.

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 as a result of the stroke. Studies have shown that a person’s social environment and living arrangements 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.

Post-stroke depression has the same kind of signs as "normal" depression. The symptoms are:

• Deep sadness
• Loss of interest
• Listlessness
• Poor concentration
• Low self-esteem
• Insomnia
• Negative and pessimistic thoughts about the future
• Suicidal tendencies

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.

Distinguishing between depression and the feelings of sadness caused by a stroke can be difficult. 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. All of this can be a great strain.

Often, people with post-stroke depression are also unable to tell others how they’re feeling because they have trouble speaking. 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. That's why it's so important that the people around them – doctors and caregivers, as well as friends and family – look out for signs of depression.

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. This increased emotionality is not the same thing as depression even if there are similarities.

As well as having a major impact on quality of life, post-stroke depression can slow down the process of recovery. 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. Someone experiencing depression will have more trouble motivating themselves and less desire to work on regaining their physical and mental abilities than someone who doesn’t have depression. As a result, it can take them longer to recover, or they might even deteriorate.

Depression is often treated with medication (antidepressants) and/or psychotherapy. But everyday support from relatives or professional carers can play an important role in the recovery process and in coping with disabilities too.

Making sure treatment and rehabilitation are well organized will help improve the impairments caused by the stroke. In turn, good physical recovery can have a positive effect on mental health.

Studies show that special medication for depression (antidepressants) can help people who have developed post-stroke depression. They may also have a positive effect on physical recovery. Research has concentrated on two groups of antidepressants: selective serotonin re-uptake inhibitors (SSRIs) and triyclic antidepressants. They are among the drugs most frequently used for treating depression.

The studies showed the following after two to four months:

• Without antidepressants, 60 out of 100 people were still experiencing depression.
• With antidepressants, 42 out of 100 people were still experiencing 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 sometimes the depression doesn’t go away despite taking medication, or it may return.

Antidepressants can cause symptoms like drowsiness, shaking and digestion problems. 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.

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

Psychiatric and psychological health professionals can help the person deal with their condition and the changes it brings. This support is provided at hospitals and rehabilitation facilities, but also at centers for psychosocial support and psychotherapy practices.

Studies indicate that psychotherapy can help relieve post-stroke depression:

• Without psychotherapy: 70 out of 100 people were still experiencing depression after one year.
• With psychotherapy: 54 out of 100 people were still experiencing depression after one year.

A person’s chances of recovery after a stroke improve if everyone around them is committed to supporting their treatment. That means the nursing staff, physiotherapists, psychologists, doctors and their friends and family. Counseling and psychoeducation can help. Psychoeducation helps the person and their loved ones understand the condition and cope with its effects.

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. Exercise and strength training are important as well and can even help ease the symptoms of depression. This also applies to traditional Eastern practices such as tai chi and qigong, as well as to music therapy. Successful rehabilitation therapy requires a lot of motivation, but it can make an important difference to people's quality of life after a stroke.

Just trying to cheer people up or give them advice when they’re depressed is usually not helpful. Coping with the illness requires a great deal of empathy and patience from friends and family. What's more, people with depression can be prone to mood swings. Depression can also have different signs. Older people with depression experience pain more frequently than younger people, for example.

Looking after a loved one who’s had a stroke can be very - sometimes too - challenging. So it’s not uncommon for family caregivers to experience depression as well. That makes it more difficult for them to provide proper support. The result can be additional strain on both the caregiver and the person being cared for. So looking after the caregivers is not only important for them and other family members, but also for the person who had the stroke.

There are plenty of places to get help, like information centers and support groups, where people who have depression and their families can get advice about various health care, financial or psychosocial matters. Many cities, local authorities and welfare associations in Germany have special centers that provide information on nursing care, free of charge. The Centre for Quality in Care (Zentrum für Qualität in der Pflege, ZQP) has a database on its website that allows you to search for local information centers for caregivers (in German).

Family members can also take nursing care courses to learn things like basic care techniques.