Surviving a stroke is not the end of a medical issue. It's the start of a new journey, with new challenges. Major depression is often one of those challenges. It interferes with recovery, rehab, adjusting to a new life, and maintaining relationships.
In short, it's big problem. And it's pretty common.
According to new research by Dr. Laura Stein from the Icahn School of medicine, depression after stroke is twice as likely to occur as depression after heart attack. There's something unique about stroke that leads to depression.
On top of that, if a person lived with Generalized Anxiety Disorder before stroke, they are 1.7 x as likely to experience Major Depression after stroke.
In this conversation, Dr. Laura Stein talk about her research and what survivors, caregivers, and medical practitioners need to know.
Bio
Laura K. Stein, MD, MPH is an Assistant Professor of Neurology at the Icahn School of Medicine at Mount Sinai and attending physician at the Mount Sinai and Mount Sinai Queens Stroke Centers. She is board certified in Neurology and Vascular Neurology by the American Board of Psychiatry and Neurology. Dr. Stein received a BA from Amherst College and her MD and MPH from the Icahn School of Medicine at Mount Sinai. She completed her internship, neurology residency, and vascular neurology fellowship at Mount Sinai.
Dr. Stein's interests are in stroke clinical care, stroke outcomes research, and medical education. She is the Neurology Residency Associate Program Director and precepts first year medical students in the Art and Science of Medicine preclinical skills course. Dr. Stein received the Department of Neurology Resident Class of 2020 Award of Appreciation for Dedication & Commitment Towards Excellence in Mentorship and 2020 Institute for Medical Education Excellence in Teaching Award.
The Research
Dr. Stein's research was part of the American Stroke Association’s virtual International Stroke Conference. You can read the paper here.
You can read the article where I first encountered her work here.
The approach of looking at depression after heart attack vs looking at depression after stroke is an interesting one. It's a nice way of controlling for other potential causes.
The research looked at Medicare recipients, Medicare is a US government health insurance program, generally for folks 65 and older. It lets researchers draw from a rich collection of data. There are two significant tradeoffs, of course.
First, it's restricted to the US so there's no international representation in the study. Obviously, depending on the research question in particular, that may or may not be an issue.
Second, it's restricted to folks 65 and older. Can we say that the results of this study apply to younger stroke survivors?
Maybe?
Probably?
We don't know. And this study was not designed to answer that question. I'd say it does get us closer, though, and it opens up an opportunity to do further research that asks different but related questions.
That's what good studies do. The answer specific question with solid evidence and clear analysis. And the result can introduce new questions for researchers to explore in different studies.
In the meantime, it's likely safe to say, that regardless of age, stroke survivors are probably more likely to experience depression, and the community needs to be vigilant for the signs of depression and seek treatment accordingly.
Symptoms of Major Depression
Diagnosing depression involves identifying symptoms from a couple lists. To "earn" a depression diagnosis, a patient needs 5 symptoms from list 1 and all 4 from list 2. They are:
List 1 (Pick 5 or more)
- Depressed Mood (most days)
- Loss of Interest or pleasure
- Weight loss or gain
- Insomnia or hypersomnia (nearly every day)
- Psychomotor agitation or limitation
- Fatigue (nearly every day)
- Feelings worthless or experiencing inappropriate guilt
- Decreased concentration (nearly everyday)
- Thoughts of death or suicide
List 2 (All 4)
- Symptoms cause significant distress or social/professional impairment
- Symptoms not attributable to a substance or medical condition
- Symptoms not explained by another disorder
- No history of manic episodes
You can read more details about the symptoms here.
You can probably see one of the issues. Many of those symptoms may be directly attributed to the disabilities and brain damage of the stroke without it being Major Depression. That's why it's important to work with a medical professional to tease them apart.
Symptoms of Generalized Anxiety Disorder
Generalized Anxiety Disorder is about more than feeling nervous. It's more complicated and severe.
The National Institute of Mental Health describes it this way:
People with generalized anxiety disorder (GAD) display excessive anxiety or worry, most days for at least 6 months, about a number of things such as personal health, work, social interactions, and everyday routine life circumstances. The fear and anxiety can cause significant problems in areas of their life, such as social interactions, school, and work.
Generalized anxiety disorder symptoms include:
- Feeling restless, wound-up, or on-edge
- Being easily fatigued
- Having difficulty concentrating; mind going blank
- Being irritable
- Having muscle tension
- Difficulty controlling feelings of worry
- Having sleep problems, such as difficulty falling or staying asleep, restlessness, or unsatisfying sleep
You can read more about the condition here.
Neuropsychology
While most psychologists and psychiatrists can help stroke survivors and others with depression and other conditions, there is a specialty that may be even more helpful -- neuropsychology.
A while back, I talked with Dr. Karen Sullivan from I Care For Your Brain. She wrote the "Interactive Stroke Recovery Guide."* You can listen to that conversation or learn more at http://Strokecast.com/Karen
A neuropsychologist has additional, specialized training to work specifically with folks who have brain injuries. They dive deep into the details of the injury to provide the best customized treatment plan, leveraging expertise that generalists don't have.
They work with folks with a wide array of functionality and challenges.
FLAME vs FOCUS
As long as we are talking about depression, we should also talk about antidepressants a little -- specifically SSRIs and how the relate to stroke.
In 2011, the FLAME study was published in the Lancet. In short, it demonstrated that stroke survivors who took Prozac (Fluoxetine) experienced stronger motor recovery. Many hospitals saw those results and began putting more stroke survivors on Prozac because, well, why not? If the patient tolerates it well, and it can help folks work better, it's probably a good idea. And if it reduces or prevent post stroke depression (or other depression) that's a solid win.
I talked with Dr. Nirav Shah about this back in November of 2018. You can listen to that episode here.
That's how I started on an SSRI in my stay. They originally tried Prozac with me, but I had a not great reaction to it. It apparently gave me an anxiety attack. So we quickly stopped that (thank you, Xanax, I think). We talked about it some more and tried again with a different SSRI -- Lexapro (Escitalopram) because I had tolerated it well during a tough time some years earlier.
Cheap, no negative side effects, and potentially helpful is win.
A month after my interview with Nirav, and a year and a half after my stroke, the FOCUS study came out, attempting to duplicate the results of the FLAME study on a bigger scale.
It failed.
The scientific consensus now is that SSRIs do not help with motor recovery. They do still help with depression.
The hospital no longer recommends SSRIs as part of the motor recovery protocol.
So what does that mean for folks like me?
I asked my doctor last year if that meant I should stop taking them. We talked about it and she explained I could certainly stop if I wanted to.
"But, dude -- it's 2020."
And she had a valid point.
(Okay, maybe I paraphrased that)
And that's why Escitalopram still has a place in my pill organizer.
As always, everyone's stroke and circumstances will vary, so talk to your doctor before making any changes to your medication.
Hack of the Week
Get a dog.
A dog can be helpful after stroke, whether it's a service dog or simply a companion animal.
When you have a dog, you have a responsibility to take care of it. You have to feed it, walk it, groom it, and give it cuddles.
Sometimes that may be reason enough to get out of bed and get moving for the day.
Links
Where do we go from here?
- If you think there's a chance you might be experiencing depression, talk to your medical team
- Share this episode with someone you know with the link http://Strokecast.com/depression
- Subscribe to the free, monthly Strokecast email newsletter at http://Strokecast.com/news
- Don't get best…get better.
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