Many patients who have had a stroke experience neuropsychiatric sequelae, such as apathy, depression, anxiety, PTSD, irritability, pseudobulbar affect, impulsivity, mania, and psychosis (Table 1). Every year in the United States, almost 800,000 people have a stroke, which creates a large population at risk for post-stroke neuropsychiatric disorders. The prevalence of stroke in younger individuals is increasing, and it is likely that psychiatrists might encounter these disorders.1 Post-stroke neuropsychiatric disorders can follow either ischemic or hemorrhagic stroke; attempts to link specific psychiatric disorders with the type, mechanism, or location of stroke have not produced clear associations.2
This review focuses on post-stroke depression (PSD), apathy, anxiety, and PTSD, because these disorders occur and have been studied most frequently. Of these disorders, PSD remains the best-understood condition.
Post-stroke neuropsychiatric disorders do not occur solely as an adjustment reaction to disability or increased awareness of ones mortalityrather, the direct neurophysiological effects of stroke can cause depression and other disorders. For example, older adults with asymptomatic ischemic white matter disease and no history of clinical stroke show higher rates of depression.3 Stroke and psychiatric disorders have a bidirectional relationship and may share common risk factorsnot only does stroke increase the risk of depression, anxiety, and mania, but individuals with premorbid idiopathic forms of these conditions also have an increased risk of stroke, even after controlling for conventional vascular risk factors. While the definitive explanation remains unknown, shared etiologic factors may include inflammation, hypothalamic-pituitary-adrenal axis deregulation, serotonin-mediated effects on platelet and endothelial function, and excessive sympathetic tone.
Some general treatment principles apply across different post-stroke neuropsychiatric disorders. Up to 25% of stroke patients will experience a second stroke in the next 5 years; a recurrent stroke may well negate any benefits received from interim psychiatric treatment.1 Thus, patients need appropriate secondary stroke prophylaxis, such as antiplatelet agents or anticoagulation for ischemic stroke; control of hypertension, hyperlipidemia, and diabetes mellitus; assistance with smoking cessation; and regular exercise.
While psychiatrists need not personally provide treatment for comorbid medical conditions, they should make sure a primary care physician (PCP) or an appropriate specialist does, and they should make referrals as necessary. If possible, psychiatrists should avoid prescribing medications with adverse metabolic effects (eg, atypical antipsychotics) or that can cause hypertension (eg, stimulants, SNRIs). Review with patients and families the warning signs of stroke and the importance of immediately calling 911 if such symptoms occur, so that thrombolytics can be administered if appropriate.
Patients with post-stroke neuropsychiatric disorders require ongoing evaluation of suicide risk. Up to 7% of patients with stroke subsequently die by suicide, a much higher rate than the general population, and elevated suicide risk may persist for 5 years after a stroke.4 Depression represents the most significant risk factor for post-stroke suicide, although patients with less severe strokes and younger patients also show increased risk. Post-stroke fatigue may constitute an independent risk factor for suicidal ideation, but this has not been clearly established.
Post-stroke depression
PSD may take the form of a major depressive episode or may resemble minor depression; however, both have significant clinical implications. Clinicians need to be able to differentiate symptoms of PSD from those of post-stroke apathy because they are similar; however, many patients experience both. Post-stroke irritability may also occur in the context of depression.2
PSD may persist for more than 1 year in up to half of patients. If depression does not manifest in the initial post-stroke period, it may develop anytime over the next year. A history of previous depression significantly increases the risk of PSD, but de novo depression can also develop following a stroke in persons without any prior psychiatric history.
Continue reading here:
Neuropsychiatric Sequelae of Stroke: Issues and Implications for Clinicians