AHA News: Understanding the Stroke-Depression Link – And What Survivors and Families Can Do

TUESDAY, Feb. 21, 2023 (American Heart Association News) -- News that one of America's best-known stroke survivors was being treated for depression highlights a common and serious connection between the two afflictions.

Last May, Sen. John Fetterman made national headlines after his near-fatal stroke. On Thursday, his staff announced he had checked into a hospital for depression. He'd experienced depression off and on throughout his life, but it had worsened in recent weeks.

The prepared statement did not explicitly link his stroke with depression. But depression commonly follows stroke, and it is important for patients, caretakers and physicians to be aware of the connection, said Dr. Ricardo Jorge, professor of psychiatry and behavioral sciences at Baylor College of Medicine in Houston.

"Stroke not only brings about physical changes and physical impairment but also psychological or behavioral impairment, and these need to be recognized," said Jorge, who also holds the college's Beth K. and Stuart C. Yudofsky Chair in Brain Injury Medicine.

According to a 2016 American Heart Association scientific statement that Jorge helped write, poststroke depression affects about a third of stroke survivors at any one time, although he said estimates vary based on how depression is defined. The likelihood is greater during the first year after a stroke and slowly declines after.

Dr. Nada El Husseini, an associate professor of neurology at Duke University in Durham, North Carolina, said that over time, up to half of stroke survivors may experience depression at some point.

The best-established predictors for poststroke depression include a previous history of depression and the stroke's severity, said El Husseini, who also helped write the 2016 statement. Significant physical disability and cognitive impairment also "go hand in hand" with poststroke depression risk.

Depression that happens after a stroke is similar in many ways to depression without a stroke, she said. "It may manifest as a sense of sadness, hopelessness, feeling unworthy, having guilty feelings over minor things or having little interest or pleasure in doing things." A person with depression might have difficulty concentrating, have little energy, become fidgety, or might not want to eat or might eat too much. They might not be able to sleep or might sleep too much. They might contemplate suicide. Symptoms typically must occur at least several days over two weeks to qualify as depression.

The diagnosis is complicated by overlapping factors that can appear to be depression but aren't, El Husseini said. A stroke survivor might be dealing with issues such as grief from a loss of ability or post-traumatic stress from experiencing a stroke and hospitalization. Stroke survivors also can experience a condition known as pseudobulbar affect, which can lead to involuntary bouts of crying, laughter or anger.

Depression can affect even people who have transient ischemic attacks, or "mini-strokes," that leave no physical effects. Depression also affects people whose strokes leave them unaware of their disabilities, a condition known as anosognosia.

The exact biology of stroke and depression is not clear. Jorge said one possibility is that a stroke affects brain circuitry that regulates emotion. Other factors cited by El Husseini include genetic susceptibility and inflammation. In addition to biological factors, psychosocial factors may contribute.

Regardless of the mechanism, it's crucial for stroke survivors and those around them to understand that depression is connected to recovery. "We have multiple studies suggesting that outcomes after a stroke are worse if someone is depressed," El Husseini said. Poststroke depression has been linked to higher mortality rates after stroke, as well as lower brain function and poorer ability to function overall.

Luckily, there are several approaches for treating post-stroke depression. Interventions such as problem-solving therapy can help, as can antidepressant medication, though studies conflict on the best one, Jorge said. Repetitive transcranial magnetic stimulation, a noninvasive form of brain stimulation, also has shown promise.

Stroke survivors who have social support fare better than isolated ones, El Husseini said. "It's not the only factor, and of course, some people who have excellent social support can still be depressed."

Early treatment of depression may improve both physical and cognitive recovery from a stroke, Jorge said. Given how many people are affected and the serious implications for their recovery, he said all stroke survivors need to be screened for depression.

"Both family and physician need to work together in trying to arrive at a diagnosis," he said. Family members might spot changes a doctor might miss and should alert a physician if they see something.

El Husseini agreed. "It is very important for caregivers and patients to understand that physical disability is not the only thing that can happen" after a stroke. Problems like depression, anxiety, fatigue, cognitive changes and sleep issues are real but can be harder to detect.

"Somebody may be walking and acting normally after stroke," she said. "But they may be experiencing a lot of other things that others cannot see."

The 988 Suicide & Crisis Lifeline connects people in crisis with suicide prevention and mental health counselors. Call or text 988 or visit the Lifeline site.

American Heart Association News covers heart and brain health. Not all views expressed in this story reflect the official position of the American Heart Association. Copyright is owned or held by the American Heart Association, Inc., and all rights are reserved. If you have questions or comments about this story, please email editor@heart.org.

By Michael Merschel, American Heart Association News