Stroke and Depression

For all of his advantages, there was a moment when actor Kirk Douglas was so despondent after suffering a stroke that he opened a drawer, grabbed the pistol he had used in the film Gunfight at the OK Corral, and put the gun in his mouth. But he accidentally knocked the barrel against his teeth. The pain made him laugh at himself long enough to reconsider pulling the trigger.

In the years following his stroke in 1995, the macho film legend recovered his ability to speak, and went on to write a book about his experience to inspire other stroke victims during their recovery.

But if severe depression could overtake Kirk Douglas, who had the best of everything -- a parade of household help, the support of his family and thousands of adoring fans -- think how emotionally devastating a stroke can be for the rest of us.

As many as half of all people who suffer a stroke become clinically depressed, according to Dr. Mustapha Ezzeddine, a stroke neurologist with the National Institute of Neurological Disorders and Stroke. It's certainly understandable that a person's outlook would be directly connected to how much he or she has lost. After having a stroke, people can experience full or partial paralysis of the muscles in their faces or limbs. They can also lose the ability to speak, significantly jeopardizing their connection to the rest of the world.

When book editor Robert McCrum suffered a stroke at age 42, he felt an overwhelming sense of failure and depression. "Every time I got into the wheelchair, I felt vulnerable and helpless, stupid and ashamed," writes McCrum in his book My Year Off. Some people, like Douglas, even feel suicidal.

Unfortunately, depression can delay or damage the prospects for recovering from a stroke, according to several medical studies. One report in the journal Stroke examined the functioning of 55 patients treated for depression after having a stroke. Researchers found that 21 patients whose depression lifted after treatment had "a significantly greater recovery in activities of daily living" than the 34 patients whose mood did not improve.

Although it's understandable to feel overwhelming anguish, there are ways to recover from depression with the help of your friends, family, and support groups as well as professional care.

How can I distinguish between depression and the effects of a stroke?

If a stroke has caused dramatic changes in your behavior or diminished your ability to function or communicate, it may be hard for people around you to distinguish disability from depression. For example, it could be harder to recognize depression in a stroke survivor who has trouble speaking or understanding language (aphasia). Sometimes family members think that it's natural for a stroke victim to mourn the loss of function, and so they fail to recognize true depression.

If you have crying outbursts that last for a few minutes and suddenly stop, it may seem like depression, but it may not be. It's a condition that doctors call "emotional lability." This is most prominent in the first few months after a stroke, and could also include outbursts of inappropriate laughter.

You should, however, suspect that you are depressed if you have experienced several of the following symptoms for two weeks or more: feelings of hopelessness, fatigue or lack of energy, no interest in activities you previously enjoyed, sleeping too little or too much, overeating or loss of appetite, low self-esteem, sadness. If you experience these things, ask your doctor to refer you to a mental health professional. If you feel suicidal, you should contact your doctor or a mental health professional immediately and seek out a friend or family member for company. Anyone who feels suicidal shouldn't be alone.

What causes depression in stroke survivors?

Some scientists believe that the stroke-induced brain injury itself can cause it. "In most patients, they develop depression secondary to brain injury," says Ezzeddine. "The hypothesis is that some of the brain circuits known to be involved in depression can be affected by stroke. If you had bouts of depression before the stroke, it's more likely you'll develop it after."

Besides psychological issues, it's hardly surprising that the more disabling the stroke, the more likely it is that the survivor will experience depression. One study, in the journal Hospital Medicine, equated severe post-stroke disability with a two to three times greater risk for depression than the people who experienced little or no disability.

What's the treatment for post-stroke depression?

The treatment can differ from the usual remedies because some medicines commonly used to treat depression may not be appropriate for stroke survivors. Medications commonly taken by people who have had strokes -- like beta blockers, a type of heart medication have been linked to depression. But there are many other medication choices.

In addition, seeking psychotherapy, setting goals for recovery, and getting involved in social activities can all help. Here are some other ways for stroke survivors to free themselves from depression:

Get involved in daily activities with friends or family. Many stroke survivors feel isolated and alone, even if they aren't physically incapacitated from the stroke.

Find a support group with a trained facilitator. It could help provide emotional support as well as useful tips for managing your disabilities. Consult the National Stroke Association for groups near you.

The American Heart Association now recommends aerobic and strengthening exercise for stroke survivors. If you're capable of exercising, ask your doctor for a referral to an exercise class. Many hospitals or senior centers offer exercise classes for stroke survivors.

Ask your doctor how to relieve any physical discomforts like pain, muscle spasms, and constipation that can all add to depression.

If you're capable of volunteering, even if it's just an hour or two a week, it will not only help others, but could also help you feel better about yourself.

Further Resources

National Stroke Association 800-787-6537 http://www.stroke.org

American Heart Association/American Stroke Association 800-242-8721 http://www.strokeassociation.org

National Aphasia Association 800-922-4622 http://www.aphasia.org

References

Dr. Mustapha Ezzeddine of the National Institute of Neurological Disorders and Stroke.

Kotila, M, Numminen, H, et al, "Post-stroke depression and functional recovery in a population-based stroke register. The Finn stroke study," Eur J Neurol, Vol. 6(3): 309-12

Chemerinski E, Robinson RG, et al, "Improved recovery in activities of daily living associated with remission of post stroke depression," Stroke, Vol. 32(1): 113-7

Larkin, Marilynn, When Someone You Love Has a Stroke, p.36 Dell 1995

Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association, p.356

Gall, A, "Post-stroke depression," Hospital Medicine, May 2001, Vol 62, No5

Bush, BA, "Major life events as risk factors for post-stroke depression," Brain Inj, Vol. 12(2): 131-7

Gordon NF, et al. Physical activity and exercise recommendations for stroke survivors. AHA scientific statement. Circulation April 27, 2004.

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