Depression after Stroke

Depression is a generic term that covers a number of different situations where the common factor is the feeling of depression or a state of depressed mood. After a Stroke, depression may occur but the situations in which it arises will lead to different types of treatment needs. Depression as an illness is common in the general community and the incidence of it is increasing with time. There are many reasons why a person may get depressed and almost as many ways to treat it. The two common terms used to describe depression after Stroke are major depression and reactive depression.

Major depression

This is a formal clinical diagnosis that may be made be a psychiatrist, psychologist or general practitioner. In a major depression there is a state of low mood or a loss of enjoyment of day-to-day activities. Sleep may be disturbed with a characteristic pattern of waking in the early hours of the morning and not being able to return to sleep. Appetite is poor and weight loss common. Constipation, a sense of physical slowing, social withdrawal and a loss of sexual interest are the classical symptoms. Suicidal ideas, feelings of guilt and worthlessness are also described.

The person may have a past history of depression or a family history of depression. It is possible, especially if the Stroke has been on the right side of the brain, that the person will then develop a depressive illness with these risk factors. Having a Stroke in the left front part of the brain is a risk factor for the development of depression regardless of a past or family history. One in four people will develop a major depression after a Stroke. The importance in recognising the condition is that it can be treated. In those people who have a Stroke and become depressed, failure to treat results in a less than optimal rehabilitation outcome.

The management of a major depression will involve the use of medication. These antidepressants are used to correct the chemical imbalance that has been precipitated by the depression. Treatment will usually only involve one medication and will probably need to be for 6 to 12 months. In combination with the antidepressants, cognitive therapy should also be incorporated into the treatment plan. This is a talking therapy that helps a person look at how their thinking style may be unhelpful and therefore maintain the depression. Usually, ten sessions are allocated to help a person with depression. Obviously, this therapy may have to be modified if the Stroke has affected the communication areas.

Reactive depression

This is a term used to describe a depressed state that occurs after an event or change. Typically, reactive depressions are less severe than major depression and there is little role for medication.

Depression after Stroke

When a person has a Stroke there are a number of things that will happen. For many people, if the Stroke involves hospitalisation it will be their first contact with a system that is new and therefore that they are unfamiliar with. The common theme in reactive depression is the state of transition. Most people fear change and it is seen as a stress. All of us grow up with a set of coping mechanisms. The common scenario is the half empty jug situation; a person with a positive outlook will see the jug as half full, while a more negatively inclined person will be upset that the jug is half empty. How a person deals with transition will be influenced by their coping mechanisms and their set pattern of cognitive sets (belief systems).

A Stroke is a time of transition. The person who has the Stroke may have to learn how to do things differently and they may need to rely on someone else for things that in the past they could easily do themselves. Often the greatest transition after a Stroke is the change from independence to dependence. However, other changes also occur – there may be the change from working to retirement, physical activity to inactivity, acute mental ability to slower thinking, driving oneself to relying on others, and the list goes on. The transition phase also occurs for the family and partner of the person who has had the Stroke and they may also go through their own reactive depression.

The most important feature of the reactive depression is the need to recognise that it occurs and that it is okay to have some depression. Following the recognition of the state is the process of dealing with the depression. This is a dynamic process and the focus of the treatment will need to be on the current issues as the situation post-stroke is usually a changing one.

The management of the transition involves talking therapies. This can be obtained from rehabilitation counsellors, psychologists, psychiatrists, and general practitioners. Community health centres and the local hospital are often the places you will find people with the necessary expertise to help in this time of transition. The rate at which the person will respond to the treatment will vary according to how flexible they are in their thinking patterns and how great the changes have been. Every person will have his or her own unique timetable of adjustment.

The process of the counselling is to identify unhelpful thinking patterns and suggest ways that the person may change their thinking style. Stages of change are mapped out for the person so that they can see the road to recovery. In the course of the treatment, the therapist aims to help the person face the changes that have occurred, reduce the patient’s fear of the changes and see that the new situation does have positives. Transition counselling needs to occur in conjunction with all the other post Stroke therapy. Often it may occur very informally in the course of the various therapies. Overall, people will respond to the therapies and recover.

‘Depression after Stroke’ article courtesy of Dr. Patricia Jungfer.

COPING WITH SYMPTOMS OF DEPRESSION

Following are some practical tips to assist you to cope with each of the symptoms of depression you may be facing.

Loss of interest, slowed activity, lack of energy

1. Set goals for daily activity. Plan full days of useful activity by making a list of the activities you are going to engage in at different times during the day. Try to stick to this plan as closely as possible. Do not forget to compensate for the fatigue factor (activity followed by rest/relaxation repeated throughout the day – do not overdo it).
2. Make a list of activities you enjoy. Try to increase the amount of time you spend on these enjoyable activities.
3. Avoid comparing the way you are behaving or feeling now, while you are depressed, with the way you used to behave or feel before becoming depressed.
4. Try to remember how far you have come in your recovery – celebrate your achievements no matter how small. Avoid comparing what you could physically do prior to your Stroke to what you can do now. Above all, reward yourself for your efforts.
5. Seek assistance from those around you to encourage and praise you for each small step you take. Recovering from Stroke and depression takes time – so be kind to yourself.
6. If a task appears too difficult, do not despair. Break the task down into smaller, easier steps and start again more slowly – praise yourself for trying and have another go.

Loss of appetite

Eat small portions of food that you particularly like. Take your time and do not feel under pressure to finish if you are eating with others. Drink plenty of fluids, especially water, fruit juices and milkshakes.

Loss of interest in sex

Seek non-sexual activities with your partner that you still enjoy. Explain to your partner that your loss of interest and affection is a symptom of your depression, not a rejection of him or her, and that these symptoms will be temporary.

Sleep disturbance

1. Exercise as much as you are able – it has a twofold effect on your body.
2. Get up at the same time every morning.
3. Avoid sleeping during the day.
4. Reduce tea and coffee intake if excessive (no more than 2-3 cups per day and none after about 4pm).
5. Do not lie awake for more than 30 minutes – get up and find a relaxing activity.
6. Try relaxation or mindfulness exercises. Ask your clinician for more information about these exercises.

Miserable feelings, unpleasant thoughts

These negative thoughts and feelings tend to focus your attention on things you do not like about yourself or your life situation. As well as concentrating on your negative features and experiences, when you are depressed you tend to underestimate your positive characteristics and your ability to solve problems. A number of strategies may assist you to achieve a more balanced view of things:

1. Make a list of your three best features – perhaps with the assistance of a friend or relative. Carry the list with you and read it to yourself whenever you find yourself focusing on negative thoughts.
2. Keep a daily record of all the small, pleasant things that happen and discuss these events with your friends when you see them.
3. Recall pleasant occasions in the past and plan pleasant occasions for the future (this may best be done in conversation with a friend).
4. Consider alternative explanations for unpleasant events of thoughts. Although your initial explanation may be that you are at fault, rethink these conclusions and write down all other possible explanations for these events or thoughts.
5. Keep yourself busy doing useful activities. Avoid sitting or lying about doing nothing.

Worrying or inefficient thinking

Put your worry to a useful purpose. Rather than endlessly pinpointing your problems, pick out one or two problems that seem really important and make a decision to resolve them. You may like to ask a friend to assist you.

Sit down with a problem-solving sheet (your clinician can provide you with one) and go through the following steps:

1. State exactly what the problem (or goal) is.
2. List 5 or 6 possible solutions – write down any ideas that occur to you, not merely the ‘good’ ideas.
3. Evaluate the good and bad points of each idea in turn.
4. Choose the solution that best fits your needs.
5. Plan exactly the steps you will take to put the solution into action.
6. Review your efforts after attempting to carry out the plan. Praise all efforts. If unsuccessful, start again.

Anger Management

1. Accept responsibility for your level of anger.
2. Learn to track your level of anger: what are the warning signs when you are becoming angry? (for example: raised voice, muscle tension, talking over others)
3. When is anger a problem? Learn to identify people, places, times of day, situations that affect the level of your mood.
4. If you find your level of anger is rising, you can gain control and lower the level by following certain steps:
   • Take in a deep slow breath
   • As you breathe out, relax your body
   • Say to yourself ‘clear head, clear body’
   • Mentally step back from the situations and smile to yourself
   • Take a walk to remove yourself from the situation
5. If you still feel angry remove yourself from the situation and focus on a pleasant activity or thought.

Conflict Resolution

1. Look for early warning signs of a developing argument.
2. As soon as you see an argument is developing say: ‘Hold it, I’m getting angry. I would like to stop the discussion for a minute’. Then think through the following options:
   • Would you be better off starting the discussion all over again?
   • Are you (or someone else) too upset to continue sensibly now? If so, walk away and make the time to come back to the issue at another time.

General strategies

1. Exercise is very effective to lift mood – try to get out of the house and go out in the sunshine. A short walk is very effective and will assist with other aspects of recovery.
2. Listen to music.
3. Try a relaxation or mindfulness tape.
4. Watch a comedy on the television, DVD or go out to a movie.
5. Laughter is a great remedy.
6. Seek the company of friends, focus on what they are doing in their lives and try not to dwell on your own issues.

REMEMBER: You are not alone
Depression is an ILLNESS that is very common after Stroke.
SEEK TREATMENT
If you had high blood pressure or a broken leg you would seek treatment, so discuss how you are feeling with your GP. There are very effective medications and therapies available for the treatment of depression.
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© Stroke Recovery Association NSW 2023