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How Common is Depression After a Stroke?

First-term Pennsylvania Sen. John Fetterman, who suffered a stroke during his campaign last year, has announced that he is undergoing hospital treatment for severe depression.

“Studies have estimated that between 20% and 40% of stroke patients develop depression, depending on how you define it,” says Joshua Willey, MD, associate professor of neurology at Columbia University Vagelos College of Physicians and Surgeons and a stroke specialist at NewYork-Presbyterian Hospital.

We spoke with Willey about the symptoms patients and their families should look out for and why treatment for depression after stroke is important.

How do you detect post-stroke depression?

We screen all of our patients for depression while they are in the hospital. We use a standard depression screening tool called the PHQ-9 for hospitalized stroke patients and repeat it or add other screening questionnaires for depression and suicide during follow-up visits.

There's a lot of overlap between the symptoms of depression and what someone might experience after a stroke, so diagnosis can be a challenge. For example, fatigue is one of the most common symptoms of a stroke, but depression can also cause fatigue so it becomes a real challenge to determine if the fatigue is caused by depression or stroke.

And if the patient can't communicate effectively because of a stroke, it's hard to interpret the results of standard screening tools that we use to diagnose depression. In those cases, we use other validated tools that you can use in people with communication problems related to stroke.

How soon does depression occur after a stroke?

Depression symptoms often become more apparent during follow-up visits, peaking at around three to six months.

We see some patients with depression in the immediate period after a stroke, but often that's because they had depression before their stroke.

How important is it to treat post-stroke depression?

Depression is a leading contributor to poor recovery after stroke. It can impact medication adherence and participation in rehabilitation. We talk to our patients about being aware of depression and that treating it early and aggressively is really important to help with recovery.

Studies show that depression independently increases the chances of having another stroke or other cardiovascular event. We also worry about the risk of psychiatry-related events, such as suicidality, that can come with depression as well.

We are increasingly recognizing that anxiety disorders that arise after having a stroke also have a very powerful role in terms of psychological health. Researchers from the departments of psychiatry, medicine, emergency medicine, and neurology at Columbia are looking at psychiatric complications after stroke. They are also looking at the impact of post-traumatic stress disorder on recurrent stroke and recovery.

Do we know how stroke might trigger depression?

Research suggests that if certain regions of the brain are affected by stroke, the greater the odds of developing depression, though scientists differ on which region is more important. One recent paper found that the left side of the brain, near the language center, was associated with greater odds of developing depression. Other studies have suggested that stroke may disrupt certain pathways in the brain that predispose you to depression.

What's the prognosis for patients with depression after stroke?

We don’t know how many patients with depression after stroke are untreated, but we do know there are several barriers to mental health care, including cost and availability of mental health providers.

At Columbia, we take a very team-based approach to handling this common complication after stroke.

When a patient screens positive for depression, our social workers may ask the patient about any circumstances—such as a home situation, financial insecurity, financial determinants of health—that may contribute to depression symptoms. The neurologists try to dig into it even further. We frequently involve our psychiatry colleagues to make sure that antidepressant medications are safe for these patients with known vascular disease.

Outside of the hospital, depression in stroke patients can be treated by a primary care physician or the stroke neurologist, who can prescribe antidepressants or refer patients to a psychiatrist or psychotherapist.

Once therapy starts, we monitor patients for several months. Typically, patients start to respond to treatment in two to four weeks; treatment response in patients with post-stroke depression is similar to other patients who are being treated for depression.