Overview: Depression following a stroke (post-stroke depression) is extremely common, and all too often is accepted as a natural, psychological reaction to stroke. During a stroke, some of the brain's neurons (nerve cells) die. The loss of these neurons produces symptoms directly related to the missing neurons—for example, paralysis if neurons directing movement die, or the inability to speak when speech neurons die. However, depression after a stroke can arise independently of the location of the stroke. Although some areas may be more likely to induce depression, this suggests that post-stroke depression might be caused indirectly from biological events associated with neuron death. Further, the psychological and social consequences of a stroke are also important in triggering depression. This places post-stroke depression squarely within the bio-psycho-social model currently used to explain the origins of most psychiatric illness.
Rate and risk factors for post-stroke depression: The rate of post-stroke depression appears to be higher in individuals who have had an episode of depression before their stroke. In individuals with a history of depression who suffer a stroke, about one-third will develop post-stroke depression. In addition, the rate of depression after strokes seems less for strokes of the lower brain (brainstem) circulation. Earlier studies had suggested that left-sided strokes in the front of the brain were the most likely to produce depression, but more recent evidence does not appear to support this idea.
Psychological variables in post-stroke depression: While it has been a little difficult to determine the relative contributions of biological and psycho-social processes to producing post-stroke depression, much evidence supports the role of the functional consequences of stroke and social factors as important in generating post-stroke depression. Earlier Viewpoints have discussed the role that stress can play in depression. Following stroke, factors like loss of the ability to move or talk, or think clearly, may contribute to depression. Some work suggests that the importance of the lost function in a person's life may be important. Other generally stressful events, such as relationship stress, loss of income, and loss of the ability to take care of oneself are probably important risk factors for developing post-stroke depression.
Treatment of post-stroke depression: In my opinion, post-stroke depression (and ALL depression) deserves aggressive treatment. The treatments for post-stroke depression seem to be largely the same as those for depression arising from other causes. As with most types of depression, treating with a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine is a reasonable first choice. However, since many people don't fully recover with SSRI therapy alone, a broader spectrum antidepressant, such as mirtazapine or venlafaxine might be needed. Cognitive behavioral psychotherapy is consistently the most effective psychotherapy for major depression, and appears useful in treating post-stroke depression.
Guido Gainotti and Camillo Marra. Determinants and consequences of post-stroke depression. Current Opinion in Neurology, Volume 15, pages 85-89, 2002.