Psychological Adjustment

following Stroke:
Improving Outcomes & Quality of Life

Loran C. Vocaturo, EdD, ABPP

Vice President of Program Development & Education
Select Medical Inpatient Rehabilitation Division
lvocaturo@selectmedical.com
2012

Disclosure
Dr. Loran Vocaturo has no industry
relationships to disclose
Dr. Loran Vocaturo will not discuss any
products or product usage

Which discipline do you represent?

1.
2.
3.
4.

Physician
Nurse
Therapist (PT,OT, SLP)
Psychologist or
Counselor
5. Social Worker/Case
Manager
6. Administrator

17%

17%

17%

17%

17%

17%

Pre-Test Questions

What percentage of stroke survivors are affected

by post-stroke depression?
1.
2.
3.
4.

2%
5-10%
10-20%
40-60%

25%

25%

25%

25%

Post-stroke depression is a left

hemisphere syndrome
1. True
2. False

50%

50%

Symptoms of post-stroke depression

are easy to identify and assess?
1. True
2. False

50%

50%

Overall, male stroke survivors have

better outcomes than female
survivors.
1. True
2. False

50%

50%

Post-stroke anxiety is more common

but less disabling than depression.
1. True
2. False

50%

50%

Objectives
Identify post-stroke depression and other common
emotional reactions
Discuss prevalence and implications on rehabilitation
outcomes
Discuss the importance of early and accurate
diagnosis
Describe differential diagnosis, characteristics and
process of assessment
Discuss treatment options to improve adjustment
and QOL

Introduction
Post-stroke depression is a common and
seriously disabling condition
Stroke survivors are more predisposed to
PSD compared to physically ill patients with
similar levels of disability, even quite a long
time after the stroke, regardless of other risk
factors.

Prevalence of Psychological &

Neuropsychological Symptoms

Post-Stroke Depression (PSD) 40-60%*

Anxiety 20-30%
Emotional Instability 10-25%
Crisis Reaction 20%
Cognitive Impairment 50-75%
39% Executive Dysfunction
38% Visual perceptual/Constructional deficits

Importance of the Problem

Impact of post-stroke depression
Prolonged hospitalization
Limit ultimate level of functional recovery
Compromise social integration
Higher mortality rate
PSD - 3.4X greater than non-depressed CVA
patients

Decreased self-care
Less attention to health-related issues
General de-conditioning
Increased suicide risk

Predictors of PSD
Stroke-related Factors

Physical changes (physical limitations, ADL, pain/

spasticity, bladder/sexual dysfunction, driving).
Fatigue*
Reduced initiative and fatigue 50-70%

Emotional reactions*
Communication difficulties*
Cognitive impairment*
Visual-spatial/visual perceptual impairment*

Individual Risk Factors

Psychiatric History (e.g. depression)
Pre-morbid personality & coping styles
Self-esteem
Self-efficacy
Coping style
Locus of control
Perception of health status
Resilience
Age, education/employment status

Individual Risk Factors

Habits and lifestyle
Substance Abuse
May be cause of stroke, particularly in young
stroke patients abusing stimulants
May be consequence or ongoing risk of future
stroke (alcohol and prescription medications)
Culture, family structure & social support

Quality of Life: Age

Younger stroke patients (age 18-55)

*Depression: 50% report general life dissatisfaction
Cognitive impairment
Fatigue
Ability to return to school/work
Having a significant other
Older stroke patients (>55)
*Depression
Affected by social support
Fatigue
Uncertainly about future
Caregiving needs

Quality of Life: Gender

Male stroke survivors impacted by

Depression *
Cognitive impairment
Inability to return to work
Life partner/support

Women stroke survivors report more dissatisfaction with

life in general than men

Depression*
Cognitive impairment
Coping styles
Social Support

*Women have poorer functional recovery after controlling for age and stroke severity
*Suggest need for age and gender specific interventions

PSD Etiology
Despite high incidence of post-stroke
depression there is limited agreement on
etiology and few studies focus on effective
treatment and prognosis

PSD Etiology
Structural alterations to the brain
Patients response to sudden and disabling
illness
Reactive depression: occurs with increased
awareness of functional limitations
Implication stroke sequelae has on independence
and community re-integration

*Biological and psychosocial factors play significant roles in the

development of this disability disease {depression}.

Structural Changes
Previous studies have suggested that PSD more likely
associated with left hemisphere stroke; especially left anterior
lesions or basal ganglia involvement.
Recent studies have found less support for specific
hemisphere involvement.
Acute depression believed to be secondary to biological
factors and location of lesions.
Neurochemical processes may play some role in the
pathophysiology of this condition (e.g depletion of
norephinephrine and serotonin)

Identification & Treatment

Early identification & treatment benefit patients and
their families by
Identifying need for psychological &
pharmacological treatment
Containing/reducing sx and related sequelae
Improving treatment investment & functional
performance
Improving staff and patient awareness of safety
concerns
Providing platform for patient/family education
Improving long-term adjustment & QOL

DSM-IV: Symptoms of Depression

Challenges for Assessment & Dx
Affective

Somatic

Cognitive

Depressed mood; loss

of interest/pleasure

Sleep disturbance

Reduced attention or
concentration

Guilt, Worthlessness

Fatigue

Indecisiveness

Flattening affect,
apathy

Appetite disturbance

Suicidal ideation;
recurrent thoughts of
death

Tearfulness

Psychomotor agitation Psychosis

or retardation

PSD Assessment

Clinical Interview
Beck Depression Inventory II
Geriatric Depression Scale
KIR admission screening (Cully, et al, 2005 )

Evidence suggests that affective information from stroke

patients is unreliable due to fatigue, confusion, reduced
arousal, cognitive impairment, reduced awareness
leading to impaired perception of emotional state.
Sole use of standard measures has lead to PSD being
underreported.

Multimodal Approach for PSD Dx

Standardized self and observer report instruments
Interview patient and family
Behavioral observations by multiple staff in multiple
contexts:
* Look for: poor, erratic participation,
noncompliance with treatment, deterioration
from previous level of functioning

Treatment for PSD

Multimodal approach most effective
Motivation Enhancement Therapy
Psychotherapy
Pharmacology

Motivational Enhancement
Early intervention program that can be modified for
use by non-mental health professionals
Facilitate discussion of and provide support around
adjustment to CVA (physical, functional, social
support, etc.)
Identify goals for recovery; perceived barriers to
progress
Reinforce optimism and positive self-efficacy

Psychotherapy
Cognitive-Behavioral Strategies
Improving self-efficacy & problem-focused
coping
Reducing cognitive distortions related to
perceived health status
Improving management of fatigue and
communication difficulties
Improving treatment investment and initiation
of daily activities
Providing compensatory strategies for
cognitive deficits

Pharmacological Intervention
*
*

Tricyclic antidepressants
nortryptiline, imipramine
*potential side-effects
SSRI
sertraline
*fluoxetine
paroxetine
*escitalopram
venlafaxine (SSNRI)
Psychostimulants
*methylphenidate
dextroamphetine
*modafinil
armodafinil

Antidepressant Treatment
Use of antidepressants among patients with a
diagnosis of PSD has been associated with
improvement in depressive symptoms
Efficacy of sertraline, citalopram and
nortriptyline to treat post-stroke depression.
Longer duration of antidepressant treatment
may be associated with greater reduction in
depressive symptoms

(Chen Y, et al, 2006; Starkstein SE, et al, 2008)

Antidepressant Prophylaxis
May also be helpful in preventing post-stroke
depression
Antidepressant prophylaxis was associated with a
significant reduction in the occurrence rate of newly
developed post-stroke depression
Suggests antidepressants may be considered along
with other vascular preventive strategies in the
management of stroke patients

(Chen Y, et al, 2007)

Combination Treatment
Escitalopram and problem-solving therapy for
prevention of post-stroke depression
Combination therapy - interpersonal psychotherapy
plus antidepressant medication
Resulted in a significantly lower incidence of
depression over 12 months of treatment

(Robinson RG, et al 2008)

Apathy
Indifference reaction, lack of initiation, motivation
caused by organic, neurological factors.
Has been associated more often with right
hemisphere lesions and posterior portion of the
internal capsule.
50% patients with subcortical infarctions
demonstrate apathy; 40% of those patients also
meet criteria for depression.

Apathy
Apathetic patients tend to be more cognitively
impaired and more functionally disabled. Tend to
have reduced awareness of deficits.
May also be due to bilateral frontal and anterior
temporal hypoactivity as measured by cerebral
bloodflow.
May be the result of cortical serotonergic deficits
that may improve with dopominergic and
serotonergic agents (e.g. psychostimulants).

Depression vs. Apathy

DEPRESSION
Is the indifference reaction a
result of the mood disorder?
Is the mood disorder
congruent with concerns over
implications of CVA?
Do other symptoms of
depression exist?
Has the indifference subsided
when depression is
successfully treated?

APATHY
Is apathy the result of
organic factors or
neurological etiology?
Does the indifference reaction
occur in the absence of other
symptoms of depression?
Does the patient demonstrate
little concern over the
implications of CVA on current
or future goals?
Does apathy exist despite
treatment of depression?

Assessment of Apathy
Assessment
Clinical Observation
Family Report
Apathy Scale
Executive functioning tests

Treatment of Apathy
Psychopharmacological Intervention
(antidepressants, psychostimulants)
Improving awareness of symptoms and
implications on daily life (CRP)
Behavioral strategies to improve initiation,
motivation and participation in daily activities
(CRP)
Family counseling, support and behavioral
strategies

Pharmacological Treatment
When added to antidepressant treatment,
psychostimulants have been found to be effective in
treating depression in the general population.
The potential benefits of psychostimulants alone or
in combination with antidepressant medication in
the stroke population is limited but has received
more attention
Impact on rehabilitation outcomes is limited

Effectiveness of Psychostimulants
Stimulant medications can enhance motor recovery,
activities of daily living (ADL), mood and cognition in
stroke rehabilitation, but human clinical trial results are
inconclusive

Psychostimulant Treatment
Methylphenidate (Ritalin) has been advocated in
patients with traumatic brain injury and stroke for a
variety of cognitive, attention, and behavioral
problems.
Rapid effects of methylphenidate may be especially
useful to speed recovery from post-stroke depression
so that patients can participate more fully in
rehabilitation programs

Pharmacological Treatment
Modafinil (Provigil)
Possible benefits include improved
wakefulness as well as antidepressant
properties to improve motivation and
participation in rehabilitation.
Fewer side-effects and potential for abuse
than other psychostimulants.

Combination Therapy: Antidepressants

+ Psychostimulants
Limited information on the role of combination
therapy (antidepressants/psychostimulants)
Several trials have shown evidence that the older, as
well as newer antidepressants and psychostimulants
may reduce/prevent depressive symptoms after
stroke.

Pharmacological Treatment &

Rehabilitation Outcomes
Impact of psychostimulants on rehabilitation outcomes
(LOS, motor recovery, cognitive recovery, discharge
destination) is unclear. Much research needs to be
completed before clinicians know precisely whether
and how rehabilitation therapies and medications
interact to assist in functional recovery.
(Zorowitz RD, et al, 2005).

The Future for PSD

Vocaturo, LC, Frisina, P, Martin, RT, Hedeman, R, Pagan, N

Retrospective analysis of N stroke patients admitted

to KIR 2011.
Review screening for positive identification of PSD on
admission
Review outcomes of depressed patients treated with
psychotherapy and/or pharmacological intervention
(antidepressants, psychostimulants)
Outcomes include participation in therapy, LOS, FIM
change, discharge disposition.

Anxiety
Driven by fear: Fear of recurrent stroke,
falling, being stranded away from home may
lead to reduced activities or Agoraphobia
(most common subtype)
24 % of CVA patients manifest Generalized
Anxiety symptoms (majority of those patients
are also depressed)

Treatment for Anxiety

Avoid or limit use of anxiolytics because of
sedating and potential anticholinergic effects
SSRI antidepressants may be a better choice
Cognitive-behavioral strategies
Problem-focused coping
Decatastrophizing
Improving self-efficacy
Relaxation training
Psychoeducation of stroke & anxiety

Summary
A CVA is a traumatic event in the lives of patients and their families
Psychological and neuropsychological sequelae after stroke is
common, but complex and requires comprehensive assessment and
treatment
Early identification and treatment can have positive impact on
rehabilitation outcomes and quality of life
Combination therapy (antidepressant, psychostimulants and
psychotherapy) may be the most effective approach to treating PSD
and other psychological syndromes following stroke
While treatment options and approaches may be similar, early and
accurate diagnosis plays an important role in patient/family
education, course of treatment and prognosis.

Post-Test Questions

A 51-year old male SP Right CVA presented with poststroke depression, apathy and executive dysfunction.
Which of the following likely contributed to his
depressive symptomology?
1.
2.
3.
4.

Fatigue
Inability to return to work
Pre-morbid alcohol use
All of the above

25%

25%

25%

25%

A 51-year old male SP Right CVA presented with post-stroke

depression, apathy and executive dysfunction.
How likely would you be to recommend the following
treatment for this patient?
Antidepressant Therapy
25%

1.
2.
3.
4.

25%

25%

25%

Very Unlikely
Unlikely
Likely
Very Likely
1

A 51-year old male SP Right CVA presented with post-stroke

depression, apathy and executive dysfunction.
How likely would you be to recommend the following
treatment for this patient?
Psychostimulants
25%

1.
2.
3.
4.

25%

25%

25%

Very Unlikely
Unlikely
Likely
Very Likely
1

A 51-year old male SP Right CVA presented with post-stroke

depression, apathy and executive dysfunction.
How likely would you be to recommend the following
treatment for this patient?
Psychotherapy
25%

1.
2.
3.
4.

25%

25%

25%

Very Unlikely
Unlikely
Likely
Very Likely
1

A 51-year old male SP Right CVA presented with post-stroke

depression, apathy and executive dysfunction.
How likely would you be to recommend the following
treatment for this patient?
Cognitive Remediation

1.
2.
3.
4.

Very Unlikely
Unlikely
Likely
Very Likely

25%

25%

25%

25%

References

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Carlsson, GE, Moller, A, Blomstrand, C. Managing an everyday life of uncertainty
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31(10):773-782. 2009
Carod-Artal, FJ, Egido, JA. Quality of life after stroke: the importance of good
recovery. Cerebrovascular Dis. 27: 204-214. 2009
Chen Y, Guo JJ, Zhan S, Patel NC. Treatment effects of antidepressants in patients
with post-stroke depression: a meta-analysis. Ann Pharmacother. 40(12):2115-22.
2006
Chen Y, Patel NC, Guo JJ, Zhan S. Antidepressant prophylaxis for poststroke
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Darlington, AS, Dippel, DW, Ribbers, GM, van Balen, R, Passchier, J, Busschbach, JJ.
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assessing prognostic relationships and estimates of cost effectiveness. Journal of
Rehabilitation Medicine. 41(4):237-241. 2009

References

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References

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References

Starkstein SE, Mizrahi R, Power BD. Antidepressant therapy in post-stroke

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