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Depression following 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, feeling 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 after a Stroke develop a major depression. The importance in recognizing the condition is that is can be treated. In those people who have a Stroke and become depressed, failure to treat results is 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. A reactive depression is common after Stroke and may occur in combination with a major depression.

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 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 commonest scenario is the half empty jug situation, a person with a positive cognitive will see the jug as half full, 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; 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 is also 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 place 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.

Article courtesy of Dr. Patricia Jungfer

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