**7. Challenges in diagnosing depression after stroke**

Diagnosing depression after a stroke may be difficult for practitioners given that stroke patients can have complex symptoms. The physicians that treat stroke patients should be aware that over a third of patients experience depression after a stroke, and to note that even subtle changes in behavior could represent an aspect of poststroke depression [17]. Small changes like irritability, frustration, extreme fatiguability, and refusing to partake in physical therapy and occupational therapy. Another challenge is that many symptoms of stroke and depression overlap, such as fatigue, pain, decreased motor activity, and decreased verbal output [7]. Only a few of the depression scales used to assess poststroke depression include somatic symptoms in their evaluation. The Beck Depression Inventory is one such scale. However, again some somatic symptoms from the stroke itself can be mistaken as a

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*Post Stroke Depression*

*DOI: http://dx.doi.org/10.5772/intechopen.86935*

recovers, and even affect their mortality.

positive finding on a depression scale. It is important to be able to tease apart what symptoms are due to a stroke and what symptoms are related to depression. If a diagnosis of poststroke depression is missed, it can negatively affect how the patient

The symptoms that make the diagnosis of poststroke depression the most difficult are aphasia, anosognosia, neglect, abulia and cognitive disabilities that result from their stroke [37]. Unfortunately, the majority of studies that evaluate poststroke depression exclude patients with these symptoms. This is largely due to their inability to answer questions, fill out questionnaires, or because it is difficult for medical staff to assign a score to the patient based on their daily interactions. Aphasia is independently associated with an increased risk of developing poststroke depression [37]. However, three scales have been developed to assess depression in aphasic patients. These scales include the Stroke Aphasic Depression Questionnaire-10 (SADQ-10), the Aphasia Depression Rating Scale (ADRS), and the Perceived Stress Scale (PSS). The (SADQ/SADQ-10/SADQH-10) and the Aphasia Depression Rating Scale are based on the observation of other people to determine if the patient being assessed is in fact depressed or not. The SADQ-10 used caregivers as the observers, with non-aphasic patients as the controls [37]. A value of 14/30 or higher was correlated with the development of depression and depressive symptoms with a sensitivity of 70% and specificity of 77%. The ADRS scoring system used external signs that could be observed such as fatigue, insomnia, changes in weight, and signs of anxiety. A score of 9/30 or higher was associated with the development of depression with a sensitivity of 83% and specificity of 71% [37]. After a comparative analysis, it was determined that either one of these tools could be used for assessing depression in aphasic patients. A review of the current studies could be more generalizable if

aphasic patients were included and analyzed with these scales.

**8. Poststroke depression effect on morbidity and mortality**

Poststroke depression was found to be an independent predictor of symptom severity after a stroke, and difficulty with managing activities of daily living [35]. In a meta-analysis of seven studies, poststroke depression was found to have an association with increased mortality [39]. Specifically, patients that experienced early poststroke depression as defined to be within 3 months of stroke onset, were found to have 1.5 increased risk of death. A literature review by Robinson and colleagues, found that using the Hospital Anxiety and Depression scale (HADS), patients that had a score greater than 7 at 3 months had increased mortality than those with a score less than 7 [38]. These scores were evaluated up to 5 years poststroke, and the hazard ratio was found to be 1.41. It was seen that mortality was increased in patients with poststroke depression that were younger than 65 years old [38]. Their study also demonstrated that in greater than 50,000 veterans that suffered an ischemic stroke, those that developed poststroke depression had higher rates of mortality within 3 years of that acute event. The hypothesis behind this being that early poststroke depression can occur in a patient with a severe disability such as neurocognitive decline, paralysis, aphasia, or dysphagia [38]. Due to the severity of their post-stroke symptoms these patients may be at increased risk of death due to complications like pneumonia secondary to dysphasia or infection from decubitus ulcers. Another hypothesis is that patients that are suffering from poststroke depression may be less likely to be compliant with medical recommendations, such as healthy diet, avoiding tobacco, alcohol, drug use, scheduled follow up appointments and medication compliance [37, 38]. These factors can increase the risk of mortality. Another theory states that mortality associated with poststroke depression may be related to

#### *Post Stroke Depression DOI: http://dx.doi.org/10.5772/intechopen.86935*

*New Insight into Cerebrovascular Diseases - An Updated Comprehensive Review*

at risk for an acute stroke, and chronic small vessel disease.

hemiparesis, vision loss, and ataxia [3].

more severe the depressive symptoms [36].

**7. Challenges in diagnosing depression after stroke**

**6. Large strokes and the effect on poststroke depression**

due to poorly controlled hypertension, tobacco, diabetes, drug use, and poor diet and lifestyle choices causing small vessel disease. These risk factors put all patients

In patients that suffer from large ischemic or hemorrhagic strokes, they are often left with a serious physical disability [2]. A proximal middle cerebral artery occlusion can result in severe expressive, or receptive aphasias, hemiparesis, facial weakness, sensory loss inability to swallow, neglect, apraxia, and a propensity toward developing seizures [34]. If the patient is relatively young, the probability of cerebral edema is high, which could result in complications such as brain herniation if a hemicraniectomy is not performed. Intracerebral hemorrhage in these vascular territories can result in similar findings that may necessitate an extra ventricular drain to remove blood from the ventricles, or a decompressive hemicraniectomy to evacuate the hemorrhage [34]. A patient with a large stroke in the posterior circulation can result in the patient being obtunded, having chronic balance issues,

Patients that survive these large strokes often experience the most debility, with the majority becoming bedbound, requiring a percutaneous endoscopic gastrostomy tube for nutrition and tracheostomy tube for assistance with breathing. Due to the severity of their disability, these patients require 24-hour care, by their families or nursing professionals. The majority of these patients experience severe depression and guilt, due to feeling like a financial or physical burden on their loved ones [35]. They also experience loss of autonomy due to their deficits. They are no longer able to manage their own activities of daily living, which results in feelings of inadequacy, and resentment for those that are doing the caregiving. Depression has also seen to be positively correlated with the national institute of health stroke scale (NIHSS) which measures stroke severity, wherein the higher the stroke scale, the

Patients with large strokes and increased debility often require management in a skilled nursing facility (SNF). At SNF, the patients do not participate in as much rehabilitation activities, as compared to other stroke patients in an inpatient rehabilitation setting [32]. These patients are therefore at disadvantage because their exposure to rehabilitation is limited. The combination of decreased functionality, less access to rehabilitation, and depression impairs the recovery for these patients. They too lose the desire to participate in meaningful interaction due to their disability [32].

Diagnosing depression after a stroke may be difficult for practitioners given that stroke patients can have complex symptoms. The physicians that treat stroke patients should be aware that over a third of patients experience depression after a stroke, and to note that even subtle changes in behavior could represent an aspect of poststroke depression [17]. Small changes like irritability, frustration, extreme fatiguability, and refusing to partake in physical therapy and occupational therapy. Another challenge is that many symptoms of stroke and depression overlap, such as fatigue, pain, decreased motor activity, and decreased verbal output [7]. Only a few of the depression scales used to assess poststroke depression include somatic symptoms in their evaluation. The Beck Depression Inventory is one such scale. However, again some somatic symptoms from the stroke itself can be mistaken as a

**264**

positive finding on a depression scale. It is important to be able to tease apart what symptoms are due to a stroke and what symptoms are related to depression. If a diagnosis of poststroke depression is missed, it can negatively affect how the patient recovers, and even affect their mortality.

The symptoms that make the diagnosis of poststroke depression the most difficult are aphasia, anosognosia, neglect, abulia and cognitive disabilities that result from their stroke [37]. Unfortunately, the majority of studies that evaluate poststroke depression exclude patients with these symptoms. This is largely due to their inability to answer questions, fill out questionnaires, or because it is difficult for medical staff to assign a score to the patient based on their daily interactions. Aphasia is independently associated with an increased risk of developing poststroke depression [37]. However, three scales have been developed to assess depression in aphasic patients. These scales include the Stroke Aphasic Depression Questionnaire-10 (SADQ-10), the Aphasia Depression Rating Scale (ADRS), and the Perceived Stress Scale (PSS). The (SADQ/SADQ-10/SADQH-10) and the Aphasia Depression Rating Scale are based on the observation of other people to determine if the patient being assessed is in fact depressed or not. The SADQ-10 used caregivers as the observers, with non-aphasic patients as the controls [37]. A value of 14/30 or higher was correlated with the development of depression and depressive symptoms with a sensitivity of 70% and specificity of 77%. The ADRS scoring system used external signs that could be observed such as fatigue, insomnia, changes in weight, and signs of anxiety. A score of 9/30 or higher was associated with the development of depression with a sensitivity of 83% and specificity of 71% [37]. After a comparative analysis, it was determined that either one of these tools could be used for assessing depression in aphasic patients. A review of the current studies could be more generalizable if aphasic patients were included and analyzed with these scales.