Diagnosis and Treatment of Depression and Anxiety in People Who Have Experienced a Stroke and Their Caregivers

Depression and anxiety are prevalent in stroke survivors and their caregivers. It is estimated that at least 33% of stroke survivors have poststroke depression (PSD) and 24% have poststroke anxiety (PSA).^1-3 Depression and anxiety are traditionally underrecognized and undertreated in both survivors and their caregivers, negatively affecting stroke outcome and poststroke quality of life.^2,3 The outpatient neurologist is uniquely positioned to identify and assist with the treatment of PSD and PSA and build awareness of these disorders among caregivers. Identifying predictors of and associations between PSD and PSA are key to understanding these disorders and developing effective screening protocols. In addition, the mental health and well-being of caregivers are affected after a loved one’s stroke, in turn affecting the health and well-being of the individual who has had a stroke. The correlation between the mental health of the stroke survivor and caregiver is often underrecognized in clinical practice; however, understanding and addressing these connections may help improve secondary stroke prevention and quality of life for stroke survivors and their caregivers.

Predictors of and Health Outcomes Associated With PSA and PSD in Stroke Survivors and Their Caregivers

Although depression and anxiety are interrelated and common in both stroke survivors and their caregivers, the predictors of depression and anxiety differ between them.^3-8 Among stroke survivors, a history of pre-stroke mood disorders and stroke symptoms, including aphasia and impaired cognition, are common predictors of PSD.^1,2,9 In addition, lack of caregiver support has also been found to play a role in PSD.^2,3 Some studies have found an association between stroke location and PSD, with risk of depression being higher after left hemisphere stroke, whereas other studies have found no association.^1,5 Variations in study outcomes are likely due to the complex pathophysiology of PSD, and further studies are needed to determine any potential association between stroke or lesion location and PSD.⁵

Caregiver depression and anxiety are associated with a variety of factors, including increased age of the caregiver, more severe stroke, and if the patient was the primary earning member of the family.^4,10 In addition, the caregiver’s perception of their burden is associated with the experience of higher caregiver burden.^4,9,10 Studies have found that depression and anxiety in caregivers are ongoing and that the caregiver’s experience is associated with the stroke survivor also experiencing PSD and PSA.^3,4,6

PSD affects quality of life and has led to increased rates of suicide and suicidal ideation.¹⁰ Early diagnosis and treatment of PSD and PSA reduce 10-year mortality risk, increase the ability of patients to adhere to secondary stroke prevention measures, enable participation in poststroke rehabilitation, and improve stroke outcome. Successful treatment of PSD can reduce cognitive impairment and long-term disability associated with stroke.¹⁰ Undiagnosed and untreated PSD and PSA are associated with a decrease in health care participation. For example, individuals with PSD and PSA have trouble adhering to medication, attending follow-up appointments, and engaging in rehabilitation.⁴ Depression is also an independent risk factor for recurrent stroke.⁵

In addition to PSD and PSA having negative effects on stroke survivors, caregiver depression or anxiety is associated with both the stroke survivor experiencing PSD and increased 6-month mortality risk for the stroke survivor.^4,9,10 Outpatient neurologists should screen for symptoms of depression and anxiety in stroke patients to assist with the early diagnosis and treatment of these disorders.^6,10

Diagnosis and Screening

PSD is diagnosed on the basis of an individual’s subjective feelings. For diagnosis, the Diagnostic and Statistical Manual of Mental Disorders, 5th edition requires ≥5 coexisting symptoms to be present (ie, depressed mood, loss of interest or pleasure, weight changes, sleep pattern alterations, restlessness or psychomotor delay, fatigue, feelings of worthlessness or excessive or inappropriate guilt, diminished ability to concentrate, or recurrent thoughts of death), occurring most of the day over at least 2 weeks, with 1 of the symptoms being either depressed mood or loss of interest or pleasure. These symptoms must affect a person’s ability to function, occur after stroke or transient ischemic attack, and be attributed to the vascular event.^11,12

The American Heart Association recommends screening for PSD; however, evidence is limited on the optimal timing and frequency of screening and neurologists follow different protocols.¹³ In general, PSA and PSD screening can co-occur and follow a similar timing protocol. Screening should be performed in all stroke survivors regardless of whether they appear depressed or anxious. The first screening for depression typically occurs during the acute stroke hospital stay, followed-up at some point in the rehabilitation process and throughout outpatient visits. For instance, if outpatient follow-up is normally scheduled for 3 months, 6 months, and 1 year, screening for PSD and PSA should be completed at these times. Screening should continue beyond 1 year, but the intervals between screening typically increase because stroke follow-up tends to be more spaced out after a year.¹¹

Some neurologic deficits after stroke (eg, aphasia) can complicate screening. Screening tools for PSD and PSA are not diagnostic but help identify individuals who need further assessment. There is some evidence that the right screening tool for PSD and PSA varies depending on the acuity of the stroke, although this requires further investigation due to a lack of standardized neuropsychologic assessments in the outpatient stroke setting.¹⁴ Commonly used screening tools for PSD include Patient Health Questionnaire–2, Patient Health Questionnaire–9, and Hospital Anxiety and Depression Scale–Depression.¹⁵ Validated scales used to assess PSA include Hospital Anxiety and Depression Scale–Anxiety and Geriatric Anxiety Inventory, and there is also evidence to support the use of Generalized Anxiety Disorder–2.¹⁵ Patient Health Questionnaire–2, Patient Health Questionnaire–9, and Generalized Anxiety Disorder–2 can be applied to caregivers.¹⁵

Treatment

Although the treatment of PSD has been studied for a long time, trials assessing various interventions including medications and behavioral therapies generally had small sample sizes and often excluded individuals with aphasia or cognitive impairments. These trials also used different screening techniques, enrolled individuals at various stages of poststroke recovery, and had different intervention time lengths. Despite the difficulty associated with generalizing the results of PSD treatment studies, many recommendations for the treatment of PSD are the result of meta-analyses of these studies.¹⁶

Initial treatment trials for PSD included tricyclic antidepressants (TCAs) and subsequent trials assessed selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, citalopram, and escitalopram.^17,18 Randomized placebo-controlled trials studying treatment of PSA are limited; however, medications such as buspirone, TCAs, and SSRIs have been studied and showed benefit.^19-23 Side effects associated with paroxetine and TCAs limited their use. The most common side effects of SSRIs in the poststroke population included seizures and fractures.^17,23 Initially, there was concern that SSRI medications could increase the risk of bleeding, especially in individuals who were receiving antiplatelet or anticoagulant therapies; however, this was not demonstrated in trials. There is conflicting evidence regarding SSRI medications and gastrointestinal side effects. Results of meta-analyses demonstrated no effect, whereas a Cochrane review showed that SSRIs were associated with nausea and upset stomach.^17,23

In addition to medication, targeted therapy with relaxation techniques, psychotherapy, and cognitive behavioral therapy (CBT) were found to be helpful.¹⁷ Individuals seem to benefit the most from combination CBT and SSRI therapy; however, benefit was also found in individuals who completed CBT alone or SSRI therapy alone.²⁴ Therefore, the optimal treatment approach includes assessing both the needs of the individual and the resources available within the community. After cessation of treatment for PSD and PSA, improvements diminished; therefore, ongoing management of PSD and PSA is imperative.²⁴

Connection Between Stroke Survivor and Caregiver Anxiety and Depression

Depression and anxiety are common in caregivers of individuals who have had a stroke, estimated at 25% and 45%, respectively.^25-27 Various factors related to the stroke survivor (eg, stroke severity, disability, and mental health status) have been found to contribute to a caregiver’s mental health status.⁶ External factors, such as socioeconomic status, support system availability, and presence of community resources, can affect caregiver depression and anxiety.²⁸ Certain characteristics (eg, female sex, older age, premorbid depression or anxiety) are common in caregivers with anxiety or depression.²⁹

The caregiver’s mental health state has been shown to affect the stroke survivor’s ability to participate in rehabilitation, and depression or anxiety in the caregiver can reduce the stroke survivor’s ability to recover from the stroke.³⁰ Caregiver depression and anxiety are associated with increased mortality rates at 6 months for people who have had a stroke.⁶ The caregiver’s well-being contributes to the stroke survivor’s well-being.^31,32

The interrelated nature of stroke survivor and caregiver well-being should be acknowledged in the outpatient setting. The simple acknowledgement of the burden of stroke and the complications it brings may have a healing effect for stroke survivors and caregivers and may help encourage the caregiver to seek treatment. Referral to support groups can also be helpful for caregivers and people who have had a stroke. Addressing the mental health of these dyads can be thought of as a step toward appropriate secondary prevention of stroke.

Conclusions

PSD and PSA are prevalent complications of stroke that can greatly affect the individual who has experienced a stroke, their caregiver, stroke recovery, and secondary stroke prevention. Future studies of PSD and PSA need to focus on the development of standardized validated screening surveys that can be used in individuals with varying neurologic deficits, including aphasia and cognitive impairment. Further research is needed to elucidate the optimal timing for screening of PSD and PSA and to best understand the benefits of therapy and its effects on stroke outcome.

Screening for PSD and PSA should be a standardized protocol in the outpatient clinic. A standardized practice would help reduce the heterogeneity that exists in treatment of the poststroke population. Outpatient neurologists need to continue to advocate for individuals and families to work toward wellness. Given that treatment of PSD and PSA affects both recovery and risk of recurrent stroke, developing methods to incorporate and address depression and anxiety may have a large effect on stroke outcome. Given the interconnectedness of depression and anxiety in stroke survivors and their caregivers, protocols are needed to assess and treat depression and anxiety in these individuals.