Recognizing Poststroke Depression Elizabeth A. Bruckbauer, BS RN
Depressionfollowing stroke is a complication thatfi-equently is untreated. Lack of awareness of those at risk for poststroke depression, conrbined with lack of information about depression in stroke patients, may be one reason for this neglect. This article reviews recent studies on characteristics ofpoststroke depression. The location of the lesion, degree offunctional loss, and distinction between major and dysthymic (minor) depression all are factors that influence poststroke depression. epression following stroke is an increasingly recognized complication, and one that appears to be a major factor in the individual’sability to participate in and benefit from rehabilitation efforts (Adams & Hurvitz, 1963; Finklestein et al., 1982; Robinson, Lipsey, &Price, 1985). In the past, depression related to stroke was described as an understandable reaction to the catastrophiconsetof strokeand the loss or impairmentof function associatedwithstroke(Feibel,Berk,&Joynt, 1979;Schwartzman, 1976). However, in a series of studies with stroke patients, Robinson, Starr, Kubos, and Price (1983) demonstrated that depression associated with stroke may have symptoms of either major or minor depression that meet the DSM-III criteria of the ‘American Psychiatric Association (APA, 1980). There also is evidence that poststroke depression runs a lengthy, discernible course(Robinsonetal., 1985),andthatthepresenceofdepression may be associated with the location of the lesion (Robinson & Price, 1982). Recent studies suggest that as many as 60% of patients experiencesignificantdepression after stroke (Robinson,Starr, Lipsey, Rao, & Price, 1984). However, despite this documentation of the presence of poststroke depression, little attention is given to the treatment of depression as part of stroke rehabilitation efforts. Finklestein et al. (1987) found that in a rehabilitation hospital with more than 200 stroke admissions per year, only 60 patients during a 7-year period were recorded as having received psychiatric consultation for depression. Feibel and Springer (1982), in their study of 91 stroke patients seen at 6 months after stroke, found that only 5 had received treatment for depression, although 24 (26%) of those patients showed significant depression symptoms. There are several possible reasons why depression following stroke is not commonly treated as part of the rehabilitation process; acceptance of depression as an inevitable grief reaction may be one of them. Other causes may be lack of awareness of stroke patients’ high risk of developing poststroke depression and lack of information about the characteristics and course of depressive disorders (Robinson & Price, 1982). This article reviews recent studies that have described characteristics of patients with poststroke depression, including depression’s relationship to location of the lesion and to functional losses.
D
Defining depression Depression can be described as a state of lowered selfesteem, accompanied by feelings of helplessness and hopelessness that may be evident to others. The term depression is confusing to clinicians who may come in contact with depressed patients, because it can refer either to a full clinical Address correspondence to Elizabeth A. Bruckbauer, 310 N . Segoe Road, Apt. 33-A, Madison, WI 53705.
syndrome or to the normal feelings of sadness and disinterest in life that accompany crisis periods (Minot, 1986). Major depression: Major clinical depression symptoms present differently in individuals. Variations may be related to differencesin severityor pattern of depression. The outstanding symptom of major depression is a dysphoric mood (sadness, irritability, anxiety, or anger), with loss of interest in all usual activities. Diagnosis of major depression can be made using DSM-111criteria, which require that four of the following eight symptoms accompany the dysphoria: (a) fatigue or loss of energy; (b) feelings of worthlessness, self-reproach, or inappropriate guilt; (c) impaired thinking or concentration;(d) poor appetite/weight loss or increased appetite/weight gain; (e) suicidal ideation or morbid thoughts; (f) loss of libido; (g) sleep disturbance, either insomnia or hypersomnia; and (h) changes in psychomotor activity, either agitation or retardation. These symptoms must be present for at least 2 weeks for the condition to be classified as depression (APA, 1980).Insomniawith early morning awakening is particularly characteristic of major depression (Minot, 1986). Dysthymia: Dysthymia, another form of clinical depression that differs from major depression, is characterizedby its longterm, chronic nature and lack of physical symptoms of depression. People with dysthymic disorders report periods of feelingnormal interspersedwith periodsof impairedfunctioning and often describe this pattern as lifelong. DSM-111 diagnostic criteria for dysthymia include (a) duration of at least 2 years but lacking the severity to be qualified as major depression; (b) intervals free of depression lasting not more than a few months; (c) depressed mood or loss of interest; and (d) at least three of the following: insomnia or hypersomnia, tiredness or low energy, low self-esteem, reduced capacity to work, poor concentration, social withdrawal, loss of interest, irritability, inability to respond with pleasure, less inclination to talk, pessimism, tearfulness, or morbid thoughts (APA, 1980). The diagnosis of depression in poststroke patients must be based on the existence of a cluster of symptoms that define the disorder, just as is the case in patients without brain injury. Although many stroke patients suffer from language disorders and cognitive impairments that can make assessment difficult, recent studies have demonstrated that stroke patients can be evaluated for depression reliably, using standard and sptyialized scales to rate the presence and degree of depression (Finklestein et al, 1982; Robinson, Starr, Lipsey, et al., 1984).
Defining poststroke depression Robinsonet al. (1985)describedthree types of mood disorders commonly seen in stroke patients. The first type is a severe depression with symptomsthat meet the APA criteria for major depression.In a 2-year longitudinalstudy of 103strokepatients during the acute stroke period (initial interviews usually took place within 2 weeks following stroke), they found that 26% of
34/Jan-Feb 199lmehabilitation NursingNol. 16, No. 1
the group had the symptoms of major depression (Robinson et al., 1983). Symptoms in more than half of these patients included sadness, anxiety, tension, loss of energy, worrying, loss of interest and concentration, sleep disturbance with early morning awakening, loss of appetite with weight loss, difficulty in concentrating and thinking, and thoughts of death or suicide. . Robinson et al. (1983) reported a second category of patients with symptoms of minor (dysthymic) depression except for the 2-year duration criteria. Of the 103stroke patients studied, 20% had dysthymic disorders. Because of the different associated variables, the patients were separated into major and minor depression categories for study purposes. These researchers found that minor depression was associated with posterior lesions of either the right or left hemisphere, while major depression was strongly associated with left frontal brain injury (Robinson, Kubos, Starr, Rao, & Price, 1984). In addition to major and minor depression, Robinson et al. (1985) described a third mood disorder associated with stroke and characterized by an indifferent, apathetic mental state associated with inappropriate cheerfulness. This disorder was found in 6 of 20 (30%) patients with single right-hemisphere lesions and in none of 28 patients with single left-hemisphere strokes. Although the studies by Robinson and associates suggestthat location of the lesion is an important determining factor in the type and severity of poststroke depression, others argue that this relationship cannot be directly documented (Finklestein et al., 1982; Sinyor, Amato, et al., 1986). Different methods of determining depression (DSM-I11 diagnosis versus scores on depression-rating scales) and difference in the length of time after stroke forevaluation may explain this difference in results (Robinson, Starkstein, & Price, 1988).
Functional impairment and depression Many studies have reported that at least in the acute phase poststroke, there is either a weak relationship or no relationship at all between the degree of depression and the degree of functional disability (Feibel & Springer, 1982; Finklestein et al., 1987;Robinson, Bolduc, & Price, 1987;Sinyor, Jacques, et al., 1986).However, in arecent comparison study of depressed and nondepressed patients, Sinyor, Amato, et al. (1986) demonstratedthat depression was associatedwith greater functional impairment at both admission to and discharge from an acute rehabilitation program. In this study, scores on the Nurse’s Rating Scale (NRS), a scale developed by Robinson and Szetela (1981) specifically for use in assessing depressive symptoms in stroke patients, were negatively correlated with functional assessment scores by both physical therapists ( I . = -.45,p< .01) andoccupational therapists (r= -.35,p< .Ol). This indicated that patients rated by nursing staff as relatively more depressed showed relatively greater functional impairment. Interestingly,these patients did improve in functional ability in the time between admission and discharge and did not differ significantly in degree of improvement from nondepressed stroke patients (Sinyor, Amato, et al., 1986). This finding conflicted with earlier findings that depression interferes with
the patient’s ability to benefit from rehabilitation efforts; therefore, it deserves further study. In studies of stroke patients that extend beyond the acute rehabilitationphase, there is agreementthat untreated depression can lead to loss of functional gains, failure to continue to improve, or a greater degree of failure to resume social activities-and therefore can have a negative effect on the longtermrehabilitationoutcome(Feibel& Springer, 1982;Robinson, Lipsey, Rao, & Price, 1986; Sinyor, Amato, et al., 1986). Sinyor, Amato, et al. (1986) speculated that active encouragement to participate in the intensive rehabilitation program and reinforcement of patient efforts by the rehabilitation team may mediate the effects of depression during hospitalization.However, depression may interfere with maintenance of functional gains following discharge when this support is withdrawn,and the patient must rely on personal initiativeto continuetherapeutic exercises and activities.
Course and outcome in poststroke depression Because untreated depression can affect long-term rehabilitation outcomes, it is important to know whether there is a discernible course of depression in stroke patients. However, this area has not received a great deal of attention in the literature. In a prospective study of mood disorders in stroke patients, Robinson et al. (1987) interviewed 37 patients at 1 year and 48 patients at 2 years after discharge. Of these 65 patients, initial in-hospital evaluationrevealed9 patients (14%) with symptom clusters of major depression, 12 patients (18%) with symptom clusters of dysthymic (minor) depression, and 44 patients (68%) who did not meet DSM-I11diagnosticcriteria fordepression.Although all ofthe patients withmajordepression diagnosed in the in-hospital exam were improved by 2 years, only 30% of patients with dysthymicdepressionimproved after the same period. In addition, of the patients who were assessed as not depressed while in the hospital, 34% had developed major or minor depression by 2 years afterward.As the patients with major depression improved, they also improved in their activity of daily living (ADL) scores, while the dysthymic patients did not improve in ADL scores. These findings suggest that the incidence of depression remains high during the first 2 years after stroke, but that untreated major depression has a natural course of 1 to 2 years (Robinson et al., 1987). The lack of improvement in patients with untreated dysthymic or minor depression, as well as the relationship to poor prognosis for functional improvement, emphasize both (a) the need to differentiate the type and severity of depression and (b) the need for ongoing assessment and treatment of depression in stroke . patients. Conclusions Although poststroke depression occurs in a large percentage of patients, it is a frequently overlooked focus of treatment in strokerehabilitation. Acceptanceof depression following stroke as a natural grief reaction and lack of awareness of stroke patients’ high risk of developing depression by rehabilitation team members may be the reason for this lack of treatment. Therefore, researchers have attempted to categorize patients at Vol. 16, No. lmehabilitation Nursing/Jan-Feb 1991/35
Recognizing Poststroke Depression
.
risk for developing poststroke depression. An important factor relating to depression in stroke patients is location of the lesion, with left-anterior cerebral lesions and (less often) right-posterior cerebral lesions tending to be associated with a greater risk for mood disorders. Some depressions may be more severe and may last longer than others. The differentiation between symptoms of major and dysthymic depression may provide useful prognostic information to clinicians. Researchers disagree as to whether depression plays a role in acute rehabilitation outcomes, but there is agreement that untreated depression has an adverse impact on long-term recovery from stroke. Therefore, further research to define the characteristics of poststroke depression is needed. Assessment and treatment strategies for depression need to be developed and included in stroke rehabilitation programs.
Implications and applications for nursing practice Nurses practicing on acute inpatient rehabilitation units, in outpatient follow-up clinics, and in the community need to be aware of the prevalence and characteristics of poststroke depression. By including assessmentfor depression in their initial and ongoing assessments of their patients, nurses may be able to identifypatients whoserehabilitationefforts are compromised by depression and aid these patients in receiving appropriate treatment. Depression has been linked to an inability to maintain functional gains, continue to improve, and resume social activities after the acute rehabilitation phase; therefore, nurses who treat patients in follow-up clinics and community settings need to be aware of depression as a possible cause when their patients have difficulty making the transition from hospital to home care. They also must provide early assessment and intervention. Knowledge of the types of patients at risk for depression, the characteristics of the different types of depression, and the availabilityof assessmenttools for depression in stroke patients will allow nurses to more effectively assess and treat patients. Elizabeth A . Bruckbauer is a graduate student at the University of Wisconsin-Madison in Madison, WI, in the nurse practitioner program focusing on primary care of chronically ill adults and the aged.
Aiinals of Neurology, 12,463-468. Finklestein, S., Weintraub, R., Karmouz, N., Askinazi, C., Davar, G., & Baldessarini, R. (1987). Antidepressant drug treatment for poststroke depression: Retrospective study. Archives of Physical Medicine and Rehabilitation, 68,772-776. Minot, S. (1986). CE depression: What does it mean? American Journal of Nursing, 86,285-293. Robinson, R., Bolduc, P., & Price, T. (1987). Two-year longitudinal study of post-stroke mood disorders: Diagnosis and outcome at one and two years. Stroke, 18,837-843. Robinson, R., Kubos, K., Starr, L., Rao, K., & Price, T. (1984). Mood disorders in stroke patients: Importance of location of lesion. Brain, 107,81-93. Robinson, R., Lipsey, J., & Price, T. (1985). Diagnosis and clinical management of post-stroke depression. Psychosoniatics, 26( lo), 769-778. Robinson, R., Lipsey, J., Rao, K., & Price, T. (1986). A two-year longitudinal study of post-stroke mood disorders: Comparison of acute onset with delayed onset depression. American Journal of Psychiatry, 143, 1238-1244. Robinson, R., &Price, T. (1982). Post-stroke depressive disorders: A follow-up study of 103 patients. Stroke, 13,635-641. Robinson, R., Starkstein, S., & Price, T. (1988). Post-stroke depression and lesion location [letter]. Stroke, 19, 125-126. Robinson, R., Starr, L., Kubos, K., & Price, T. (1983). A two-year longitudinal study of post-stroke mood disorders: Findings during the initial evaluation. Stroke, 14,736-741. Robinson, R., Starr, L., Lipsey, J., Rao, K., & Price, T. (1984). A twoyear longitudinal study of post-stroke mood disorders: Dynamic changes in associated variables over the first six months of followup. Stroke, 15,510-517. Robinson, R., & Szetela, B. (1981). Mood change following left hemisphere brain injury. Annals of Neurology, 9,447-453. Schwartzman, S. (1976). Anxiety and depression in the stroke patient: A nursing challenge. Journal of Psychiatric Nursing and Mental Health Services, 14(7), 13-18. Sinyor, D., Amato, P., Kaloupek, D., Becker, R., Goldenberg, M., & Coopersmith, H. (1986). Post-stroke depression: Relationships to functional impairment, coping strategies, and rehabilitation outcomes. Stroke, 17, 1102-1 107. Sinyor, D., Jacques, P., Kaloupek, D., Becker, R.,Goldenberg, M.,& Coopersmith, H. (1986). Post-stroke depression and lesion location: An attempted replication. Brain, 109,537-546.
References Adams, G., & Hurvitz, L. (1963). Mental barriers to recovery from strokes. Lancet, I, 533-537. American Psychiatric Association. (1980). Diagnostic and statistical nianual of ntental disorders (3rd ed.). Washington, DC: Author. Feibel, J., Berk, S., & Joynt, R. (1979). The unmet needs of stroke survivors. Neurology, 29,592. Feibel, J., & Springer, C. (1982). Depression and failure to resume social activities after stroke. Archives of Physical Medicine and Rehabilitation, 63,276-278. Finklestein, S., Benowitz, L., Baldessarini, R., Arana, G., Levine, D., Woo, E., Bear, D., Moya, K., & Stoll, A. (1982). Mood, vegetative disturbance, and dexamethasone suppression test after stroke. 36/Jan-Feb 1991/Rehabilitation NursingNol. 16, No. 1
Depressionfollowing stroke is a complication thatfi-equently is untreated. Lack of awareness of those at risk for poststroke depression, conrbined with lack of information about depression in stroke patients, may be one reason for this neglect. This article reviews recent studies on characteristics ofpoststroke depression. The location of the lesion, degree offunctional loss, and distinction between major and dysthymic (minor) depression all are factors that influence poststroke depression. epression following stroke is an increasingly recognized complication, and one that appears to be a major factor in the individual’sability to participate in and benefit from rehabilitation efforts (Adams & Hurvitz, 1963; Finklestein et al., 1982; Robinson, Lipsey, &Price, 1985). In the past, depression related to stroke was described as an understandable reaction to the catastrophiconsetof strokeand the loss or impairmentof function associatedwithstroke(Feibel,Berk,&Joynt, 1979;Schwartzman, 1976). However, in a series of studies with stroke patients, Robinson, Starr, Kubos, and Price (1983) demonstrated that depression associated with stroke may have symptoms of either major or minor depression that meet the DSM-III criteria of the ‘American Psychiatric Association (APA, 1980). There also is evidence that poststroke depression runs a lengthy, discernible course(Robinsonetal., 1985),andthatthepresenceofdepression may be associated with the location of the lesion (Robinson & Price, 1982). Recent studies suggest that as many as 60% of patients experiencesignificantdepression after stroke (Robinson,Starr, Lipsey, Rao, & Price, 1984). However, despite this documentation of the presence of poststroke depression, little attention is given to the treatment of depression as part of stroke rehabilitation efforts. Finklestein et al. (1987) found that in a rehabilitation hospital with more than 200 stroke admissions per year, only 60 patients during a 7-year period were recorded as having received psychiatric consultation for depression. Feibel and Springer (1982), in their study of 91 stroke patients seen at 6 months after stroke, found that only 5 had received treatment for depression, although 24 (26%) of those patients showed significant depression symptoms. There are several possible reasons why depression following stroke is not commonly treated as part of the rehabilitation process; acceptance of depression as an inevitable grief reaction may be one of them. Other causes may be lack of awareness of stroke patients’ high risk of developing poststroke depression and lack of information about the characteristics and course of depressive disorders (Robinson & Price, 1982). This article reviews recent studies that have described characteristics of patients with poststroke depression, including depression’s relationship to location of the lesion and to functional losses.
D
Defining depression Depression can be described as a state of lowered selfesteem, accompanied by feelings of helplessness and hopelessness that may be evident to others. The term depression is confusing to clinicians who may come in contact with depressed patients, because it can refer either to a full clinical Address correspondence to Elizabeth A. Bruckbauer, 310 N . Segoe Road, Apt. 33-A, Madison, WI 53705.
syndrome or to the normal feelings of sadness and disinterest in life that accompany crisis periods (Minot, 1986). Major depression: Major clinical depression symptoms present differently in individuals. Variations may be related to differencesin severityor pattern of depression. The outstanding symptom of major depression is a dysphoric mood (sadness, irritability, anxiety, or anger), with loss of interest in all usual activities. Diagnosis of major depression can be made using DSM-111criteria, which require that four of the following eight symptoms accompany the dysphoria: (a) fatigue or loss of energy; (b) feelings of worthlessness, self-reproach, or inappropriate guilt; (c) impaired thinking or concentration;(d) poor appetite/weight loss or increased appetite/weight gain; (e) suicidal ideation or morbid thoughts; (f) loss of libido; (g) sleep disturbance, either insomnia or hypersomnia; and (h) changes in psychomotor activity, either agitation or retardation. These symptoms must be present for at least 2 weeks for the condition to be classified as depression (APA, 1980).Insomniawith early morning awakening is particularly characteristic of major depression (Minot, 1986). Dysthymia: Dysthymia, another form of clinical depression that differs from major depression, is characterizedby its longterm, chronic nature and lack of physical symptoms of depression. People with dysthymic disorders report periods of feelingnormal interspersedwith periodsof impairedfunctioning and often describe this pattern as lifelong. DSM-111 diagnostic criteria for dysthymia include (a) duration of at least 2 years but lacking the severity to be qualified as major depression; (b) intervals free of depression lasting not more than a few months; (c) depressed mood or loss of interest; and (d) at least three of the following: insomnia or hypersomnia, tiredness or low energy, low self-esteem, reduced capacity to work, poor concentration, social withdrawal, loss of interest, irritability, inability to respond with pleasure, less inclination to talk, pessimism, tearfulness, or morbid thoughts (APA, 1980). The diagnosis of depression in poststroke patients must be based on the existence of a cluster of symptoms that define the disorder, just as is the case in patients without brain injury. Although many stroke patients suffer from language disorders and cognitive impairments that can make assessment difficult, recent studies have demonstrated that stroke patients can be evaluated for depression reliably, using standard and sptyialized scales to rate the presence and degree of depression (Finklestein et al, 1982; Robinson, Starr, Lipsey, et al., 1984).
Defining poststroke depression Robinsonet al. (1985)describedthree types of mood disorders commonly seen in stroke patients. The first type is a severe depression with symptomsthat meet the APA criteria for major depression.In a 2-year longitudinalstudy of 103strokepatients during the acute stroke period (initial interviews usually took place within 2 weeks following stroke), they found that 26% of
34/Jan-Feb 199lmehabilitation NursingNol. 16, No. 1
the group had the symptoms of major depression (Robinson et al., 1983). Symptoms in more than half of these patients included sadness, anxiety, tension, loss of energy, worrying, loss of interest and concentration, sleep disturbance with early morning awakening, loss of appetite with weight loss, difficulty in concentrating and thinking, and thoughts of death or suicide. . Robinson et al. (1983) reported a second category of patients with symptoms of minor (dysthymic) depression except for the 2-year duration criteria. Of the 103stroke patients studied, 20% had dysthymic disorders. Because of the different associated variables, the patients were separated into major and minor depression categories for study purposes. These researchers found that minor depression was associated with posterior lesions of either the right or left hemisphere, while major depression was strongly associated with left frontal brain injury (Robinson, Kubos, Starr, Rao, & Price, 1984). In addition to major and minor depression, Robinson et al. (1985) described a third mood disorder associated with stroke and characterized by an indifferent, apathetic mental state associated with inappropriate cheerfulness. This disorder was found in 6 of 20 (30%) patients with single right-hemisphere lesions and in none of 28 patients with single left-hemisphere strokes. Although the studies by Robinson and associates suggestthat location of the lesion is an important determining factor in the type and severity of poststroke depression, others argue that this relationship cannot be directly documented (Finklestein et al., 1982; Sinyor, Amato, et al., 1986). Different methods of determining depression (DSM-I11 diagnosis versus scores on depression-rating scales) and difference in the length of time after stroke forevaluation may explain this difference in results (Robinson, Starkstein, & Price, 1988).
Functional impairment and depression Many studies have reported that at least in the acute phase poststroke, there is either a weak relationship or no relationship at all between the degree of depression and the degree of functional disability (Feibel & Springer, 1982; Finklestein et al., 1987;Robinson, Bolduc, & Price, 1987;Sinyor, Jacques, et al., 1986).However, in arecent comparison study of depressed and nondepressed patients, Sinyor, Amato, et al. (1986) demonstratedthat depression was associatedwith greater functional impairment at both admission to and discharge from an acute rehabilitation program. In this study, scores on the Nurse’s Rating Scale (NRS), a scale developed by Robinson and Szetela (1981) specifically for use in assessing depressive symptoms in stroke patients, were negatively correlated with functional assessment scores by both physical therapists ( I . = -.45,p< .01) andoccupational therapists (r= -.35,p< .Ol). This indicated that patients rated by nursing staff as relatively more depressed showed relatively greater functional impairment. Interestingly,these patients did improve in functional ability in the time between admission and discharge and did not differ significantly in degree of improvement from nondepressed stroke patients (Sinyor, Amato, et al., 1986). This finding conflicted with earlier findings that depression interferes with
the patient’s ability to benefit from rehabilitation efforts; therefore, it deserves further study. In studies of stroke patients that extend beyond the acute rehabilitationphase, there is agreementthat untreated depression can lead to loss of functional gains, failure to continue to improve, or a greater degree of failure to resume social activities-and therefore can have a negative effect on the longtermrehabilitationoutcome(Feibel& Springer, 1982;Robinson, Lipsey, Rao, & Price, 1986; Sinyor, Amato, et al., 1986). Sinyor, Amato, et al. (1986) speculated that active encouragement to participate in the intensive rehabilitation program and reinforcement of patient efforts by the rehabilitation team may mediate the effects of depression during hospitalization.However, depression may interfere with maintenance of functional gains following discharge when this support is withdrawn,and the patient must rely on personal initiativeto continuetherapeutic exercises and activities.
Course and outcome in poststroke depression Because untreated depression can affect long-term rehabilitation outcomes, it is important to know whether there is a discernible course of depression in stroke patients. However, this area has not received a great deal of attention in the literature. In a prospective study of mood disorders in stroke patients, Robinson et al. (1987) interviewed 37 patients at 1 year and 48 patients at 2 years after discharge. Of these 65 patients, initial in-hospital evaluationrevealed9 patients (14%) with symptom clusters of major depression, 12 patients (18%) with symptom clusters of dysthymic (minor) depression, and 44 patients (68%) who did not meet DSM-I11diagnosticcriteria fordepression.Although all ofthe patients withmajordepression diagnosed in the in-hospital exam were improved by 2 years, only 30% of patients with dysthymicdepressionimproved after the same period. In addition, of the patients who were assessed as not depressed while in the hospital, 34% had developed major or minor depression by 2 years afterward.As the patients with major depression improved, they also improved in their activity of daily living (ADL) scores, while the dysthymic patients did not improve in ADL scores. These findings suggest that the incidence of depression remains high during the first 2 years after stroke, but that untreated major depression has a natural course of 1 to 2 years (Robinson et al., 1987). The lack of improvement in patients with untreated dysthymic or minor depression, as well as the relationship to poor prognosis for functional improvement, emphasize both (a) the need to differentiate the type and severity of depression and (b) the need for ongoing assessment and treatment of depression in stroke . patients. Conclusions Although poststroke depression occurs in a large percentage of patients, it is a frequently overlooked focus of treatment in strokerehabilitation. Acceptanceof depression following stroke as a natural grief reaction and lack of awareness of stroke patients’ high risk of developing depression by rehabilitation team members may be the reason for this lack of treatment. Therefore, researchers have attempted to categorize patients at Vol. 16, No. lmehabilitation Nursing/Jan-Feb 1991/35
Recognizing Poststroke Depression
.
risk for developing poststroke depression. An important factor relating to depression in stroke patients is location of the lesion, with left-anterior cerebral lesions and (less often) right-posterior cerebral lesions tending to be associated with a greater risk for mood disorders. Some depressions may be more severe and may last longer than others. The differentiation between symptoms of major and dysthymic depression may provide useful prognostic information to clinicians. Researchers disagree as to whether depression plays a role in acute rehabilitation outcomes, but there is agreement that untreated depression has an adverse impact on long-term recovery from stroke. Therefore, further research to define the characteristics of poststroke depression is needed. Assessment and treatment strategies for depression need to be developed and included in stroke rehabilitation programs.
Implications and applications for nursing practice Nurses practicing on acute inpatient rehabilitation units, in outpatient follow-up clinics, and in the community need to be aware of the prevalence and characteristics of poststroke depression. By including assessmentfor depression in their initial and ongoing assessments of their patients, nurses may be able to identifypatients whoserehabilitationefforts are compromised by depression and aid these patients in receiving appropriate treatment. Depression has been linked to an inability to maintain functional gains, continue to improve, and resume social activities after the acute rehabilitation phase; therefore, nurses who treat patients in follow-up clinics and community settings need to be aware of depression as a possible cause when their patients have difficulty making the transition from hospital to home care. They also must provide early assessment and intervention. Knowledge of the types of patients at risk for depression, the characteristics of the different types of depression, and the availabilityof assessmenttools for depression in stroke patients will allow nurses to more effectively assess and treat patients. Elizabeth A . Bruckbauer is a graduate student at the University of Wisconsin-Madison in Madison, WI, in the nurse practitioner program focusing on primary care of chronically ill adults and the aged.
Aiinals of Neurology, 12,463-468. Finklestein, S., Weintraub, R., Karmouz, N., Askinazi, C., Davar, G., & Baldessarini, R. (1987). Antidepressant drug treatment for poststroke depression: Retrospective study. Archives of Physical Medicine and Rehabilitation, 68,772-776. Minot, S. (1986). CE depression: What does it mean? American Journal of Nursing, 86,285-293. Robinson, R., Bolduc, P., & Price, T. (1987). Two-year longitudinal study of post-stroke mood disorders: Diagnosis and outcome at one and two years. Stroke, 18,837-843. Robinson, R., Kubos, K., Starr, L., Rao, K., & Price, T. (1984). Mood disorders in stroke patients: Importance of location of lesion. Brain, 107,81-93. Robinson, R., Lipsey, J., & Price, T. (1985). Diagnosis and clinical management of post-stroke depression. Psychosoniatics, 26( lo), 769-778. Robinson, R., Lipsey, J., Rao, K., & Price, T. (1986). A two-year longitudinal study of post-stroke mood disorders: Comparison of acute onset with delayed onset depression. American Journal of Psychiatry, 143, 1238-1244. Robinson, R., &Price, T. (1982). Post-stroke depressive disorders: A follow-up study of 103 patients. Stroke, 13,635-641. Robinson, R., Starkstein, S., & Price, T. (1988). Post-stroke depression and lesion location [letter]. Stroke, 19, 125-126. Robinson, R., Starr, L., Kubos, K., & Price, T. (1983). A two-year longitudinal study of post-stroke mood disorders: Findings during the initial evaluation. Stroke, 14,736-741. Robinson, R., Starr, L., Lipsey, J., Rao, K., & Price, T. (1984). A twoyear longitudinal study of post-stroke mood disorders: Dynamic changes in associated variables over the first six months of followup. Stroke, 15,510-517. Robinson, R., & Szetela, B. (1981). Mood change following left hemisphere brain injury. Annals of Neurology, 9,447-453. Schwartzman, S. (1976). Anxiety and depression in the stroke patient: A nursing challenge. Journal of Psychiatric Nursing and Mental Health Services, 14(7), 13-18. Sinyor, D., Amato, P., Kaloupek, D., Becker, R., Goldenberg, M., & Coopersmith, H. (1986). Post-stroke depression: Relationships to functional impairment, coping strategies, and rehabilitation outcomes. Stroke, 17, 1102-1 107. Sinyor, D., Jacques, P., Kaloupek, D., Becker, R.,Goldenberg, M.,& Coopersmith, H. (1986). Post-stroke depression and lesion location: An attempted replication. Brain, 109,537-546.
References Adams, G., & Hurvitz, L. (1963). Mental barriers to recovery from strokes. Lancet, I, 533-537. American Psychiatric Association. (1980). Diagnostic and statistical nianual of ntental disorders (3rd ed.). Washington, DC: Author. Feibel, J., Berk, S., & Joynt, R. (1979). The unmet needs of stroke survivors. Neurology, 29,592. Feibel, J., & Springer, C. (1982). Depression and failure to resume social activities after stroke. Archives of Physical Medicine and Rehabilitation, 63,276-278. Finklestein, S., Benowitz, L., Baldessarini, R., Arana, G., Levine, D., Woo, E., Bear, D., Moya, K., & Stoll, A. (1982). Mood, vegetative disturbance, and dexamethasone suppression test after stroke. 36/Jan-Feb 1991/Rehabilitation NursingNol. 16, No. 1
