How Common Is Depression After a Stroke?

Pennsylvania Senator John Fetterman, who suffered a near-fatal stroke last year, voluntarily checked himself into Walter Reed National Military Medical Center on Wednesday night to seek treatment for clinical depression, his office said Thursday.

Fetterman, 53, was hospitalized last week after feeling lightheaded at a Democratic Senate retreat. Though doctors were able to rule out a second stroke, as well as the possibility of a seizure, his medical team at Walter Reed eventually recommended inpatient care for depression.

The senator’s office said in a statement that he had experienced depression “off and on” in the past, but that it had recently become severe in recent weeks. There has been no confirmation that Fetterman’s depression is related to his stroke.

Depression following a stroke—sometimes known as post-stroke depression—is common among stroke survivors, but is often overlooked or mistaken for other cognitive or behavioral changes that can occur after a stroke. Here’s what to know about the risk of depression after a stroke, and how to manage a diagnosis.

Understanding the Risk of Depression After Stroke

Post-stroke depression is a common complication in stroke survivors and is due to a variety of factors, including changes in a person’s day-to-day life, genetic risk factors, and personal history of depression. Many people have to learn to live with the disabling cognitive and behavioral challenges that can follow a stroke, making the recovery process an emotionally-taxing journey.

“Anyone who has had depression in the past is at risk for experiencing depression again, and the more episodes they have had, the higher their risk for episodes in the future,” Will Cronenwett, MD, the chief of psychiatry at Northwestern University Feinberg School of Medicine, told Health. “Having a stroke raises the risk even further.”

Younger people who experience a stroke may as also be as much as three times more likely to develop depression or anxiety following a stroke, compared to older patients, said Karen D. Sullivan, PhD, ABPP, a board-certified neuropsychologist and author of the stroke recovery guide I Care For Your Brain.

“The reason for this is thought to be how the negative impact of stroke symptoms derail the normal developmental life processes that are happening at this time: attending college, raising children, and building careers,” Dr. Sullivan told Health.

Certain structural and biochemical changes that take place in the brain after an injury like a stroke may also play a role in post-stroke depression.

“Damage to specific regions that regulate emotion—such as the left frontal pole, which tends to elevate mood—can lead to depression,” David Spiegel, MD, a psychiatrist and professor of psychiatry and behavioral Sciences with Stanford Health Care, told Health. Strokes can also alter brain chemistry, he said; for example, dopamine function is usually impacted after strokes and low dopamine levels can cause moodiness and irritability.

Strokes also trigger inflammation in the brain—thus, triggering the release of cytokines, or proteins secreted by the immune system—which in turn may affect a person’s mood as well, Dr. Spiegel said.

How Common Is Depression After Stroke?

About one-third of stroke survivors will experience depression at any time following a stroke, but that could be an underestimation of the true prevalence—by some estimates, up to 80% of stroke patients will develop depression, Dr. Sullivan said.

Post-stroke depression may be commonly misdiagnosed due to shared symptoms of other cognitive or behavioral issues that can occur following a stroke. “[The] symptoms common to both stroke and depression include sleep changes, difficulty concentrating, motor slowness and loss of appetite,” Dr. Sullivan said.

Many people who develop depression following a stroke do so within a year of their medical trauma—typically at the three-month mark, which is when people tend to be released from the hospital and the reality of post-stroke life sets in.

“Accepting a sudden change in abilities and identity is often a traumatic experience for folks, especially when they happen within just a few minutes, like in a stroke [situation],” Dr. Sullivan said.

But three months is not a hard-and-fast rule—in some cases, depression can strike years after a stroke, Dr. Cronenwett said.

Preventing or Managing Depression After Stroke

In recent years, there’s been an increased effort to develop prevention strategies that can help stroke patients minimize their risk of developing depression.

According to Dr. Cronenwett, people can lower their risk of depression by practicing healthy lifestyle habits, like eating well, avoiding overuse of alcohol, staying physically active, and maintaining relationships with other people. Of course, in some cases, even if people do these things, they can still develop depression, he added.

There’s no clear-cut guide on how medications can prevent post-stroke depression, but recent evidence has found that taking antidepressants after a stroke could cut the risk. Research has found that escitalopram—a selective serotonin reuptake inhibitor (SSRI)—can significantly lower the risk of depression and improve daily functioning and social skills in the aftermath of a stroke. 

The American Heart Association recommends that all stroke survivors undergo routine screening for depression, however, research shows only a fraction of stroke patients are adequately screened. The process is relatively straight-forward: patients are asked a few questions about their mental health, and depending on their responses, will undergo a more thorough evaluation by a mental health professional. According to Dr. Spiegel, early diagnosis and treatment can significantly improve outcomes by reducing the duration and severity of symptoms. 

Untreated depression can wreak havoc on stroke survivors’ lives. “Depression is the main factor limiting recovery and rehabilitation after a stroke and leads to greater disability, social isolation and reduced quality of life across all domains,” Dr. Sullivan said.

Post-stroke depression is often treated like regular depression; treatment plans can include standard antidepressants, therapy, and exercise rehabilitation programs. Due to the role of inflammation in depression among stroke patients, anti-inflammatory medications may also alleviate depressive symptoms, Dr. Spiegel said. Transcranial magnetic stimulation—a tool that uses magnetic fields to stimulate nerve cells—can be helpful for post-stroke depression as well, even in cases of severe depression, he added.

Post-stroke depression may be more common than not, but with early detection and prompt treatment, it can be well-managed. “Depression is a common and treatable disorder,” Dr. Spiegel said.