Review
Neuropsychiatric outcomes of stroke

https://doi.org/10.1016/S1474-4422(14)70016-XGet rights and content

Summary

The most common neuropsychiatric outcomes of stroke are depression, anxiety, fatigue, and apathy, which each occur in at least 30% of patients and have substantial overlap of prevalence and symptoms. Emotional lability, personality changes, psychosis, and mania are less common but equally distressing symptoms that are also challenging to manage. The cause of these syndromes is not known, and there is no clear relation to location of brain lesion. There are important gaps in knowledge about how to manage these disorders, even for depression, which is the most studied syndrome. Further research is needed to identify causes and interventions to prevent and treat these disorders.

Introduction

Every year, about 16 million people worldwide have a first-ever stroke. Of this population, about 5·7 million people die and another 5 million remain disabled.1 Neuropsychiatric disorders after stroke are common and can be distressing to patients and their families, but their effects are often underappreciated by health-care professions and patients' treatment needs are often unmet.2 In this Review, we focus on the most common non-cognitive neuropsychiatric outcomes of stroke—ie, depression, anxiety, emotional lability, and apathy. We also discuss post-stroke fatigue (which is generally classified as a neuropsychiatric disorder), personality changes, psychosis, and mania. For each disorder, we discuss definition and identification, prevalence, associations, natural history and outcome, prevention, and treatment, and then make recommendations for future research. Researchers tend to consider each neuropsychiatric disorder separately, so we follow this approach, but we acknowledge that substantial overlap exists between the syndromes. Our management recommendations are based on data from randomised controlled trials or meta-analyses of these trials, but not from uncontrolled case series. In the absence of randomised data, we provide consensus recommendations.

Section snippets

Depression

The fifth US Diagnostic and Statistical Manual of Mental Disorders (DSM-5)3 defines depression as depressed mood or anhedonia (loss of interest or pleasure) for 2 weeks or longer, plus the presence of at least four of the following symptoms when they are persistent and they interfere with daily life: substantial weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, worthlessness or inappropriate guilt, diminished concentration, or

Anxiety

For patients to meet diagnostic criteria for a generalised anxiety disorder, anxiety symptoms that are out of proportion to the actual threat or danger the situation poses must be present for 6 months, plus at least three of the following: feeling wound-up, tense, or restless; fatigue; difficulty concentrating; irritability; substantial muscle tension; and difficulty sleeping. To our knowledge, the Hamilton Depression Rating Scale8 is the only anxiety-specific case-finding instrument validated

Emotional lability

DSM-53 describes emotional lability in patients as unstable emotional experiences and frequent mood changes, with emotions that are easily aroused, intense, or out of proportion to events and circumstances. It is also referred to as emotionalism, pathological laughing or crying, emotional incontinence, involuntary emotional expression disorder, and pseudobulbar affect. There is no standard method of assessment. Emotional lability usually presents as an increase in crying or, less commonly,

Fatigue after stroke

There is no standardised definition for fatigue after stroke.57 The published work distinguishes between physiological (or normal) fatigue (a state of general tiredness that develops acutely after overexertion and improves after rest), and pathological fatigue (constant weariness unrelated to previous exertion levels and not usually ameliorated by rest).58 In neurological disorders, pathological fatigue is more prominent than is physiological fatigue.59 Fatigue after stroke can be identified

Apathy

Apathy is a disorder of motivation with diminished goal-directed behaviour and cognition,78 which has distinct biological correlates, clinical course, and treatment. Nevertheless, phenomenological overlap (eg, affective blunting, loss of interest, and psychomotor retardation) with depression can make differential diagnosis difficult.78 Apathy can be identified by informant-rated scales—eg, Apathy Scale79 or Apathy Evaluation Scale80 (designed and tested for use in brain-injured populations)—or

Mania

Mania is defined as a prominent and persistently elevated, expansive, or irritable mood, accompanied by changes in energy or activity, not accounted for by other mental disorders and not exclusively present in the course of delirium.3 Accompanying symptoms are hyperactivity, pressured speech (highly talkative and difficult to interrupt), flight of ideas, grandiosity, decreased sleep, distractibility, or poor judgment. To qualify, symptoms need to cause substantial distress or impairment in

Personality disorders after stroke

The DSM-53 differentiates three clusters of personality disorders: “Cluster A includes paranoid, schizoid, and schizotypal personality disorders. Individuals with these disorders often appear odd or eccentric. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders. Individuals with these disorders often appear dramatic, emotional, or erratic. Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders”. For a person to have a

Psychosis and psychotic symptoms

Psychosis refers to disorders involving a severe distortion in thought content. Although this feature is commonly used to classify schizophrenia and related disorders, it also applies to mania and severe depression.111 Isolated psychotic symptoms can also be due to causes other than stroke, including delirium, dementia, or use of psychoactive drugs or dopamine agonists. The most prominent symptoms of psychosis include delusions and hallucinations. Delusions are fixed beliefs that are not

Conclusions and future directions

Considerable overlap exists between the neuropsychiatric syndromes discussed in this Review. Depression frequently coexists with anxiety and emotional lability, fatigue is a symptom of depression and anxiety, apathy is associated with depression and cognitive impairment, and personality changes are associated with emotional lability, depression, and cognitive impairment. This overlap raises questions about whether shared underlying mechanisms exist—eg, fluctuations in neurotransmitters, aspects

Search strategy and selection criteria

We searched Medline Ovid with the term “stroke” and keywords for each neuropsychiatric problem in turn, to identify systematic reviews and primary research. These searches complemented previous searches that we had done. For the section about stroke and depression, we searched Medline for articles published from Jan 1, 2004, to June 19, 2013 (date of last published systematic review) with the following terms: “depressive disorder/ or depressive disorder, major/ or depressive disorder,

References (118)

  • RS Marin et al.

    Reliability and validity of the Apathy Evaluation Scale

    Psychiatry Res

    (1991)
  • P Robert et al.

    Proposed diagnostic criteria for apathy in Alzheimer's disease and other neuropsychiatric disorders

    Eur Psychiatry

    (2009)
  • S van Almenkerk et al.

    Institutionalized stroke patients: status of functioning of an under researched population

    J Am Med Dir Assoc

    (2012)
  • PECA Passier et al.

    Life satisfaction and return to work after aneurysmal subarachnoid haemorrhage

    J Stroke Cerebrovasc Dis

    (2011)
  • C McKevitt et al.

    Self-reported long-term needs after stroke

    Stroke

    (2011)
  • Diagnostic and Statistical Manual of Mental Disorders

    (2013)
  • N Meader et al.

    Screening for poststroke major depression: a meta-analysis of diagnostic validity studies

    J Neurol Neurosurg Psychiatry

    (2014)
  • K Kroenke et al.

    The PHQ-9: validity of a brief depression severity measure

    J Gen Intern Med

    (2001)
  • LS Radloff

    The CES-D scale: a self report depression scale for research in the general population

    Appl Psychol Meas

    (1977)
  • L de Coster et al.

    The sensitivity of somatic symptoms in post-stroke depression: a discriminant analytic approach

    Int J Geriatr Psychiatry

    (2005)
  • National clinical guideline for stroke

    (2012)
  • S Gilbody et al.

    Screening and case-finding instruments for depression: a meta-analysis

    CMAJ

    (2008)
  • C Benaim et al.

    Validation of the aphasic depression rating scale

    Stroke

    (2004)
  • L Turner-Stokes et al.

    The Depression Intensity Scale Circles (DISCs): a first evaluation of a simple assessment tool for depression in the context of brain injury

    J Neurol Neurosurg Psychiatry

    (2005)
  • L Ayerbe et al.

    Natural history, predictors and outcomes of depression after stroke: systematic review and meta-analysis

    Br J Psychiatry

    (2013)
  • ML Hackett et al.

    Frequency of depression after stroke: a systematic review of observational studies

    Stroke

    (2005)
  • CK Loong et al.

    Post-stroke depression: outcome following rehabilitation

    Aust N Z J Psychiatry

    (1995)
  • M Aström et al.

    Major depression in stroke patients. A 3-year longitudinal study

    Stroke

    (1993)
  • L Ayerbe et al.

    The natural history of depression up to 15 years after stroke: the South London Stroke Register

    Stroke

    (2013)
  • A House et al.

    Mood disorders after stroke and their relation to lesion location. A CT scan study

    Brain

    (1990)
  • DT Wade et al.

    Depressed mood after stroke. A community study of its frequency

    Br J Psychiatry

    (1987)
  • ML Hackett et al.

    Predictors of depression after stroke: a systematic review of observational studies

    Stroke

    (2005)
  • ML Hackett et al.

    Interventions for preventing depression after stroke

    Cochrane Database Syst Rev

    (2008)
  • RG Robinson et al.

    Escitalopram and problem-solving therapy for prevention of poststroke depression: a randomized controlled trial

    JAMA

    (2008)
  • C-S Tsai et al.

    Prevention of poststroke depression with milnacipran in patients with acute ischemic stroke: a double-blind randomized placebo-controlled trial

    Int Clin Psychopharmacol

    (2011)
  • J Xu et al.

    Preventive effects of antidepressants on post-stroke depression

    Chin Ment Health J

    (2006)
  • ML Hackett et al.

    Interventions for treating depression after stroke

    Cochrane Database Syst Rev

    (2008)
  • E Ohtomo et al.

    Clinical evaluation of aniracetam on psychiatric symptoms related to cerebrovascular disease

    J Clin Exp Med

    (1991)
  • G Andersen et al.

    Effective treatment of poststroke depression with the selective serotonin reuptake inhibitor citalopram

    Stroke

    (1994)
  • S Fruehwald et al.

    Early fluoxetine treatment of post-stroke depression: a three months double-blind placebo-controlled study with an open-label long-term follow up

    J Neurol

    (2003)
  • J Yang et al.

    Controlled study on antidepressant treatment of patients with post-stroke depression

    Chin Psychol

    (2002)
  • V Murray et al.

    Double-blind comparison of sertraline and placebo in stroke patients with minor depression and less severe major depression

    J Clin Psychiatry

    (2005)
  • F Ponzio

    An 8-week, double-blind, placebo controlled, parallel group study to assess the efficacy and tolerability of paroxetine in patients suffering from depression following stroke. PAR 625

  • JC Fournier et al.

    Antidepressant drug effects and depression severity: a patient-level meta-analysis

    JAMA

    (2010)
  • L-T Li et al.

    The beneficial effects of the herbal medicine Free and Easy Wanderer Plus (FEWP) and fluoxetine on post-stroke depression

    J Altern Complement Med

    (2008)
  • EL Miller et al.

    Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientific statement from the American Heart Association

    Stroke

    (2010)
  • TJPS Quinn et al.

    Evidence-based stroke rehabilitation: an expanded guidance document from the European stroke organisation (ESO) guidelines for management of ischaemic stroke and transient ischaemic attack 2008

    J Rehabil Med

    (2009)
  • G Johnson et al.

    Screening instruments for depression and anxiety following stroke: experience in the Perth community stroke study

    Acta Psychiatr Scand

    (1995)
  • CA Campbell Burton et al.

    Frequency of anxiety after stroke: a systematic review and meta-analysis of observational studies

    Int J Stroke

    (2013)
  • CA Campbell Burton et al.

    Interventions for treating anxiety after stroke

    Cochrane Database Syst Rev

    (2011)
  • Cited by (223)

    View all citing articles on Scopus
    View full text