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,
ReviewNeuropsychiatric outcomes of stroke
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
References (118)
- et al.
Preventing stroke: saving lives around the world
Lancet Neurol
(2007) - et al.
Validity of the Beck Depression Inventory, Hospital Anxiety and Depression Scale, SCL-90, and Hamilton Depression Rating Scale as screening instruments for depression in stroke patients
Psychosomatics
(2002) - et al.
Fluoxetine for motor recovery after acute ischaemic stroke (FLAME): a randomised placebo-controlled trial
Lancet Neurol
(2011) - et al.
Nortriptyline treatment of post-stroke depression: a double-blind study
Lancet
(1984) - et al.
Screening for anxiety and depression after stroke: comparison of the hospital anxiety and depression scale and the Montgomery and Asberg depression rating scale
J Psychosom Res
(2009) - et al.
Fatigue associated with stroke and other neurologic conditions: implications for stroke rehabilitation
Arch Phys Med Rehabil
(2003) - et al.
Fatigue in neurological disorders
Lancet
(2004) - et al.
Fatigue after stroke: the development and evaluation of a case definition
J Psychosom Res
(2007) - et al.
Frequency and natural history of fatigue after stroke: a systematic review of longitudinal studies
J Psychosom Res
(2012) - et al.
Poststroke fatigue: course and its relation to personal and stroke-related factors
Arch Phys Med Rehabil
(2006)
Reliability and validity of the Apathy Evaluation Scale
Psychiatry Res
Proposed diagnostic criteria for apathy in Alzheimer's disease and other neuropsychiatric disorders
Eur Psychiatry
Institutionalized stroke patients: status of functioning of an under researched population
J Am Med Dir Assoc
Life satisfaction and return to work after aneurysmal subarachnoid haemorrhage
J Stroke Cerebrovasc Dis
Self-reported long-term needs after stroke
Stroke
Diagnostic and Statistical Manual of Mental Disorders
Screening for poststroke major depression: a meta-analysis of diagnostic validity studies
J Neurol Neurosurg Psychiatry
The PHQ-9: validity of a brief depression severity measure
J Gen Intern Med
The CES-D scale: a self report depression scale for research in the general population
Appl Psychol Meas
The sensitivity of somatic symptoms in post-stroke depression: a discriminant analytic approach
Int J Geriatr Psychiatry
National clinical guideline for stroke
Screening and case-finding instruments for depression: a meta-analysis
CMAJ
Validation of the aphasic depression rating scale
Stroke
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
Natural history, predictors and outcomes of depression after stroke: systematic review and meta-analysis
Br J Psychiatry
Frequency of depression after stroke: a systematic review of observational studies
Stroke
Post-stroke depression: outcome following rehabilitation
Aust N Z J Psychiatry
Major depression in stroke patients. A 3-year longitudinal study
Stroke
The natural history of depression up to 15 years after stroke: the South London Stroke Register
Stroke
Mood disorders after stroke and their relation to lesion location. A CT scan study
Brain
Depressed mood after stroke. A community study of its frequency
Br J Psychiatry
Predictors of depression after stroke: a systematic review of observational studies
Stroke
Interventions for preventing depression after stroke
Cochrane Database Syst Rev
Escitalopram and problem-solving therapy for prevention of poststroke depression: a randomized controlled trial
JAMA
Prevention of poststroke depression with milnacipran in patients with acute ischemic stroke: a double-blind randomized placebo-controlled trial
Int Clin Psychopharmacol
Preventive effects of antidepressants on post-stroke depression
Chin Ment Health J
Interventions for treating depression after stroke
Cochrane Database Syst Rev
Clinical evaluation of aniracetam on psychiatric symptoms related to cerebrovascular disease
J Clin Exp Med
Effective treatment of poststroke depression with the selective serotonin reuptake inhibitor citalopram
Stroke
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
Controlled study on antidepressant treatment of patients with post-stroke depression
Chin Psychol
Double-blind comparison of sertraline and placebo in stroke patients with minor depression and less severe major depression
J Clin Psychiatry
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
Antidepressant drug effects and depression severity: a patient-level meta-analysis
JAMA
The beneficial effects of the herbal medicine Free and Easy Wanderer Plus (FEWP) and fluoxetine on post-stroke depression
J Altern Complement Med
Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientific statement from the American Heart Association
Stroke
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
Screening instruments for depression and anxiety following stroke: experience in the Perth community stroke study
Acta Psychiatr Scand
Frequency of anxiety after stroke: a systematic review and meta-analysis of observational studies
Int J Stroke
Interventions for treating anxiety after stroke
Cochrane Database Syst Rev
Cited by (223)
Changes in depressive symptoms before and after the first stroke: A longitudinal study from China Family Panel Study (CFPS)
2023, Journal of Affective DisordersDepressive symptom dimensions predict the treatment effect of repetitive transcranial magnetic stimulation for post-stroke depression
2023, Journal of Psychosomatic ResearchInterventions for improving psychosocial well-being after stroke: A systematic review
2023, International Journal of Nursing StudiesDepression during the COVID-19 pandemic among older adults with stroke history: Findings from the Canadian Longitudinal Study on Aging
2024, International Journal of Geriatric Psychiatry