Post-Stroke Mood Disorders

Although stroke effects are unpredictable, mood disorders such as depression, anxiety and pseudo-bulbar affect (PBA) are fairly common.



Although stroke effects are unpredictable, mood disorders such as depression, anxiety and pseudo-bulbar affect (PBA) are fairly common. We talked to neuropsychologist Dawn Giuffre, Ph.D., of Medstar National Rehabilitation Hospital, about these common post-stroke conditions.

Depression affects between one- and two-thirds of stroke survivors. It’s characterized by feelings of overarching sadness, lack of pleasure in activities that were previously enjoyed, or changes in eating and sleeping patterns. For more information, visit StrokeAssociation.org/depression.Researchers are actively investigating if certain kinds of strokes or strokes in certain areas of the brain produce mood disorders. So far, studies suggest that simply having a stroke increases the risk of either anxiety or depression, or having both. Research indicates that PBA is more common in survivors of brainstem stroke, but it can occur in strokes in other areas.

By contrast, anxiety occurs when a survivor focuses on worries and concerns. “They go over them again and again in their minds but without necessarily reaching a conclusion,” Giuffre said. Anxiety affects about 20 percent of survivors.

PBA is characterized by a mismatch between feelings and expression – laughing at a funeral, crying at a joke. PBA hasn’t been investigated as much as depression or anxiety, but it’s not uncommon, impacting 28 to 52 percent of stroke survivors, according to studies.

Mood disorders significantly alter the lives of survivors and their families. Because crying or a lack of emotions characterize the disorders, it’s best to identify them accurately and receive treatment based on a psychological assessment. A mental health professional talks with the survivor to determine their internal state of mind and their behavior.

Dawn Guiffre, Ph.D.

According to Giuffre, it is not uncommon for survivors to experience all three mood disorders. “Patients experience many things when they are going through recovery,” Giuffre said. “And they experience different things at different points. With PBA, if it is going to happen, it usually occurs in the acute phases of a stroke because it is a symptom of the neurological changes that occurred as a result of the stroke.”

Any of the disorders can cause a lot of post-stroke suffering, so one is not worse than another. The severity of symptoms is what matters – “mild PBA would be less likely to have a continual impact on someone’s day-to-day ability to participate in life, whereas severe PBA could really have an impact.”

The good news is that treatment is available. For depression and anxiety, one of the best treatments is counseling or therapy with a licensed mental health practitioner. “We’ve learned through research that cognitive behavioral therapy or solution-focused or problem-focused therapies tend to be quite useful for patients with depression and anxiety,” Giuffre said. “Some other types of counseling methods such as mindfulness therapy, attitude and commitment therapy and interpersonal therapy have been shown to be useful.”

However, the majority of research has been done in people who have not had a stroke. But in general, problem-based and behavioral therapies seem to be useful for patients with stroke. “There are also medications for depression and anxiety that research indicates can be useful, particularly if combined with therapy or counseling.”

Both medication and counseling are typically covered by insurance.

Although there isn’t much research about counseling and talk therapy’s effect on PBA, a new medication, Nuedexta™, was recently approved to treat it. The drug is covered by many insurance plans, although there is not yet a generic form. (For more on this, see “A Social Disability,” January/February 2012.)

Nutrition often affects anxiety and depression. “Nutrition is not necessarily the biggest factor in recovery, but we have certainly learned that poor nutrition can make either condition worse,” Giuffre said. Poor nutrition can lead to additional health conditions or make people not feel well day-to-day, both of which may worsen psychological symptoms.

Physical activity, on the other hand, can ease the effect of mood disorders, although there’s a lack of research on how nutrition and exercise affect PBA.

Giuffre advises caregivers to get their loved ones assessed so they can be treated. If they are reluctant to see a mental health professional, they might be willing to see a pastor, priest or rabbi. Sometimes a trusted medical doctor can write a prescription for an antidepressant or encourage a reluctant survivor to seek counseling.

“When people develop depression and anxiety or PBA that is so intense that it makes them feel depressed, it is important to seek treatment,” Giuffre said. “Not just to improve how they feel in their day-to-day life, but also to insure that they are not feeling so depressed or worried that they skip their medications or fail to pay attention to their diet or miss doctor appointments.”


Different Types of Therapy

SOLUTION FOCUSED THERAPY (SFT) — As the name suggests, SFT is future-focused, goal-directed and centers on solutions, rather than on the problems that bring individuals to seek therapy. It is also called Solution Focused Brief Therapy and Solution Building Practice Therapy.

PROBLEM SOLVING THERAPY (PST) — PST is a brief psychological intervention, or “talking therapy,” usually provided over a series of between four and eight sessions with a therapist. During these sessions the therapist and individual collaborate to identify problems in the person’s life. The therapist teaches the person a structured approach to solving these problems, and a focus on improving their general approach to problems.

COGNITIVE BEHAVIORAL THERAPY (CBT) — CBT focuses on examining the relationships between thoughts, feelings and behavior. By exploring patterns of thinking that lead to self-destructive actions and the beliefs that direct these thoughts, people can modify their patterns of thinking to improve coping. In CBT the therapist and individual actively work together to help recovery.

ATTITUDE AND COMMITMENT THERAPY (ACT) — ACT (also known as Acceptance and Commitment Therapy) is a comprehensive theory of language and cognition that is an offshoot of behavior analysis. ACT teaches people to “just notice,” accept and embrace their thoughts, feelings, sensations, memories and other private events, especially those that were previously unwanted, rather than trying to better control them, as in CBT.

INTERPERSONAL THERAPY (IT) — IT focuses on the interpersonal relationships of the depressed person by improving the way they communicate and relate to others to treat their depression. Techniques used in interpersonal therapy help the person identify their emotion and where it is coming from; express their emotions in a healthy way; and deal with emotional baggage from unresolved issues from past relationships.

MINDFULNESS THERAPY (MT) (also called Mindfulness-Based Cognitive Therapy) — MT is designed to help those who suffer repeated bouts of depression and chronic unhappiness. It combines the ideas of cognitive therapy with meditative practices and attitudes based on cultivating mindfulness. Its goal is to become acquainted with the mental states that often characterize mood disorders while learning to develop a new relationship to them.


Rina Terry | SURVIVOR

Rina Terry of Cordova, Maryland, had a stroke in 2005 when she was 38 years old – the result of a blood clot slipping through a hole in her heart. The stroke left her with a useless left arm and what she termed “invisible wounds” in a May/June 2010 article. In the four years since, those wounds have not healed. “I have always worked, but now I can’t,” she said. “In my brain, I think of myself as how I was pre-stroke, and I can’t understand why I haven’t gotten better.”

A few years post-stroke Rina was having suicidal thoughts, which prompted her to see a psychologist who put her on anti-depressants: “I can feel the difference.” She will soon begin counseling. “I hope with the new therapist to talk about a plan for getting past the stroke. I feel stuck between a rock and a hard place.”

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AHA-ASA Resources

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When Stroke Affects the Temporal Lobe

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