Depression and Anxiety after stroke

As part of ‘Action on Stroke Month‘ The Stroke Association held a round-table event on the 13th May to discuss anxiety and depression after stroke.

Dr Madina Kara, Research Awards Manager at The Stroke Association, writes up the latest research findings which were discussed on the day. 

Stroke changes peoples’ lives in an instant and can have a profound psychological and emotional impact on the stroke survivor and their family or caregiver. In the last 20 years there has been significant improvement in the prevention and treatment of stroke as well as an increasing focus and provision of rehabilitation services after stroke.

Today, stroke survivors undergo physiotherapy, occupational therapy and speech and language therapy to support them to overcome the physical and communication challenges that they have been left with. However, there is one area in which healthcare is failing and that is recognising and treating the psychological and emotional impact of stroke.

The emotional impact of stroke

The report ‘Feeling Overwhelmed’, published by the Stroke Association, highlights the fact that the emotional impact of stroke can be just as devastating as its physical effects. We received over 2,700 responses to our survey and they exposed some of the failures of our healthcare system in providing support for those experiencing the psychological and emotional effects of stroke.

Experiencing feelings of anxiety was reported by 67 % of stroke survivors and 59 % felt depressed. Yet despite this tremendous emotional burden, only 2 in 10 stroke survivors were given information, advice and support on coping with the psychological consequences of stroke. The emotional impact on carers is also often overlooked. With 79 % of carers reporting experiencing anxiety and 56 % feeling depressed, it is important to increase the level of support being provided to carers.

Research Roundtables

It is important that research funders, researchers, clinicians and policy stakeholders all work together to make progress in meeting the needs of stroke survivors. With this in mind the Research Department at the Stroke Association have launched a new programme of research roundtable meetings to bring together key stakeholders and discuss important topics in stroke. We aim to:

• Share emerging findings of our research with researchers, policy makers and stroke survivors
• Discuss the clinical and policy implications of the findings. Ensure the research we fund is relevant and addresses the existing needs of stroke survivors

To link in with Action on Stroke Month, the theme of our first meeting on 13 May 2013 was Anxiety and Depression after stroke. We heard from three of the Stroke Association’s current grant holders in the field about their latest research findings.

The natural history, predictors and outcomes of depression after stroke

Dr Luis Ayerbe, a Primary Care Lecturer, who has undertaken systematic reviews on post-stroke depression, reported that depression is a frequent problem that persistently affects one in two patients up to 15 years after stroke. Most episodes of depression start shortly after stroke and are of relatively short duration but there is a high proportion of recurrence.

There are several major predictors of depression after stroke including disability, stroke severity, cognitive impairment, poor family support and anxiety. Dr Ayerbe recommends that all stroke patients should be routinely assessed for depression during the acute phase as well as periodically after discharge, perhaps as part of primary care stroke management.

Anti-depressants to aid recovery after stroke
Professor Gillian Mead, Professor of Stroke and Elderly Care Medicine at University of Edinburgh, is lead researcher on the FOCUS trial. This randomised controlled trial aims to investigate whether taking a 6 month course of the anti-depressant fluoxetine can improve recovery after stroke. Evidence from previous small studies has shown that Selective Serotonin Reuptake Inhibitors (SSRIs), like fluoxetine, can enhance recovery after stroke but larger trials are needed to confirm whether fluoxetine is beneficial and can be used for routine care. As a secondary outcome, the FOCUS trial will look for beneficial effects on treatment on depression and mood after stroke.

Screening for anxiety in older people after stroke

Anxiety is the most common mental health disorder and is prevalent after stroke. Whilst the condition is distressing in itself, it can also affect peoples’ long term outcomes. The National clinical guidelines for stroke discuss post-stroke anxiety and the importance of identifying and addressing the psychological needs of stroke survivors.

Accurate screening for anxiety is the first step towards identifying patients in need of further diagnosis and treatment. However, this is problematic in older patients (over 65s) as most measures have been developed for younger adults. Dr Ian Kneebone, a Consultant Clinical Psychologist and visiting Reader at the University of Surrey, is leading a study on screening for anxiety in older people after stroke. This study is investigating whether the Geriatric Anxiety Inventory is valid, reliable and shows good sensitivity in stroke patients over 65. The research is still in its early days but if the GAI is a valid method to test for anxiety in older stroke survivors then it will be important to introduce its routine use in clinical practice.

Implications for those involved in stroke care

Attendees at the roundtable included other eminent researchers in the field of anxiety and depression after stroke including Professor Reg Morris, a Clinical Psychologist at Cardiff University. Professor Morris has written an article ‘Addressing the emotional impact of stroke’ for the Health Service Journal in which he discusses the findings and implications of the Stroke Association’s ‘Feeling Overwhelmed’ report. He recommends the inclusion of psychological expertise in stroke teams to ensure the psychological and emotional effects of stroke are adequately recognised, a point that was echoed at the roundtable.

There is a need to lobby for not only screening of these emotional disorders to be put in place but also the need to follow up the results of the screening by supporting stroke survivors, carers and families to recover from the emotional impact of stroke.

Clinicians should advise stroke survivors that they are at high risk of developing depression and encourage them to come forward and seek help. It is important to reduce the stigma associated with depression and ensure that stroke survivors, carers and their families are made aware of the support available. The Stroke Association has produced the ‘You’re not alone’ booklet that provides information about coping with the emotional impact of stroke.

Some of the most common problems after stroke, including communication disorders like aphasia, and cognitive problems make it difficult for stroke survivors to seek emotional support. It is important to diagnose anxiety and depression in these stroke survivors who may not be able to communicate their feelings and who are at a high risk of feeling socially isolated.

The roundtable on Anxiety and Depression provided a forum for discussion and has helped raise the profile of current research in this area. It has given us a better idea of the measures needed to tackle the issue and to best meet the needs of those affected by psychological conditions after stroke.

The next roundtable event will focus on upper limb rehabilitation. It will be held in October 2013.