Post-Stroke Depression And Its Implications
Strokes are unexpected events caused by an abrupt loss of blood to the brain which leads to permanent tissue damage (Robinson & Jorge, 2015). In stroke survivors, post-stroke depression (PSD) is one of the most common comorbid mental disorders (Wang et al. , 2018) and affects one-third of all stroke patients (Lewin, Jögbes, & Werheid, 2013). PSD is linked to impaired recovery of activities of daily living, decreased quality of life, and increased mortality (Lewin et al. , 2013). With an increasingly aging population, higher incidences of stroke are occurring (Graven et al. , 2011), and as 30-40% of all stroke survivors experience PSD, this will be a mental disorder that will progressively become more prevalent in society (Turner, 2012).
Post-Stroke Depression Implications on Activities of Daily Life (ADL)
As stated, PSD is highly prevalent in those who are impacted by stroke, this disorder is seen to then negatively affect an individual’s activities of daily life (ADL). A quantitative study that looked at the affects PSD had on ADL in a rehabilitation center took measures of motor recovery of paralytic symptoms through an assessment called Brunnstrom Recovery Stage (BRS), depressive symptoms through the Geriatric Depression Scale (GSD) and ADL through an assessment called Functional Independence Measure (FIM) (Tsuchiya, et al. , 2016). The researchers compared these measures between individuals with PSD and those without, they found that PSD was related to both a decrease in the level of ADL as well as decreased improvement of ADL in rehabilitation (Tsuchiya, et al. , 2016). This is similar to the findings of Lewin, et al. (2013), who noted that impaired ADL was associated with depressive symptoms during stroke. However, research by Lewin, et al. (2013) differs in that the relationship between ADL impairment and depressive symptoms was only observed three months after stroke onset and not during the acute phase, which they attributed to the constant change of ADL impairment during the first weeks after stroke that only stabilize later on.
Post-Stroke Depression Implications on Independence
Along with impairments in daily activities, individuals with PSD lose the ability to do these activities independently. A quantitative study that took measures of post-stroke depression, aphasia, and physical independence through ranking scales and questionnaires, found that depressive symptoms in patients were seen to be independently associated with physical dependence (Wang, et al. , 2018). Physical dependence was attributed to behavioural and biological irregularities, such as poor treatment compliance and dysregulation in the autonomic system that results from depressive symptoms after stroke (Wang, et al. , 2018). This is similar to the findings of Turner (2012) in which participants reported that their stroke caused physiological losses resulting in loss of independence and the need to rely on hospital staff for even basic activities of daily living.
External Factors associated with Post-Stroke Depression
The environmental factors of a hospital that increases PSD in patients were analyzed in a qualitative study that took on a grounded theory approach, this is defined as a type of method in which data collected through field work are conceptualized through identification, development, and integration (Corbin, 2017). In that article, the author interviewed participants and found that the predominant theme of the stroke patients’ attitudes was disempowerment, this was further differentiated into “reduced feeling of control” and the sense of “being in a time capsule” (Turner, 2012, p. 14). The author identified external factors that instigated post-stroke depression in the patients. Certain patients felt as though they were confined within indoor cubicles in a foreign environment where they sometimes were unable to see outside (Turner, 2012).
Another external factor that contributed to the patients’ depression was the change in family dynamics (Turner, 2012). Due to restricted visits and decreased privacy during visits, participants felt a separation from their loved ones, one man reportedly wept when expressing this during his interview (Turner, 2012). Supporting this idea, a quantitative study that utilized tests and questionnaires to measure the influence that self-efficacy, pre-stroke depression, and perceived social support had on depressive symptoms after stroke, found that perceived social support is reported as one of the protective factors for depressive symptoms (Lewin, et al. , 2013). As social support is seen to reduce depressive symptoms in stroke patients (Lewin, et al. , 2013), the environmental factors of the hospital that interrupts patients’ meaningful interactions with loved ones therefore increases the prevalence of depression (Turner, 2012).
Internal Factors associated with Post-Stroke Depression
General self-efficacy, one’s beliefs about their capabilities to cope with life challenges (Lewin, et al. , 2013), was one of the measured factors in a quantitative study that looked at certain factors’ influence on depressive symptoms (Lewin, et al. , 2013). In this quantitative study, depressive symptoms were measured using a questionnaire called the Geriatric Depression Scale these scores were taken as the dependent variable whereas the influencing factors, such as self-efficacy, were taken as the independent variables (Lewin, et al. , 2013). In this study, low general self-efficacy, which was assessed by a self-report scale called the German Generalized Self-Efficacy Scale was the strongest predictor of depressive symptoms in the stroke patients (Lewin, et al. , 2013). Both Lewin, et al. (2013) and Turner’s (2012) study only included stroke patients who were at least past 4 weeks post-stroke onset. In Turner’s (2012) study, it was reported that patients spent many of their hours in the hospital sitting or lying inactively without any satisfying sensory stimulation. Along with this, the physiological losses due to stroke led the patients to become very dependent on others (Turner, 2012). In both these situations, participants were left feeling disempowered (Turner, 2012), which relates to low self-efficacy and thus, PSD (Lewin, et al. , 2013).
Another internal factor that is related to PSD is aphasia, a language disorder which is caused by damage to the language control areas of the brain (Ispahany, 2012). Aphasia is prevalent in about one third of stroke patients and is linked to impaired activities of daily life and higher risks of PSD (Wang, et al. , 2018). In a quantitative study that measured the relationship between post-stroke depression, aphasia, and physical independence in patients 3-months post stroke, PSD was seen in much higher rates in those with aphasia than those without, therefore, researchers argued for aphasia being a risk factor for the development of PSD (Wang, et al. , 2018). Additionally, both aphasia and PSD are seen to be associated with impairments in activities of daily life (Wang, et al. , 2018; Tsuchiya, et al. , 2016).
Future research
Research shows the high rate of comorbidity between stroke and depression (Wang et al. , 2018) and the factors that may cause a stroke survivor to develop this disorder. Although external factors in the hospital that influence post-stroke depression are noted in Turner’s (2012) paper, future research should examine specific modifications that hospitals and rehabilitation centers can implement and if they have a positive effect on reducing post-stroke depression. As well, future research can be done on specific approaches to increase a patient’s motivation for rehabilitation therapy and if these methods will increase successful rehabilitation of function. Research can examine if motivation for rehabilitation is increased by individualized treatment that takes into account a patient’s need for feelings of independence and purpose. As the global burden of stroke is increasing as populations age (Hankey, 2017) this research would benefit the aging population and their caretakers, doctors, and therapists.
