Understanding the Connection Between Stroke and Depression

Pennsylvania Sen. John Fetterman, who suffered a stroke during his campaign last year, has been open about his ongoing struggles with depression both before and after his stroke, shining a light on this important issue.

It is not unusual to learn that someone who has had a stroke also suffers from depression, and vice versa, says Dr. Joshua Willey, a stroke neurologist at NewYork-Presbyterian/Columbia University Irving Medical Center. Depression is a common consequence after having a stroke, affecting approximately 30% of stroke survivors. Rates of depression in stroke survivors far outpace the rates of depression overall, which are between 5% and 13% of the adult population.

Conversely, new research has shown that people with a pattern of consistently high number of depressive symptoms, like change in appetite or sleep routines, feelings of guilt or worthlessness, or irritability, had an 18% higher risk of stroke than those who had fewer than three symptoms.

Health Matters spoke with Dr. Willey, who is also an associate professor of neurology at Columbia University Vagelos College of Physicians and Surgeons, about the connection between stroke and depression and why treatment for post-stroke depression is important.

Why is depression common following a stroke?
There are a number of reasons. If someone had a prior history of depression, that can increase the risk of post-stroke depression. For example, if a person loses their independence or ability to do routine activities after a stroke, those changes can impact one’s mental health and lead to depression.

When stroke is a near-fatal event, it can be a traumatic experience for survivors that may trigger a cycle of anxiety and depression. People may feel anxiety from almost dying, or become depressed if they feel like they’re a burden on their family. Part of recovery and treatment is trying to stop this cycle of anxiety and depression.

Can stroke cause physical changes in the brain that trigger depression?
The brain injury itself may alter brain chemistry enough to cause depression, but there isn’t enough science to fully support a consensus. One recent paper found that the left side of the brain, near the language center, was associated with greater odds of developing depression. Other studies have suggested that stroke may disrupt certain pathways in the brain that predispose you to depression.

Is depression also a risk factor for stroke?
Depression itself isn’t a risk factor, but it can be seen as a predictor of stroke because depression can impact a person’s ability to manage more direct risk factors like diabetes or blood pressure, their motivation to exercise, or generally do the things to keep your brain and heart healthy.

Can medications for depression increase a person’s stroke risk?
Generally speaking, no. There is one class of antidepressants, known as selective serotonin reuptake inhibitors, or SSRIs, that has been associated with an increased risk bleeding in the brain, but recent studies have shown that people who take SSRIs were no more likely to have a stroke due to bleeding in the brain than people not taking an SSRI. The benefits of antidepressants on a person’s mental health and improved quality of life far outweighs any bleeding risks.

If someone is on an antipsychotic medication to treat depression and other mental health issues like anxiety, schizophrenia, or post-traumatic stress disorder, those medications are associated with weight gain, which can cause pre-diabetes or full-blown diabetes. These patients need to be particularly vigilant about managing their cardiovascular health because the medications can make it worse, increasing stroke risk.

What are the health risks of post-stroke depression?
Depression is a leading contributor to poor recovery after stroke. Studies show that depression independently increases the chances of having another stroke or other cardiovascular event. That’s because depression may compromise a person’s ability to take their recommended medications or participate in rehabilitation.

It’s important for patients and families to be aware of post-stroke depression so we can identify and treat it early to best help with recovery. It’s also important for caregivers to have their own support network because caring for a stroke survivor can be an enormous burden, and the stress can impact their mental and physical health.

How is post-stroke depression treated?
There are a lot of tools to treat post-stroke depression. This can include antidepressant medications or cognitive behavioral therapy, which can be very effective.
Once therapy starts, we monitor patients for several months. Typically, patients start to respond to treatment in two to four weeks; treatment response in patients with post-stroke depression is similar to other patients who are being treated for depression.

Family members and caregivers also play a big role in treatment and recovery. First, they can make sure the recovery environment is safe. There might be physical signs of depression, such as self-harm or missing medication, so it’s important to keep track of medication and keep dangerous items locked away.

Loved ones also can be a motivator for the patient. For example, exercise is important for cardiovascular health, but it might be hard for a person with depression to find the energy. Offering to go for a walk together can be the motivation they need to get exercise and get better.

*A version of this article originally appeared in the Columbia University Irving Medical Center newsroom.

Joshua Willey, MD, is an attending neurologist on the stroke service at NewYork-Presbyterian/Columbia University Irving Medical Center and an associate professor of neurology at Columbia University Vagelos College of Physicians and Surgeons. Dr. Willey has an outpatient clinical practice in neurology with a focus on cerebrovascular diseases and stroke and he treats inpatient stroke patients.