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Depression may affect as many as 60% of stroke survivors, although the exact incidence is unclear. Yet it is estimated that less than 5% of these patients are properly diagnosed and treated. Depression may be related to mourning the loss of function or to actual alteration of function of catecholamine-containing neurons (specialized cells in the brain). There appears to be no association between the presence of depression and neuroanatomical location of the stroke. Though depression may occur in the period immediately following a stroke, it appears to be more prevalent in stroke survivors 6 months to 2 years poststroke.

Major depression generally abates 1-2 years after stroke with medications and is not typically chronic. However, minor depression may persist for many years. Studies have shown that depression at different stages of recovery relates to different aspects of handicap being experienced by the patient. For example, depression in early stages right after stroke may relate to presence of aphasia and not being able to live alone; after a few months depression may be association with dependence on other people for activities of daily living; after 1 year, depression may be association with lack of social contacts and feelings of isolation.

Poststroke depression has a strong impact on recovery and is associated with poor functional outcome. Additional affects of depression include:

• Increased mortality
• Severe physical disability
• Reduced social activities
• Reduced response to rehabilitation program
• Poor language and communication
• Longer hospitalizations

Management of poststroke depression includes traditional approaches, such as exercise, proper diet, counseling, and good sleeping habits. However, because patients typically need faster relief for their depression than these treatments provide, most clinicians will also begin treatment with antidepressant medications as soon as the patient is diagnosed. Some of the medications used to treat poststroke depression include sertaline (Zoloft), trazodone (Desyrel), fluoxetine (Prozac), citalopram (Celexa), nortriptyline (Aventyl), and methylphenidate (Ritalin).

Poststroke depression may be difficult to distinguish from symptoms resulting from the stroke itself, such as fatigue, loss of appetite, or difficulty focusing. In some cases, these common symptoms are mistakenly attributed to depression while in other cases, they may be attributed to the stroke when they are indicative of depression. One of the major factors in the difficulty of diagnosing true poststroke depression is the presence of cognitive deficits or communication difficulties such as aphasia which prevent the patient from accurately responding to questions or limit their reporting of symptoms. In addition, some stroke patients experience anosognosia (denial of a handicap) where they deny their depressive state even though it can be observed clinically. Also, the most common Depression Scales used for diagnosing poststroke depression (Beck Depression Inventory, Hamilton Depression Rating Scale, and the Zung Self-Rating Scale) are not specific to poststroke depression and, therefore, do not account for the special communication difficulties that relate to this specific population of patients.

In order to address the issue of stroke patients whose deficits may prevent them from being properly diagnosed with depression, researchers are designing new instruments to use more of a non-verbal assessment, including: