Neuropsychiatric Disorders following Stroke

Abstract

Can J Psychiatry. 2010;55(6):339-340. This issue contains 3 In Review articles,1-3 each dealing with different aspects of the mental and emotional disorders associated with stroke. Stroke produces a wide range of emotional disorders, to which I have devoted an entire book4 because of the diversity and complexity of these multiple disorders. The mental disorders associated with stroke are commonly seen in patients without brain injury. These disorders include depression, anxiety disorders, psychotic disorders, and apathy. In addition, however, there are other disorders that occur following stroke that are unique to patients with brain injury. These include disorders such as anosognosia, pathological laughing and crying, catastrophic reactions, and aprosody. I selected depression, apathy, and anosognosia for this In Review series to emphasize the breadth of neuropsychiatric disorders associated with focal brain infarcts. Although depression has been a focus of clinical care and research in psychiatry for many years, apathy, characterized by a lack of drive and motivation, is frequently one of the cardinal features of patients with longstanding schizophrenia and dementia, as well as a common phenomenon of patients with psychomotor retardation and depression. My article with Dr Gianfranco Spalletta1 demonstrates the large amount of research that has been devoted to the study of poststroke depression (PSD). Studies examining the prevalence of depression have included more than 7000 patients worldwide. Increasingly, geriatric psychiatrists are recognizing that a large percentage of late-life depressions are associated with ischemic events in the brain and that small vessel disease producing hyperintensities on a magnetic resonance imaging scan or large vessel disease producing strokes lead to most depressions that have late-life onset among patients without other severe debilitating illness. Psychiatrists are increasingly asked to treat patients with depressive disorders associated with vascular disease, and this In Review includes all of the randomized controlled studies that have been shown to be effective in the treatment of PSD. In addition, evidence is accumulating that depression has a significant influence on the long-term outcome of patients who survive an acute stroke. Recovery in cognitive impairment, physical impairment, and survival are all negatively affected by the existence of PSD. A few studies have shown that these negative consequences of PSD may be counteracted by the administration of antidepressants. However, the most recent clinical trial using antidepressant therapy demonstrated the effectiveness of escitalopram treatment in the prevention of PSD. The In Review article on apathy by Dr Ricardo E Jorge, Dr Sergio E Starkstein, and me2 emphasizes the progress that has been made in identifying and establishing diagnostic criteria for apathy in a wide variety of disorders including stroke. Numerous studies of apathy following stroke have established that this is a common condition occurring in about 1 in 4 or 1 in 5 survivors of acute stroke. The syndrome of apathy includes disturbances in goal-directed behaviour, cognition, and emotion. A general concensus - that apathy includes these 3 areas of amotivation - has led to an effort to include apathy as a disorder in the emerging Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, classification. Although there is no treatment trial that has established the efficacy of a medication that is available worldwide for treatment of apathy, many studies that reported the effectiveness of stimulant medications and (or) dopamine agonists in the treatment of this condition have been included in our article.2 Although apathy does not manifest itself in overt behavioural manifestations, it severely affects both patients and their families. …