Stroke is a leading cause of serious long-term disability and has profound emotional and psychological consequences. Mental disorders caused by stroke are common, affecting approximately one-third of stroke survivors. The most common mental disorders linked to stroke are anxiety, depression, and dementia.
Anxiety
Anxiety disorders are very common after stroke, affecting around 25% of survivors. The sudden onset of a stroke is an extremely stressful life event that can trigger anxiety disorders like generalized anxiety disorder, panic disorder, phobias, and post-traumatic stress disorder (PTSD). The loss of function and independence after a stroke contributes to anxiety as the individual struggles to cope with disability. Anxiety can also arise from the fear of having another stroke.
Some of the most common anxiety symptoms reported after stroke include:
- Feeling tense, restless or on edge
- Fatigue
- Difficulty concentrating
- Irritability
- Muscle tension
- Difficulty sleeping
- Panic attacks
Anxiety often occurs alongside depression following stroke. Persistent anxiety can significantly impair quality of life and functional recovery during stroke rehabilitation.
Depression
Depression is the most common neuropsychiatric consequence of stroke, affecting around one-third of survivors. The sudden cerebrovascular event causes neurological changes that can precipitate mood disorders like major depressive disorder. Factors such as loss of independence, disability, social isolation, and personality changes also increase the risk of depression after stroke.
Symptoms of post-stroke depression include:
- Feelings of sadness, tearfulness, emptiness
- Irritability, frustration
- Loss of interest in pleasurable activities
- Changes in appetite
- Fatigue, lack of energy
- Feelings of worthlessness, guilt
- Difficulty concentrating, indecisiveness
- Sleep disturbances
- Thoughts of death or suicide
Post-stroke depression, even in milder forms, can significantly impair recovery and reduce quality of life. Screening and prompt treatment are essential.
Dementia
Dementia refers to progressive deterioration in cognitive functions that affects memory, thinking, orientation, comprehension, learning capacity, language, and judgment. There are several types of dementia linked to stroke:
- Vascular dementia – caused by stroke and ischemia damaging the brain’s blood supply. It accounts for around 20% of dementia cases.
- Post-stroke dementia – dementia occurring after stroke, caused by widespread brain lesions.
- Mixed dementia – dementia with both vascular and Alzheimer’s disease pathologies. Stroke increases risk of Alzheimer’s dementia.
Symptoms arise gradually over time and include:
- Impaired memory, confusion
- Reduced ability to perform daily activities
- Language problems like aphasia
- Impaired judgment and decision making
- Disorientation
- Mood and personality changes
- Difficulty concentrating, finder motor coordination
The location and severity of the stroke impacts the development and progression of post-stroke dementia. Even mild strokes increase dementia risk.
Other Mental Disorders
Stroke can also contribute to the development of other mental health conditions, including:
- Delusional misidentifications – false beliefs that people, places or objects have been changed or distorted in some way.
- Mania – elevated mood, hyperactivity, impulsivity, racing thoughts, poor judgment.
- Catatonia – lack of movement, mutism, rigidity, stupor.
- Psychosis – detachment from reality, hallucinations, delusions, confused thinking.
- Obsessive-compulsive disorder – intrusive thoughts and repetitive behaviors.
- Emotional lability – frequent mood swings, emotional outbursts.
Although less common than anxiety, depression and dementia, these disorders can arise from both the psychological stressors and neurobiological changes linked to stroke.
Mechanisms
There are several ways stroke can trigger mental health disorders:
- Brain injury – Stroke causes cell death and damages neural pathways, especially in brain regions critical for mood, cognition and behavior like the frontal cortex and limbic system. This disrupts neurotransmitters like serotonin, dopamine and norepinephrine.
- Psychosocial stress – The trauma of the event, and loss of abilities, independence and identity after stroke are significant stressors.
- Biochemical changes – Stroke causes inflammation, oxidative stress, metabolic changes and disrupted cortisol levels which affect mental health.
- Vascular factors – Shared risk factors like high blood pressure, diabetes and atherosclerosis underlie both stroke and dementia.
- Side effects of treatment – Some medications prescribed after stroke have psychological side effects.
- Genetic susceptibility – Gene variants may increase vulnerability to developing mental illness after stroke.
Mental disorders arise from a complex interplay between the biological impact of stroke, psychological reactions, and social factors surrounding disability and recovery.
Factors That Increase Risk
Certain factors appear to increase a stroke survivor’s risk of developing mental health disorders:
- Female gender
- Younger age at stroke onset
- History of depression or anxiety
- Pre-existing cognitive impairment
- Stroke severity, degree of disability
- Large strokes or multiple strokes
- Lesions in frontal lobe, temporal lobe, basal ganglia, thalamus
- Dominant hemisphere stroke (left side for right-handed people)
- Post-stroke complications like seizures
- Vascular risk factors also linked to dementia like hypertension, atrial fibrillation, diabetes, hyperlipidemia
- High stroke/disability-related stress
- Lack of strong social support
- Isolation, loneliness
- Family history of psychiatric illness
Identifying these risk factors can help detect survivors vulnerable to mental health problems who may benefit from early screening and intervention.
Screening and Diagnosis
Mental disorders after stroke often go undiagnosed and untreated due to complex medical needs taking priority during recovery. However, routine screening for neuropsychiatric symptoms is recommended to improve outcomes. Instruments like the Patient Health Questionnaire-2 and the Generalized Anxiety Disorder-2 questionnaire can help identify symptoms of depression and anxiety.
To meet diagnostic criteria for a mental disorder, symptoms must:
- Develop following the stroke, or represent a marked worsening of pre-existing symptoms.
- Persist beyond the acute recovery phase, often defined as about 2 weeks post-stroke.
- Impair function and quality of life.
- Not be better accounted for by direct neurological consequences of stroke like aphasia or delirium.
A psychiatrist or neuropsychologist conducts a clinical interview exploring the patient’s mental health history, administering cognitive testing, and ruling out other potential causes. Neuroimaging and bloodwork also help characterize changes associated with vascular cognitive impairment.
Treatment
Treatment plans are tailored to each mental disorder resulting from stroke but often include:
- Medications – Antidepressants like SSRIs can treat both depression and anxiety. Cholinesterase inhibitors may alleviate vascular dementia symptoms. Antipsychotics help manage psychosis or catatonia.
- Psychotherapy – Cognitive behavioral therapy helps patients adapt thoughts and behaviors. Family counseling provides support.
- Brain stimulation – Repetitive TMS stimulation is FDA-approved treatment for major depression, including post-stroke.
- Lifestyle changes – Stress management and increased physical/social activity.
Comprehensive stroke rehabilitation also aids the recovery of mental health. Goals include regaining independence, adjusting to disability, developing new skills, and improving coping strategies. This requires a coordinated effort from the care team including psychiatrists, neurologists, therapists, social workers, and nurses.
Prevention
The most effective way to prevent post-stroke mental disorders is to prevent strokes from occurring. This is achieved through:
- Treating underlying risk factors like hypertension, high cholesterol, diabetes, sleep apnea, cardiovascular disease.
- Following a healthy lifestyle – regular exercise, balanced diet, stress management, no smoking.
- Taking preventive medications like aspirin or anticoagulants when appropriate.
- Promptly treating minor strokes (TIAs) to reduce recurrence risk.
For patients with previous stroke, optimal control of vascular risk factors and leading a brain-healthy lifestyle can help slow the progression of vascular cognitive impairment. Treating depression, anxiety, sleep disorders, and other conditions may also lower dementia risk after stroke.
Prognosis
Mental disorders arising after stroke vary greatly in their duration and long-term prognosis:
- Anxiety – Often gradually improves over the first year but can persist long-term in around 20% of patients.
- Depression – Remits spontaneously within the first year in around half of patients. Other cases follow a more chronic course requiring ongoing treatment.
- Dementia – Typically displays gradual progression over years. Rate depends on extent of vascular pathology and comorbid Alzheimer’s disease.
Early recognition and treatment of neuropsychiatric symptoms after stroke can maximize functional recovery and quality of life. The outlook depends on the type and severity of stroke, response to treatment, and access to psychosocial support. Counseling on adjusting expectations can help patients adapt to permanent disability.
Impact on Recovery
Mental health disorders profoundly impact outcomes following stroke. Depression, anxiety, and dementia each independently predict:
- Reduced quality of life
- Greater disability
- Impaired daily functioning
- Lower rehabilitation engagement
- More severe cognitive deficits
- Higher long-term mortality
Other negative effects associated with post-stroke psychiatric illness include:
- Higher healthcare costs and longer hospital stays
- Strain on caregivers
- Poor medication adherence
- Greater dependency
- Social isolation
Better screening, monitoring and management of mental health is essential for optimizing outcomes in stroke survivors. An integrated, multidisciplinary approach is key.
Conclusion
Stroke can trigger a range of mental disorders including anxiety, depression, dementia, psychosis and emotional lability. These conditions arise from the neurological damage and significant psychological stress caused by stroke. Neuropsychiatric symptoms are very common following stroke but often remain under-recognized and undertreated. Routine screening for mental illness in stroke survivors could improve early diagnosis and management. Comprehensive treatment that combines medications, psychotherapy, and stroke rehabilitation is the most effective approach for maximizing functional recovery and quality of life.