Matthew Ashley, MD, JD

The relationship between psychiatric illness and cerebrovascular disease is complex, with comorbidity and bidirectional influences common. And, with nearly 2 million brain cells dying every minute that a stroke goes untreated, it is no wonder that the neuropsychiatric implications are vast.

What do you need to know to best support your patients? In honor of National Stroke Awareness Month, 

Recent studies have highlighted the association of 

. How prevalent is depression among patients who have had a stroke, and how does depression affect these patients and their recovery and prognosis?

: Depression is very common after a stroke, and the symptoms of depression can limit the recovery from stroke as well. According to American Heart Association, the cumulative incidence of depression following stroke is 55%.

 It is likely that the stroke itself, and the situational effect of having suffered a stroke, both contribute to the association of stroke with depression. Regardless of the exact cause, however, it is important to address and manage depression appropriately to help promote patients’ recovery. There is even some evidence that the use of antidepressant medications helps not only treat depression after stroke but also may even help with other aspects of rehabilitation such as motor recovery.

Similarly, psychotic symptoms have been associated with stroke. Can you tell us more about this link?

 A certain subgroup of stroke patients does, unfortunately, have symptoms of 

. One meta-analytic study from 2018, while acknowledging a dearth of studies regarding psychosis poststroke, identified an estimated prevalence rate for delusions of 4.67% and hallucinations of 5.05%, for a combined prevalence of 4.86%.The same analysis identified a cumulative incidence rate for psychosis of 6.7% within the first 12 years poststroke in patients without premorbid psychiatric diagnosis.

Of the various neuropsychiatric consequences of stroke, psychosis is a particularly disabling one for obvious reasons. The exact cause may often be multifactorial, including the location of the ischemia, an underlying primary psychiatric diagnosis or, in some instances, sundowning, circadian rhythm disturbance, or even iatrogenesis. 

These symptoms may be limited to the early period following a stroke and improve over time, but medication is often required to manage the psychosis. It is important to avoid sedating and prescribing potentially harmful medications like antipsychotics as much as possible. In addition to the multitude of adverse effects inherent to this class of medications, generally any sedation is detrimental to rehabilitation progress. Of particular relevant to the stroke patient population are the increased risk of metabolic syndrome and the association of such risk factors as obesity, diabetes, and dyslipidemia. When these medications are used, clinicians should prescribe the minimum effective dose.

The popular press has indicated an increase in the prevalence of stroke in younger patients. Is the causality and prognosis similar regardless of age?

: We are seeing an increase in strokes in 

. The Centre for Neuro Skills (CNS) has treated patients as young as 20 years old who have fortunately returned to productive lives. Their stories provide perspective and hope for families who are faced with this circumstance. [

It is no longer uncommon for younger patients to experience strokes. In doing so, they often face unique challenges. Here, their recovery stories offer words of inspiration.

According to a 2022 study published in the American Heart Association journal, 

, a certain type of stroke that causes bleeding in the brain is increasing in the United States, growing at a faster rate in younger adults.

Even earlier accounts have shown that stroke are not limited to older patients, with the Centers for Disease Control also reporting 38% of people hospitalized for stroke were less than 65 years old.

In older people, stroke is usually a consequence of chronic illnesses such as high blood pressure, high cholesterol, diabetes, cardiac conditions, etc. When stroke occurs in younger people, many times there is another contributing cause, such as a clotting disorder, trauma or a blood vessel abnormality.

How can psychiatrists help prevent strokes in their patients?

Appropriate management of stroke risk factors is the primary way we can prevent stroke. Prominent medical factors include hypertension, dyslipidemia, and diabetes. Clotting disorders or cardiac conditions in individuals that have an increased risk of stroke, such as atrial fibrillation, should be addressed appropriately as well. Other lifestyle factors should also be managed; clinicians should encourage patients to avoid smoking, alcohol and drug use, and to manage their weight.

Do psychiatric medications and/or conditions cause or exacerbate stroke risk?

 Many of the antipsychotic medications, unfortunately, can contribute to stroke risk by causing hyperglycemia, weight gain, or both. Metabolic syndrome increases stroke risk, so any medications that increase risk for metabolic syndrome can be problematic. Similarly, any prothrombotic medications such as birth control medications also can increase risk. Any strategy that can be used to reduce the use of medications that alter the metabolic profile is helpful.

 What advice do you have for psychiatrists treating patients who have recovered from strokes but are now experiencing psychiatric symptoms?

 Look for other treatable factors such as circadian rhythm disturbance, sundowning, or medications that might be contributing to the psychiatric complications. In the absence of those factors, psychiatrists should treat patients with the minimal dose of medication necessary to control the symptoms and allow for maximal recovery from stroke.

 Stroke prevention is important and should be encouraged for all patients. For individuals who have suffered a stroke, there is help in the form of rehabilitation and recovery.

, which operates postacute brain injury rehabilitation programs. He also serves as visiting assistant clinical professor in the department of neurology at the University of California, Los Angeles.

1. Towfighi A, Ovbiagele B, El Husseini N, et al. 

Poststroke Depression: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

2. Chollet F, Tardy J, Albucher JF, et al. 

Fluoxetine for motor recovery after acute ischaemic stroke (FLAME): a randomised placebo-controlled trial

Poststroke psychosis: a systematic review

Deadly type of stroke increasing among younger and middle-aged adults

. February 4, 2022. Accessed May 2, 2022. American Heart Association. 

https://www.heart.org/en/news/2022/02/04/deadly-type-of-stroke-increasing-among-younger-and-middle-aged-adults

. Accessed May 2, 2022. https://www.cdc.gov/stroke/facts.htm

Articles

The neuropsychiatric implications of stroke are vast. Here's what you need to know to support your patients. 

Stroke Awareness: Issues for Psychiatrists to Consider

, there are more than 5 million children and adults who live with a permanent brain injury-related disability, and at least 2.8 million individuals in the US sustain a traumatic brain injury every year. To help bring attention to what can be a preventable disability, and to focus on ways to support patients with 

, March is commemorated as Brain Injury Awareness Month.

 invited Matthew J. Ashley, MD, JD, to discuss some of the overlap between brain injuries and psychiatric symptomology and illness.

What should psychiatrists be aware of to better help their patients prevent brain injury?

 is a problem that would be wonderful to solve. Unfortunately, human beings are pretty poor at assigning relative risk to low probability events. I suppose the most practical advice I can offer is to pay attention to the most common situations that result in TBI and try to educate others about those risks.

The most common cause of TBI isn’t car accidents, believe it or not, but falls. So if your patient works in an industrial job where there is a risk of an on-the-job injury, remind them to follow safety protocols.

Similarly, remind patients to wear a seatbelt. And, if you ride anything with two wheels—not just a motorcycle but also a bicycle—then please wear a helmet and operate the vehicle defensively.

Much attention has been paid to brain injuries as a result of accidents and sports, what are some other common causes of brain injuries? How do the causes of brain injury impact treatment and prognosis?

 The most common cause overall is falling, and even a ground-level falls, if suffered in the right way, can cause a significant brain injury. Other high-risk activities might seem obvious once we consider the nature of the activities, but it might not seem so obvious otherwise. This would include equestrian activities, downhill activities, skateboarding, and the like. Essentially, anything where someone is operating at a height above ground or accelerating themselves through space rapidly.

Firearm-related incidents, whether accidental or intentional and related to assault or suicide, are another common cause.

Lastly, although it doesn’t cause traumatic brain injury, another common and often preventable cause of brain injury is anoxic injury, which can be due to many causes, including cardiac arrest or respiratory arrest. Both are, unfortunately, all too common as a consequence of drug overdose. The cause of the injury can definitely have an impact on a patient’s prognosis. That is a complicated discussion, and every patient is, of course, unique.

. What are the most common neuropsychiatric symptoms associated with brain injury from the virus or time on respirators?

 As I mentioned, respiratory or cardiac arrest can result in anoxic brain injury. COVID-19 also has an association with ischemic stroke, which is another form of brain injury altogether.

We are still learning the other more direct consequences of COVID-19 on the brain, but many effects have been reported, ranging from anosmia (ie, lack of smell), cognitive impairments (which has sometimes been colloquially referred to as 

), to more severe forms of encephalitis that occur later on in the course of disease as what is presumably an autoimmune consequence.

In addition, there is post-ICU syndrome, including the traumatic experience of critical illness, the social isolation, and any other form of critical illness myopathy or neuropathy that patients might experience after a long ICU course.

 With the attention in the popular press around TBIs, have we seen a decrease in their prevalence?

 This is hard to determine. With increased awareness of TBI, it is possible that we have increased our detection of milder cases, which would result in seemingly higher prevalence numbers. Conversely, with awareness and improved adherence to safety measures such as seatbelts, helmets, and concussion protocols, we probably reduce the actual number of cases that are occurring, but it is pretty difficult to understand all of that entirely.

Does treatment for brain injury differ for patients with serious mental illness?

Obviously, there are some differences, in the sense that we have to concomitantly treat both the underlying mental health disorder along with the brain injury, but the fundamentals of treatment for brain injury don’t change all that much. And, perhaps I have a bias, but I believe that the comprehensive, cognitive, behavioral, medical, and therapeutic treatment paradigm that we use to treat traumatic brain injury likely has other, coincidental benefits for individuals with other mental health disorders as well.

Anything else you want psychiatrists to know about brain injury?

I would say that every psychiatrist should know that there is help out there for TBI survivors, that comprehensive and dedicated programs exist, and they can be beneficial even long after the initial injury.

is the chief medical officer for Centre for Neuro Skills, which operates postacute brain injury rehabilitation programs. He also serves as visiting assistant clinical professor in the department of neurology at the University of California, Los Angeles.

To help bring attention to what can be a preventable disability, and to focus on ways to support patients with brain injury, March is commemorated as Brain Injury Awareness Month.

Bringing Awareness to Brain Injury Awareness Month

Traumatic brain injury, stroke, anoxic brain injury, encephalitis, and other neurological conditions leading to brain insult can be devastating to individuals and those close to them (

). Not only can neurological injury result in lifelong physical and cognitive changes, but it can also change individuals’ behavior and profoundly alter 

 Medical, functional, and behavioral challenges impair the ability to live independently. 

Profound changes in personality and behavior

 are also often the most significant barrier to successful reintegration into the community, family, work, and recreational/social activities.

Clinicians today are increasingly recognizing the neurological consequences of COVID-19. The infection has been associated with various conditions, including cerebrovascular complications such as ischemic stroke, intracerebral hemorrhage, and microangiopathic thrombotic findings on autopsy.

 Para-infectious encephalopathy is also reported, including with psychosis, seizure, and even nonconvulsive status epilepticus as symptomatic manifestations.

 Less commonly reported have been posterior reversible leukoencephalopathy, necrotizing encephalopathy

, post-infectious and presumably autoimmune mediated encephalitis

, and acute disseminated encephalomyelitis.

 In addition, predictable consequences of the cardiopulmonary effects of COVID-19, including cardiac arrest and respiratory failure, can lead to anoxic brain injury. Common to all these neurological injuries is the possibility of behavioral manifestation and coincident need for specialized care.

Common behavior difficulties following brain injury include behavioral excesses such as irritability (eg, poor tolerance, short temper), aggression (eg, hitting, grabbing, kicking), property destruction (eg, striking furniture, throwing items), and inappropriate vocalizations (eg, cursing, yelling, threats) (

). Just as important are the additional challenges of behavior deficits, such as non-compliance with tasks (eg, cooperation with requests), impaired social skills (eg, overfamiliar discussions, uncharacteristically rude remarks), lack of initiative (eg, knowing when to begin tasks), and deterioration of the skills necessary for academic and professional success (eg, being on time, following directions).

Some of the most problematical behaviors can be dangerous to the patients and others around them. Treating these dangerous and challenging behaviors (including physical aggression, self-injurious behavior, sexual disinhibition, escape, or elopement) require a treatment commitment across the continuum of care. Pharmacologic management of these behaviors alone is often unsuccessful. In many instances, medications can be either counterproductive, due to the sedative and cognitive impacts, or can unnecessarily expose patients to significant adverse effects. These approaches must therefore be used judiciously and target specific neurological symptoms that are not better addressed using the behavioral approach (eg, psychosis, epilepsy, pseudobulbar affect, depression, etc). In nearly all cases, pharmacologic management of behavior following brain injury should be accompanied by an appropriate, comprehensive behavior approach that is non-pharmacologic.

In the early, acute stages of recovery from brain injury many of the behavioral complications are considered a normal part of recovery.

 Clinicians familiar with the acute care and management of neurologic patients will be familiar with the agitation, disorientation, combative, and impulsive behavior that can occur during the initial hospitalization and other early rehabilitation courses. If these behaviors continue beyond the early phases and the individual forms negative patterns of interacting with others, then specialized interventions are required. While this pattern may be obvious in more severe brain injuries, altered behavior is also frequently displayed in subtle fashion for individuals with milder injuries and impairments. Nevertheless, these behavior changes can be incredibly disturbing to families and staff, disruptive to activities and therapy, and can jeopardize patient safety and successful recovery.

Consider the subtle difference between individuals who can effectively tell a joke versus those who cannot; those who can read a room and adjust a social approach accordingly versus the opposite; those who make an appropriate amount of eye contact versus those who stare and appear disengaged, or someone who is assertive as opposed to demanding. The importance of these subtle changes cannot be overstated. They can mean the difference between being socially effective or awkward, funny or rude, disarmingly interesting or off-unsettlingly weird, and they all can be influenced by brain insult. The patient and family’s future quality of life, depends on effective interventions.

Interdisciplinary rehabilitation teams, often including behavior analysts (professionals in 

), neurologists/physiatrists, and therapists should develop programs both for skill acquisition and behavior reduction. It is essential that all members providing treatment understand the behavioral concerns and participate in implementing the most effective approach.

Behavior analysts and therapists can provide direct observations of interactions, consider what may be motivating the difficult behaviors, and what patient responses may need to be strengthened and reinforced. Basic principles of applied behavior analysis, such as reinforcing positive and effective behavior patterns while not reinforcing ineffective and inappropriate behavior, are key to achieving a successful outcome.

 All involved parties must be consistent in their response to behaviors to efficiently promote prosocial behaviors. Many behavior difficulties result in the individual gaining attention, escaping or avoiding difficult tasks, or getting access to preferred materials. It is vital that the patient neither gains attention nor escapes responsibilities by demonstrating problem or disruptive behaviors. The treatment team must work to establish a good, working relationship with the patient, ignore “junk” behaviors, redirect the patient to positive behavior patterns, and reward good effort and compliant interacting.

 These points are valid in managing behavior in any context, but even more so in the context of neurological impairment.

A specialized and specific behavior intervention plan aims to establish the most effective and acceptable response patterns and framework. It helps the patient maintain positive, prosocial responses and learn more efficient functional skills. Skilled and trained professionals, such as behavior analysts, can guide this process. Therapists can provide training and best-practices regarding the intervention plan to all those who may interact with the patient, including, most importantly, the family. They will need to rely on these tools for the long term.

Programs should teach patients to pursue their needs in positive ways and how to make others understand them without resorting to problem behavior. Physicians can augment programs with judicious use of appropriate medications. They should manage specific neurological impairments, while avoiding the pitfalls previously mentioned: sedation and other adverse effects. It is also essential that data be collected, such as the frequency or context of a behavior, to help determine if the intervention plan is working or requires adjustment. The effects of brain injury and recovery are highly individual. The family and others on the treatment team must evaluate the responses, goals, and outcomes throughout recovery (eg, monitoring response to new medications, understanding of program expectations).

Considering risks to patients and families, the rising cost of health care, and the possibility of reduced services, clinicians should focus on structured, efficient, and effective interventions, such as the use of behavior analytic principles. Reliable interventions are essential to a well-integrated, interdisciplinary rehabilitation treatment plan. The quality of life for those affected by brain injury depends on having the opportunity to receive specialized, experienced, and effective treatment specifically designed to address the unique difficulties these patients face, including problem behaviors.

The significance of brain injury, including damage from the consequences of COVID-19, cannot be overstated. Whether it is the skills required to complete daily activities or behavior difficulties that limit social integration, the deficits must be addressed.

is the regional director of clinical services and director of behavior programming at Centre for Neuro Skills. 

is chief medical officer at Center for Neuro Skills.

1. Centers for Disease Control and Prevention. Report to congress on traumatic brain injury in the United States: epidemiology and rehabilitation. Accessed October 7, 2020. 

https://www.cdc.gov/traumaticbraininjury/pdf/tbi_report_to_congress_epi_and_rehab-a.pdf

2. Beaulieu C, Wertheimer JC, Pickett L, et al. Behavior management on an acute brain injury unit: evaluating the effectiveness of an interdisciplinary training program. 

3. Hernández-Fernández F, Valencia HS, Barbella-Aponte RA, et al. Cerebrovascular disease in patients with COVID-19: neuroimaging, histological and clinical description. 

4. Ellul MA, Benjamin L, Singh B, et al. Neurological associations of COVID-19. 

5. Poyiadji N, Shahin G, Noujaim D, et al. COVID-19-associated acute hemorrhagic necrotizing encephalopathy: imaging features. 

6. Khoo A, McLoughlin B, Cheema S, et al. Postinfectious brainstem encephalitis associated with SARS-CoV-2. 

7. Ellul MA, Benjamin L, Singh B, et al. Neurological associations of COVID-19. 

8. Persel CH, Persel CS. The use of applied behavior analysis in traumatic brain injury rehabilitation. In: Ashley M,Hovda D, eds. 

Traumatic Brain Injury: Rehabilitation, Treatment and Case Management

. CRC Press, Taylor & Francis Group; 2018: 411-450.

9. Rao V, Rosenberg P, Bertrand M, et al. Aggression after traumatic brain injury: prevalence and correlates. 

10. Professional Crisis Management Association. 

 Professional Crisis Management Association, Sunrise, FL.

1. Heinicke MR, Carr, JE. Applied behavior analysis in acquired brain injury rehabilitation: a meta-analysis of single-case design intervention research. 

Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. 

3. Traumatic Brain Injury Rehabilitation and Resources

COVID-19 may lead to changes in personality and behavior, which require treatment across the continuum of care. 

Matthew Ashley, MD, JD

Articles

Stroke Awareness: Issues for Psychiatrists to Consider

Bringing Awareness to Brain Injury Awareness Month

COVID-19 and Brain Injury