The neuropsychiatric implications of stroke are vast. Here's what you need to know to support your patients.
PSYCHIATRY & BRAIN INJURY
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, Matthew Ashley, MD, JD, shared some insights with Psychiatric TimesTM.
Psychiatric TimesTM: Recent studies have highlighted the association of depressive symptoms with stroke. How prevalent is depression among patients who have had a stroke, and how does depression affect these patients and their recovery and prognosis?
Matthew Ashley, MD, JD: 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%.1 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.2
PT: Similarly, psychotic symptoms have been associated with stroke. Can you tell us more about this link?
Ashley: A certain subgroup of stroke patients does, unfortunately, have symptoms of psychosis after a stroke. 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.3
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.
PT: The popular press has indicated an increase in the prevalence of stroke in younger patients. Is the causality and prognosis similar regardless of age?
Ashley: We are seeing an increase in strokes in younger patients. 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. [Sidebar]
According to a 2022 study published in the American Heart Association journal, Stroke, 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.4
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.5
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.4
PT: How can psychiatrists help prevent strokes in their patients?
Ashley: 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.
PT: Do psychiatric medications and/or conditions cause or exacerbate stroke risk?
Ashley: 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.
PT: What advice do you have for psychiatrists treating patients who have recovered from strokes but are now experiencing psychiatric symptoms?
Ashley: 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.
PT: Any concluding thoughts for readers?
Ashley: 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.
Dr Ashley 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.
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. Stroke. 2017;48(2):e30-e43.
2. Chollet F, Tardy J, Albucher JF, et al. Fluoxetine for motor recovery after acute ischaemic stroke (FLAME): a randomised placebo-controlled trial [published correction appears in Lancet Neurol. 2011 Mar;10(3):205]. Lancet Neurol. 2011;10(2):123-130.
3. Stangeland H, Orgeta V, Bell V. Poststroke psychosis: a systematic review. J Neurol Neurosurg Psychiatry. 2018;89(8):879-885.
4. Williamson L.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
5. CDC. Stroke Facts. Accessed May 2, 2022. https://www.cdc.gov/stroke/facts.htm