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Ask the Experts: Depression

Williams, Linda S. M.D.

doi: 10.1097/
Departments: Your Questions Answered

My husband had a stroke and seems to be depressed. Should he see his neurologist, or a psychiatrist, for depression?

Answer to a reader's question about post-stroke depression.

Linda S. Williams, M.D., is the director of the U.S. Department of Veterans Affairs/Health Services Research & Development Stroke Quality Enhancement Research Initiative and a professor of neurology at the Indiana University School of Medicine in Indianapolis. Dr. Williams is also a Fellow of the American Academy of Neurology and the American Heart Association.


Q My husband had a stroke and seems to be depressed. Should he see his neurologist, or a psychiatrist, for depression?




A Some symptoms of depression can be a natural reaction to a sudden, stressful event—such as a stroke—and to changes in one's ability to do prior work or leisure activities. Symptoms of depression are common after a stroke. Nearly 25 percent of stroke survivors will develop depression in the first few months after a stroke. However, your husband should see a neurologist or psychiatrist if his depression symptoms continue for at least two weeks post-stroke, if they are present at least half of the time, and if they are interfering with relationships, healthy behaviors, or participation in rehabilitation activities.

Researchers suggest several reasons for the increased risk of depression after stroke and other brain injuries, including changes in brain chemicals (lower levels of serotonin and norepinephrine, which have both been tied to mood changes and depression); differences in genes that regulate serotonin metabolism and other responses of the brain to injury; and situational factors, such as the ability of individual patients to adjust to stroke-related changes in their body, lifestyle, and sense of self. Since post-stroke depression can be associated with slower and less complete recovery of function and with increased risk of death, all stroke patients should be screened for depression between one and two months post-stroke. (This time period is meant to maximize early diagnosis and treatment, while recognizing that symptoms may resolve on their own in the first few weeks.)

Depression can be difficult for both patients and their doctors to recognize post-stroke. Patients and their families often think that it is normal to feel down, excessively tired, irritable, slowed down in thinking and reacting, worthless, or guilty after a stroke. Some of the common effects of a stroke—like trouble concentrating, remembering, or speaking—can both mimic symptoms of depression and make it difficult to assess how the patient is feeling. Doctors may miss depression symptoms because they are focused on reviewing test results, identifying the cause of the stroke, and prescribing the right medicines to prevent a future stroke. Because no blood test for depression exists, a diagnosis requires taking the time for a thoughtful, honest conversation between the patient and their healthcare provider.

It may be helpful for you or another family member to accompany your husband to his first post-stroke clinic appointment and ask about these symptoms if they have not otherwise come up during the appointment. It is important for stroke survivors and caregivers to remember that depression symptoms are not a sign of weakness or that the patient has given up. For patients reluctant to accept treatment for depression, it is also helpful to remind them that treatment will also assist their recovery from stroke. In addition to the many safe, effective medications that are available, gentle physical activity like walking or stationary bicycling, staying in touch with friends and family, and talking with a counselor may also be helpful in reducing depression symptoms. Finally, just like other conditions that require ongoing evaluation, monitoring the response of depression symptoms after 6 to 8 weeks of treatment is critical so that treatment can be adjusted to achieve the best effect.

© 2013 American Academy of Neurology