A stroke is a sudden episode of ischaemia resulting in a number of pathological changes in the human body and functional impairment. It is an extremely dangerous event, often leading to death or causing severe disability. People who have suffered a stroke are often unable to function independently, which contributes to a significant decrease in their quality of life and the development of post-stroke depression, which reduces motivation and slows down the rehabilitation process.
Table of contents:
- Stroke
- Symptoms of stroke
- Complications
- Quality of life after stroke
- Depression
- Diagnosis
- Pharmacotherapy or psychotherapy?
Post-stroke complications are mainly related to physical limitations, the struggle with disability and the rehabilitation and pain accompanying it. The psychological sphere does not remain intact either, hence a frequently observed post-stroke complication turns out to be depression, which in many publications and specialist descriptions is treated as a condition qualified for pharmacological treatment. However, important from the point of view of the person affected by post-stroke complications is psychotherapy, which, unfortunately, in many cases is difficult mainly due to the neurological state of the person after the stroke, as well as cognitive impairment [1].
Stroke
The phenomenon of stroke itself is not fully understood by most people, despite the fact that it is one of the 3 most serious conditions causing death worldwide [2].
A syndrome of neurological symptoms resulting from a sudden disturbance in the blood supply to the brain is the very definition of a stroke. It occurs when an artery responsible for the blood supply to the brain, or an arteriole inside our brain, narrows significantly or ruptures. As a result, the supply of oxygen and nutrients to a specific area of the brain is blocked [2].
Stroke is therefore a severe ischaemic condition that is fatal in 10 per cent of cases and in the vast majority of cases becomes the cause of very significant disability. Considering statistics worldwide, stroke accounts for almost half of all hospital stays for neurological reasons. Polish statistics show an incidence rate of 170 cases per 100,000 people, which places Poland in the average incidence rates of other European countries. Stroke affects mainly elderly people. This does not change the fact that it can also affect younger people. Based on statistics, 1 out of 4 people who experience a stroke are under 65 years of age [1].
Only quick response and rapid intervention - getting to a hospital where specialised and expert help can be obtained - will save lives and prevent severe disability [2].
Symptoms of stroke
Depending on whether the arteriole has ruptured or closed and in which area of the brain the event has occurred, the symptoms of a stroke can vary greatly. There may be paresis in the arm, leg or face on one side of the body, numbness, tingling, lack of sensation and even complete paralysis may occur. Other symptoms that may occur may be aphasia, which is the inability to speak, even though the patient understands exactly what is being said to them. Disturbed vision, dizziness, nausea or vomiting may also be observed. In addition, patients often become depressed and the indifference they feel at the time has a significant impact on the treatment and rehabilitation process [2].
Complications
It is not only the physical sphere that suffers from stroke-induced complications, although their scale and severity is often extensive and significant. Among the most common stroke-related psychological complications is post-stroke depression, which is suffered by about one-third of sufferers and, as noted, is more common in those patients in whom the treatment process for the effects of stroke is less effective than in others. This is particularly true for rehabilitation and treatment of the neurological sphere, but the degree of cognitive impairment is also important, which is usually associated with limitations in daily activities and a decrease in quality of life for post-stroke patients. Depression, however, is a condition that further slows down the process of recovery and function - a decrease in motivation is closely associated with a decrease in psychomotor drive. An increased late post-stroke mortality is therefore observed in people who experience post-stroke depression - it is as much as 3-fold higher [1].
Quality of life after stroke
Emerging depression is not a spontaneous phenomenon, it is a response to the changes that occur in the sufferer's life - there is a significant decrease in quality of life in terms of daily functioning, which many times carries with it a decrease in life satisfaction compared to before the episode. This is due to the reduced mobility, which affects one-fifth of stroke survivors, as they are unable to move around independently or perform basic activities such as personal hygiene or housekeeping. It is estimated that between 20% and 60% of stroke survivors suffer from depression, which is associated with decreased motivation and motor drive [3].
Depression
Depression and related disorders in the 21st century pose a serious and real threat not only to the individual, but also to the population and society in which they live and function. According to the World Health Organisation, it is the fourth most widespread health problem in the world, affecting approximately 10% of the population, regardless of age, position in society or gender. Depression has its place in the medical classification, hence it is considered an illness that requires appropriate treatment. People affected by depression refer to it as suffering of the soul and body, while medicine refers to the human mental sphere, and depression is placed in this group of disorders [4].
Post-stroke depression, photo: panthermedia
Diagnosis
However, the diagnosis of post-stroke depression itself is not straightforward - there are 4 main groups of causes that give rise to it.
The first group of diagnostic difficulties is the illness picture, which takes an unusual shape in post-stroke people. Indeed, people suffering from depression mainly focus their complaints on somatic complaints and pain, as well as on slowing down, fatigue, lack of joy in life or often present a depressed mood and apathy.
Another limitation, which is also another of the diagnostic difficulties, is the existence of differences in the methods of diagnosis and the schemes that are used for this purpose.
Attention is also drawn to masking the symptoms of depression, blaming many of the complaints or current conditions on the stroke itself and associated neurological complications such as aphasia, psychomotor disorders, appetite disorders or anosognosia.
In addition, there is an ongoing debate as to when psychological distress can be defined as hyperresponsive to a given situation, i.e. when psychological distress is adequate to the physical state and when it ceases to be a normal reaction and becomes a manifestation of depressive symptoms [1].
Pharmacotherapy or psychotherapy?
The vast majority of the specialist literature deals mainly with the efficacy of pharmacotherapy and pharmacological agents, leaving psychotherapy to the side. However, it is noteworthy that psychotherapy is repeatedly mentioned as an adjunct to the treatment of depression in people without brain damage. Unfortunately, it is not possible to apply psychotherapeutic interventions to all people affected by stroke and suffering from depression mainly due to limited intellectual capacity [1].
To date, a small number of publications clearly define and explore the effectiveness of psychotherapy in patients with post-stroke depression. Analyses by some authors indicate a low impact of psychotherapeutic interventions in the course of pharmacotherapy and a low preventive impact in terms of the risk of developing post-stroke depression. However, it should be borne in mind that the studies conducted to date on this topic have not been large-scale and have not involved large numbers of people [1].
It was only in 2007 that the American Stroke Association, expanding its studies and research, pointed to guidelines to guide prevention efforts. Since then, the number of studies and, consequently, scientific papers addressing the problem of psychotherapy in people with post-stroke depression has increased significantly, although the research material is still small [1].
In order to consider the effectiveness of the two methods, it is necessary to compare their advantages and disadvantages in the context of the effectiveness of treatment for post-stroke depression. The specialist literature, which is recognised as a mainstay in this field, speaks of the prophylactic use of psychotropic agents in people who are only at risk of developing post-stroke depression; however, this type of management raises some ethical and moral questions for many doctors, mainly because of the complications and side effects that the use of such substances entails. So why not use psychotherapy on a wider scale? Because at the moment it is a method that has not been researched and there is no clear evidence of its effectiveness. The scarcity of publications in the specialist literature is evidence that it is a method that is primarily time-consuming and that its effects themselves may even be very delayed. Another difficulty is the specialised and qualified personnel, which requires adequate training and therefore financial outlay. Another difficulty, and in fact a limitation, is the fact that not every post-stroke patient can be treated with psychotherapy, as its basic requirement is cognitive function, which can be impaired in post-stroke patients [1].