About a third of stroke patients are likely to feel depressed

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. People who survive stroke commonly may experience depression, and that can make the rehabilitation process more challenging. With me to talk about this are two Upstate providers who care for people who are recovering from stroke. Carrie Garcia is a speech pathologist, and Jessica Mungro is an assistant professor of rehabilitation psychology. Welcome to "The Informed Patient," Dr. Mungro and Ms. Garcia.

[00:00:38] Carrie Garcia: Thank you.

[00:00:39] Jessica Mungro, PhD: Thank you. Happy to be here.

[00:00:41] Host Amber Smith: What percent of stroke survivors would you estimate deal with some form of depression?

[00:00:48] Jessica Mungro, PhD: The research in this area estimates about 30% of people post-stroke will experience depressive symptoms. There is some variation in the research, though.

[00:00:59] Host Amber Smith: That seems like a pretty big number. Are people who had depression prior to the stroke more at risk?

[00:01:06] Jessica Mungro, PhD: Yes. Prior depressive symptoms are considered a risk factor.

[00:01:13] Host Amber Smith: So what causes depression after stroke?

[00:01:16] Jessica Mungro, PhD: So that's a complicated question. There's not one single cause of depression. The etiology is likely more multifactorial, with biological, psychological and social factors. So by that I mean there's ways that the anatomy of the brain, the neurotransmitters and the neural networks may be impacted. But there's also ways that changes in function and cognition and language abilities may impact how people feel about themselves, impacting things like their identity, their role in the family, their career trajectory, their ability to engage in all of the activities that bring them joy. So all of these things can impact the development of depression.

[00:02:00] Host Amber Smith: Is there a specific type of stroke or area of the brain that you see that's more affected in post-stroke depression? Does it all look the same in different patients?

[00:02:13] Jessica Mungro, PhD: Another complicated question. A number of studies have aimed to better understand this question, but there's a lot of inconsistencies in the research in terms of stroke location and how it impacts post-stroke depression. The way I look at it is, is ultimately anybody who suffered a stroke may experience symptoms of depression, making psychological health a huge component of stroke rehab, regardless of the type of stroke or the location of the stroke.

[00:02:41] Host Amber Smith: Does the severity of the stroke, do you see depression in people who've had a more severe stroke than in those who their symptoms are minor?

[00:02:52] Jessica Mungro, PhD: Yes. So stroke severity is another factor that's considered a risk factor for developing stroke depression.

[00:03:00] Host Amber Smith: Well, let me ask you to compare this to non-stroke depression. Are there similarities or differences that you can see in stroke-based depression versus non-stroke depression?

[00:03:14] Jessica Mungro, PhD: The clinical symptoms that are assessed are the same, although I will say it's important to parse out the symptoms that may be implications of the brain injury. So things like fatigue, or initiation, or sleep changes. It's important to assess how those symptoms are presenting. But an important piece is whether it's depression occurring post-stroke, or not associated with the stroke. They both can be treated with, therapy and/or medication.

[00:03:46] Host Amber Smith: Now, sometimes I think depression is tied in with anxiety. Do you see that in post-stroke survivors?

[00:03:53] Jessica Mungro, PhD: Yes. So post-stroke anxiety, estimates are around 20 to 25% of people that experience post-stroke anxiety.

[00:04:02] Host Amber Smith: How soon during recovery would depression emerge?

[00:04:07] Jessica Mungro, PhD: The highest rates of depression are in the first three months. But with that being said, there's not a single time that depression can surface. I've worked with people experiencing post-stroke depression who may still be in the hospital, but also people who may be well into a year past a stroke. So, just something important to keep in mind.

[00:04:32] Host Amber Smith: Are there symptoms that loved ones might recognize before depression sort of settles in? Are there triggers or red flags to be aware of?

[00:04:44] Jessica Mungro, PhD: So the most prominent symptoms are depressed mood and anhedonia, which is really that lack of interest or enjoyment or pleasure in activities. They're the most frequently reported, but also paying attention to things like fatigue, changes in sleep, changes in appetite, feelings of guilt or worthlessness. Sometimes suicidal ideation can surface. Those are all things to pay attention to.

[00:05:14] Host Amber Smith: Is some sadness to be expected, though, after this sort of medical crisis?

[00:05:19] Jessica Mungro, PhD: Well, of course. Sadness is a natural reaction to a traumatic situation. It can also be a natural reaction to loss. I know we often think about grief and loss in the context of death and dying, but we also experience grief reactions in response to several different kinds of loss.

In the context of stroke, for example, somebody may be feeling a sense of loss even if it's temporary while they're rehabilitating. But sadness would certainly be a normal reaction.

[00:05:49] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking about post-stroke depression with two Upstate providers who care for people recovering from stroke, speech pathologist Carrie Garcia, and rehabilitation psychologist Jessica Mungro.

So, Ms. Garcia, how does depression impact speech therapy? Because I know that's often part of the recovery after a stroke.

[00:06:15] Carrie Garcia: Depression can impact a patient's participation in speech therapy, their motivation in participation in speech therapy, and just their overall recovery because depression can stand in their way of, obviously, their mood, their affect, and just in overall interest.

[00:06:38] Host Amber Smith: So do you see a difference in the progress made by patients who have depression compared with those who don't?

[00:06:47] Carrie Garcia: Yes. We tend to see a slower progression, like Jessica was saying, you know, depending on if they're sleeping, if they're eating, if they have interest. Patients with depression, especially overt depression, aren't really interested or motivated and not always willing to do the work that a patient who is not experiencing those overt signs and symptoms can accomplish.

[00:07:16] Host Amber Smith: Well, correct me if I'm wrong, but isn't stroke recovery, it's important to do it as soon after the stroke as possible? So you can't just let a patient be depressed for weeks and put off their efforts for recovery, right?

[00:07:32] Carrie Garcia: Nope. And we surely don't, especially on the acute care units, especially on the inpatient rehab units. We are in there early. We are in there from day one. Inpatient rehab is five days a week for at least three hours of therapy a day. So no. We are not letting that happen, and we are encouraging their participation. The hardest part is if they're still having post-stroke depression and they're discharged to home because we're not in there every day, and that falls to the family members to help them and encourage them and motivate them. Because on outpatient, we might only be seeing them one to two times a week.

[00:08:15] Jessica Mungro, PhD: I just wanted to emphasize that rehab psychology is a part of the multidisciplinary rehabilitation team at the acute inpatient rehabilitation program. So again, just echoing Carrie's voice in that it's something that's attended to right from the beginning.

[00:08:30] Host Amber Smith:

Well, let's talk more about the treatment. Is a psychiatrist or a psychologist always involved?

[00:08:37] Jessica Mungro, PhD: So I work as a rehabilitation psychologist, so I don't prescribe medications. Frequently I'm working with a physiatrist who's managing the medical care post stroke. So certainly medications can be a conversation with that provider. If need be, there's also psychiatry that can be part of the discussion with medication.

[00:09:01] Host Amber Smith: Is there talk therapy? Is that part of it?

[00:09:04] Jessica Mungro, PhD: Yes, that is my role. I tend to work with people who are struggling with the depressive symptoms I mentioned earlier. So really, my focus is that talk therapy component that helps with reducing symptoms of depression, of anxiety, helping to promote overall health and adjustment to their current abilities and functioningsubsequent to stroke.

[00:09:29] Host Amber Smith: Do you see people whose personalities change after a stroke?

[00:09:35] Jessica Mungro, PhD: Stroke can impact a person's brain functioning in a lot of different ways, so it certainly can impact how people behave, how they regulate emotions, how they react to different situations and stressors, which all are sort of interpreted as personality change.

I tend to see people who may be struggling with changes like depressed mood or apathy, maybe irritability or anger. Like we were mentioning earlier, also anxiety or difficult-to-control worry. And all of those symptoms that may be impacting their overall functioning.

[00:10:11] Host Amber Smith: So are those changes permanent or will they go away as the person's recovery moves along?

[00:10:21] Jessica Mungro, PhD: They're not always permanent. For example, the changes I mentioned associated with post-stroke depression and anxiety, they're quite treatable. In terms of changes associated with, like, cognition or things like impulsivity, problem solving, memory or attention, speech language therapies and occupational therapies can also be very helpful.

[00:10:41] Host Amber Smith: As patients see progress in their speech therapy and other therapies after a stroke, does that have an effect on depression? Does that help it get better or go away?

[00:10:53] Carrie Garcia: I think it absolutely does have an impact on it. It does improve their mood. It improves their motivation, especially when they can see the progress. I think one of the barriers is when our patients don't always see the progress that they're making, because not all of our patients can remember ground zero and where they started from.

So it is very important to help them see the gains, whether it's via video or photo, as well as, even, sometimes we use testing scores to show them the gains they've made from the beginning, to the middle, until the end. Especially on outpatient therapies, we're required to do outcome measures and goal review every 10 visits. So every 10 visits we're really reinforcing the progress and the gains made.

[00:11:50] Host Amber Smith: Well, before we wrap up, I'd like to ask both of you, Dr. Mungro and Ms. Garcia, how can friends or loved ones help? What can they do that would be helpful during this time? Dr. Mungro?

[00:12:04] Jessica Mungro, PhD: In general, I think one of the most important things you can do is to be present with your loved one, to really listen, to be patient with them, to validate their emotions and their experience. I also think it's really important, as Carrie alluded to, to learn as much as you can about the individual's strengths and challenges. I think knowing the challenge areas allows you to know where to help, to know how to help. But I also think knowing their strengths helps you to know where to foster feelings of independence or a sense of competency and all those things that can really help with those depressive symptoms. And the only other thing I think about with families is the importance for self-care. It can be a huge adjustment to the entire system, and I think it's really important that the family members who are assisting someone through this experience are also taking care of themselves and giving themselves grace and getting their needs met.

[00:13:09] Carrie Garcia: The only other thing I would add to what Dr. Mungro said is including being present, but to also making sure not to facilitate that isolation. It's very isolating to have a stroke. A lot of our stroke survivors feel alone. They feel like they're the only one. So encouraging the participation in life and in life events.

And we have multiple support networks in the community. We have the stroke support group. There's another stroke support group that runs locally, but we also have events and activities and fundraisers that run at least monthly or a couple times a year that those stroke survivors and their family members and even extended family can participate in.

[00:14:00] Host Amber Smith: That's really good to know. I appreciate both of you making time for this interview, Dr. Mungro and Ms. Garcia.

[00:14:06] Carrie Garcia: Thank you.

[00:14:07] Jessica Mungro, PhD: Thank you.

[00:14:08] Host Amber Smith: My guests have been Carrie Garcia, a speech pathologist, and Jessica Mungro, an assistant professor of rehabilitation psychology, both at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please tell a friend to listen too. And you can rate and review "The Informed Patient" podcast on Spotify, Apple Podcasts, YouTube, or wherever you tune in. This is your host, Amber Smith, thanking you for listening.