Diagnosis and treatment of post-stroke affective disorders
With the aging of the population and the increasing standard of living, the incidence of stroke is increasing year by year, especially in China, where the incidence rate is around 2 per 1,000, and a series of complications, even disability and death, are inevitable. In the past, the focus was only on the physical disability after stroke, but not on the emotional and cognitive effects of stroke. In fact, the incidence of post-stroke depression is high and can be as high as 31.2% to 63.1%.
Post-stroke depression (PSD) is highly prevalent and long-lasting after the onset of stroke and usually requires intervention, without which it can affect daily life and, most importantly, the prognosis for limb function. Because post-stroke depression is highly underdiagnosed and not easily detected, it needs to be repeatedly emphasized, especially to bring it to the attention of primary care hospitals and patients’ families.
Once we are aware of the existence of these possibilities, we take the initiative to detect them. The course of post-stroke depression is usually long and can occur at all stages of post-stroke and is multi-nodal. Acute depression is important for the prognosis of cerebrovascular disease and should generally be evaluated before discharge so that subsequent rehabilitation guidance can be carried out and appropriate aspects of intervention should be continued after returning to the community. Post-stroke treatment is only complete if it takes into account post-stroke depression and vascular dementia treatment. (See my other articles on the treatment of vascular dementia for details)
The specific clinical manifestations of post-stroke depression are mainly emotional instability, such as strong crying and laughing; personality change, which may change from extroversion to introversion, or from mildness to irritability, etc. In addition, it should be noted that somatization symptoms may occur, sometimes the patient complains of headache, dizziness, poor sleep, etc., but the corresponding responsible disease is not detected in the examination, it should be thought of neurological somatization, i.e. somatization disorder. The administration of antidepressant treatment will result in significant improvement.
The diagnostic criteria for post-stroke depression are mainly based on the CCMD-3 diagnostic criteria, and the presence of post-stroke depression can be considered if four of the following nine criteria are met: 1) decreased interest, no pleasant feelings; 2) decreased energy or fatigue; 3) psychomotor retardation or agitation; 4) low self-esteem, self-blame, or feelings of guilt; 5) difficulty in association or decreased ability to think; 6) recurrent thoughts of death or suicidal or self-injurious behaviors; 7) sleep disorders: insomnia, early awakening, excessive sleep; 8) decreased appetite or significant weight loss; 9) decreased sexual desire.
For the diagnosis, in addition to the doctor’s consultation and the patient’s family’s statement of history, objective examination is also important, and the most commonly used clinically is the Hamilton Depression and Anxiety Inventory.
Regarding the pharmacological treatment of PSD, the most commonly used first-line drugs are selective 5-HT reuptake inhibitors (SSRIs), 5-HT and NE reuptake inhibitors, NE and specific 5-HT antidepressants, preferably among the five golden flowers of SSRIs (paroxetine, fluvoxamine, citalopram, sertraline, fluoxetine), and for patients with somatization disorders, especially those with severe various pains patients, duloxetine is more effective; patients with significant insomnia or loss of appetite are usually supplemented with a small dose of mirtazapine. The application of all kinds of drugs for depression treatment should start with small doses, gradually increase the measurement, prevent the adverse effects caused by sudden large doses, increase compliance and give the body a process of adaptation.
Treatment principles are: 1) individualized treatment: comprehensive consideration of the patient’s symptom characteristics, age, physical condition, drug tolerance, the presence of comorbidities; 2) gradual increase in dose, as far as possible, using the minimum effective amount, small dose is not effective, according to the adverse effects and tolerance, increase to the full amount (the upper limit of effective drugs, long enough efficacy); 3) if still ineffective, consider changing the drug (another similar or another drug with a different mechanism of action) 4) As far as possible, a single drug should be used, but if the treatment and change of drug are not effective, the combination of 2 antidepressants can be considered; 5) Generally, the combination of more than 2 antidepressants is not recommended.
Treatment in the acute phase is very important, and only patients in the acute phase can prevent relapse with a full dosage and full course of treatment; drug treatment usually starts to take effect in 2-4 weeks, and the efficiency of treatment is linear in time; if the patient is not effective with drug treatment for 6-8 weeks, it may be effective to switch to other drugs with different mechanisms of action. The maintenance period is also important. After the acute and consolidation periods, the patient’s symptoms are controlled, social function is further restored, and he/she realizes the need for treatment, he/she can start to reduce the drug dosage. It is recommended to maintain the treatment for 6-8 months for the first episode, 2-3 years for 2 episodes, and long-term treatment should be given for more than 2 episodes. After the maintenance treatment period, the disease is stable and the drug can be slowly reduced until the termination of treatment, but early signs of relapse should be closely detected: once early signs are detected, the initial treatment is quickly resumed.
Post-session Q&A
Doctor’s station: What is the timing of post-stroke depression and what should be considered in the course of medication administration?
Prof. Han: Theoretically, the treatment of post-stroke depression should last at least half a year in full dosage, but in practice, patients’ compliance is very poor. Many people believe that changes in mood can be improved by self-adjustment, so they do not intervene with medication. Studies of transmitters have shown that deficiencies in 5-HT and NE affect the transmission of neuroelectrical signals and thus function, and that deficiencies in transmitters in brain regions responsible for mood can lead to mood changes. The role of antidepressants is to replenish the neurotransmitters that are lacking between synapses and to normalize the neurological signaling and thus the regulation of mood. Pharmacological treatment of post-stroke depression is essential.
Precautions: In order to increase patient compliance and reduce side effects, gradually increase the dose from small titration until it increases to the therapeutic dose. Antidepressants are used to gradually reach a certain time and concentration of the drug and do not work immediately after use, but need a period of time to start taking effect, to inform patients in advance to reduce expectations and increase patient compliance. The doctor should also make it clear before the start of the medication that the dosage should be sufficient and the course of treatment should be adequate.
Doctor’s station: Is post-stroke affective disorder very common?
Prof. Han: This is a very good question. With the aging of the population and lifestyle changes, the incidence of stroke is on the rise, and the incidence of stroke in China is about 2 per 1,000. In fact, stroke not only causes physical disorders, but also a series of emotional disorders. Studies have shown that the incidence of post-stroke depression is as high as 31.2%-63.1%, and cognitive decline, which is called vascular dementia. This shows that post-stroke affective disorders are common and affect the recovery of physical function and emotional well-being of stroke patients, which requires both doctors and patients to recognize the dangers of stroke and pay attention to post-stroke affective problems.
Doctor’s Station: What are the characteristics of post-stroke depression?
Prof. Han: Post-stroke depression (PSD) is characterized by five aspects. Firstly, PSD, as the name suggests, is depression that occurs after stroke, and is causally related to stroke. Third: PSD affects the patient’s ability to perform daily life and even long-term prognosis. Fourth: PSD has a long course and thus usually requires pharmacological intervention. Fifth: PSD has a high rate of underdiagnosis and is not easily detected. Families tend to think that it is normal for patients to be in a bad mood, to have a fallout, to lose their temper, or to have sleep disruptions, etc., when they go from health to serious illness, and therefore do not seek medical attention for this reason, or do not pay attention to it and do not give timely drug interventions, especially for doctors in primary care hospitals.
Doctor’s Station: Since post-stroke depression is not easily detected, what tests can we do to detect it in time?
Prof. Han: PSD is not easy to detect and pay attention to, unlike post-stroke distorted mouth and limb paralysis, which are subjective in nature. In general, we should assess stroke patients before they are discharged from the hospital and draw up a good treatment plan and instruct the family to implement it carefully after they go home, paying equal attention to it with rehabilitation training, because if post-stroke depression is not effectively controlled, it will affect the process of rehabilitation and the quality of life of the patient.
Doctor’s station: What kind of patients should be more important to our attention?
Prof. Han: All post-stroke patients need to be monitored for the possibility of depression, especially for patients with post-stroke disability or communication disorders.
Doctor’s Station: What are the signs of post-stroke depression?
Prof. Han: The specific manifestations of PSD are diverse, but in summary, there are four aspects: first: emotional instability, inexplicable crying or laughing, reduced emotional control; second: personality change, previously an optimistic and positive person, but after the stroke appears pessimistic and depressed, reluctant to contact people, become introverted; third: somatization disorder, or neurosis, which is often overlooked. Patients feel uncomfortable all over the body, such as headache, dizziness, poor sleep, panic, poor digestive function, etc. Various examinations down suggest that they are normal and cannot find out the cause of discomfort, or various inexplicable pains that cannot be explained by pathological changes and do not conform to anatomical localization. Fourth: cognitive dysfunction. Post-stroke patients may have memory loss, or slow movement and unresponsiveness.
Doctor’s Station: What criteria do doctors generally rely on to diagnose post-stroke depression?
Prof. Han: In China, the diagnosis of PSD is based on the “China Psychiatric Disorders (CCMD-3) Diagnostic Criteria”, which includes three criteria.
1) Symptom criteria, mainly depressed mood, including at least 4 of the following 9: ① Decreased interest, no sense of pleasure. For example, they used to like to play cards, chess or dance, but they are not interested in these after stroke; ② Decreased energy or fatigue, feeling tired and unmotivated all day; ③ Psychomotor retardation or agitation; ④ Low self-evaluation, guilt, self-blame: loss of confidence in life, feeling that they can’t do anything after disability, becoming a burden to the family; ⑤ Difficulty in association, decreased ability to think consciously: decreased ability to deal with problems; ⑥ Recurrent thoughts of death or suicidal or self-injurious behavior; ⑦ Sleep disorders: insomnia, early awakening or excessive sleep. Sleep problems are highly suggestive of depression and anxiety problems; ⑧ Decreased appetite or significant weight loss; ⑨ Decreased sexual desire or reduced sexual function.
2) Disease duration criteria: symptoms for at least 2 weeks. If these symptoms appear only occasionally, they are not considered.
(3) Exclusion criteria: Exclude organic mental disorders or depression due to psychoactive and non-painful substances. For example, depression can also occur in the late stages of dementia.
Thus, PSD can be diagnosed if the post-stroke patient satisfies at least 4 symptoms, if the symptoms are present for more than 2 weeks and if other disorders are ruled out.
Doctor’s station: There are so many drugs for post-stroke depression, which one is better for the patient?
Prof. Han: There is no fixed formula for choosing medication because each person is a unique individual with his or her own characteristics. Doctors will consider the patient’s symptoms, age, physical condition, drug tolerance, comorbidities, etc. for individualized treatment.
Doctor’s station: Is it better to use 1 drug or multiple drugs for post-stroke depression?
Prof. Han: Generally, it is not recommended to use more than 2 antidepressants in combination; if possible, a single medication should be used, but only if there is no effect after a full dose and a full course of treatment and medication adjustment, the combination of 2 antidepressants can be considered.
Doctor’s Station: What are the things that need to be noted when taking antidepressants?
Prof. Han: Yes, this determines whether the symptoms are fully cured or not. Be sure to titrate the dose: start with a small dose and gradually increase it to find out the minimum dose and maximum effect. After the symptoms disappear completely, maintain it for as long as possible to reach the minimum effective dose and maximum effect. When the small dose is not good, the dose can be gradually increased according to the adverse reactions and tolerance, and when it is still ineffective, consider changing the drug; when the drug reaches the effective dose it needs to be maintained for a certain period of time, and cannot be immediately reduced, the first time the drug is maintained for 6 months, and the dose can be reduced when there are no residual symptoms, and the dose should and needs to be gradually reduced, otherwise the withdrawal reaction will occur, the symptoms will rebound or further aggravate, and the symptoms will recur. The duration of the second dose is 2-3 years, and the third dose requires lifelong medication. Therefore, it is very important to emphasize that the acute treatment of post-stroke depression is the only way to avoid recurrence of symptoms and lifelong medication if the symptoms are effectively controlled during the acute phase.
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