SAN ANTONIO – Preventing or treating depression after a stroke can help patients with varying degrees of disability and adaptive skills recover functional ability.
Treatment for depression can help patients develop the plasticity they need to recover physical function, or in the case of more serious poststroke disabilities, help them more readily adapt to their limitations, Dr. Ellen M. Whyte said at the annual meeting of the American Association for Geriatric Psychiatry.
Both the brain’s plasticity and adaptation rely on the ability of patients to practice and learn new skills to help themselves recover or adapt after a major medical illness such as a stroke. But evidence from several studies shows that "depression after a stroke is associated with poor functional recovery and decreased efficiency of recovery," said Dr. Whyte, a geriatric psychiatrist at the University of Pittsburgh.
Decreased Participation. Depression may impede recovery from a stroke by decreasing a patient’s participation in rehabilitation activities, she said. Depression is also associated with cognitive problems, such as executive impairment, that can interfere with recovery or adaptation, and with motor impairment, such as decreased gait speed, which may also hinder rehabilitation.
A 2004 study from the University of Pittsburgh of 242 patients admitted for rehabilitation showed that patients who were "frequent poor participators" in rehabilitation activities had less physical recovery and longer length of stay, and were more likely to be institutionalized than either occasionally poor participators or good participators (Arch. Phys. Med. Rehabil. 2004;85:1599-601).
A separate study by Dr. Whyte and her colleagues looked at the effects of mood, apathy, memory, attention, executive function, and level of disability on participation in rehabilitation. The patients all had evidence of cognitive impairment, but they were without major depression.
The investigators found that among the 44 stroke survivors aged 60 years and older who were admitted for inpatient rehabilitation, baseline disability and impairment of executive function were independent predictors of participation. They also found that "while level of depressive symptoms was not an independent predictor of rehabilitation participation in this sample, it was strongly correlated with executive functions. Depressive symptoms and impairment in executive functions frequently overlap in late lifeand after stroke, and potentially represent ischemic injury to frontal-subcortical pathways" (Arch. Phys. Med. Rehabil. 2010;91:203-7).
Falls and Depression Linked. Other studies found that depression, as measured by the Symptom Checklist-90, was associated with a doubling of falls in community-dwelling adults aged 70 years or older (J. Clin. Epidemiol. 2002;55:1088-94), and that poor self-rated health, poor cognitive status, impaired activities of daily living, two or more clinic visits in the past month, and slow walking speed predicted both an elderly patient’s risk of falling and depressive symptoms (J. Epidemiol. Community Health 2002;56:631-6), she said.
Additionally, investigators looking at the effect of depression remission after a stroke found that patients with remission of a depressive disorder at follow-up had significantly greater recovery in activities of daily living (ADL) functions than did patients without remission. The authors also found that patients with remission of either major or minor depression showed greater improvement in ADL than did patients without remission, some of whom had received the antidepressant nortriptyline, and some of whom had received placebo. The finding suggests that nondrug mechanisms of recovery from depression may have accounted for the improvements in ADL among patients with remission (J. Nerv. Ment. Dis. 2001;189:421-5).
The evidence points to a stroke-recovery model in which preventing or treating depression would lead to increased motivation and participation in rehabilitation programs, reduced depression-related cognitive impairments, and decreases in depression-related motor impairments, Dr. Whyte said.
Dr. Whyte receives research support from the National Center for Medical Rehabilitation Research. She has previously received research support from Eli Lilly, Forest Pharmaceuticals, Ortho-McNeil, Pfizer Pharmaceuticals, and the National Institute of Mental Health.