Depression After Stroke: Emotional Recovery Following a Stroke

How can you recognise depression after stroke? Read what patients and loved ones can do about withdrawal, crying spells and anger in the months after a stroke.

On the day he was discharged from hospital, everyone was relieved: his speech had partly recovered, and with help he could take a few steps. But a few weeks after coming home, something changed. He doesn't want to do his physiotherapy exercises, he sits blankly in front of the television for hours, and not even the voices of his grandchildren bring a smile to his face. Sometimes he cries for no reason, sometimes he flares up at the smallest thing. Depression after stroke is a condition often seen in people who have had a stroke, yet it is frequently dismissed with "He's just low, it'll pass." In fact, emotional recovery is an important part of physical recovery too. In this article I look at how post-stroke depression can be recognised, why it may arise, what family and loved ones can say and do, and when professional support is needed. Decisions about diagnosis and treatment should be made together with the neurology team following the patient and, where necessary, a psychiatrist.

What Is Depression After Stroke?

A stroke occurs when the blood flow to the brain is disrupted, and it can affect a person's ability to move, speak, think or regulate emotions. Depression following a stroke can be fed by two different sources:

• A reaction to the losses experienced. In an instant, the person may have partly or completely lost abilities such as walking, speaking, working or looking after themselves. These losses can create deep grief and hopelessness.
• The effect of changes in the brain. Depending on the area of the brain affected by the stroke, emotional regulation can also be directly affected. So in some patients, depression is not only a psychological reaction; it may also be related to the stroke itself.

This distinction matters, because post-stroke depression is not the person "failing to pull themselves together" or a "lack of willpower". Neither the patient nor the family is to blame.

What Are the Signs of Depression After Stroke?

Recognising post-stroke depression can sometimes be difficult, because some symptoms can be confused with the physical effects of the stroke. The following signs deserve attention if they continue for more than two weeks:

• Constantly feeling low, hopeless or empty
• Loss of interest in things they used to enjoy
• Reluctance to do physiotherapy and rehabilitation exercises
• Marked changes in sleep patterns
• Decreased or increased appetite
• Thoughts of worthlessness such as "I'm no use any more" or "I'm a burden on everyone"
• Marked irritability, impatience or angry outbursts
• Withdrawal, not wanting to see visitors
• Talk about death or about life being meaningless

You can find the general signs of depression in more detail in the article on symptoms of depression. These signs on their own do not amount to a diagnosis; the assessment needs to be made by a professional.

Conditions that can be confused with depression

Some conditions after a stroke may resemble depression or appear alongside it:

• Emotional swings and involuntary crying or laughing. Some patients may cry or laugh out of proportion to what they feel, or at moments they cannot control. This can be related to the effect of the stroke on the brain and is a different picture from depression. However, the two can also occur together in the same person. The neurology team should be consulted for an assessment.
• Apathy. A person can be unmotivated and inactive without appearing sad. This is a condition that can be confused with depression but needs to be addressed differently.
• Difficulty speaking. Patients with speech and language problems such as aphasia find it hard to express their feelings in words. This makes depression harder to recognise. In these patients, facial expression, body language and changes in behaviour offer more important clues.

Why Does Depression Occur After a Stroke?

Several factors play a role in how this picture develops:

• Sudden and unexpected loss. A stroke usually comes without warning. Someone who wakes up healthy in the morning may find themselves in hospital that evening, unable to speak. This sudden break gives the person no chance to prepare.
• A sense of dependence. Needing help with basic tasks such as dressing, eating or going to the toilet can create deep shame, especially in people with a strong sense of dignity.
• Loss of role. Someone who supported the household, made the decisions as the head of the family or looked after their grandchildren may go through an identity crisis when they lose these roles.
• Fear of another stroke. The worry "What if it happens again?" can keep a person constantly on alert and anxious.
• Social isolation. Because of limited mobility, difficulty speaking or embarrassment, a person may withdraw from social life.
• Previous mental health history. The risk may be higher in people who have experienced depression or anxiety before.

Depression After Stroke: What Should Loved Ones Say, and What Should They Avoid?

During recovery after a stroke, the family is the patient's most important source of support. But finding the right words is not always easy. I have discussed separately how to approach someone who has had a stroke in general in the article on approaching a patient who has had a stroke; here I focus on the patient who shows signs of depression.

Fictional examples of supportive sentences:

• "I can see you're having a hard day. If you'd like to tell me how you feel, I'll listen; if not, I'll just sit with you."
• "I know it upsets you so much not to be the way you were. That sadness makes complete sense."
• "Today you took two more steps. I noticed that."
• "I'm not angry that you're angry. This situation really is very hard."

Sentences to avoid:

• "Pull yourself together a bit; if you just lie there you'll never get better." This presents depression as a problem of willpower and burdens the patient with guilt.
• "If you keep your spirits up, you'll recover faster." Linking recovery to mood pushes the patient to feel like a failure on the days they feel low.
• "Be thankful, it could have been worse." This minimises the loss the person has experienced and stops them from expressing their feelings.
• "Why are you crying now?" For a patient who has involuntary crying spells, this question can be humiliating.
• Talking about the patient in the third person in front of them. Remarks such as "He doesn't understand anything any more" deeply wound a patient who, even if unable to speak, can hear and understand.

When communicating with patients who have difficulty speaking, it is important to be patient, use short and clear sentences, ask questions that can be answered with yes or no, and try alternative ways such as writing, pictures or gestures.

While the body slowly recovers after a stroke, the mind also needs to heal at its own pace; the two cannot be separated.

Depression After Stroke by Age

Stroke at a young or middle age

Although stroke is often associated with old age, it can also occur in young and middle-aged adults. In this age group, depression is fed in particular by job loss, financial worries, a shaken sense of their role as a parent and plans for the future becoming uncertain. The question "My children are still young, how will I look after them?" is a source of deep anxiety. The relationship between partners also changes; while one partner moves into the caregiver role, the other may feel dependent. At a time of rising living costs, loss of income can also increase tension within the family.

Stroke in older age

In older patients, a stroke can be a new blow added to existing losses (retirement, the loss of a spouse, health problems). In this age group, depression is sometimes overlooked with the comment "It's just old age." Yet depression in older age is also a treatable condition; I have discussed this separately in the article on depression in older adults. In older patients it is especially important to protect dignity and autonomy, involve them in decisions and make room for them to keep doing what they can.

Children in the family

Children whose grandfather, grandmother or parent has had a stroke may be frightened by the changes in their loved one's speech, facial expression or behaviour. Giving the child an age-appropriate explanation such as "A blood vessel in Dad's brain got blocked, so he finds it hard to talk. But he hears you and he loves you" reduces their fear.

Everyday Steps That Support Emotional Recovery

The suggestions below do not replace medical treatment and rehabilitation; they can support emotional recovery in line with the treatment team's advice:

1. Making small progress visible. Recovery after a stroke is slow and the person often sees only what they have lost. Noting small weekly gains together nourishes hope.
2. Establishing a daily routine. Getting up at set times, getting dressed, a short walk or exercise, a favourite activity; routine protects against the disorganisation that depression brings.
3. Making room for meaningful activities. Helping the person continue the things they love in an adapted form. For example, a few pots on the balcony for someone who used to garden, or reading aloud for someone who loved reading the newspaper.
4. Protecting social ties. Short, calm visits, phone calls or meet-ups with old friends matter in the face of loneliness. However, crowded and long visits can tire the patient. In Turkey, "get well soon" visits usually pile up in the first weeks after discharge and then suddenly stop. Spreading visits over the weeks and making sure the patient keeps being called after the initial rush has passed reduces this sudden sense of emptiness.
5. Working with the rehabilitation team. Regular contact with the physiotherapist, speech and language therapist and occupational therapist supports both physical and emotional recovery.
6. Giving the patient a say. Leaving decisions such as what time to exercise, which clothes to wear or when to receive visitors to the patient as far as possible gives back part of the sense of control that the stroke took away.
7. The caregiver looking after themselves. Burnout in the caregiver also affects the patient's mood. It is important for the load to be shared within the family and for the caregiver to have access to support as well.

When Should You Seek Professional Support?

Some sadness and anxiety for a while after a stroke is to be expected. However, in the following situations it is important to contact the treatment team and ask for an emotional assessment:

• Low mood and loss of interest lasting more than two weeks
• Completely refusing rehabilitation exercises
• Stopping eating or taking prescribed medication
• Marked sleep disturbance
• Constant expressions of hopelessness and worthlessness
• Sudden and marked changes in behaviour

Post-stroke depression is a treatable condition. For assessment and a treatment plan, it is important to talk with the neurology team and ask for an assessment by a psychiatrist. If the patient says things like "I wish I had died" or "I don't want to live", has thoughts of ending their life or wishes to harm themselves, take it seriously; in an emergency, call 112 (emergency services). Also, if you notice new stroke symptoms such as a drooping face, sudden weakness in an arm or leg or sudden difficulty speaking, call 112 without delay.

How Is Depression After Stroke Addressed in Therapy?

Psychological support plays an important part in treating post-stroke depression and can be carried out alongside medical treatment. The therapy process is adapted to the patient's cognitive and communication abilities.

Within cognitive behavioural therapy, work can focus on the following:

• Noticing thoughts of worthlessness. Recognising thoughts such as "I'm no use any more" and helping the person see the values and contributions they still have.
• Behavioural activation. Helping the person return step by step, in line with their capacity, to activities in which they find enjoyment and meaning.
• Grief work. Making room for the grief felt for lost abilities and their former life.
• Anxiety management. Developing skills for coping with the fear of another stroke.

In sessions with the family, communication, role changes, the burden of care and ways of supporting the patient are explored. Work in the area of depression and mood can offer direction for both the patient and their loved ones. For patients who find it hard to leave home because of limited mobility, sessions can also be held online where suitable.

Frequently Asked Questions

My father keeps crying since his stroke. Is this depression?

It may be, but there may be other causes too. A stroke can sometimes affect emotional control and lead to involuntary crying spells. This is different from depression, although the two can also appear together. For an accurate assessment, consult the neurology team and, if necessary, a psychiatrist.

Does depression after a stroke go away on its own?

In some patients, mood may improve over time; but waiting for depression to pass by itself can harm rehabilitation and quality of life. If symptoms persist, a professional assessment is important.

How can I tell if a patient who cannot speak is depressed?

You can pay attention to behavioural clues such as facial expression, eye contact, level of interest, changes in sleep and appetite, and willingness to take part in activities. The speech and language therapist and the treatment team can help assess mood in patients with communication difficulties.

The patient doesn't want to exercise. Should I push them?

Pushing often increases resistance. Beneath the reluctance there may be depression, fatigue, pain or embarrassment. Trying to understand the reason, setting small goals and sharing the situation with the rehabilitation team are more effective.

• #stroke
• #cerebrovascular accident
• #depression
• #family caregiver

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Eda Erkan Alapala

Klinik Psikolog. İstanbul Kent Üniversitesi Klinik Psikoloji Tezli Yüksek Lisans mezunu; bilişsel davranışçı terapi, çocuk merkezli oyun terapisi ve çocuk-ergen psikoterapisi alanlarında eğitimlerini tamamlamıştır.

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