"In my wildest dreams I never could have imagined that I would have a stroke. One day I was a successful salesman who was the strength of my family. Then one morning I fell as I tried to get out of bed. I called for help but no words came out -- I couldn't speak and my right side wouldn't move. Things are better now, but I am sad about what I have lost. I want to find out what I need to do to get better.--Jake, a 55-year-old stroke survivor
Jake is just one of 800,000 new stroke survivors each year, and like one half of them he developed depression in the first few months after his initial injury. Depression is about loss, so it is not uncommon for depression to be delayed until a point in time when the person begins to realize what they have lost as a result of a stroke or brain injury. The problem is that many of those affected by depression are never diagnosed and a significant number are never treated. We know that patients who are depressed don't perform as well in rehabilitation and they may never achieve the same level of functional recovery as someone who receives early treatment for their depression. In other words, failing to treat the survivor may create a glass ceiling for them and prevent them from reaching their full potential.
What Causes the Depression?
Depression following a stroke can be related to the person's loss of ability to do the things that they always took for granted. Brushing our teeth and going to the bathroom by ourselves may seem to be automatic until we suddenly lose the ability to perform these activities without assistance. Although the disabilities themselves can cause a loss of independence and self-esteem, the degree of functional impairment does not always predict whether a person will become depressed. It may be that the damage to the substance of the brain causes a change in the chemical neurotransmitters that pass messages from one brain cell to another -- the end result being depression.
Some people are at a greater risk to develop depression after a stroke or brain injury. We know that depression is more common in people who:
• Have a prior history of depression
• Live alone
• Are women
• Have a prior history of social inactivity or distress
• Have intellectual impairment as a result of the stroke
• Exhibit pathological crying
• Have their stroke on the left side of the brain
In addition, when depression causes impairments in memory, cognition and attention, it may contribute to a poor functional recovery because the person may not feel like participating in therapy or exercise programs. These are all good reasons to treat the depression but, it also appears that antidepressants do more than just treat the depression; they may help promote nerve cell repair and recovery.
Antidepressants Help More Than Depression
A new study, published in the American Journal of Geriatric Psychiatry, suggests that antidepressant medications given soon after a stroke may improve stroke recovery and have a direct impact on the neural mechanisms of recovery. This benefit appears to be independent of whether or not the person is depressed. Stroke survivors who were given either fluoxetine (generic Prozac) or notriptyline (an older antidepressant) for three months after their stroke improved more than those who received a placebo. This was true whether or not the person was depressed and the beneficial effect of the medication persisted even after the medicine was discontinued, suggesting that it had an early influence on neural repair.
Another recent study in the Journal of Neurotrauma reported that in brain-injured mice, the use of the antidepressant imipramine increased the number of brain cells in the hippocampus by approximately 70 percent. The hippocampus is the part of the brain responsible for memory and the mice treated with the antidepressant actually performed better in memory experiments.
What Does it Mean for You?
We believe that there are three important factors that drive the brain to repair itself after a stroke or brain injury. They are:
• The dose of rehabilitation -- the amount of therapy
• The performance of functional/meaningful tasks in rehabilitation
• The person's motivation to participate and to get better
Antidepressants appear to exert multiple effects on the nervous system to help the brain repair itself but, they may promote recovery by also improving a person's participation in his therapies. Remember that the dose of therapy matters and that more time in therapy provides a greater opportunity for the brain to rewire its pathways.
Studies in humans and animals demonstrate that certain drugs can enhance the recovery of the brain after a stroke or brain injury. If you have had a stroke or brain injury, you should ask your physician if you are a candidate to try an antidepressant medication -- even if you are not depressed.
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