Psychobiology of stroke: a neglected area
The editorial by Antoine Hakim and colleagues1 provides a comprehensive review of the human and financial burden of stroke on the Canadian health care system. The article also draws attention to the current state of disorganized stroke care in Canada and suggests remedies for this problem. However, we are concerned that both the editorial and the accompanying supplement2 fail to address the psychological consequences of stroke and the importance of integrating psychiatric services into the treatment of stroke patients.
The prevalence of post-stroke depression in 2 rehabilitation hospitals in Canada was estimated at 36% to 50%.3,4 Given that at any given time approximately 300 000 Canadians are suffering the consequences of stroke, at least 100 000 of these may be disabled by depression. Furthermore, depression after acute stroke was the only treatable condition independently associated with limitations in physical functioning.5 This finding emphasizes that early recognition and effective treatment of depression after stroke may optimize rehabilitation potential and thereby reduce the human and financial costs associated with post-stroke functional impairment.
Because depression after stroke increases the risk of death6 and diminishes intellectual functioning,7 early intervention in the treatment of depression would have a positive effect on outcome.
Recent studies have also suggested that selective serotonin reuptake inhibitors may have a role in augmenting functional recovery.8,9 Besides the causative relation between cerebrovascular disease and depression, there is indirect evidence that depression may increase the risk of cerebrovascular disease. Understanding the cause-andeffect relation between psychological factors and cerebrovascular disease might be relevant to primary, secondary and tertiary prevention of stroke. From a research perspective, the interaction between psychological and biological mechanisms underlying causation of and recovery from stroke need to be explored. The psychological issues related to “brain attack” should be as important for health care providers as the psychological problems associated with heart attack. Enhancing awareness among neurologists, psychiatrists, granting agencies and policy-makers would benefit thousands of stroke patients in Canada and around the world. Rajamannar Ramasubbu, MD Assistant Professor University of Ottawa Royal Ottawa Hospital Ottawa, Ont.
1.Hakim AM, Silver F, Hodgson C. Is Canada falling behind international standards for stroke care? CMAJ 1998;159(6): 671-3.
2.Stroke: costs, practices and the need for change. CMAJ 1998;159(6 Suppl):S1-33.
3.Eastwood MR, Rifat SL, Nobbs H, Ruderman J. Mood disorder following cerebrovascular accident. Br J Psychiatry 1989;154:195-200.
4.Sinyor D, Amato P, Kaloupek P. Post stroke depression: relationship to functional impairment, coping strategies, and rehabilitation rehabilitation outcome. Stroke 1986;17:112-7.
5.Ramasubbu R, Robinson RG, Flint AJ, Kosier T, Price TR. Functional impairment associated with acute post stroke depression: the stroke data bank study. J Neuropsychiatry Clin Neurosci 1998;10:26-33.
6.Morris PLP, Robinson RG, Andrzejewski PA, Samuels J, Price TR. Association of depression with 10 year post stroke mortality. Am J Psychiatry 1993;150:124-9.
7.Wade D, Legh-Smith J, Hewer R. Depression after stroke: a community study of its frequency. Br J Psychiatry 1987;151:200-6.
8.Dam M, Toruin P, Deboui A. Effects of fluoxetine and maprotiline on functional recovery in post stroke hemiplegic patients undergoing rehabilitation therapy. Stroke 1996;27:1211-4.
9.Ramasubbu R, Flint AJ, Brown G, Awad G, Kennedy S. Diminished serotonin mediated prolactin responses in nondepressed stroke patients compared with healthy normal subjects. Stroke 1998;29:1293-8. Source: JAMC 23 MARS 1999; 160 (6).
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