Stroke and Depression-2 Nursing CEs

Author: Dana Stradling RN, BSN, CNRN

Written: July 5, 2007

Updated: September 25, 2009

Course Description

This course is designed to give an overview of how post- stroke depression (PSD) affects stroke patients. Focus will be placed on defining depression, managing depression with a care program (AIM) and with medical management (including pharmaceutical therapy).  Nursing considerations and risk factors for PSD will also be the final focus of this course.

Course Objectives:

Upon completion of this course the student will be able to:

• Discuss the symptoms of depression
• Describe the concept of the AIM model
• Explain how depression can impact stroke recovery
• List two appropriate medications used for the treatment of depression
• List two risk factors of post- stroke depression
• Discuss important nursing considerations for PSD patients
• List three appropriate NANDA nursing diagnoses for the patient with depression

Post-stroke depression (PSD) occurs in about 40 to 50 percent of all stroke survivors.  It can occur soon after the stroke or several months after.

Depression can be caused by biochemical changes in the brain caused by the stroke.  When the brain is injured, the survivor may not be able to feel positive emotions, which can lead to depression.  Depression can also be a normal psychological reaction to the losses from stroke.

Depression is an important complication of stroke that may impede rehabilitation, recovery, quality of life, and caregiver health.  Furthermore, stroke associated depression may reduce survival and increase the risks of recurrent vascular events.  Yet many stroke patients may not receive effective treatment because their mood disorder goes underdiagnosed or their doctor is uncertain about the most appropriate therapy. This can be attributed to the complexities in determining the significance of abnormal mood in patients with stroke-related disability, but it could also be related to continued uncertainty about the balance of benefits and risks of antidepressants in this setting.

Symptoms of Depression

·        Persistent sad, anxious or “empty” mood

·        Feelings of hopelessness, pessimism

·        Feelings of guilt, worthlessness, helplessness

·        Loss of interest or pleasure in hobbies and activities that were once enjoyed

·        Decreased energy, fatigue, being “slowed down”

·        Difficulty concentrating, remembering, making decisions

·        Insomnia, early morning awakening, or oversleeping

·        Appetite and/or weight changes

·        Thoughts of death or suicide, or suicide attempts

·        Restlessness/irritability

What is a Depressive Disorder?

Depressive disorders come in different forms, just as in the case with other illnesses such as Stroke. Below are the three most common types of depressive disorders.  However, within these types there are variations in the number of symptoms, their severity, and persistence.

• Major depression is manifested by a combination of symptoms that interfere with the ability to work, study, sleep, eat, and enjoy once pleasurable activities. Such a disabling episode of depression may occur only once but more commonly occurs several times in a lifetime.
• Dysthymia is a less severed type of depression that involves long-term, chronic symptoms that do not disable, but keep one form functioning well or from feeling good.  Many people with dysthymia also experience major depressive episodes at some time in their lives.
• Bipolar disorder, also called manic-depressive illness is not nearly as prevalent as other forms of depressive disorders, but is characterized by cycling mood changes: severe highs (mania) and lows (depression). Sometimes the mood switches are dramatic and rapid, but most often they are gradual.  When in the depressed cycle, an individual can have any or all of the symptoms of a depressive disorder.  When in the manic cycle, the individual may be overactive, over talkative, and have a great deal of energy.  Mania often affects thinking, judgment, and social behavior in ways that cause serious problems and embarrassment.  Mania, left untreated, may worsen to a psychotic state.
• Symptoms of Mania
  • Abnormal or excessive elation
  • Unusual irritability
  • Decreased need for sleep
  • Grandiose notions
  • Increased talking
  • Racing thoughts
  • Increase sexual desire
  • Markedly increased energy
  • Poor judgment
  • Inappropriate social behavior

Risk Factors for Post Stroke Depression

• Female gender
• Age 60 or younger
• Divorced
• Alcoholism
• Nonfluent aphasia
• Having a major motor deficit or cognitive deficit
• Nursing- home placement

Depression Not Often Treated

Stroke patients suffering form depression have been found to have a reduced quality of life and higher rate of death, so it is important to identify and treat depression after stroke.

From May 1, 1997 to April 30, 1999 researches identified those who had a stroke among 306,631 people in the North East Melbourne Stroke Incidence Study (NEMESIS). 

Nurse researchers visited the 289 participants in their homes five years after their stroke.  During the interviews, the researchers assessed participants for depression and asked about all medications they were taking, including antidepressants.

At five years after stroke, researchers found:

·        Nearly one in five stroke survivors (17 percent) were suffering from depression.

·        Only 22 percent of those with depression were taking an antidepressant.

·        About 28 percent of those taking antidepressants were still depressed.

·        72 percent of these taking antidepressants were not depressed, which could mean the medication was successful in this group.

The low treatment levels found in this study may indicate that physicians are unwilling to prescribe treatments that have not been demonstrated to be an effective and safe treatment for depression among stroke patients.

Stroke Survivors who are not depressed live longer, high- quality lives than those who are depressed. Consequently, educating physicians, stroke survivors and their families about the risk of depression after stroke may increase identification of depression and lead to improvement.

AIM at Stroke Depression

• AIM consists of three steps: activating stroke survivors and their families to understand and accept depression diagnosis and treatment; initiate antidepressant medication and monitoring treatment effectiveness.
• This system was highly effective in ending or reducing post-stroke depression in patients enrolled in the largest randomized clinical trial to date for this prevalent and disabling consequence of stroke.
• AIM is a new straight-forward care management program that is significantly more effective than usual care, which often focuses solely on antidepressants, in improving depression in stroke survivors.
• Thirty-nine percent of AIM patients had complete remission form depression after 12 weeks of treatment as compared with only 23 percent who achieved complete remission with usual care.
• A similar magnitude of absolute difference, about 16 percent, was seen inpatients whose depression symptoms improved substantially but did not completely end.  Forty-four percent of the care management group had reduction of depression symptoms, compared with only 29 percent on the usual care group.
• AIM, the new three-part post-stroke depression care management program developed by Dr. Williams and the study co-authors, was administered by nurse care managers under the supervision of physicians. 

Medication Choices for Depression

Antidepressants increased the risk of suicidal thinking and behavior in short-term studies in children and adolescents with major depressive disorder and psychiatric disorders.  Families and caregivers should be advised of the need for close observation and communication with the prescriber.

Caution is needed when using antidepressants in stroke patients. Antidepressants have side effects such as falls, seizures, and sedation. The following are a few common antidepressant medications which include dosages, some selected side effects, precautions and drug interactions.

Selective serotonin reuptake inhibitors (SSRIs)

Prozac:

Dosage: For adults the treatment of depression and obsessive compulsive disorder, a dose of 20 mg/day, taken in the morning, is recommended as the initial dose.  The maximum Prozac dose should not exceed 80 mg/day.

Side Effects and Precautions: The most common side effects seen in people taking Prozac include anxiety, insomnia, drowsiness, headache, diarrhea and rash.  Alcohol beverages should be avoided. Unless directed by a physician, Prozac should be avoided if patient is recovering form a heart attack or if they have liver disease or diabetes.

Drug Interactions: Do no take Prozac while using an MAO inhibitors, it can cause serious life-threatening reactions.  Must wait at least 14 days after stopping an MAOI before taking Prozac.  Also, wait at least 5 weeks after stopping Prozac before taking an MAOI.

Zoloft:

Dosage: For adults the initial dose is 50 mg/day.  Maximum dose is 200 mg/day.

Side Effects and Precautions:  Abdominal pain, agitation, anxiety, constipation, decreased sex drive, diarrhea, dizziness, headache, decreased appetite, insomnia and nausea.  Alcoholic beverages should be avoided while taking Zoloft and over-the counter remedies should be used with caution.

Drug Interactions: Do not use this drug while taking an MAO inhibitor.

Paxil:

Dosage: The usual starting does is 20 mg/day, taken as a single dose, usually in the morning.  At intervals of at least 1 week, the physician may increase the dosage by 10 mg/day, up to a maximum of 50 mg/day.

Side Effects and Precautions: Abnormal ejaculation, constipation, decreased appetite, decreased sex drive, diarrhea, dizziness, sleeplessness, nausea, weakness, and vertigo. Paxil should be used cautiously by people with a history of manic disorders and those with high pressure in the eyes (glaucoma). Paxil should be used cautiously with people that have a history of seizures.  Alcohol beverages should be avoided.

Drug Interactions: Paxil should never be taken with a MAOI or combined with thioridazine, or taken within 2 weeks of starting or stopping a MAOI.

Tricyclic and teracyclic antidepressants

Elavil:

Dosage: The usual starting dosage is 75 mg/day divided into 2 or more smaller doses. The doses may be gradually increased to 150 mg/day.  The total daily dose is generally never higher than 200 mg.

Side Effects and Precautions: Rapid heartbeat, constipation, dry mouth, blurred vision, sedation, and confusion.  Elavil should not be taken if recovering from a heart attack, unless directed by the physician.  Alcohol beverages should be avoided.  Elavil may be needed to be taken regularly for several weeks before it becomes full effective. A dosage should not be skipped.

Drug Interactions:  Elavil should not be taken with MAOIs

Pamelor:

Dosage:  The usual starting dosage is 25 mg/day, 3 or 4 times per day.  Doses above 150 mg/day are not recommended.

Side Effects and Precautions: Anxiety blurred vision, confusion, dry mouth, heart attack, hallucinations, heart beat irregularities and high blood pressure. Pamelor must be taken regularly to be effective.  Skipping doses is not recommended. Alcohol beverages should be avoided.

Drug Interactions: Pamelor should not be taken with MAOIs.

Ludiomil:

Dosage: The recommended initial dose is 75mg daily 2 or 3 divided doses.  The maximum recommended dose is 150 mg/day.

Side Effects and Precautions: Stomach upset, loss of appetite, nausea, dizziness, blurred vision, low blood pressure. Alcohol beverages should be avoided.  Ludiomil is usually not given to people with irregular heart beats or low blood pressure. Contraindicated in known or suspected seizure disorder.

Drug Interactions: Ludiomil should not be taken with MAOIs

Atypical antidepressants

Wellbutrin:

Dosage: No single dose of Wellbutrin should exceed 150 mg. The maximum recommended dosage is 450 mg/day.

Side Effects and Precautions: Agitation, constipation, dizziness, dry mouth, and headache. Wellbutrin is associated with an increased risk of seizure.  Alcohol beverages should be avoided.

Drug Interactions:  Do not take Wellbutrin with MAOIs or with any drug that lowers the seizure threshold.

Effexor:

Dosage: The usual starting dose of Effexor is 75 mg/day divided into 2 or 3 smaller doses.  Maximum dose is 375 mg/day.

Side Effects and Precautions: Abnormal ejaculation, anxiety, blurred vision, constipation, weight loss, and impotence.  Alcohol beverages should be avoided.

Drug Interactions: Do not take Effexor with a MAOI.

Remeron:

Dosage: The usual starting dose of Remeron is 15 mg taken before going to sleep.  Maximum dosage is 45 mg/day.

Side Effects and Precautions: Abnormal dreams and thinking, constipation, dizziness, dry mouth, flu-like symptoms, increased appetite, sleepiness, and weakness. Rameron makes some people drowsy or less alert, and may affect judgment and thinking.  Alcohol beverages should be avoided.

Drug Interactions: Never combine Remeron with a MAO Inhibitor.

Monoamine oxidase inhibitors (MAOIs)

Nardil:

Dosage: The usual starting dose is 15 mg 3 times a day.  Maximum does is 90 mg/day.

Side Effects and Precautions: Constipation, dizziness, dry mouth, headache, liver problems, sexual problems, sleep disturbances, weight gain, and water retention.  Taking Nardil with the following food or beverages can cause serious, potentially fatal, high blood pressure.  Avoid: Alcohol beverages, caffeine (excessive amounts) , foods high in tyramine e.g. cheese (except for cottage cheese or cream cheese), chocolate (excessive amounts),  dry sausage, fava bean pods, liver, meat extract, pickeled herring, sauerkraut, yeast extract, yogurt.

Drug Interactions: All other antidepressants, other MAOIs, amphetamines, nasal decongestants, asthma inhalants, appetite suppressants.

Marplan:

Dosage: Recommended initial dosage is 10 mg twice daily.  Caution is indicated in patients or whom dose of 40 mg/day is exceeded.

Side Effects and Precautions: Dizziness, tiredness, problems sleeping, constipation, and dry mouth.  Marplan could cause an attack of extremely high blood pressure, which may be fatal.  Avoid foods high in tyramine.

Drug Interactions: All other antidepressants, other MAOIs, appetite suppressants, and antihistamines.

Parnate:

Dosage: The usual dosage for Parnate is 30 mg/day.  Maximum dose is 60 mg/day.

Side Effects and Precautions: Blood disorders, diarrhea, drowsiness, dry mouth, insomnia, muscle spasm, rapid or irregular heartbeat, water retention, and weakness.  The most dangerous reaction to parnate is a surge in blood pressure, which sometimes has been fatal.  Avoid foods high in tyramine.

Drug Interactions: Avoid other MAOIs, other antidepressants, amphetamines, and antihistamines.

Depression and Recovery

Some researchers suggest that stroke patients experience more depression than other individuals with comparable disabilities; other researchers suggest that these symptoms impeded the recovery process.

Stroke recovery can be negatively affected by depression, especially major depression, because it can cause the stroke survivor to loose their motivation to recover and to become less compliant with their rehab program.

Depression may jeopardize a patient’s ability to meet functional goals and to reintegrate into society. The incidence of complications (e.g., skin breakdown, urinary tract infections), hospital length of stay, and medical costs expenses may all increase because of depression.

NANDA Nursing Diagnoses

Ineffective Individual Coping- This may be due to inadequate available resources, or multiple life changes e.g. hemiparalysis, aphasia.  A plan of a care must be initiated with a multidisciplinary approach.

Impaired Physical Mobility- Stroke patients that have major deficits such as hemiparalysis, depressive move state, or developmental delay, may now experience intolerance to physical activity and or decreased strength endurance.  Recognizing what the challenges are regarding the mobility is the first step in resolving the problem.

Impaired Adjustment- It is important for the nurse to recognize that a patient with a disability or health change may require a change in lifestyle.  The patient will need a support system to assist them with the adjustment.

Altered Role Performance- A stroke can alter a patients’ role in the family.  They now may exhibit cognitive disabilities or mental health issues and thus may now have to depend on their loved ones for physical and or emotional support.

Nursing Considerations

• A post-stroke patient may need spiritual support, counseling with a provider who has experience with the diagnoses, and support groups. 
• Providing resources including printed materials, websites, and organizations is helpful for the patient and family members.
• Assess the patient’s and family’s perception of the diagnoses, and coping mechanisms.
• If the patient is intubated and unable to speak, identify alternative methods of communication. 
• Reviewing prescribed medications (antidepressants) with patients and or family members is important e.g. side effects and dosages.
• Encourage patient and family to prioritize needs and learn to accept help.
• Refer patient and family to a social worker.
• Ask a discharge planner or case manager to coordinate inpatient rehabilitation or home care, if necessary.
• Discuss legal and financial counseling.
• Establish a trusting relationship with the patient and family to reduce anxiety and fear.

References:

National Institute of Mental Health (2008). Co-occurence of depression and stroke. Retrieved on August 28, 2009 at:

http://www.healthyplace.com/depression/nimh/co-occurrence-of-depression-with-stroke/menu-id-1419/

Bader, M. K., Littlejohns, L. R. (2004).  AANN Core Curriculum for Neuroscience Nursing (4^th ed.). Saunders, St. Louis MO.

Barker, E. (2002). Neuroscience Nursing; A Spectrum of Care (2^nd ed.) Mosby Inc., MO.

Hackett, M. L., et. al. (2005). Management of Depression after Stroke; A Systematic Review of Pharmacologic Therapies. Stroke; 36:1092.

Kaplan, A. (2005).  Neuropsychiatric Symptoms in Poststroke Patients. Psychiatric Times. Vol XXII: Issue 1. Retrieved on July 6, 2007 at:

http://www.psychiatrictimes.com/showArticle.jhtml?articleId=60400128

National Institute of Mental Health (2006). Depression. Retrieved on July 6, 2007 at:

nimh.nih.gov/publicat/depression.cfm#ptdep1

Williams, L. S., et. al. (2007). Care and Management of Poststroke Depression; A Randomized, Controlled Trial.  Stroke; 38:998.