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Tuesday, October 16, 2012
I just wanted to drop you a note about Dad and how’s he doing with us after the move . It has been three years since the stroke and I think Dad has finally come to peace with it all.
His mood comes and goes, and I don’t know what to think about that. … Knowing Dad as the upbeat, positive person he always was, I never thought he would ever be depressed … about anything. When you told me that you saw signs of depression during his rehabilitation, I simply did not believe it. But the more I read about it … the more I see it.
I think the medication has helped . He tries to take care of himself and do little things the best he can, so he is better from where we started from and I’m thankful for that.
Finally, I must thank you for talking to my kids about how special it was going to be to have Grand-pops living with them. You set out just what they would see and just what to expect. If you can believe it, in some ways, we’re a better family than before the stroke.
— Washington, D.C.
Studies demonstrate that approximately one in five stroke patients will suffer with clinical depression in the immediate post-stroke period; if not identified, it can go on for many years.
In my clinical experience, I think this is a conservative number at best and I teach my residents and medical students to have a high index of suspicion for depression when caring for a stroke victim during the patient’s rehabilitation.
The reasons for this are many and complex. If we think that what a heart attack is to the heart a stroke is to the brain and that both involve the death of vital tissue, then we can see the patient is already dealing with a decreased amount of brain tissue as a result of the stroke and depending on its location, key bodily functions and cognitive adaptations are at risk.
Next, because of the patient’s age and possible co-morbidities such as hypertension, high cholesterol, diabetes, smoking, etc., the blood supply to the brain is already limited by the narrowing of the blood vessels, straining the brain’s recuperative powers . And if the patient already had a history of a depressive disorder , it adds to the challenge .
This is not to say that the diagnosis of depression in this patient population is clear-cut. In fact, it can be very subtle.
To be honest, I “sense it” more than anything else as I work with the patient: not making eye contact, answers that trail off with no conclusion, lack of interest in topics that were once fun, no animation in dealing with loved ones, not being able to make choices, the loss of a sense of humor, losing interest in food, etc.
These are in addition to the usual signs of depression that we have discussed in previous articles. Keep in mind that I think this form of apathy will lead to depression and it is a sign of the bio chemical shifts that have occurred.
When I feel depression is in play, the team approach of the family, psychiatric and rehabilitation departments are called in. Often , the tip of the spear in this process is the occupational therapists, who can report the functional signs of depression as they help the patient regain functionality.
The psychological approach is based on interviews and various screening tools . Through it all, a sympathetic, caring and involved family provides a sheltered environment for the patient .
The stress that this period of time can bring can either rally the family around the patient and humanize their care, or break the family and marginalize the patient.
I must say that since I have been here, I have seen many more families come together and support their loved ones in their hour of need than ever before. This may be because of the strong sense of faith of many and varied types in this community. But whatever the reason, it does make my job a bit easier!
When we approach pharmacological treatment, we evaluate the patient to choose a drug that makes sense with the patient’s other medications and we go “low and slow,” knowing these medications take a few weeks to be effective.
As I have said in past articles, taking advantage of support groups brings on many subtle and real benefits of getting the patient past the shock of what has occurred . Psychotherapy can be helpful also in adjusting the patient’s self-image to his or her new reality.
At this point, I must raise a flag of warning: Do not delve into what the patient could have done or should have done to prevent the stroke from happening. Doing this only makes the anger, frustration and depression worse .
Now is the time to define a positive game plan for the future as the past cannot be undone. In all of this, keep in mind that when depression presents itself, it is treatable and people can look forward to many years of productive life.
Dr. Michael Camardi is a geriatrician at the Carilion Center for Healthy Aging and an assistant professor of medicine of the Virginia Tech Carilion School of Medicine. His column runs monthly in Extra.
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