**10. Depression and stroke rehabilitation**

Depression after stroke strongly affects the way patients participate in and respond to rehabilitation. Depression has been linked with decreased participation in rehabilitation efforts which in turn results in more increased morbidity and mortality and decreased quality of life. In a Japanese study that evaluated poststroke depression in patients admitted to a rehabilitation center, their results demonstrated that the patients that were identified as having poststroke depression had less response to rehab and minimal improvement in activities of daily living and functional independence measures [32]. This study found that the level of independence in the activities of daily living at the time of discharge from rehab was related to the severity of poststroke

depression at the time of admission. Poststroke depression had a negative 5-year correlation with the ADL. Psychological factors accounted for a large part of how patients responded to rehabilitation [32]. This study found that patients with poststroke depression experience feelings of hopelessness and were thus not motivated to participate in rehabilitation. Depression in these patients also leads to listlessness and inattention, which predisposed the patients with poststroke depression to falls. Thus, another reason why mortality is higher in patients with poststroke depression. Falling was also correlated with a decreased ability to manage their ADL [32].

Another study on depression and rehabilitation found that patients with hemiparesis and poststroke depression had 51% less participation in rehabilitation activities [43]. This study showed that any amount of depression after a stroke can affect a patient's quality of life despite the severity of the stroke. This is because each patient has a unique response to acute stress. The perceived stress score is valuable in rehabilitation because it helps practitioners identify which patients are more at risk of developing depression. If they are identified early, treatment of depression can be initiated, and rehabilitation does not need to be adversely affected. Some of the indexes used to measure the quality of life in patients with poststroke depression include the Stroke Specific Quality of Life Scale SS-QOL, stroke impact scale, Barthel index of ADL as well as the multiple depression rating scales [43]. The Scandinavian Stroke Scale (SSS) and Bergman Balance Scale (BBS) are measures used to assess the progress of rehabilitation, which is more encompassing than the Modified Rankin Score [10]. If patients are able to meaningfully participate in rehabilitation, studies have proven that symptoms of depression can improve, and their quality of life scores increase as well [43]. This coupled with the use of antidepressants can help patients with depression poststroke manage their symptoms of depression and improve their functional outcome. It could also help prevent a subsequent ischemic event [43].

Depression has also been found to be a risk factor for stroke [44]. This has been demonstrated even when controlling for confounders like tobacco use or substance use. Patients with psychosocial stressors put patients at an increased risk of stroke [11, 12, 44, 45]. Not only do these patients have an increased risk of hypertension, and diabetes, but also have an increased prevalence of tobacco use and substance use that also put them at greater risk for an ischemic stroke [44]. A meta-analysis by Dong and colleagues, looked at 17 prospective studies that included greater than 200,000 patients [45]. Of this subset of patients, greater than 6000 had a positive association between depression and a second stroke. A depressed patient had 34% higher risk of developing stroke, even when age and sex were controlled for [45]. Thus, stroke and depression may be a part of a vicious cycle where a stroke results in depression and then depression results in another stroke. This process repeats and, in turn, hinders recovery and rehabilitation. Thus, proving again why it is important to diagnose depression after a stroke, and treat it adequately.

### **11. Poststroke depression and effect on the health care system**

Poststroke depression can increase the burden on the healthcare system. In two literature reviews the effect of depression after a stroke was assessed by looking at large veteran populations [46, 47]. These studies demonstrated that patients that suffered from poststroke depression had on average a longer hospital stay, as well as increased outpatient and inpatient physician visits over 1 year. These patients also had a higher likelihood of having significant deficits such as dysphagia after their stroke, and complex comorbidities that required frequent hospital visits, or prolonged stays in nursing facilities/rehabilitation centers [47]. They were also noted to have higher risk of a subsequent stroke within 1 year of their first stroke, and readmissions for complications related to their strokes such as aspiration

**269**

**Figure 1.**

*depression [49].*

*Post Stroke Depression*

*DOI: http://dx.doi.org/10.5772/intechopen.86935*

overall healthcare burden (**Figure 1**).

pneumonia, or falls [47]. In Husaini and colleague's analysis of 17,010 patients from Tennessee, their study demonstrated that patients with stroke and depression had higher average health care costs than patients with only stroke, or stroke with another comorbid psychiatric disorder, even while controlling for age, sex and race [48]. On average stroke patients with depression had a healthcare cost of \$77,864, compared to \$47,790 in patients with stroke only these costs are due to increase use of diagnostic tests, increased pharmacologic interventions, and addition therapist and physician consultations [47, 48]. If poststroke depression could be identified early, and treated it could reduce the total cost to the patient, and could decrease the

*The diagnostic and treatment procedures of PSD. MDD = major depressive disorder; PSD = poststroke* 

*Post Stroke Depression DOI: http://dx.doi.org/10.5772/intechopen.86935*

*New Insight into Cerebrovascular Diseases - An Updated Comprehensive Review*

was also correlated with a decreased ability to manage their ADL [32].

**11. Poststroke depression and effect on the health care system**

Poststroke depression can increase the burden on the healthcare system. In two literature reviews the effect of depression after a stroke was assessed by looking at large veteran populations [46, 47]. These studies demonstrated that patients that suffered from poststroke depression had on average a longer hospital stay, as well as increased outpatient and inpatient physician visits over 1 year. These patients also had a higher likelihood of having significant deficits such as dysphagia after their stroke, and complex comorbidities that required frequent hospital visits, or prolonged stays in nursing facilities/rehabilitation centers [47]. They were also noted to have higher risk of a subsequent stroke within 1 year of their first stroke, and readmissions for complications related to their strokes such as aspiration

depression at the time of admission. Poststroke depression had a negative 5-year correlation with the ADL. Psychological factors accounted for a large part of how patients responded to rehabilitation [32]. This study found that patients with poststroke depression experience feelings of hopelessness and were thus not motivated to participate in rehabilitation. Depression in these patients also leads to listlessness and inattention, which predisposed the patients with poststroke depression to falls. Thus, another reason why mortality is higher in patients with poststroke depression. Falling

Another study on depression and rehabilitation found that patients with hemiparesis and poststroke depression had 51% less participation in rehabilitation activities [43]. This study showed that any amount of depression after a stroke can affect a patient's quality of life despite the severity of the stroke. This is because each patient has a unique response to acute stress. The perceived stress score is valuable in rehabilitation because it helps practitioners identify which patients are more at risk of developing depression. If they are identified early, treatment of depression can be initiated, and rehabilitation does not need to be adversely affected. Some of the indexes used to measure the quality of life in patients with poststroke depression include the Stroke Specific Quality of Life Scale SS-QOL, stroke impact scale, Barthel index of ADL as well as the multiple depression rating scales [43]. The Scandinavian Stroke Scale (SSS) and Bergman Balance Scale (BBS) are measures used to assess the progress of rehabilitation, which is more encompassing than the Modified Rankin Score [10]. If patients are able to meaningfully participate in rehabilitation, studies have proven that symptoms of depression can improve, and their quality of life scores increase as well [43]. This coupled with the use of antidepressants can help patients with depression poststroke manage their symptoms of depression and improve their functional outcome. It could also help prevent a subsequent ischemic event [43]. Depression has also been found to be a risk factor for stroke [44]. This has been demonstrated even when controlling for confounders like tobacco use or substance use. Patients with psychosocial stressors put patients at an increased risk of stroke [11, 12, 44, 45]. Not only do these patients have an increased risk of hypertension, and diabetes, but also have an increased prevalence of tobacco use and substance use that also put them at greater risk for an ischemic stroke [44]. A meta-analysis by Dong and colleagues, looked at 17 prospective studies that included greater than 200,000 patients [45]. Of this subset of patients, greater than 6000 had a positive association between depression and a second stroke. A depressed patient had 34% higher risk of developing stroke, even when age and sex were controlled for [45]. Thus, stroke and depression may be a part of a vicious cycle where a stroke results in depression and then depression results in another stroke. This process repeats and, in turn, hinders recovery and rehabilitation. Thus, proving again why it is important to diagnose depression after a

**268**

stroke, and treat it adequately.

pneumonia, or falls [47]. In Husaini and colleague's analysis of 17,010 patients from Tennessee, their study demonstrated that patients with stroke and depression had higher average health care costs than patients with only stroke, or stroke with another comorbid psychiatric disorder, even while controlling for age, sex and race [48]. On average stroke patients with depression had a healthcare cost of \$77,864, compared to \$47,790 in patients with stroke only these costs are due to increase use of diagnostic tests, increased pharmacologic interventions, and addition therapist and physician consultations [47, 48]. If poststroke depression could be identified early, and treated it could reduce the total cost to the patient, and could decrease the overall healthcare burden (**Figure 1**).

#### **Figure 1.**

*The diagnostic and treatment procedures of PSD. MDD = major depressive disorder; PSD = poststroke depression [49].*
