Post-Stroke depression and pathological crying: Clinical aspects and new pharmacological approaches

Abstract

Despite it having been firmly established that depression and pathological crying are common and debilitating sequelae of stroke, one of the major unmet needs of stroke patients is still for these conditions to be recognized and treated. About 40% of stroke survivors become depressed the first year following stroke, with most cases developing within the early stroke period. Half of initially depressed patients will recover spontaneously within the first months, whereas the remainder are likely to develop chronic depression. As a consequence their quality of life suffers, greater stress is placed on the family and social activity decreases. While less is known of depression in aphasic patients, because of the lack of reliable assessment methods, the frequency is probably the same as in non-aphasic stroke patients. The aetiology of post-stroke depression seems to involve mainly organic but also non-organic factors, although no single factor has been identified which is able to explain the majority of cases. Pathological crying is extremely socially embarrassing for stroke patients. The frequency is lower than that of depression, the 1-year incidence being about 20%. In contrast to depression most cases occur in the very acute stroke period and 10% are still afflicted 1 year after stroke. There is now increasing evidence that post-stroke pathological crying is attributable to stroke-induced partial destruction of the serotoninergic raphe nuclei in the brainstem or their ascending projections to the hemispheres. Although the condition is classically described as being unrelated to depression, stroke patients with pathological crying have higher mood scores on quantitative measures, and are more likely to have depression than are other stroke patients. The need for active treatment of pathological crying is therefore two-fold. With both conditions effective and well tolerated treatment is provided by the selective serotonin re-uptake inhibitor, citalopram, side-effects if any being sparse, mild and transient.