Maree Hackett talks about her research on depression after stroke
In our most recent podcast, we spoke to Associate Professor Maree Hackett, Acting Director of the Neurological and Mental Health Division of the George Institute for Global Health in Sydney. Here are some of the things she had to say about treatments and research on depression after stroke.
How common is depression after stroke?
It's very common. In fact, it's almost unusual not to have it at some point.
If you look at all the really good quality research studies that have been conducted on people who have had a stroke, about half of them will experience depressive symptoms of clinical concern in the first 12 months. And at any time in that first year, one in three stroke survivors have depressive symptoms that would concern us.
Between one and five years after their stroke, that proportion might drop to about one in four. That's still a lot of people experiencing depression.
Is there a particular part of the brain that can cause depression if it’s damaged by a stroke?
It's a really appealing idea, that where the damage occurs in your brain might put you at greater risk of experiencing depression, anxiety or other changes in your mood.
Despite all the studies that have been done, there’s been no consistent evidence. We can’t say, for instance, if you've had a lesion – that's the damaged part of your brain – on the back right-hand side and that means you're going to have depression. We do think that if you've had a very bad stroke, then there may be a bigger lesion and that may be more important than where the lesion is located. But again, that data isn’t very strong.
The correlation’s not clear, possibly because the imaging we use to find out where your lesion is might still be a bit crude. Or, it might be that there’s multiple aspects that make up your risk of having depression. It might not just be the damage.
Having a stroke is a big, life-threatening event that can drastically change your own impression of you and what you used to be able to do. There’s definitely a distinctive, reactive depression, where something untoward has happened and you're reacting to that. In fact it's normal to have that reaction after a big, life-changing event like a stroke. Where it becomes not normal, is if that reaction or low mood persists for a long time.
It’s equally unpleasant regardless of whether there is a biological cause for the depression versus a reactive cause and it doesn't change how we manage the depression.
What are some of the treatments and positive things that can be done?
There’s a whole series of things that can start from very simple.
If you've got access to a computer or smartphone and the internet, you can do some guided self-help therapy. There are websites and apps, e.g. MoodGYM, where you login and it takes you through some steps a therapist would take you through. The website and apps enable you to do the exercises in the privacy of your own home at your own pace. They'll ask you questions about your thinking patterns and might suggest some ways to train you to think a bit differently. That might help with your motivation, your mood and your ability to get around. That's quite good if you've got mild or low level depressive symptoms, when you might be feeling down but it's not having a massive impact on your day-to-day life.
Once your symptoms start getting to the point where you're really noticing it's impact – you're not going to work, not eating properly or not talking to anyone – go to the next step and talk to your GP.
Your GP can do a couple of things. One, they can organise for you to talk to someone about your mood. For those who need to do that, you can get up to ten Medicare-funded talking sessions. Talking therapies are really good if you get in early when the symptoms are mild because it helps you to change your thinking and your practices before the symptoms develop further.
If you're very disabled right from when your symptoms first hit you, your GP may prescribe you an antidepressant. There are a lot of different types of antidepressants.
Your GP will talk to you about how depressants interact with any other medications you're on, because that's important to know. You also want your GP to tell you when to come back so that you can have your mood assessed, to see whether the dose needs to be changed or whether your medication needs to be changed. About 50 percent of people don't like their first antidepressant, usually due to side effects, so they go on to a different one.
You also want to know at what point your symptoms have improved enough to look at taking you off your antidepressant.
What do you look at in your own research?
One of the things I do is bring together the totality of the research that has been published in something called a systematic review. This is so you don't just get the results from one antidepressant trial, you get the results from 16 trials. That's how I can say, we know that antidepressants work if you're depressed, you've got to balance out the benefit and risks, we know they cause some side effects but they do treat depression to remission. (See http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003437.pub3/abstract)
The talking therapies, if you're very depressed there's less evidence. That's why I suggested that if you get in early when your symptoms are mild, you can ameliorate your symptoms and hopefully stop the development to full-blown depression. (See http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003689.pub3/abstract)
We also have a current trial where we provide antidepressants to people immediately after a stroke, regardless of whether or not they've got depression. This is because there is some evidence, from a small trial conducted in France showed that antidepressants actually improved physical function. Patients may have less restrictions, they might be able to walk better and might be able to move their arm or face better after three months of treatment.
There's our Australian trial, which we've called AFFINITY, and there's a trial of the same design being conducted in the UK called FOCUS and another one in Sweden called EFFECTS. We're combining all our trial results and by the end of all three trials we'll have over 6000 patients. We’ll be able to look at the data to see if that is true, do antidepressants improve physical function? In addition, we’re looking at the impact on depression and giving antidepressants as a preventative strategy. So far we haven't had any strong evidence for that.
The brain is one amazing organ, and we don’t really understand all the connections.