Post-Stroke Depression and Post-Stroke Pain

Post-stroke depression (PSD) — definition and burden. Depressive disorder occurring after stroke, affecting about one-third of survivors and peaking at 3–6 months. Predictors are stroke severity, physical disability, aphasia, cognitive impairment, previous depression, female sex and social isolation. PSD independently causes poorer functional recovery, reduced participation in rehabilitation and increased mortality.

Recognition of PSD. Detection is difficult because of aphasia, apathy, emotionalism and anosognosia. Distinguish PSD from apathy (loss of motivation without sadness), pseudobulbar affect / emotionalism (pathological crying or laughing) and normal adjustment reaction. Screen with PHQ-9, Geriatric Depression Scale or HADS, and the Aphasic Depression Rating Scale in aphasic patients — at admission, at discharge and at follow-up.

Management of PSD. SSRIs are first line — escitalopram, sertraline or citalopram; avoid tricyclics because of anticholinergic burden, falls and arrhythmia. Watch for hyponatraemia/SIADH, gastrointestinal bleeding (especially with antiplatelets), falls and fractures, and QT prolongation with citalopram. Non-drug measures: structured psychosocial support, CBT or problem-solving therapy, early mobilisation, exercise, and treatment of pain and insomnia. Continue treatment at least 6 months after remission.

Central post-stroke pain (Dejerine–Roussy thalamic pain). Neuropathic pain in the body region corresponding to the lesion, typically after thalamic or lateral medullary strokes, appearing weeks to months later. It is burning, aching or lancinating, with allodynia, hyperalgesia and dysaesthesia, worsened by cold, touch and emotion. Treatment: amitriptyline (with caution in the elderly), pregabalin or gabapentin, lamotrigine or duloxetine. Simple analgesics and opioids are largely ineffective.

Hemiplegic shoulder pain and other nociceptive post-stroke pain. Caused by glenohumeral subluxation, rotator cuff injury, adhesive capsulitis and spasticity. Prevention is by correct positioning, arm support with a lap tray or sling, and never pulling on the flaccid arm during transfers. Treat with physiotherapy, analgesia, intra-articular steroid injection, and botulinum toxin for spasticity-related pain. Also consider shoulder–hand syndrome (complex regional pain syndrome) and post-stroke headache.

Geriatric principles. Mood and pain interact — untreated pain worsens mood, sleep and rehabilitation outcome, and untreated depression amplifies pain. Assess pain in aphasic or cognitively impaired patients with observational tools (PAINAD, Abbey Pain Scale). Apply “start low, go slow”, review anticholinergic burden and drug interactions, and remember that multidisciplinary rehabilitation with early mobilisation is the single most effective intervention for both problems.

VA/DoD Clinical Practice Guideline for Stroke Rehabilitation, 2024 update. It now recommends against the routine use of antidepressants for the prevention of post-stroke depression — a change from “neither for nor against” in 2019 to “weak against”. This follows the FOCUS, AFFINITY and EFFECTS trials and their individual-patient-data meta-analysis (Int J Stroke 2024), which showed that fluoxetine 20 mg daily for 6 months did not improve functional recovery and increased seizures, falls with injury and bone fractures, although it did reduce the frequency of depression. The message is: treat established post-stroke depression, but do not prescribe antidepressants prophylactically.