Post-Stroke Depression Treatment Improves Chances of Functional Recovery
SAN ANTONIO – Preventing or treating depression after a stroke can help patients with varying degrees of disability and adaptive skills recover functional ability.
Treatment for depression can help patients develop the plasticity they need to recover physical function, or in the case of more serious poststroke disabilities, help them more readily adapt to their limitations, Dr. Ellen M. Whyte said at the annual meeting of the American Association for Geriatric Psychiatry.
Both the brain’s plasticity and adaptation rely on the ability of patients to practice and learn new skills to help themselves recover or adapt after a major medical illness such as a stroke. But evidence from several studies shows that “depression after a stroke is associated with poor functional recovery and decreased efficiency of recovery,” said Dr. Whyte, a geriatric psychiatrist at the University of Pittsburgh.
Decreased Participation. Depression may impede recovery from a stroke by decreasing a patient’s participation in rehabilitation activities, she said. Depression is also associated with cognitive problems, such as executive impairment, that can interfere with recovery or adaptation, and with motor impairment, such as decreased gait speed, which may also hinder rehabilitation.
A 2004 study from the University of Pittsburgh of 242 patients admitted for rehabilitation showed that patients who were “frequent poor participators” in rehabilitation activities had less physical recovery and longer length of stay, and were more likely to be institutionalized than either occasionally poor participators or good participators (Arch. Phys. Med. Rehabil. 2004;85:1599-601).
A separate study by Dr. Whyte and her colleagues looked at the effects of mood, apathy, memory, attention, executive function, and level of disability on participation in rehabilitation. The patients all had evidence of cognitive impairment, but they were without major depression.
The investigators found that among the 44 stroke survivors aged 60 years and older who were admitted for inpatient rehabilitation, baseline disability and impairment of executive function were independent predictors of participation. They also found that “while level of depressive symptoms was not an independent predictor of rehabilitation participation in this sample, it was strongly correlated with executive functions. Depressive symptoms and impairment in executive functions frequently overlap in late life and after stroke, and potentially represent ischemic injury to frontal-subcortical pathways” (Arch. Phys. Med. Rehabil. 2010;91:203-7).
Falls and Depression Linked. Other studies found that depression, as measured by the Symptom Checklist-90, was associated with a doubling of falls in community-dwelling adults aged 70 years or older (J. Clin. Epidemiol. 2002;55:1088-94), and that poor self-rated health, poor cognitive status, impaired activities of daily living, two or more clinic visits in the past month, and slow walking speed predicted both an elderly patient’s risk of falling and depressive symptoms (J. Epidemiol. Community Health 2002;56:631-6), she said.
Additionally, investigators looking at the effect of depression remission after a stroke found that patients with remission of a depressive disorder at follow-up had significantly greater recovery in activities of daily living (ADL) functions than did patients without remission. The authors also found that patients with remission of either major or minor depression showed greater improvement in ADL than did patients without remission, some of whom had received the antidepressant nortriptyline, and some of whom had received placebo. The finding suggests that nondrug mechanisms of recovery from depression may have accounted for the improvements in ADL among patients with remission (J. Nerv. Ment. Dis. 2001;189:421-5).
The evidence points to a stroke-recovery model in which preventing or treating depression would lead to increased motivation and participation in rehabilitation programs, reduced depression-related cognitive impairments, and decreases in depression-related motor impairments, Dr. Whyte said.
Dr. Whyte receives research support from the National Center for Medical Rehabilitation Research. She has previously received research support from Eli Lilly, Forest Pharmaceuticals, Ortho-McNeil, Pfizer Pharmaceuticals, and the National Institute of Mental Health.
Promising new depression treatment
A new, non-invasive treatment for depression that delivers barely perceptible electric currents to the scalp has had promising results in a Sydney trial, and researchers are now looking for participants for a follow up study.
Around half of depressed participants in the trial of transcranial Direct Current Stimulation (DCS) experienced substantial improvements, according to a team of researchers based at the Black Dog Institute and the University of New South Wales (UNSW).
An even larger number enjoyed a clinically meaningful improvement, said study leader, Professor Colleen Loo, from UNSW’s School of Psychiatry. The team is now preparing the results for academic publication.
“These are excellent outcomes when you consider that most of these people had depression that had not responded to other treatments, including medication,” Professor Loo said. “What’s more, further benefits were sustained when we followed people up a month later. That’s an exciting result.”
The trial, the largest of its type in the world, involved stimulating frontal areas of the brain with very small, barely perceptible currents, while patients remained awake and alert. The procedure has no known serious side effects.
“Direct Current Stimulation primes the neurons so that, when they are triggered, their response is enhanced. This trial is suitable for patients seeking an alternative to medication or who are unable to tolerate anti-depressant drugs or Electroconvulsive Therapy (ECT),” Professor Loo said.
Studies in the 1960s and 70s reported good results using small electrical currents over a few hours. From 2000, the technique has been further developed, using currents of 1-2 milliamps. Recently, two small overseas studies found promising improvements in depressed patients treated with DCS.
The UNSW researchers are planning another trial to further investigate the optimal way to administer DCS. To begin later this month, the trial is recruiting around 120 people to receive DCS for 20 minutes, five times a week over four to eight weeks. Participants can attend the clinic on an outpatient basis.
Treatment for depression a long-term solution
(Edmonton) Ian Colman, an epidemiologist in the School of Public Health at the University of Alberta, recently completed a study that suggests that treatment of depression may have long-term benefits.
The data Colman reviewed came from the National Population Health Survey, a longitudinal Canadian study, and showed depressed adults who use antidepressants are three times less likely to be depressed eight years later, compared to depressed adults who don’t use antidepressants.
To date, research into the effects of antidepressant treatments for individuals with major depression has only concentrated on short-term outcomes says Colman, and that there is limited knowledge about long-term results.
However, it’s important to note that it’s unlikely that the effects are just the result of ongoing treatment; Colman says, “It’s more likely that results from the study speak to the importance of getting evidence-based treatment, drugs or other therapies, in the first place and treatments that ensure that all of your symptoms are resolved.”
Colman also stresses that, while proper treatment is vital, he also points the importance of treatment that continues until an individual’s symptoms have completely ceased.
“It’s common that depressed individuals will have a partial remission of symptoms where they feel better but some symptoms remain; those people have poor long-term outcomes,” he says. “It’s important to have successful treatment that deals with all of your symptoms.”
The study, Colman hopes, will shed even more light on a complex issue. While depression can be a difficult topic to discuss in everyday conversation, recent research has shown more than 50 per cent of people who are depressed are not receiving treatment, possibly because, Colman says, they don’t recognize symptoms, don’t want treatment, or are not getting appropriate treatment due to stigma around mental illness.
Colman offers several options in order for treatment to be successful. Psychotherapy and cognitive behavioural therapy, which focuses on problem solving and skills building, help the patient deal with stressful situations for example, and have proved to have long-term beneficial outcomes.
“Evidence suggests that cognitive behavioural therapies are as effective as anti-depressants, and the two treatments together is even more effective,” he says.
Pointers for responsible reporting on mental health
Meyers said on the show: “The conference is organised for South African journalists by the South African Depression and Anxiety Group (SADAG) and the Carter Centre Mental Health Programme, based in Atlanta, Georgia.” Meyers explained on the radio show that the Carter Centre encourages journalists to explore and write about mental health issues, to gain understanding of the technical issues involved with mental health issues and that he would raise questions at the conference on how journalists make sense of the often very technical information provided by doctors, psychiatrists and psychologists.
I attended the second day of the conference, held at the Pfizer building in Sandton on Monday, 4 and Tuesday, 5 April. The second day of the seminar kicked off with a welcome by the Master of Ceremonies, Marion Scher, who is a freelance journalist and a Carter Fellow. She stated that there is a lack of knowledge out there, and that as a result, mental disease becomes “a silent illness”. It is not perceived as serious, and we need to get this awareness out there through the media.
SADAG’s founder, Zane Wilson, introduced the day’s first speaker, Dr Leigh Janet, who deals with “some of South Africa’s most difficult, treatment-resistant patients”. He is a psychiatrist, psychopharmacologist and expert in Bipolar Mood Disorder, who presented on ‘Riding the emotional rollercoaster – understanding Bipolar Mood Disorder’. He likened Bipolar Mood Disorder to the ‘emotional rollercoaster’ you would ride if we were to win the soccer, cricket and rugby world cups on the same day – then to find out a loved one has been booked into hospital and since died. He said, “Now imagine your mood moving like that for no reason,” calling Bipolar the most interesting disorder on the planet as one can have periods of ‘normal mood’ for years, and other conditions can co-occur with the disorder. He added that the mood swings, which range from depression to mania, “don’t feel abnormal to the person at the time.” It is also one of the top disorders associated with suicide and depression, and is linked to strong feelings of guilt. Interestingly, ECT, or electric shock therapy, is often used as treatment in an attempt to imitate a series of epileptic fits, which can be seen to cure depression.
This was followed by an off-the-record case study of a patient who lives with Bipolar Mood Disorder, where she described the prejudices she has faced in the workplace and within her own family, along with the difficulty she has had in convincing people that a mood disorder is as real a disease as diabetes or cancer. It’s a fight to get people to listen. She added that this is made worse by the fact that “government is interested in AIDS and TB, not mental illness.”
Next, Dr Shadi Motlana, Director of Psychiatry M Powered, took to the podium. As the head of Psychiatry at Tara Psychiatric Hospital, she elaborated on mental health patients’ rights and the Mental Health Care Act. She feels that Tara is misunderstood, particularly in the way it screens its patients. In explaining the rights of the mentally ill in South Africa, Motlana stated that the many abuses of government during the Apartheid era were redressed with 2002’s Mental Health Care Act, which sought to bring our practices in line with those of the World Health Organisation (WHO) and the African Banjul Charter. Mental Health Care Users (MCHU) of today have the right to respect, protection from unfair discrimination, and the right to intimate adult relationships, as well as knowledge of their rights and the right to appeal. Care treatment and rehabilitation must therefore not be used as punishment or for the convenience of others. Motlana added that the workplace should be made aware of any mental illness as there are reasonable protections in place by the law. She stated, “Silence causes more problems down the line.” She added that certain terminology is problematic, and that there is lots of discriminatory thinking regarding mental health issues. “The obligation lies with reporters to watch how they report on stories and to not exaggerate the facts or ostracise anyone,” Motlana said. Responsible reporting on mental health can destigamatise and raise awareness of mental health issues, getting people comfortable with the topic, so that they realise, “This doesn’t have to be your destiny” – it can be treated. She applauded SADAG for its role in making mental health issues visible to the public eye in terms of raising awareness. Wilson added that it would cost roughly R20 000 per month to run a 24-hour suicide line – the group can currently only afford to run the line from 08:00 to 20:00.
We then heard from Peter Matlhaela, the Siyabuswa Support Group Leader, who discussed the complications of getting patients’ care in a rural community, in an interview session with SADAG’s Operations Director, Cassey Chambers. He described his ordeal in dealing with panic attacks following his involvement in a taxi accident, and highlighted the fact that there is lots of stigma or lack of knowledge concerning mental health problems in the rural areas, adding that many people in these areas are illiterate and needed support groups so as to reach the people and educate them in the way they would understand. He said a key issue affecting understanding is that some African cultures lack separate words for depression and panic attacks, lumping them all together as ’madness’ – and if there’s no word for it, how would they understand it? Matlhaela gets around this problem by getting support group attendees to act out how they feel.
Following a tea break, Kevin Bolon, a clinical psychologist and Cognitive Behavioral Therapy (CBT) expert who has developed a course for the fear of flying, spoke about how obsession and compulsion go hand in hand, offering an insight into Obsessive Compulsive Disorder (OCD). He explained that many psychological terms have become popular and are now in everyday use, such as ‘depression’ and ‘panic attack’ – he stated that mental disorders are debilitating and should not be treated lightly – much in the way that anyone with a runny nose and sore throat claims to have the flu, which is actually a serious, potentially fatal illness. He mentioned that washing and counting are among the most common compulsions, and that prayer often gets hijacked into compulsion, in that we feel a need to pray when we think a ‘bad thought’ – the act of praying works to ease our anxiety. He added that the compulsions are targeted in treatment, so that eventually the patient is less likely to feel a need to react a certain way when a certain thought crosses their mind, because they are associating a consequence with a certain unrelated behaviour – this is known as ‘magical thinking’ as people connect a cluster of ‘what ifs’ to reach an unlikely outcome. It is also known as the ‘doubting disease’ because of this. The compulsion only results in a temporary release of anxiety as it reloads. Bolon reassured attendees that “we all have bits of OCD behaviour”, but actual diagnosis is based on the amount of time spent on the compulsions, as well as the level of impairment or interference caused in day-to-day functioning. He added that there is a risk of misdiagnosis and that people are becoming more aware of the disorder due to it receiving greater coverage in articles and TV shows. It is not treated with Cognitive Behavioural Therapy, which aims to change thoughts during the behaviour – instead, an ‘exposure and response prevention’ method is used, where the patient is made to face their obsession trigger and resist the compulsion. The thoughts get weaker and weaker as treatment goes on. OCD only gets worse if it is not treated as it acts as an addiction. Traditional therapy is also not effective in treatment of OCD as going through past traumas can make OCD worse. Antidepressants are also used to boost levels of serotonin – but not because there is a lack of serotonin or the person is depressed. Bolon explained this is similar to the fact that Panado is used to cure a headache even though a lack of Panado is not the cause of the headache. He asserted that mental health issues are often misrepresented in the media, and that there is no such thing as ‘compulsive’ shopping or gambling, as these are based on impulses.
SADAG Counsellor, Shai Friedland, then gave a personal account of living with OCD, titled, ‘When worry hijacks the brain: An OCD patient takes back his life.’ He shared his typical obsessive thought processes and explained that anyone who suffers from mental health issues is “not a freak – it’s a disorder”. To this, Bolon added, “These people are not weird or strange – they are as normal as you and me. They are normal people dealing with abnormal situations.” SADAG’s Project Manager, Roshni Parbhoo-Seetha, spoke about creating mental health awareness and developing successful school outreach programmes. SADAG promotes several mental health awareness days to raise awareness, as well as school prevention programmes, such as ‘Suicide shouldn’t be a secret’ and ‘When death impacts your school’ in order to discuss the warning signs in a safe environment, as teenagers don’t seem to understand the permanence of the act and it is sometimes seen as a way to attract attention. Wilson interjected that SADAG has revamped its website (www.sadag.org), which is a valuable resource for mental health journalists as it includes local and international articles on many topics. She also provided surprising statistics from a survey taken the previous day that proved 30% of the journalists attending the conference suffer from mild depression, 25% from major depression, with one so high that the person might be verging on suicide. A definite sign that there’s a need for better education on the topic!
After a lunch break, Clinical Psychologist, Robyn Rosin, spoke on the topic of ‘Flashbacks: when the worst thing that ever happened to you keeps happening everyday’ in the sense of treating Post-Traumatic Stress Disorder (PTSD). She stated that the media has a great role to play in terms of getting factual information out there and breaking the stigma of mental health disorders. She said knowledge of PTSD is especially important to field reporters who are at the scene of horrible accidents and violence, often taking horrific images as photojournalists, which continue to haunt them for years. It is also known as vicarious or secondary traumatisation if journalists hear traumatic stories and need to recount them. She added that we like to feel our world is safe and predictable, and we think that “bad things happen to other people” – this is why it is such a shock when something bad happens to us. For the first 24 to 48 hours after experiencing a traumatic event, the typical reaction is to feel numbness and disbelief as we try to make sense of what has happened – debriefing is often essential to put the event into perspective. This involves education and ‘normalising’ the symptoms in order to redress the trauma experiences and put them into perspective, understanding that the symptoms are normal. PTSD is only diagnosed if symptoms persist for a month after the event which triggered the symptoms and is easy to trace. Rosin echoed Bolon’s words, that mental illness is “a normal reaction to an abnormal set of circumstances.” Treatment revolves around getting the person back to their normal state of functioning as soon as possible.
Meyers then presented the final session of the day, on ‘Presenting to editors, producers and supervisors: how to portray your story’. This was a workshop brainstorming session where attendees broke into small groups to discuss possible article ideas based on the topics that had been presented for the day. He spoke of the importance of using a common/ neutral language that does not make mental health patients sound deficient in any way, adding that standards differ greatly among different media, ad that there has been a “coarsening of civil dialogue,” which is why so many newspapers lead with shocking images of bodies splattered on the ground and graphic images of violence.
Rebecca Palpant, Assistant Director of the Rosalynn Carter Fellowships for Mental Health Journalism, concluded the session by stating, “This is just the beginning for mental health journalism in South Africa,”adding that personal stories are so powerful – stories about mental health should not quote numbers, they should speak of the singular self that is affected. Scher interjected that interested parties should enter the Pfizer Awards for mental Health Journalism through the SADAG website, which results in two awards of R25 000 for mental health journalists.
Best Supplements for Depression
Far from just a “down in the dumps” day or two, depression is a serious illness that affects about 12 million women in America each year. It can cause energy levels to plummet, changes in sleeping and eating patterns, problems with memory and concentration, and feelings of hopelessness, worthlessness, and negativity.
Many different factors can cause depression (it’s usually a combination of genetic, environmental, and psychological issues) and there’s rarely a one-size-fits-all treatment. People with severe depression seem to have a brain chemistry that predisposes them to bouts. It’s important to see a doctor if you experience five or more of these depression symptoms for more than 2 weeks: persistent sad, anxious, or empty feelings; loss of interest or pleasure in activities; feelings of hopelessness, pessimism, guilt, worthlessness, or helplessness; insomnia or oversleeping; appetite loss or overeating; fatigue; restlessness; irritability; difficulty concentrating or remembering; or thoughts of death or suicide.
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Depression is usually treated with some combination of medications, therapy, and lifestyle changes. Antidepressant drugs are commonly a primary treatment for adults with moderate to severe cases. It can take some trial and error to find the med that works best for you, and can take up to 3 months for the med’s effects to kick in. Research shows that talk therapy helps beat depression too; up to two-thirds of people could recover just as well from therapy alone, skipping drugs entirely. Exercise is also a proven natural remedy—in one study, people with mild to moderate depression who started exercising 3 to 5 times a week improved depressive symptoms like anxiety and insomnia by 47%.
Certain supplements may also help manage depression.
St. John’s Wort: This popular herb has been used to treat depression for centuries. One major review found that it was as effective as standard drugs in many cases, although evidence suggests it’s not as helpful for people who are severely (compared to mildly) depressed. SJW may work by helping to rebalance levels of brain chemicals linked to mood, like dopamine and serotonin. The big warning sign with SJW, though, is that it interacts with many different medications (including some antidepressants), so you should always check with your doctor before you take it.
Omega-3s: Numerous studies have found that heart-healthy fish oil may also benefit your brain and mood. A big study in the Journal of Clinical Psychiatry found that omega-3 intake significantly improved depression and certain other psychiatric conditions. Although some study results are mixed, there are many other healthy reasons to eat fish or take a fish oil supplement, and many experts agree it’s a good idea to use it in conjunction with other depression treatments.
SAMe: Short for S-adenosylmethionine, this naturally occurring compound in your body helps boost brain chemicals serotonin and dopamine; low levels of both are implicated in causes of depression. Research shows SAMe is as effective as many antidepressant meds.