Introduction

Post-stroke depression (PSD) is a significant factor affecting functional and social disability, even long after neurological and neuropsychological recovery. Fatigue is a commonly reported complaint in clinical practice. Fatigue after stroke (PSF), often disabling, is frequently reported and can in some cases be the only significant sequelae. It is often neglected or is considered as one aspect of PSD.

Post-stroke depression

The occurrence of PSD has been extensively investigated, with over 200 scientific papers published between 1985 and 1995 (Gordon and Hibbard, 1997). However, major methodological differences between the studies prevent straightforward conclusions being drawn and the following paragraphs are more descriptive than synthetic. For example, PSD has been reported in both less than 25% and in more than 75% of patients. The role of the side and site of stroke also remains controversial.

Diagnosis

The diagnostic accuracy of the standardized psychiatric assessment for patients with neurological impairment is questionable. Psychiatric criteria of mood disorders rely heavily on patients' reports of their own symptoms. This requires patients to be aware of their situation and to be capable of providing an accurate report of it, a task that can be difficult or impossible in patients with aphasia and other cognitive impairment caused by stroke. The presence of neurobehavioral sequelae such as aphasia, psychomotor slowing, anosognosia, and denial often compromises the validity of patients' answers. The presence of conditions interfering with the appreciation of the symptoms of depression should be carefully considered. (Table 21.1).

The diagnosis of mood disorders caused by medical conditions, including stroke, is actually based on the DSM-IV criteria (American Psychiatric Association, 1994). According to these criteria, the diagnosis of PSD requires the presence of persistent symptoms and cannot be made in the very acute phase of stroke. It is also uncertain if the DSM-IV diagnosis of PSD is valid for all depressive episodes occurring at any time after stroke. It is still a subject of controversy whether behavioral changes and subjective symptoms of PSD, and endogenous depression are equivalent (Robertson, 1998) or at least partially different (Lipsey et al., 1986), and whether the two conditions share the dysfunction of the same cerebral areas and neurotransmitters.