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A stroke is an interruption in the blood supply to the brain, causing damage or death to brain cells and, often, loss of function in some part of the body. Even when the loss of function involves a part of the body distant from the brain, such as the inability to control the movement of a foot, there are often many direct and indirect mental health consequences. Stroke is considered a neurological condition, not a psychiatric one, but it can cause perceptual, cognitive, and emotional impairments that benefit from some form of treatment.
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The damage caused by a stroke depends on where in the brain the incident occurs. If the involved blood vessel is in the right hemisphere of the brain, noticeable symptoms show up as impaired movement—weakness or paralysis—affecting the left side of the body; the reverse is true if the stroke occurs in the left hemisphere. The right hemisphere also handles an individual’s sense of their position in space (and other perceptions in three dimensions), awareness and consideration of music and art, imagination, intuition, insight, and holistic thinking. A person may experience memory problems, visual problems, or an inability to recognize body parts.
Every year, more than 795,000 people in the United States have a stroke. About 610,000 of these are first or new strokes. While strokes are most common among the elderly, the U.S. Centers for Disease Control report that 38 percent of people hospitalized for stroke in 2014 were less than 65 years old. Stroke rates in the U.S. are increasing among the young, largely because conditions that put people at risk for stroke—high blood pressure, high cholesterol levels, diabetes, and obesity—are increasing among the young.
The risk for stroke varies by race as well as age. In the U.S., the risk of having a first stroke is nearly twice as high for non-Hispanic Black adults as for White adults. Non-Hispanic Black adults and Pacific Islander adults have the highest rates of death due to stroke.
The risk for stroke also varies by geographic region. Globally, the lifetime risk of stroke among men and women over age 25 is 25 percent. But the risk varies from a low of 8 percent in sub-Saharan Africa (where both younger and older people are at greater risk of dying from other causes) to 39 percent in East Asia and Central and Eastern Europe. In the U.S., the lifetime risk of stroke is 21.1 percent among women and 16.9 percent among men.
There are essentially two types of stroke: ischemic and hemorrhagic. In an ischemic stroke, the blood supply to a part of the brain is blocked wholly or partially, depriving brain cells of vital oxygen and nutrients. Within minutes, brain cells begin to die. Loss of function depends on where in the brain the blockage occurred.
In a hemorrhagic stroke, a blood vessel in the brain ruptures, causing sudden bleeding. The accumulating blood exerts pressure on brain cells, damaging them.
The vast majority of strokes—87 percent, according to the National Heart, Lung, and Blood Institute—are ischemic, the result of a blockage in a blood vessel.
Strokes can occur in people of any age but are most common among those over age 65. A stroke is always a critical medical emergency, causing lasting brain damage, long-term disability, and even death. Strokes are the fifth leading cause of death in the U.S.
Left hemisphere strokes are more common than ones in the right hemisphere. In addition to controlling movement of the right side of the body, the left hemisphere controls more logical and critical thinking and reasoning and writing, speech, and language comprehension, functions that are often affected by a stroke. Stroke is a major cause of long-term disability and reduces mobility in 50 percent of stroke survivors over age 65.
Many psychological changes may occur in the wake of a stroke. Some are the direct consequence of changes in the brain; others are reactions to the changes, such as loss of function, that may follow a stroke. They can add up to personality change and also add to the hard work of rehabilitation.
Depression is very common after a stroke. It may be the effect of both biological changes in the brain and reactions to the event. Both social support and psychotherapy can be very helpful, as alleviating depression not only aids physical, cognitive, and intellectual recovery but also makes stroke survivors more willing to engage in the often challenging work of rehabilitation.
Sadness and grief are also common reactions to the losses that may follow a stroke, which can include not only loss of mobility but also loss of confidence, loss of independence, and loss of a career. Guilt may accompany the grief, as survivors may feel they have become a burden to those around them, who often bear a large burden of care and support. Social support from family and friends, as well as from stroke survivor support groups, can help survivors manage the emotional upheaval strokes can create.
Difficulties getting around, difficulties communicating, and reactions to myriad losses can generate frustration and anger—often anger at the stroke itself, but also often expressed at the people closest to the survivor. Frustration and anger may even prompt the survivor to lash out verbally or physically at those around them. Anger can also be a direct result of the primary brain injury.
The many changes to one’s self and one’s life that may follow a stroke can radically upend a sense of self. Identity loss can be another psychological consequence of stroke. Psychotherapy can help. In addition, the work of post-stroke rehabilitation can create improvements in function that ameliorate identity loss and help survivors reshape their sense of self.
Cognitive difficulties after a stroke are common. Ranging from mild cognitive impairment to full-blown dementia, cognitive problems may develop in the immediate aftermath of the stroke or years later. Stroke can cause impairments in memory, thinking and reasoning, planning, language generation and/or comprehension, and deficits in the ability to pay attention. Such cognitive changes commonly impede the ability to work, drive, or live independently after a stroke.
According to the American Heart Association (AHA), as many as 60 percent of people who survive a stroke develop cognitive impairment within the first year after their stroke. As many as one in three may develop dementia within five years.
The AHA also reports that up to 20 percent of stroke survivors who experience mild cognitive impairment in the immediate aftermath of a stroke fully recover cognitive function; cognitive recovery is most likely within the first six months after a stroke. Experts find that a program of cognitive rehabilitation started soon after a stroke occurs, as well as increased physical activity, may mitigate the risk of cognitive impairment and dementia.
Language is important and can shape how people see themselves and behave. Seeing a person who has experienced a stroke as a victim compounds a sense of hopelessness. Seeing them as a survivor—and helping them see themselves as a survivor—facilitates a positive mindset. It activates mechanisms of psychological resilience and can motivate people to develop strategies for improvement and get the most out of rehabilitation programs
Ischemic strokes occur in one of two ways:
- when a piece of plaque breaks off an atherosclerotic lesion (a build-up of fatty substances and cholesterol on a blood vessel wall, often called “hardening of the arteries”) and travels through the bloodstream to the brain
- a blood clot occurs either locally in the brain (thrombosis) or elsewhere in the body and is circulated to the brain (embolism)
As plaques of atherosclerosis build up on artery walls, they not only stiffen the artery walls but narrow the arterial opening, limiting blood flow. Such plaques can build up in any part of the body, but they commonly occur in the carotid artery, the large artery on either side of the neck carrying blood to the head and brain. Further, atherosclerotic deposits can also rupture, which attracts blood platelets to the site, and they can clump together to form blood clots.
Heart conditions such as atrial fibrillation are known to be a risk factor for stroke. In atrial fibrillation, a type of arrhythmia, blood pools in one of the chambers of the heart, and the stagnation can activate the formation of blood clots.
Hemorrhagic strokes are most commonly caused by high blood pressure (hypertension) or a ruptured aneurysm. While brain aneurysms—weakness in a blood vessel wall—are relatively common and often detected only incidentally, they rarely rupture. However, hypertension can put constant pressure on blood vessels and cause a weak spot to leak or burst.
Many of the risk factors for stroke—hypertension, high levels of blood fats such as cholesterol and triglycerides (hyperlipidemia), obesity, smoking, diabetes, and physical inactivity—can be controlled, often by lifestyle changes. High blood pressure can be treated medically but is also amenable to such lifestyle changes as salt restriction, weight loss, and increased levels of activity. In addition, there is evidence that some specific dietary changes offer a form of protection that minimizes brain damage after a stroke. For example, an especially antioxidant-rich diet has been shown in animals to reduce by 50 percent or more the brain damage caused by stroke.
There are usually two components to the treatment of strokes—immediate measures to address the cause, followed as soon as possible by rehabilitation to restore function. If the cause is an ischemic stroke, a clot-dissolving substance—tissue plasminogen activator (TPA)—is injected, usually intravenously. It is effective only in the first couple of hours after symptoms start, which is why it is essential to seek medical treatment immediately. TPA can restore blood flow in the brain and can make full recovery a possibility.
Depending on the source of the blood-flow blockage, an ischemic stroke may also be treated with a surgical procedure that targets the carotid artery if it has been narrowed by plaque. Vascular surgeons may perform a procedure (carotid endarterectomy) that removes the plaque, or they may place a stent in the narrowed artery (angioplasty) to ensure adequate blood flow.
If the cause is a hemorrhagic stroke, the goal is to stop or control the bleeding and then reduce the pressure on brain tissue created by the accumulating blood. Doctors may perform immediate surgery to repair an aneurysm or a blood vessel malformation in the brain, and they may perform surgery to remove pooled blood and relieve pressure on the brain.
The second major component of treatment is rehabilitation to enable patients to maintain or recover as much function as possible. Depending on the location of the stroke and the damage it causes, rehabilitation may include physical therapy, speech therapy, and occupational therapy—all aimed at restoring physical, cognitive, social, and emotional ability and living independently. Rehabilitation is typically tailored to each person’s needs and usually begins within days of a stroke.
The earlier treatment can be administered, the more likely that brain damage can be prevented or minimized. Some treatments for stroke are effective only within a short window of time—for example, clot-dissolving drugs, which can be administered in an ambulance on the way to a hospital.
Post-stroke rehabilitation is a program of structured, repetitive activities designed to help stroke survivors relearn skills lost through stroke damage. The typical hospital stay after a stroke is five to seven days, and rehabilitation often begins during the initial hospitalization. Depending on the degree of impairment, it may continue at an inpatient rehabilitation facility, in an outpatient program, or even at home, with visits by a therapist.
Rehabilitation is aimed at improving a person’s movement, speech, strength, and daily living skills. It is usually tailored to be challenging to maximize recovery of impaired functions. And indeed, researchers have found that those who participate in stroke rehabilitation programs do better than those who don’t participate.
In physical therapy, patients engage in motor-skill exercises to gain muscle strength and coordination and improve balance. They may undergo mobility training to learn how to use a walker, a cane, or a wheelchair. They undergo exercises to restore the full range of motion to damaged limbs.
Cognitive and emotional recovery is targeted through occupational and speech therapy to improve memory, processing information, comprehension, problem-solving, judgment, and social skills. A psychological evaluation may indicate the need for psychotherapy or participation in a support group to facilitate emotional adjustment.
Depending on the stroke survivor’s stamina, therapy may be scheduled for three or more hours a day.
Mental health is an important dimension of stroke recovery. Depression is a common occurrence after a stroke, and its treatment is considered a vital element of recovery, as depression can rob people of the motivation to participate in rehabilitation programs. In addition, depression destroys adaptability, a trait important for learning to cope with any impairments. Post-stroke depression (PSD) may be a direct consequence of brain injury as well as a reaction to the life changes it brings about.
PSD may benefit from a course of psychotherapy. In addition, informal programs of social support prove to be helpful to those with PSD—and all others. Both local and online stroke recovery support groups exist, and in addition to providing human connection and emotional support, they can be valuable sources of recovery information and motivation.
Just as physical movement and exercise are important in relieving any-cause depression, they are vital in post-stroke depression. Further, the movement that alleviates depression additionally benefits recovery of function after a stroke.
Immediate treatment of a stroke is one of the most important factors in recovery, as it can significantly limit brain damage. The greatest functional gains occur in the first three months after a stroke. Patients may regain lost functions through training, or they may learn ways to compensate for lost skills. Sometimes, during the early months, they experience spontaneous recovery of an ability that seemed lost. The pace of recovery slows markedly by six months, although gains are still possible thereafter.
