Keywords: Stroke, mental health, hemorrhagic stroke, ischemic stroke, depression, anxiety, mania, schizophrenia, pseudo bulbar affect, Nigeria.

Introduction.                                                                                                                

Stroke has Mental Health Connections – Nigeria.  How does stroke happen? Is there any relationship between stroke and mental health? Do Nigerians have a high risk of having mental health conditions after a stroke? What are the complications that can arise when stroke and mental health conditions come together? Are there prevention and treatment methods?

Stroke occurs when the Central Nervous System (CNS) gets damaged from an abnormal blood supply. The CNS is made up of the brain and the spinal cord. This damage can be focal (localized) part of the brain or global (generalized) part of the brain.

Mental health refers to one’s, psychological and social well being. And all these affects the way a person think, feel emotionally and acts.

After a stroke, survivors usually experience emotional and behavioral changes. This is because stroke affects the brain and the brain controls behaviours and emotions.

How does stroke happen?           

There are two types of stroke, hemorrhagic and ischemic, but ischemic is more common. When any of these happen, the brain cells in the area(s) affected die off and stoke occurs.

Types of stroke.

Hemorrhagic stroke:

This comes about when the blood vessel(s) supplying the CNS bursts and bleeds out.   There could be bleeding in the localized area of the brain, for example. Sometimes many tiny blood vessels are involved in a particular brain area or different parts of the brain. It is usually progressive, that means that it can get worse over days and can be deadly. Most probable cause is usually hypertension.  Due to the bleeding, nutrients can no more get to the affected brain area(s).

Ischemic stroke:

The ischemic strokes are due to the blocking of the blood supply to a particular area of the brain. It can affect a local brain area, or a bigger area of the brain, depending on the blood vessel that is affected.

Diseases that can cause these types of blockage include what is called atherosclerosis. This atherosclerosis is due to deposition of fats, cholesterol and other substances on the walls of the blood vessels. As these substances builds up on the walls of these vessels, the blood flowing through such vessels keeps getting less. It will get to a point that the substances completely block the flow of blood through such a vessel. Other ways a blood vessel can be blocked is through thrombosis or embolism. A thrombus occurs when a blood clot forms in a blood vessel and blocks the blood flow. An embolus is a blood clot or a piece of fat or air, flowing through the blood vessels. It gets to a point that the embolus blocks a vessel because of how small the vessel is.

Ischemic stroke occurs when the blood vessel(s) is blocked by any of these means. And nutrients cannot get to the affected brain area(s) and even nearby brain areas get involved.

Mechanism of stroke.

Stroke from hemorrhage or from ischemia will deprive the brain cells nutrients and oxygen. The deprivation of oxygen and nutrients to the brain cells will cause some of these brain cells to die off. It will also affect muscle movements. This is because every part of the body has a center of the brain controlling it on the opposite side. So a stroke on the right side of the brain paralyzes the body structures on the left side.

Also neurotransmitters or brain neurochemicals are affected. The glutamate is increased and GABA is reduced. These contribute to the destruction of brain cells. The destruction of these brain cells also will affect other neurotransmitters such as serotonin, dopamine, etc.

Stroke has Mental Health Connections – Nigeria.

It is important to note that not all persons that have stroke survive it. But for those who do survive a stroke, they can breakdown with mental health conditions. So there is a relationship between stroke and mental health. There is a brain body connection. There are neuropsychiatric conditions that exist after a stroke. In short, the entire spectrum of psychiatric illness can come about after a stroke.

After a stroke, the brain on its own will start a recovery process. By this, new brain cells and connections are formed. This new brain cells and connectivity can accelerate recovery, but can also predispose the stroke survivor to mental illness.

Risk factors to mental health conditions after a stroke:

The genetic factor –

Stroke patients with family history of mental illness are more likely to have mental health conditions after a stroke.

The neurotransmitters –

With the damage of some of the brain cells, some of the neurotransmitters or neurochemical will be negatively affected. These will thus bring about mental health conditions.

Age and gender –

It occurs more in women. And it is more prevalent in those age 70 years and above, no matter the gender.

Loss of physical function –

The stressors of having lost one’s independence and poor physical functions after a stroke can be overwhelming.  

There are other risk factors –

The severity of the stroke can also predispose to mental illness. Not having good social or family support can get a stroke survivor to have mental illness. Even those with low education and the poor, are at a high risk of mental health conditions after a stroke.

Some mental health conditions that can arise in stroke survivors:

Depression –

Post stroke depression is the most common mental illness in stroke survivors. And it is observed more when the stroke affects the left side of the brain. Depression interferes with recovery, rehabilitation and the quality of life of the stroke survivor. Major depressive disorder is the most common of the depressive types seen in stroke survivors.

The symptoms of major depressive disorders observed in stroke survivors include the following. These are increased or decreased appetite, increased or decreased weight, as well as poor sleep or excessive sleep. Other symptoms are loss of interest in things one once enjoyed, loss of energy and poor concentration. There are also the feeling of worthlessness or guilt and suicidal thoughts.

The post stroke depression usually starts within hours to days or months after a stroke. But reduces by 1 year later and disappears within 2 years.

Anxiety disorders –

The most common of the post stroke anxiety disorders is the generalized anxiety disorder. This presents as excessive worrying, restlessness, irritability, poor sleep, poor concentration and muscle tension. A stroke that affects the right side of the brain is more likely to present with anxiety disorders.

Generalized anxiety disorder negatively affects the recovery of a stroke patient. And on some occasions, depression and anxiety, known as cothymia, will present in a stroke survivor. And these will prevent the recovery of the person.

Some of the people with anxiety post stroke can also present with phobia and avoidance of crowded places. They could also be afraid of traveling alone or have fear of having another stroke.

Mania –

This is usually rare in stroke patients, but can occur. Such persons present with excessive happiness, increased energy, excessive interest in doing things and poor need for sleep. Irritable mood and copious speech are also symptoms. There could be hallucinations and delusions, especially delusion of grandeur. Delusion of grandeur is a false belief that one is very important or is a prophet or god. Most often mania presents when the stroke occurs on the right side of the brain.

Schizophrenia –

This is another rare mental illness post stroke. It can present with delusions hallucinations and abnormal behaviours. The delusions could be persecutory, etc. These abnormal behaviours include physical and verbal aggression, stripping self naked in public, etc.  Problems at the right side of the brain will lead to schizophrenia.

Catastrophic reaction –

The catastrophic reactions after a stroke includes emotional out bursts. These emotional outbursts include agitations or crying when frustrated during a task. Other emotional outbursts are outbursts of laughter or tearfulness that are not appropriate with the situations at hand. Such people cry or laugh without reasons. This is called pseudobulbar affect.

The pseudobulbar affect can be triggered by fatigue, stress, anxiety and a noisy environment. Also being around people that are emotional or being put under pressure can bring about the pseudobulbar affect.

Personality change –

After a stroke, an existing personality trait may become worse. The person’s character may also change. Such a person may not feel like doing anything, may become irritable or aggressive. The person may become disinhibited in speech and behaviours. By so doing such a person will use profane or vulgar words. The person may perform inappropriate touching of people at inappropriate body parts.

For some persons with personality change, their abnormal behaviours are directed only to family members.   

Fatigue –

Excessive tiredness can occur in up to 70% of stroke patients. Causes include physical impairment, sleep disorders, etc.

Sleep disorder –

Those with post stroke sleep disorder have problem with sleep. They can sleep excessively during the day, and poor sleep at night. The poor night sleep called insomnia is most often due to damage at the brain stem or can be part of mental illness.

Such people also have habitual snoring when asleep. And this can disturb their night sleep.

Post stroke dementia –

This includes all types of dementia that occur after a stroke. So the cognitive function gets worse. The aspects of cognitive functions most affected are mainly attention, planning, organizing, etc. So the person finds it difficult to pat attention, think, plan and manage him or herself.

Do Nigerians have a high risk of having mental health conditions after a stroke?    

Stroke has Mental Health Connections in Nigeria. The burden of stroke is high in low and middle income countries like Nigeria. In a study at the University College Hospital Ibadan, in a study of 2001, showed the stroke is on the increase. And stroke is now a leading cause to neurological admissions in the hospital. The prevalence of post stroke depression in Nigeria is up to 53% and more in Nigerian women. A history of stressful life events in Nigeria is a predictor to post stroke depression. Stressful life events like job loss, marital separation, etc. are high risk factors.

The major risk factor for stroke in Nigeria is hypertension and ischemic stroke occurs in 48% of cases. But there are other risk factors to stroke in Nigeria and they are diabetes mellitus and heart diseases. Nigerians do not check their blood pressure regularly, due to not being aware of the consequences. There are also late presentations to the hospital after a stroke due to ignorance and financial issues. The poor socioeconomic factors are high and can predispose stroke survivors to mental health conditions.

What are the complications that can arise when stroke and mental health conditions come together?

The major complications that can occur in such situations are problems with rehabilitation of the stroke patient. Recovery will be delayed or may not be possible. There could also be problems with compliance to treatment and a of risk more stoke and death. Suicide is also a risk factor here. There is also high financial involvements in treating two conditions at a time.

Those who take care of these patients also develop both physical and mental health issues. They too as caregivers can suffer burnout syndrome, etc. The burnout syndrome is a physical, emotional exhaustion experienced by those who care for these patients.

Are there prevention and treatment methods?                  

Having understood that stroke has mental health connections in Nigeria, there is need for regular medical checkups. This is to prevent the occurrence of stroke. For those who have the risk factors to stroke, there is need for compliance to treatments from a qualified medical doctor. Early treatment of stroke is extremely important to preventing complications. There is need for a physiotherapist.

For those post stroke mental health conditions, it is important to consult both the psychologist and the psychiatrist. And there is need to comply with medications.

For the caregivers, it is important to be conscious of your own health, both physical and psychological. So get medical evaluations, comply with treatments and request for help from relatives and friends for the care giving.

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