What are the management options for mood and speech symptoms after a stroke?

Management of Mood and Speech Symptoms After Stroke

Speech and language therapy should be initiated as early as tolerated after stroke onset, with intensive therapy (at least 45 minutes daily, five days a week) for speech disorders, while mood disorders should be actively screened for and treated with SSRIs and psychotherapy. 1, 2

Speech and Communication Disorders

Assessment

• All stroke patients should be screened for communication disorders by a certified speech-language pathologist 2
• Assessment should evaluate multiple domains:
  • Comprehension
  • Speaking ability
  • Reading and writing capabilities
  • Gesturing
  • Use of technology
  • Pragmatic communication skills 1

Treatment Approaches for Speech Disorders

1. Early Intervention

   • Begin speech therapy as early as tolerated after stroke onset 1
   • Initial phase (first 4 weeks): 30-45 minutes of direct language therapy, 2-3 days per week 1
   • Intensive phase (first few months): At least 45 minutes daily, five days a week 1
   • Chronic phase (>6 months post-stroke): At least 10 hours/week of therapist-led therapy and 5+ hours/week of self-managed training 1

2. Specific Therapy Techniques

   • For aphasia: Task-specific practice focused on improving functional communication 2
   • For neglect: Prism adaptation, visual scanning training, optokinetic stimulation, virtual reality, limb activation, mental imagery 2
   • For dysarthria: Respiratory muscle strength training, chin tuck against resistance 2

3. Alternative Communication Methods

   • Gesture training
   • Drawing techniques
   • Writing strategies
   • Augmentative and alternative communication (AAC) devices 1

4. Delivery Methods

   • Individual therapy with speech-language pathologist (primary approach)
   • Group therapy and conversation groups (supplemental)
   • Computer-based practice to supplement therapist-provided intervention
   • Family/caregiver training in supported conversation techniques 1

Mood Disorders

Assessment

• Screen all stroke patients for emotional disorders given their high incidence after stroke 2
• Use appropriate screening tools that account for language and cognitive impairments 3
• Visual Analog Mood Scales (VAMS) are recommended for patients with aphasia 3
• Watch for subtle signs of depression such as refusal to participate in therapy 2

Treatment Approaches for Mood Disorders

1. Pharmacological Interventions

   • Selective serotonin reuptake inhibitors (SSRIs) are recommended for treatment of post-stroke depression 2
   • Begin with standard dosing and titrate as needed

2. Non-pharmacological Interventions

   • Psychotherapy (cognitive-behavioral therapy) 2
   • Mindfulness-based therapies for depression 2
   • Psychosocial interventions during transition to community 2

3. Integrated Care

   • Primary care providers should screen patients for ongoing cognitive concerns, mental health issues, and psychosocial issues 2
   • Initial review with primary care provider should occur within 2-4 weeks following hospital discharge 2

Special Considerations

Timing of Interventions

• Speech therapy benefits can still be achieved in chronic stages (>6 months post-stroke) 1
• Spontaneous recovery of speech is most remarkable in first three months after stroke onset 4
• Recovery from ischemic stroke occurs earlier (most intensive in first two weeks) compared to hemorrhagic stroke (fourth to eighth week) 4

Potential Pitfalls to Avoid

1. For Speech Disorders:

   • Discontinuing therapy too early - benefits can still be achieved in chronic stages 1
   • Focusing only on language structure while neglecting pragmatic aspects of communication 1
   • Failing to involve family members and communication partners in the rehabilitation process 1

2. For Mood Disorders:

   • Misinterpreting flat affect or aprosodic speech (caused by organic changes) as depression 2
   • Overlooking depression in patients with aphasia due to communication difficulties 3
   • Failing to recognize that different hemispheric strokes may present with different mood disorders (left hemisphere strokes often result in depression/anxiety; right hemisphere strokes may lead to emotional indifference or euphoria) 5

By implementing these evidence-based approaches to managing both speech and mood symptoms after stroke, healthcare providers can significantly improve functional outcomes and quality of life for stroke survivors.