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Drs. Sugden and Bourgeois Reply

TO THE EDITOR: We appreciate the opportunity to respond to the letter from Dr. Berkowitz and hope our response will resolve any concerns. In recent literature, the term "poststroke depression" has come to include "major" and "minor" depression, in which "minor" depression is subsyndromal to "major" depression.¹ Also, there is considerable overlay between depressive symptoms and more "focal" poststroke apathy, as apathy may overlap with the major depressive episode symptoms of diminished interest and fatigue.² In attempts to avoid confusion in terminology, we used the term "poststroke" depression and never described our patient’s case as "major" depression. Clearly, one could look at our patient’s apathy as her predominant symptom, consistent with the apathy condition, as has been described by Levy et al.²

Unfortunately, DSM-IV-TR nomenclature and criteria do not fully address such cases. There is no "apathy disorder" diagnosis. "Pure" poststroke mood disorders may be classified as "a mood disorder due to a general medical condition" (further stratified as "with depressive features," with "major depressive-like episode," "with manic features," or "with mixed features") or as "depressive or mood disorder not otherwise specified." Further affecting the diagnosis of our patient was her history of bipolar disorder. In light of these factors, we felt that depressive disorder not otherwise specified was the best diagnostic fit, even if imperfectly precise.

Ms. A had not been taking lithium for several weeks before her stroke. During her hospitalization, she had not received lithium until she was transferred to the inpatient rehabilitation service. At this time, lithium (300 mg b.i.d.) was restarted, and the subsequent day, consultation-liaison psychiatry was asked to address the patient’s need for mood-stabilizing medication. Lithium was promptly discontinued after she had received only two doses because she was in a controlled environment in which possible evolving manic symptoms could be closely monitored. It is unlikely that the minimal amount of lithium the patient received would have contributed to her reported symptoms.

The decision to treat her with modafinil was based on a review of the literature supporting stimulant use and poststroke depression and the benefits of recovery from early intervention.^1,3,4 Our results are consistent with those seen in the literature, which describe a rapid response.^3,4 Modafinil was specifically chosen over psychostimulants because of its more favorable side effect profile. Clearly, close clinical follow-up is needed in such cases, both to monitor the response to treatment of poststroke apathy/depression symptoms and for surveillance of recurrence of manic or hypomanic episodes from preexisting bipolar disorder.

REFERENCES

1. Chmerinski E, Robinson RG, Kosier JT: Improved recovery in activities of daily living associated with remission of poststroke depression. Stroke 2001; 32:113–117[Abstract/Free Full Text]
2. Levy ML, Cummings JL, Fairbanks LA, Masterman D, Miller BL, Craig AH, Paulsen JS, Litvan I: Apathy is not depression. J Neuropsychiatry Clin Neurosci 1998; 10:314–319[Abstract/Free Full Text]
3. Grade C, Redford B, Chrostowski J, Toussaint L, Blackwell B: Methylphenidate in early poststroke recovery: a double-blind, placebo-controlled study. Arch Phys Med Rehabil 1998; 79:1047–1050[CrossRef][Medline]
4. Masand P, Murray G, Pickett P: Psychostimulants in post-stroke depression. J Neuropsychiatry Clin Neurosci 1991; 3:23–27[Abstract/Free Full Text]

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