Book Review

The Clinical Neuropsychiatry of Stroke: Cognitive, Behavioral, and Emotional Disorders Following Vascular Brain Injury

N Engl J Med 2007; 356:533-534February 1, 2007

Article

The Clinical Neuropsychiatry of Stroke: Cognitive, Behavioral, and Emotional Disorders Following Vascular Brain Injury
Second edition. By Robert G. Robinson. 470 pp., illustrated. New York, Cambridge University Press, 2006. $150. ISBN: 978-0-521-84007-1

The usual care of patients affected by stroke is focused on limiting or remediating impairments in sensorimotor function and on facilitating improvements in the performance of activities of daily living. This focus, however, affords too limited a view of the clinically important sequelae of stroke. Cognitive, emotional, and behavioral disorders complicate sensorimotor and functional recovery and are themselves substantial sources of further complication and suffering for stroke survivors and their families. Nonetheless, the neuropsychiatric consequences of stroke remain uncommon subjects of evaluation and treatment in most general medical settings.

In this second edition of The Clinical Neuropsychiatry of Stroke, Robert G. Robinson discusses in detail the phenomenology, neurobiology, and treatment of post-stroke neuropsychiatric disorders, particularly depression. Psychological theories of post-stroke depression are considered in historical context as well as in response to published debates generated by Robinson's own work. He thoughtfully acknowledges that psychosocial factors are involved in the development of post-stroke depression and other stroke-related emotional and behavioral problems. However, he also makes a strong argument — with volumes of supporting data — for the view that neurobiologic disturbances are primary contributors to post-stroke neuropsychiatric disorders.

Topography of Focal Cerebral Reperfusion after Ischemia Associated with Obstruction of a Major Cerebral Artery.

Working from a review of his own work as well as the world literature, Robinson makes several important and clinically relevant observations. Post-stroke depressions are phenomenologically similar to idiopathic depressive disorders and can be identified using standard psychiatric diagnostic criteria. Depression, particularly in the period shortly after a stroke, is a major contributor to cognitive and functional impairments, rather than a purely psychological response to such problems. Although the issue of the association between lesion location and post-stroke depression is contentious, anterior left-hemisphere stroke is identified as a clear risk factor for episodes of post-stroke major depression. Serotoninergic depression and noradrenergic dysfunction resulting from such lesions are further identified as contributors to post-stroke emotional disturbances and as targets for pharmacotherapy. Finally, the treatment of post-stroke depression not only improves recovery from this condition but also improves stroke outcome more generally. Conversely, failure to treat post-stroke depression not only impedes recovery from stroke but also increases long-term post-stroke mortality.

Robinson concludes that depression is a neurobiologically understandable consequence of stroke, one for which treatments are both available and necessary. The evidence presented in this book indicates that post-stroke depression responds to pharmacotherapies in a manner similar to that of depressions resulting from other causes, including idiopathic ones. By contrast, and in opposition to purely “psychological” views of this condition, cognitive behavioral psychotherapy — an intervention widely regarded as effective for the treatment of idiopathic major depressive disorder — is identified as an ineffective treatment for post-stroke depression.

Other post-stroke neuropsychiatric disturbances, including mania, anxiety disorders, irritability and aggression, psychosis, and pathologic laughing and crying, among others, are also addressed in this book, albeit more briefly. Vascular cognitive impairments arising independently of post-stroke emotional and behavioral disorders are not addressed, but Robinson acknowledges this issue in the final chapter and suggests that vascular cognitive impairments merit consideration in a separate volume.

In this edition, Robinson demonstrates clearly and convincingly that a neurobiopsychosocial approach to the study and treatment of post-stroke neuropsychiatric disorders affords unprecedented opportunities to improve the lives of stroke survivors and their families. As a clinician, educator, and scientist involved daily in stroke neurorehabilitation, I found that reading this book improved my understanding of the neuropsychiatry of stroke and is already changing for the better my practice, teaching, and research. This book is essential reading for anyone interested in stroke rehabilitation, and it deserves a place in the libraries of all clinics and clinicians involved in the care of people affected by stroke.

David B. Arciniegas, M.D.
University of Colorado School of Medicine, Denver, CO 80262
david.arciniegas@uchsc.edu