Emotional changes after a stroke: low mood, tears and a changed temper

The Stroke Association, the UK charity for stroke survivors and their families, gives two reasons a stroke changes how somebody feels. One is the size of what has happened: a stroke is sudden, and shock, grief, anger and guilt are normal responses to losing the life somebody had. The other is physical. If the part of the brain that controls emotions has been damaged, it can change how somebody experiences and expresses them. Both can happen at once, and its page on emotional and behavioural changes after a stroke says that talking about problems and seeking help can make a difference.

Different emotions may surface over time as recovery goes on. A few notes on what you see and when let you describe a pattern to a doctor rather than a feeling. The first weeks home after a stroke covers the early period.

The Stroke Association lists signs of depression including feeling worthless or hopeless, losing confidence and interest in things, lacking energy, avoiding people, and changes in sleep and appetite. A low mood from time to time can happen to anyone, but feeling this way most of the time over several weeks or more could be a sign of depression. Its page on depression and anxiety after a stroke is written for survivors and families together.

Anxiety after a stroke may have a clear subject, such as another stroke, going out alone or money. The Stroke Association says to seek help when worry spreads to many things, stops somebody doing what they need to do, or comes for no clear reason. On the fear of another stroke, preventing a second stroke sets out what lowers the risk.

This is not something the family has to raise alone. The NICE guideline on stroke rehabilitation in adults asks stroke teams to assess each person for changes in emotions, behaviour and mental health, including signs of increased risk of suicide, and for how they are adjusting and coping. It asks teams to support and educate families as well. When new or lasting changes in mood are found at the six-month or annual stroke review, NICE says the person should be referred for detailed assessment and treatment. The review covers the needs of carers as well as the person, so it is a good time to say how you are managing too.

The Stroke Association explains emotionalism after a stroke as a change in the ability to control emotions, also known as emotional lability. The NICE guideline describes it as difficulty controlling emotions which can cause uncontrollable crying or laughter. You may also see it called pseudobulbar affect. The MS Trust's page on pseudobulbar affect lists the different names and explains that it is a disturbance in how emotions are expressed rather than in the feelings themselves.

The Stroke Association says emotionalism can get better with time and that many people find it improves or disappears within the first six months. If it lasts longer, treatments may help, and because tearfulness can also be a sign of depression, the GP is the right person to tell the two apart.

What helps at home is mostly about how people react. Ask your relative what they would like you to do when it happens: some people want it ignored and the conversation carried on, others find a hand on the arm or a hug comforting. The Stroke Association suggests telling new people about it in advance, and changing the subject or the television channel as an outburst starts. It also says a person who is upset is still entitled to comfort, so do not assume every tear is the stroke.

Fatigue feeds much of the rest. A person exhausted by getting washed and dressed has little left for a visitor or the physio exercises, and that can look like low mood or lack of effort. The Stroke Association's page on fatigue after a stroke says the GP or therapist can check whether a medicine or an infection is part of it, and that you can ask whether there is a local fatigue management service. NICE asks teams to consider a standardised fatigue assessment early in rehabilitation and at the six-month review. Rehab at home after a stroke explains how to plan the day around the therapy and the rest it needs.

If speech has been affected, frustration at not being able to say what is wanted can look like bad temper, and aphasia and communication after a stroke explains how to help. For somebody of working age, a lost job and lost income add their own weight, which care for a younger stroke survivor covers.

1. 1

   Tell the GP or a member of the stroke team

   The first call

   Describe what you have seen, how long it has been going on and what it stops your relative doing. The doctor can discuss treatment, which may include a talking therapy such as cognitive behavioural therapy (CBT).
2. 2

   Ask whether the stroke team has a psychologist

   Where one exists

   NICE lists clinical psychologists or clinical neuropsychologists as part of the core stroke rehabilitation team. It is a fair question to ask whether yours has one.
3. 3

   Refer to NHS Talking Therapies

   No GP needed

   In England, adults can refer themselves to NHS Talking Therapies for anxiety and depression, which is free. The service also helps people with anxiety or depression alongside a long-term health condition.
4. 4

   Medication, if the doctor advises it

   The GP decides

   The Stroke Association says medication is sometimes recommended for depression and anxiety, and there are medicines that may help emotionalism. Whether it is right, and which one, is for the GP or the stroke consultant to decide with your relative.
5. 5

   Raise it at the six-month and annual reviews

   And between them

   NICE says new or lasting mood problems found at these reviews should be referred for assessment and treatment. Being discharged by the therapists does not close the door, and your relative can ask their GP for more help at any time.

NHS Talking Therapies can be found through the NHS page find NHS talking therapies for anxiety and depression. If aphasia makes talking therapy hard, say so when you refer, because the therapist needs to know. The Stroke Association runs a Stroke Support Helpline for survivors, families and friends, and its pages list other organisations that help with mental health after a stroke.

The Stroke Association's tips for family and friends include telling your relative that you are willing to listen, supporting their independence rather than doing everything, and being patient, because improvement takes time. If their behaviour upsets you, it suggests saying so while keeping the focus on the behaviour rather than on them: "it upsets me when you shout" rather than "you are always upsetting me".

It is hard for the family too. The NHS says looking after someone who has had a stroke can be difficult, frustrating and lonely, and a partner may be grieving for the life they had together while doing more of the work. Caring for a husband, wife or partner is about what that does to a marriage, and caring for the caregiver covers your own health and when to ask for help. NICE says families and carers should be told about their right to a carer's assessment, which what is a carer's assessment? explains. If you are feeling low yourself, you can refer yourself to NHS Talking Therapies in the same way.

Where a carer fitsSection titled Where%20a%20carer%20fits

A carer does not treat depression or emotionalism. They can give the day a shape, keep your relative company, encourage the exercises the therapists have set, and notice changes. Noticing works best when it is the same person each week, and the same carer every visit explains how to ask for it. Visits for company and outings are advertised by carers on PrimeCarers at £15 to £20 an hour; companionship care explains what those visits involve. Hourly visits with personal care cost £18 to £25 an hour on PrimeCarers with our fee included, against £28 to £35 at an agency. If you want a steady, patient person to spend time with your relative, you can search for carers near you and compare their rates, then talk to two or three before you decide.

Tell the carer which of the changes above sound like your relative, what to do when tears come, and who to ring if they are worried. Ask them to tell you, the same day, if your relative talks about not wanting to live.