Introduction

Some cerebral strokes cause an impairment of motor, intellectual and cognitive functions. This was the cause1 that cerebral vascular diseases became a social problem. In recent years1 great interest has been aroused by emotional reactions occurring in the course of cerebral strokes.1 Depressive reactions described in literature as post-stroke depression became the subject of many reports. Already in 1921, Kraepelin reported frequent occurrence of depressive states in the course of cerebral ischaemic strokes. The reports by Blenler in 1951 also demonstrated that after cerebral infarcts the condition of melancholia can appear. A number of studies confirmed that emotional reactions and behaviour disturbances are the manifestation of focal damage of the central nervous system. Robinson and Starkstein demonstrated that depression developed more frequently and was more intense in patients with ischaemic focus in the anterior part of the left frontal lobe cortex or in the basal nuclei. The same authors proved higher incidence of depression in the cases of infarcts in the middle cerebral artery region than in the case of their location in regions supplied by the vertebrobasilar arteries. Sinyor et al. confirmed the fact of higher intensity of depression in patients with infarct focus in the frontal region. The occurrence of depression in the cases of cerebral strokes with aphasia remains still a significant problem. Benson in his paper on psychiatric aspects of aphasia suggested that aphatic speech disturbances may cause secondary and understandable depressive reactions. Starkstein and Robinson, on the basis of the American Psychiatric Association classification (DSM-III), distinguished two types of post-stroke depression: major depression and minor depression. Major depression is similar to endogenous depression. The occurrence of major depression remains in strong relation with ischaemic focus location in the left cerebral hemisphere, in the frontal lobe or basal nuclei. On the other hand, minor depression may correspond to the criteria of dysthymic disorders. The occurrence of minor depression is connected with focal lesion location in the parieto-occipital region on the left as well as the right sides.

Case Report

Male patient BG, aged 57 years previously never received any psychiatric treatment. The patient was born after normal pregnancy and labour. His childhood was very good. He was the only child in the family. His parents were very quiet, considerate, affective, caring, hard working. At home a warm and loving atmosphere was always present. In primary school and secondary school the patient achieved very good results. He was very friendly, not quarrelsome, maintaining close and cordial social contacts with his peers. Then, after obtaining his secondary school certificate, he studied with very good results and graduated from the Faculty of Economics. Since the graduation until now he has been working as chief accountant in a big trading company. In his work he has been liked by co-workers, friendly, hard working, dutiful. He failed to settle a family. He suffers from chronic impotence and does not want to make his future wife unhappy. He still lives with his parents who, in spite of elderly age, are in good mental and physical shape. The patient never wanted to diagnose or treat his impotence. In spite of the fact that he failed to settle a family, he regards himself as a happy man. He has a girlfriend with whom he is in strong platonic love.

No mental diseases occurred in the patient’s family. The patient denied any head trauma or loss of consciousness. Of serious somatic diseases, the patient has had since years fixed atrial fibrillation which he refuses to diagnose or treat.

The patient was hospitalized due to cerebral ischaemic stroke. The ischaemic focus was located in the anterior part of the left frontal lobe cortex. After discharge from hospital he came to the author of this paper. Detailed psychiatric examination revealed major depression of high intensity. The diagnosis was confirmed by the following tests:

• Hamilton Depression Scale
• Montgomery-Asberg Scale
• Beck Depression Self-Assessment Inventory
• DSM-III Scale
• CGI Scale

Laboratory tests:

• laboratory blood and urine analyses gave normal results
• ECG record demonstrated fixed artial fibrillation with ventricular rate about 80 bpm,
• EEG record was normal,
• chest radiogram was normal,
• neurological examination: slight motor aphasia, trace right-sided hemiparesis, trace bilateral extensor plantar response,
• eye fundus examination: normal,
• cerebrospinal fluid analysis gave normal result,
• physical examination: completely arrhythmic heart function with about 82 bpm rate; besides that the physical examination gave normal results,
• result of magnetic resonance imaging of the head: by MRI examiantion numerous small ischaemic foci were visualized in the anterior part of the left frontal lobe cortex. The ventricular system and other fluid spaces were unchanged.

The author treated the patient with individual psychotherapy and oral sertraline from low doses up to 100 mg daily. Complete remission of the major depression was obtained.

Discussion

The author decided to treat the patient with sertraline in view of the very high safety of the drug.5 Extrapyramidal symptoms after the drug are rare.3 Extremely rare, isolated cases of catatonic syndromes after the drug were described worldwide.4 Apart from depression treatment, the author intended to improve the quality of life of the described patient after his cerebral stroke. It is known7 that sertraline improves the quality of life of patients with respect to their energy, vitality, cognitive functions, social interactions, vivid reactions, behaviour in the place of work, coping at home, satisfaction with life and taking of sick-leaves.

In the described patient, sertraline evidently improved his quality of life with respect to most of the above mentioned aspects.

The author administered sertraline to the described patient in view of its safety in cardiac diseases. The patient has fixed atrial fibrillation. Other authors6 used the drug in patients after acute myocardial infarction.2

References

1. Baniukiewicz Ewa. Depression and cerebral ischaemic strokes - doctoral thesis, University School of Medicine in BiaBystok. Depresja a udary niedokrwienne mózgu - rozprawa doktorska, Akademia Medyczna w BiaBymstoku
2. Beshay H, Pumarega AJ. James H. Quillen College of Medicine, East Tennessee State University, Quillen/Mountain Home Veterans Administration Medical Center, Johnson City 37684, USA. Sertraline treatment of mood disorder associated with prednisone: a case report. Leczenie zaburzeD nastroju wyst’pujcych podczas podawania prednisonu przy pomocy sertraliny. Journal of Child and Adolescent Psychopharmacology 1998; 8 (3) : 187-93.
3. Lambert MT, Trutia C, Petty F. Extrapyramidal adverse effects associated with sertraline. Pozapiramidowe objawy niepo|dane zwizane ze stosowaniem sertraliny. Progress in Neuro-Psychopharmacology and Biological Psychiatry 1998; 22 (5) : 741-8.
4. Lauterbach EC. Department of Psychiatry and Behavioral Sciences, Mercer University School of Medicine, Macon, Georgia, USA. Catatonia - like events after valproic acid with risperidone and sertraline. Wystpienie objawów o typie katatonii po Bcznym podaniu kwasu walproinowego, risperidonu i sertraliny. Neuropsychiatry, Neuropsychology and Behavioral Neurology 1998; 11 (3) : 157-63.
5. Murdoch D, McTavish D. Adis International Limited, Auckland, New Zeland. Sertraline. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential in depression and obsessive compulsive disorder. [Review][72 refs]. Sertralina. Przegld wBa[ciwo[ci farmakologicznych i farmakokinetycznych oraz skuteczno[ w leczeniu depresji i zespoBu obsesyjno-kompulsyjnego. Drugs 1992; 44 (4) : 604-24.
6. Shapiro PA, Lesperance F, Frasure-Smith N. Department of Psychiatry, Columbia University College of Psysicians and Surgeons, New York, NY 10032, USA. An open-label preliminary trial of sertraline for treatment of major depression after acute myocardial infarction. Otwarte, wst’pne badanie skuteczno[ci sertraliny w leczeniu du|ej depresji u chorych po ostrym zawale mi’[nia sercowego.
7. Turner R. Pfizer Central Research, Groton, CT. Quality of life: experience with sertraline. Jako[ |ycia: do[wiadczenia z sertralin. International Clinical Psychopharmacology 1994; 9 Suppl 3: 27-31.

Professor Jan Krzysztof Podgorski, Department of Neurosurgery with Outpatient Clinic, Private Practice, Central University Teaching Hospital with Polyclinic, Armed Forces School of Medicine, Independent Public Health Care Institution.