Post-stroke depression (PSD) and anxiety disorders are the most common psychiatric issues that occur after cerebrovascular accident (CVA), with prevalence rates of up to 50%. Less studied, post-stroke apathy and pseudobulbar affect (PBA) also occur in a subset of individuals after CVA leading to reduced quality of life. Cognitive impairments also persist, especially memory, language, and executive difficulties. Residual cognitive and emotional sequelae after CVA limit return-to-work with between 20-60% becoming disabled or retiring early. This study examined the frequency and relative contribution of cognitive, behavioral and emotional factors for not returning-to-work after CVA.

Participants included 242 stroke survivors (54% women, average age of 59.2 years) who underwent an outpatient neuropsychological evaluation approximately 13 months after unilateral focal CVA. Exclusion criteria were a diagnosis of dementia, comprehension issues identified during assessment, multifocal or bilateral CVA, and inpatients. Predictors of return-to-work included in logistic regression analyses were psychological (depressive and anxiety disorders, apathy, PBA, history of psychiatric treatment before stroke) and neuropsychological (memory, executive functioning) variables. Depression and anxiety were diagnosed using DSM-IV-TR or -5 criteria. Apathy was operationalized as diminished goal-directed behavior, reduced initiation and decreased interest that impacted daily life more than expected from physical issues after stroke (including self- and family-report using the Frontal Systems Behavior Scale [FrSBe]). PBA was defined by the Center for Neurologic Study-Lability Scale and clinical judgment based on chart review.

Post-stroke apathy persisted in 27.3% of patients 13 months after stroke, PBA persisted in 28.2% of patients (i.e., uncontrollable crying spellings not simply attributable to depression alone, uncontrollable laughing spells), anxiety disorders persisted in 18.6% of patients (mainly panic attacks), and PSD persisted in 29.8% of patients. Memory loss persisted in 67.4% of patients and executive difficulties persisted in 74.4% of patients. Thirteen months after stroke, 34.7% of individuals had returned-to-work and 47.1% had not returned-to-work. The other 18.2% were not working either at the time of their stroke or after the stroke. Logistic regression indicated that post-stroke apathy, PBA, and memory loss were significant predictors of not returning-to-work (odds ratio p < 0.001). Patients who experienced post-stroke apathy were 7.1 times more likely to not return-to-work after stroke (p=0.008), those who suffered from PBA were 4.8 times more likely to not return-to-work (p=0.028), and those with memory loss were 6.6 times more likely to not return-to-work (p=0.005). PSD, history of treatment for psychiatric issues before the stroke, presence of an anxiety disorder after stroke, and executive difficulties were not significant predictors (p’s>0.05).

Results replicate the finding that return-to-work is hindered by residual cognitive deficits after stroke and extends previous research by clarifying the multifactorial emotional and behavioral barriers to not returning-to-work. Results highlight the importance of quantifying post-stroke apathy and pseudobulbar affect in a standard neuropsychological work-up after stroke to identify candidates for services to facilitate efforts in returning to work (e.g., vocational rehabilitation services, psychotherapy, interventions for decreased initiation).