What Fetterman’s Hospitalization Underscores About the Biology of Depression
Reading Time: 4 minutesFetterman hospitalization: Why depression is so common after stroke.
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I learned how to recognize strokes from TV. I must have seen the PSA urging me to ‘Act FAST‘ hundreds of times, slotted between episodes of Rugrats and Hey Arnold!, and I still recall the signs easily: facial droop, arm weakness, speech problems, timely response.
Those PSAs have surely saved lives. According to the National Institutes of Health, 795,000 people have strokes each year in the U.S.; 137,000 of them die. But although obvious physical signs are essential to recognize in an emergency situation, and are what we often associate with the subsequent recovery, they provide an anemic window on the reality of stroke.
Since Sen. John Fetterman experienced a severe stroke last May, his long-term physical side effects—and how they influence his job—have been analyzed and perseverated over to the point of offense. Fetterman does still struggle with auditory processing, a limitation he shares with about 20 percent of stroke survivors. But, by all accounts, he can smoothly conduct conversations using a tablet that provides him with automatic captions—an accommodation that is becoming more common in many workplaces and can help a wide range of people besides stroke survivors.
But because we see stroke almost exclusively as a matter of physical signs like weak limbs and slurred speech, the internal struggles of recovery often remain invisible. That’s why last week’s announcement that Fetterman has admitted himself to the hospital for depression treatment may have come as such a surprise, judging by the flurry of attention around it.
In reality, depression is even more common than auditory processing issues in people who have had a stroke: One in every three stroke survivors will contend with it. Yet it remains a relatively unrecognized complication, and understandably so. Despite the enormous strides that continue to be made in mental health awareness, depression still carries a weighty stigma and may be perceived as a personal failing rather than a medical issue. Even someone who freely discusses their physical impairments may be reluctant to share the emotional effects of their stroke. For a public figure like Fetterman, such candor may be particularly consequential: Fifty years ago, a history of inpatient depression treatment scuttled Sen. Thomas Eagleton’s chances at the vice presidency, and only a few current congresspeople have divulged their mental health diagnoses.
Any neurological disease can spark mental illness, and many do at astronomical rates. Plenty of people can recognize the characteristic tremors of Parkinson’s disease, but few realize that three-quarters of patients may also experience psychiatric symptoms, which can sometimes be as debilitating as hallucinations or suicidal thoughts. And almost everyone with Alzheimer’s disease will eventually develop some degree of mental illness—even at the earliest stages of the disease, about a third of patients have depression.
This makes sense: Living with chronic illness can be challenging, and for someone like Fetterman, with a prominent public profile and an enormous burden of responsibility, the psychological strain is immense. And because Fetterman has contended with depression in the past, it is possible that he is now dealing with a resurgence of that previous illness, perhaps ignited by the simultaneous pressures of stroke recovery and serving in the Senate.
But there’s a more basic reason for the link between stroke and depression: Mental illnesses are diseases of the brain, and stroke kills brain cells. Fetterman struggles to understand spoken language because the parts of his brain that process speech were damaged when they were deprived of oxygen; he may be experiencing depression because other regions of his brain were damaged as well.
The idea that depression is biological is not new, but the disease’s neurological underpinnings have long remained obscure, despite intensive research. In the past few years, patients like Fetterman have helped researchers make some material progress. Doctors have long assumed that stroke patients developed depression when important emotional brain regions were deprived of oxygen, but they had struggled to prove it. Damage to some regions—like the dorsolateral prefrontal cortex, DLPFC, which sits underneath the forehead—had appeared to cause depression in some studies, but other studies found no such link. By examining data from patients with stroke or other brain damage, scientists have recently started to figure out why: Depression may result not only from stroke in the DLPFC, but also from stroke in a whole host of other areas throughout the brain that are closely connected with the DLPFC. Fetterman’s speech processing issues may come from damage to a specific brain region; his depression, from damage to a specific circuit of regions.
The recent scientific results provide powerful evidence that physical and mental illness are equally rooted in biology. They could also help doctors develop better mental illness treatments. These days, medication-resistant depression—both post-stroke and otherwise—is often treated by transcranial magnetic stimulation, TMS, a form of brain stimulation in which neurons are activated by a magnetic wand. It turns out that stimulating the depression-linked brain circuit may provide the most relief for stroke survivors. As tools like TMS become more widely available, the insight that stroke survivors can provide into the neurological basis of depression becomes ever more valuable.
With the advent of TMS, as well as new drugs like ketamine, depression is now more treatable than it has ever been. Though we don’t know what particular treatment Fetterman is receiving, by opting to be admitted, he has ensured that he will recover as quickly as possible. Like any other disability, Fetterman’s depression may require some accommodations once he returns to the Senate—flexibility in his schedule for medical appointments, for example, or remote meetings. But to assume his depression fundamentally changes the terms of his senatorial service is not only ableist: It is unscientific.
Already Fetterman has done a great deal for both stroke survivors and people with depression, simply by being candid about his treatment. Long before last week’s disclosure, Fetterman’s health had been subjected to unending, and often ableist, interrogation—and while that’s unlikely to change, his openness demonstrates to Americans that depression is a common consequence of stroke, and that mental health care is as essential to stroke recovery as physical and cognitive rehabilitation. Patients like Fetterman are a refutation of the antiquated idea that depression is a character flaw, a source of shame, and a challenge that can be overcome with sufficient grit. Depression is a brain disease, not a moral failing—and it must be accommodated in the workplace.
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