Post-Stroke Depression Undertreated

Many patients with persistent depression following stroke or transient ischemic attack (TIA) are not receiving the treatment they need, a study suggested.

Of the patients with stroke and TIA, 9.2% and 7.6%, respectively, had depression at both 3 and 12 months after the event, according to Nada El Husseini, MD, of Duke University Medical Center, and colleagues.

Among those patients with persistent depression, 67.9% of those with stroke and 70% of those with TIA were not using antidepressants at either time point, suggesting undertreatment, the researchers reported online in Stroke: Journal of the American Heart Association.

“Systematic evaluation for depression in patients with stroke or TIA may improve detection and treatment of this condition,” the authors wrote.

El Husseini and colleagues performed a secondary analysis of the prospective Adherence Evaluation After Ischemic Stroke Longitudinal (AVAIL) study. Depression was defined as a score of 10 or higher (out of 24) on the Patient Health Questionnaire-8 (PHQ-8).

The current analysis included 1,450 adult patients with ischemic stroke and 397 with TIA who were treated at hospitals participating in the Get With The Guidelines-Stroke program.

There were no differences between patients with stroke and TIA in the rates of depression at 3 months (17.9% versus 14.3%, P=0.09) and 12 months (16.4% versus 12.8%, P=0.08). The rates were higher than those seen in the general population in the Behavioral Risk Factor Surveillance Survey (9%).

Prevalence and course of post-stroke depression

In the present study the prevalence of post-stroke depression was high, more than half of the ischemic stroke patients having depression at the 3-month follow-up visit and almost half of them at the 12-month visit. The results also showed that the proportion of patients suffering from major depression increased from 9% to 16% during the follow-up. In other studies using psychiatric examinations in diagnosing depression, the prevalence of PSD has varied from 24% to 41%, major depression occurring in 12-31% of patients and minor depression in 9-29% of patients, depending on the time elapsed after stroke (Åström et al. 1993, Burvill et al. 1996, Pohjasvaara et al. 1998). Robinson et al. (1987) found a stable 14% prevalence of depression up to 2 years in a subsample of their original group. In the study of Åström et al. (1993) the majority of patients with depression experienced remission within the first year, the prevalence of major depression decreasing from 31% at 3 months to 16% at 12 months after the stroke.

The occurrence of depression in the present series was even higher than in most of the previous studies, but the prevalence of major depression was lower (Morris et al. 1992, Åström et al. 1993, Herrmann et al. 1998). The differences in the occurrence of major depression may be due to the selection of the study population. Contrary to those of the previous reports the present patients had experienced only their first-ever stroke and the patients with other central nervous system lesions, as well as with previous psychiatric illnesses were excluded. The increase in the prevalence of major depression during the follow-up may be due to the fact that patients with limited awareness of their deficits avoid depression at the acute stage. Eventually they have to face the demands of everyday life with the loss of cognitive, verbal and functional abilities, and this may contribute to the development of a depressive mood.

The relatively constant rate of depression throughout the first year following an event “argues against the hypothesis that the increased risk of depression is limited to the first few months after a cerebrovascular event,” according to the researchers.

“In light of the higher frequency of depression at 3 and 12 months, screening for depression appears to be warranted in the first year after stroke or TIA at both time points,” they wrote.

The rates of newly identified depression from 3 to 12 months and of persistent depression were similar between patients with stroke and TIA, and there were no differences in the use of antidepressants at any point during the study.

“Some of the subjects with ‘depression’ in this study may not have needed treatment with antidepressants, because a PHQ-8 score of [10 or higher] reflects ‘current depression,’ which includes major depression, other depressive disorders, depressed mood, or anhedonia,” the researchers wrote. “However, it is very likely that those who were characterized as persistently depressed may have had clinically significant depression that warranted treatment.”

But, they added, “Other nonpharmacological treatments for depression such as cognitive behavioral therapy were not captured in this study, thus possibly overestimating the frequency of ‘undertreatment.’”

Post-stroke depression may affect as least one in every four individuals who have had a significant stroke event. The stroke patient is at greatest risk in the first six months after a stroke. Depression may affect a patient’s ability to participate in post-stroke therapy and is associated with slower progress in rehabilitation and increased length of stay. Clinicians need to be watchful and recognize depression before it interferes significantly with therapy and the patient’s well being. Standardized screening assessments for depression can indicate that depression exists and also can be used to monitor progress. However, there is no single, universally accepted tool for the assessment of post-stroke depression. An alternative to verbal scales to assess mood should be sought when assessing someone who is aphasic.

Anxiety should be assessed and treated, especially when found in conjunction with depressive symptoms. Antidepressant medications and counseling appear to be helpful in treating this condition. Aphasic patients provide a unique challenge for assessment and treatment.

The authors acknowledged some limitations of the study, including some differences between the patients who were included and those who were excluded, such as ability to complete the PHQ-8 instrument; the use of self-report to assess antidepressant use; the lack of information on pre-stroke depression; and the lack of a baseline assessment of stroke severity.

El Husseini was fully supported and two co-authors were partially supported by an American Stroke Association-Bugher Foundation Stroke Prevention Research Center award. The AVAIL project was supported by unrestricted funds from Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership and conducted through collaboration with the American Heart Association and the “Get With The Guidelines-Stroke” program. AVAIL analyses were also supported in part by the Agency for Healthcare Research and Quality.

El Husseini reported having no conflicts of interest. Her co-authors reported relationships with the Critical Care Research and Practice, the National Institutes of Health, Allergan, Pfizer, Boehringer Ingelheim, Merck, Bristol-Myers Squibb, Abbott, the Agency for Healthcare Research and Quality, the Department of Veterans Affairs, the Foundation for Informed Medical Decision Making, the Department of Defense, and the Bristol-Myers Squibb-Sanofi Joint Partnership.

From the American Heart Association:

  Guidelines for Ischemic Stroke
  Racial & Ethnic Disparities Stroke Care
  Get With The Guidelines - Stroke

Primary source: Stroke: Journal of the American Heart Association
Source reference: El Husseini N, et al “Depression and antidepressant use after stroke and transient ischemic attack” Stroke 2012; DOI: 10.1161/STROKEAHA.111.643130.

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