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.