Depression Rates Similar After TIA or Stroke

Pauline Anderson

March 30, 2012

March 30, 2012 — At 3 and 12 months after hospitalization, patients who had a transient ischemic attack (TIA) have similar rates of depression as those who suffered a stroke, adding weight to the argument for a vascular contribution to depression, a new study suggests.

The frequency of depression up to a year after a stroke highlights the need for continued depression screening, said study author, Nada El Husseini, MD, MHS, Stroke Fellow, Duke University Medical Center, Durham, North Carolina.

Dr. Nada El Husseini

"The study results clearly show that we need to be screening for depression following both stroke and TIA, and I think that this should become standard practice," said Dr. Husseini. "It seems from this study that both time points (3 and 12 months) seem to be appropriate for screening."

The researchers also concluded that depression among these patients was often undertreated, she said.

The study is published online March 29 in Stroke.

Similar Depression Frequency

The study is a secondary analysis of AVAIL (Adherence eValuation After Ischemic stroke Longitudinal), a multicenter, prospective cohort registry study. That study was designed to assess adherence to stroke prevention medication from hospital discharge to 1 year in 2889 patients admitted to the Get With The Guidelines stroke program.

The current analysis included 1847 mostly white AVAIL subjects from 99 hospitals across the United States. Of these, 1450 had a diagnosis of stroke and 397 of TIA. The median age was 64 years for patients who had suffered a stroke and 68 years for patients with TIA.

The primary end-point was self-reported symptoms of depression using the Patient Health Questionnaire-8 (PHQ-8). Persistent depression was a PHQ-8 score of 10 or higher at 3 and 12 months; incident depression was a PHQ-8 score of 10 or higher at 12 months and a PHQ-8 score less than 10 at 3 months. For this analysis, medication use was self-reported.

Researchers used a cutoff of 3 on the modified Rankin Scale (mRS) to differentiate mild from moderate/severe stroke.

The study showed that the proportional frequency of depression was similar in patients with stroke and TIA at 3 months (17.9% vs 14.4%; P = .09) and at 12 months (16.4% vs 12.8%; P = .08).

Although this similarity could be partly explained by the fact that most patients with stroke had only mild disability (76.7% had mRS<3 at 3 months) and 15% of those with TIA had severe disability, the frequency remained comparable even after adjusting for disability as well as history of stroke/TIA and baseline demographics.

"We already knew that the rate of depression in stroke patients is higher than in the general population, so this is not new, and we knew that the rate of depression may be higher in TIA patients as several recent studies have shown that," said Dr. Husseini. "But there has never been a head-to-head comparison between these 2 populations that controlled for important factors such as gender and age and disability."

After excluding those with previous stroke/TIA, the proportional frequency of depression was higher after a stroke than after a TIA at 3 months (17.4% vs 12.4%; P = .038), but not different at 12 months (15.9% vs 12.0%; P = .100). This suggests that other factors play a more important role in late versus early depression, according to the authors.

Although the study was not designed to look at underlying causes of depression, the similar rate of this mood disorder after controlling for important confounders "infers that depression is not just a simple association with functional impairment that results from stroke," said Dr. Husseini. "It could be related to the vascular injury or to cerebral vascular disease or to the vascular risk factors that predispose patients to stroke or TIA that these 2 groups share."

The frequency of newly identified depression between 3 and 12 months was similar and significant in both groups. Being younger, having poor functional outcome, and being depressed and unable to work at 3 months were factors associated with depression at 12 months. This, said the authors, suggests that more vigilance may be needed in treating younger patients who have had a stroke who are unable to work and have significant disability.

Antidepressant Use

Researchers looked at antidepressant use and found similarities at 3 months (13.9% for stroke; 15.4% for TIA) and 12 months (16.0% vs 14.6%). In both groups, about 70% of patients who were persistently depressed were not using antidepressants.

"You may argue that if patients are only depressed at 1 point that may resolve with time, and they may not necessarily need to be treated," said Dr. Husseini. "However, we thought that if you were depressed at both 3 and 12 months and were still not reporting the use of antidepressants that probably reflects undertreatment."

Asked to comment, Daniel Lackland, DPH, professor and director of graduate training, Medical University of South Carolina, and an American Heart Association spokesperson, said the study added important new information to what is known already about poststroke depression.

"We knew there was an association with depression after stroke, but we didn't know whether it was just immediately after the stroke or whether it was something that is maintained over time," said Dr. Lackland. "Knowing that it is maintained, at least 12 months out, gives you some idea that it's important to follow up.

"It's particularly important if patients continue treatment in a primary care setting," added Dr. Lackland. "This is something that primary care physicians should probably be aware of."

Dr. Husseini was fully supported by an American Stroke Association–Bugher Foundation Stroke Prevention Research Center award. Disclosures for the researches can be found in the original article. Dr. Lackland has disclosed no relevant financial relationships.

Stroke. 2012 Published online March 29, 2012.

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