New AHA/ASA Scientific Statement on Depression After Stroke

December 21, 2016

The American Heart Association/American Stroke Association (AHA/ASA) has issued a Scientific Statement on depression in patients who have had a stroke, which it calls an "underrecognized, underinvestigated, and undertreated problem."

This multispecialty statement, published online in Stroke on December 8, provides a comprehensive review of the current evidence and gaps in current knowledge of the epidemiology, pathophysiology, outcomes, management, and prevention of poststroke depression and provides implications for clinical practice, the authors state.

A separate review paper about post-traumatic stress disorder (PTSD) following stroke, which could affect as many as 1 in 4 stroke patients, has also been published online in Stroke.

"We want to raise awareness about depression following a stroke," chair of the writing committee of the Scientific Statement on depression, Amytis Towfighi, MD, University of Southern California, Los Angeles, commented to Medscape Medical News. "We know that depression after a stroke is common, affecting about one third of patients, so we need to have a high index of suspicion for detecting this condition in stroke patients."

But she noted that there are few guidelines on how to manage these individuals — on whether to screen for depression and how to treat it when it is identified. "After reviewing all the available literature, we came to the decision that the evidence was not robust enough for formal clinical guidelines, so we issued a scientific statement instead summarizing what is known, identify the gaps in knowledge and what needs to be studied more."

Dr Towfighi explained that physicians seeing stroke patients are often more concerned about their physical recovery, and they may overlook depression. "And stroke patients may have cognitive changes which can be confused with depression, so it is not always straightforward to identify."

She added: "We also know that stroke patients who have depression have worse functional outcomes and mortality — and they have a worse quality of life than those without depression, so it is important for these patients to be identified and treated."

The mechanisms involved in post-stroke depression are not completely understood but probably include both biological and psychosocial factors. Patients at highest risk are believed to be those with a history of depression before their stroke and those who have had a severe stroke or who have cognitive impairment.

Dr Towfighi reported that some simple screening tools may be useful to identify these patients, but more research is needed on the optimal time to screen for depression after stroke and the optimal treatment.

Three screening tools have been shown effective: the Center of Epidemiological Studies-Depression Scale, the Hamilton Depression Rating Scale, and the 9-item Patient Health Questionnaire (PHQ9), but Dr Towfighi noted that the first two are fairly lengthy so PHQ9 is probably best as a pragmatic tool in a busy setting. "This just consists of 9 questions and has pretty good specificity and sensitivity."

The statement notes that systematic screening for post-stroke depression may improve outcomes, provided that processes are in place to assure accurate diagnosis, timely and effective treatment, and follow-up. But further research is needed to determine whether screening for post-stroke depression — in conjunction with collaborative care to ensure timely intervention, treatment, and follow-up — improves outcomes in diverse populations of stroke survivors.

In terms of treatment, Dr Towfighi said, "Antidepressants may be effective, although the choice of agent must be made carefully as some antidepressants interact with secondary prevention medications prescribed to stroke patients. There is also some promise for psychological interventions as well, although the evidence is quite weak and more research is needed."

In the statement, the authors report that 12 trials in a total of 1121 patients have suggested that antidepressant medications may be effective in treating post-stroke depression, but that further research is needed to determine optimal timing, threshold, and medications for treatment.

They add that 7 trials in a total of 775 patients have suggested that brief psychosocial interventions may be useful and effective in treatment of post-stroke depression. Whether antidepressant medication is a necessary or beneficial adjuvant cannot be established from these trials because of a lack of placebo controls.

The statement also addresses the possibility of intervening to prevent depression in the stroke population. It notes that given the high prevalence and association with functional impairment, poor quality of life, and increased morbidity and mortality, post-stroke depression is an ideal target for selective prevention.

The authors report that 8 trials in a total of 776 patients suggest that pharmacologic treatment may be effective in preventing post-stroke depression; however, further studies are needed in more representative samples of stroke survivors, and additional study is required to determine the optimal timing and duration of treatment.

Five trials in a total of 1078 patients suggest that psychosocial therapies may prevent post-stroke depression, but the studies are not generalizable to all stroke survivors because of their narrow inclusion and exclusion criteria, so further research with more rigorous methods is needed.

PTSD

A separate review paper on PTSD following stroke reports that although post-stroke depression is a well-researched and established phenomenon, far less is known about the development of post-stroke PTSD.

Lead author Andrew Garton, BS, commented to Medscape Medical News: "PTSD is a common and debilitating consequence of stroke, with as many as 1 in 4 stroke patients potentially being affected. It is important for clinicians to be attentive to the possibility of this condition developing and for affected patients to be identified and to receive appropriate care."

The review notes that PTSD is differentiated by the hallmark findings of intrusive thoughts and avoidance of stimuli-bearing reminders of the trauma, in addition to experiencing hyperarousal and heightened fear.

Studies report conflicting incidence rates from 4% to 37%, and a meta-analysis of survivors of stroke and transient ischemic attack reported that 1 out of every 4 patients experienced significant PTSD symptoms in the year after a cerebrovascular event. "Overall, these findings are much higher than the prevalence of PTSD in the general population, which is estimated to be 6.8%," the authors say.

They conclude: "Although treatment approaches for PTSD exist, there have not been any controlled trials examining the efficacy of pharmacological or psychotherapeutic interventions for post-stroke PTSD, specifically. As management of PTSD and depression differs, approaches for these psychiatric conditions should be distinguished in a post-stroke population as well."

Stroke. Published online December 8, 2016. Scientific Statement, PTSD Review

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