The Impact of Poststroke Depression on Healthcare Use by Veterans With Acute Stroke

Impact of depression on stroke outcomes among stroke survivors: Systematic review and meta-analysis

BACKGROUND

Depression may negatively affect stroke outcomes and the progress of recovery. However, there is a lack of updated comprehensive evidence to inform clinical practice and directions of future studies. In this review, we report the multidimensional impact of depression on stroke outcomes.

METHODS

Data sources. PubMed, PsycINFO, EMBASE, and Global Index Medicus were searched from the date of inception. Eligibility criteria. Prospective studies which investigated the impact of depression on stroke outcomes (cognition, returning to work, quality of life, functioning, and survival) were included. Data extraction. Two authors extracted data independently and solved the difference with a third reviewer using an extraction tool developed prior. The extraction tool included sample size, measurement, duration of follow-up, stroke outcomes, statistical analysis, and predictors outcomes. Risk of bias. We used Effective Public Health Practice Project (EPHPP) to assess the quality of the included studies.

RESULTS

Eighty prospective studies were included in the review. These studies investigated the impact of depression on the ability to return to work (n = 4), quality of life (n = 12), cognitive impairment (n = 5), functioning (n = 43), and mortality (n = 24) where a study may report on more than one outcome. Though there were inconsistencies, the evidence reported that depression had negative consequences on returning to work, functioning, quality of life, and mortality rate. However, the impact on cognition was not conclusive. In the meta-analysis, depression was associated with premature mortality (HR: 1.61 (95% CI; 1.33, 1.96)), and worse functioning (OR: 1.64 (95% CI; 1.36, 1.99)).

CONCLUSION

Depression affects many aspects of stroke outcomes including survival The evidence is not conclusive on cognition and there was a lack of evidence in low-income settings. The results showed the need for early diagnosis and intervention of depression after stroke. The protocol was pre-registered on the International Prospective Register of Systematic Review (PROSPERO) (CRD42021230579).

Post-stroke depression in Vietnamese patients is associated with decreased sleep quality and increased fatigue: a one-institution cross-sectional analysis

PURPOSE

This study aimed to determine the prevalence of post-stroke depression (PSD) during the first year and its associated factors, especially focusing on sleep quality and fatigue severity.

METHODS

A cross-sectional study was conducted among stroke patients in Vietnam's National Geriatric Hospital. Data were collected by using standardized questionnaires for interviewing and evaluating patients at the research site. Several covariables were presented including demographics, stroke-related characteristics, activities of daily living, post-stroke fatigue, and sleep quality (Pittsburgh Sleep Quality Index [PSQI] scale). PSD was assessed as an outcome variable through the Patient Health Questionnaire-9 scale. To summarize sociodemographic and clinical variables, descriptive statistics were performed. A logistic regression model was used to explore the factors related to PSD.

RESULTS

Of 157 patients with stroke, mean age 73.1 (± 9.6), PSD was present in 60 patients (38%). The global score and all PSQI components of participants with PSD showed worse levels than those without depression. Furthermore, the prevalence of PSD was higher in patients with low IADL scores and functional disability at high levels. In the multivariate logistic regression analysis, the patients with PSD showed higher Fatigue Severity Scale (FSS) scores (OR = 4.11; 95% CI = 1.39; 12.19) and higher scores in two domains of the PSQI scale including subjective sleep quality (OR = 3.03; 95% CI = 1.21; 7.58) and sleep disturbance (OR = 5.22; 95% CI = 1.33; 20.47).

CONCLUSION

There is a significant prevalence of depression following stroke. Furthermore, post-stroke fatigue and two PSQI scale components (subjective sleep quality and sleep disturbance) were shown to be associated with PSD. This finding may guide early screening and intervention strategies to address depression following stroke.

Neural Substrates of Poststroke Depression: Current Opinions and Methodology Trends

Poststroke depression (PSD), affecting about one-third of stroke survivors, exerts significant impact on patients’ functional outcome and mortality. Great efforts have been made since the 1970s to unravel the neuroanatomical substrate and the brain-behavior mechanism of PSD. Thanks to advances in neuroimaging and computational neuroscience in the past two decades, new techniques for uncovering the neural basis of symptoms or behavioral deficits caused by focal brain damage have been emerging. From the time of lesion analysis to the era of brain networks, our knowledge and understanding of the neural substrates for PSD are increasing. Pooled evidence from traditional lesion analysis, univariate or multivariate lesion-symptom mapping, regional structural and functional analyses, direct or indirect connectome analysis, and neuromodulation clinical trials for PSD, to some extent, echoes the frontal-limbic theory of depression. The neural substrates of PSD may be used for risk stratification and personalized therapeutic target identification in the future. In this review, we provide an update on the recent advances about the neural basis of PSD with the clinical implications and trends of methodology as the main features of interest.

Depression after stroke

Stroke treatment has dramatically improved in recent decades. However, although new treatments have reduced its mortality and the severity of its physical and cognitive sequelae, many people still have incapacitating disabilities following a stroke. Depression is the most common psychiatric disorder following stroke; it is important to recognise and treat as it limits motor and cognitive rehabilitation. Antidepressant medication is an effective treatment and can improve adherence to clinically recommended physical and cognitive tasks, thereby enhancing functional remodelling of neuronal pathways and improving rehabilitation outcomes.

Post-stroke depression: Chaos to exposition

Cerebral ischemia contributes to significant disabilities worldwide, impairing cognitive function and motor coordination in affected individuals. Stroke has severe neuropsychological outcomes, the major one being a stroke. Stroke survivors begin to show symptoms of depression within a few months of the incidence that overtime progresses to become a long-term ailment. As the pathophysiology for the progression of the disease is multifactorial and complex, it limits the understanding of the disease mechanism completely. Meta-analyses and randomized clinical trials have shown that intervening early with tricyclic antidepressants and selective serotonin receptor inhibitors can be effective. However, these pharmacotherapies possess several limitations that have given rise to newer approaches such as brain stimulation, psychotherapy and rehabilitation therapy, which in today's time are gaining attention for their beneficial results in post-stroke depression (PSD). The present review highlights numerous factors like lesion location, inflammatory mediators and genetic abnormalities that play a crucial role in the development of depression in stroke patients. Further, we have also discussed various mechanisms involved in post-stroke depression (PSD) and strategies for early detection and diagnosis using biomarkers that may revolutionize treatment for the affected population. Towards the end, along with the preclinical scenario, we have also discussed the various treatment approaches like pharmacotherapy, traditional medicines, psychotherapy, electrical stimulation and microRNAs being utilized for effectively managing PSD.

Economic burden associated with inadequate antidepressant medication management among patients with depression and known cardiovascular diseases: insights from a United States-based retrospective claims database analysis

Aims: The current study examined the association between insufficient major depressive disorder (MDD) care and healthcare resource use (HCRU) and costs among patients with prior myocardial infarction (MI) or stroke.Methods: This was a retrospective study conducted using the MarketScan Claims Database (2010-2015). The date of the first MI/stroke diagnosis was defined as the cardiovascular disease (CVD) index date and the first date of a subsequent MDD diagnosis was the index MDD date. Adequacy of MDD care was assessed during the 90 days following the index MDD date (profiling period) using 2 measures: dosage adequacy (average fluoxetine equivalent dose of ≥20 mg/day for nonelderly and ≥10 mg/day for elderly patients) and duration adequacy (measured as the proportion of days covered of 80% or higher for all MDD drugs). Study outcomes included all-cause and CVD-related HCRU and costs which were determined from the end of the profiling period until the end of study follow-up. Propensity-score adjusted generalized linear models (GLMs) were used to compare patients receiving adequate versus inadequate MDD care in terms of study outcomes.Results: Of 1,568 CVD patients who were treated for MDD, 937 (59.8%) were categorized as receiving inadequate MDD care. Results from the GLMs suggested that patients receiving inadequate MDD care had 14% more all-cause hospitalizations, 4% more all-cause outpatient visits, 17% more CVD-related outpatient visits, 13% more CVD-related emergency room (ER) visits, higher per patient per year CVD-related hospitalization costs ($21,485 vs. $17,756), higher all-cause outpatient costs ($2,820 vs. $2,055), and higher CVD-related outpatient costs ($520 vs. $434) compared to patients receiving adequate MDD care.Limitations: Clinical information such as depression severity and frailty, which are potential predictors of adverse CVD outcomes, could not be ascertained using administrative claims data.Conclusions: Among post-MI and post-stroke patients, inadequate MDD care was associated with a significantly higher economic burden.

Association between depression and disease-specific treatment

BACKGROUND

Depression is a known risk factor for noncompliance to medical treatment. However, it remains unclear whether comorbidities alter the relationship between depression and treatment compliance. We explored whether depression is associated with disease-specific treatment service utilization.

METHODS

This cross-sectional study utilized data from 499,492 individuals who had at least one comorbidity in the Korean Community Health Survey, 2009-2013. Self-reported lifetime depression diagnosis by a physician, current depressive symptoms, and utilization of medical services were queried. The association between depression status and the use of overall treatment services was investigated using multiple logistic regression models and further stratified by use of specific medical treatment under conditions predefined with the Charlson Comorbidity Index (CCI).

RESULTS

Compared with non-depressed people, individuals with a "lifetime history of depression with current depressive symptom" showed higher odds of using overall medical treatment services in both men (OR=1.21, 95%CI: 1.00-1.47) and women (OR=1.13, 95% CI: 1.02-1.25). However, depressed individuals with CCI comorbidities (e.g., diabetes mellitus or angina) exhibited less utilization of treatment services than non-depressed individuals.

LIMITATIONS

The nature of the cross-sectional study limits the ability to infer a temporal causal relationship.

CONCLUSION

Overall, depressed individuals with a lifetime history of depression used treatment services more frequently than non-depressed individuals; however, depressed individuals with major illnesses tended to seek treatment for their medical conditions less. The mental health of patients who seek for medical services should be carefully considered in primary care for the proper health service utilization.

Effect of a novel designed intensive patient care program on cognitive impairment, anxiety, depression as well as relapse free survival in acute ischemic stroke patients: a randomized controlled study

Objective: We aimed to evaluate the influence of a novel designed intensive patient care program (IPCP) on cognitive impairment, anxiety, depression and relapse-free survival (RFS) in acute ischemic stroke (AIS) patients. Methods: Two hundred forty-two AIS patients were consecutively recruited in this randomized controlled study and randomly allocated to IPCP group or control group as 1:1 ratio. Patients received IPCP and conventional treatment in IPCP group, while received usual education, cognitive rehabilitation training and conventional treatment in control group for 12-month intervention. Cognitive impairment, anxiety and depression were assessed by Mini-Mental State Examination (MMSE), Hospital Anxiety and Depression Scale (HADS) anxiety (HADS-A), and HADS depression (HADS-D) at baseline (M0), month (M)3, M6 and M12. After intervention, patients were followed up until 2018/7/30 and RFS was calculated. Results: IPCP increased MMSE score at M12 and change of MMSE score (M12-M0), while decreased cognitive impairment rate at M12. For anxiety, decreased change of HADS-A score (M12-M0) and lower anxiety rate at M12 were observed in IPCP group compared to control group. For depression, decreased HADS-D score at M6 and M12, reduced change of HADS-D score (M12-M0) and lower depression rate at M12 were shown in IPCP group compared to control group. Besides, RFS was numerically longer in IPCP group compared to control group, but without statistical significance. Conclusions: IPCP presents with a positive influence on improving cognitive impairment and decreasing anxiety as well as depression, while a less effect on improving RFS in AIS patients. Abbreviation: IPCP: intensive patient care program; RFS: relapse free survival; AIS: acute ischemic stroke; MRA: magnetic resonance angiography; ITT: intention-to-treat; LOCF: last observation carried forward.

Does service heterogeneity have an impact on acute hospital length of stay in stroke? A UK-based multicentre prospective cohort study

OBJECTIVES

To determine whether stroke patients' acute hospital length of stay (AHLOS) varies between hospitals, over and above case mix differences and to investigate the hospital-level explanatory factors.

DESIGN

A multicentre prospective cohort study.

SETTING

Eight National Health Service acute hospital trusts within the Anglia Stroke & Heart Clinical Network in the East of England, UK.

PARTICIPANTS

The study sample was systematically selected to include all consecutive patients admitted within a month to any of the eight hospitals, diagnosed with stroke by an accredited stroke physician every third month between October 2009 and September 2011.

PRIMARY AND SECONDARY OUTCOME MEASURES

AHLOS was defined as the number of days between date of hospital admission and discharge or death, whichever came first. We used a multiple linear regression model to investigate the association between hospital (as a fixed-effect) and AHLOS, adjusting for several important patient covariates, such as age, sex, stroke type, modified Rankin Scale score (mRS), comorbidities and inpatient complications. Exploratory data analysis was used to examine the hospital-level characteristics which may contribute to variance between hospitals. These included hospital type, stroke monthly case volume, service provisions (ie, onsite rehabilitation) and staffing levels.

RESULTS

A total of 2233 stroke admissions (52% female, median age (IQR) 79 (70 to 86) years, 83% ischaemic stroke) were included. The overall median AHLOS (IQR) was 9 (4 to 21) days. After adjusting for patient covariates, AHLOS still differed significantly between hospitals (p<0.001). Furthermore, hospitals with the longest adjusted AHLOS's had predominantly smaller stroke volumes.

CONCLUSIONS

We have clearly demonstrated that AHLOS varies between different hospitals, and that the most important patient-level explanatory variables are discharge mRS, dementia and inpatient complications. We highlight the potential importance of stroke volume in influencing these differences but cannot discount the potential effect of unmeasured confounders.

Post stroke depression and risk of stroke recurrence and mortality: A systematic review and meta-analysis

BACKGROUND

Post stroke depression is a significant neuropsychiatric manifestation, predicting a range of poor outcomes. There are several studies investigating the association between post stroke depression and stroke recurrence/mortality, but results have been inconsistent.

OBJECTIVE

A systematic review, meta-analysis and meta regression of observational studies assessing the association between post stroke depression and risk of stroke recurrence and mortality.

METHODS

A search of Medline (via PubMed), Web of Science databases, EMBASE, Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews was conducted until August 2018. We extracted and pooled hazard ratios from observational studies that reported the risk estimates of stroke recurrence and mortality in stroke survivors with/without depression.

RESULTS

The reviewed sample comprised 15 prospective cohort studies with 250,294 participants, 139,276 cases, and follow-up periods ranging from 1 to 15 years. The meta-analysis concluded a hazard ratio for post stroke depression and all-cause mortality of 1.59 (95% CI, 1.30-1.96), but research to date has been insufficient to determine the association between post stroke depression and stroke recurrence.

CONCLUSION AND RELEVANCE

Post stroke depression is associated with a significantly increased risk of mortality in stroke survivors. More researches are required on the association with stroke recurrence.

Healthcare utilization and cost trajectories post-stroke: role of caregiver and stroke factors

BACKGROUND

It is essential to study post-stroke healthcare utilization trajectories from a stroke patient caregiver dyadic perspective to improve healthcare delivery, practices and eventually improve long-term outcomes for stroke patients. However, literature addressing this area is currently limited. Addressing this gap, our study described the trajectory of healthcare service utilization by stroke patients and associated costs over 1-year post-stroke and examined the association with caregiver identity and clinical stroke factors.

METHODS

Patient and caregiver variables were obtained from a prospective cohort, while healthcare data was obtained from the national claims database. Generalized estimating equation approach was used to get the population average estimates of healthcare utilization and cost trend across 4 quarters post-stroke.

RESULTS

Five hundred ninety-two stroke patient and caregiver dyads were available for current analysis. The highest utilization occurred in the first quarter post-stroke across all service types and decreased with time. The incidence rate ratio (IRR) of hospitalization decreased by 51, 40, 11 and 1% for patients having spouse, sibling, child and others as caregivers respectively when compared with not having a caregiver (p = 0.017). Disability level modified the specialist outpatient clinic usage trajectory with increasing difference between mildly and severely disabled sub-groups across quarters. Stroke type and severity modified the primary care cost trajectory with expected cost estimates differing across second to fourth quarters for moderately-severe ischemic (IRR: 1.67, 1.74, 1.64; p = 0.003), moderately-severe non-ischemic (IRR: 1.61, 3.15, 2.44; p = 0.001) and severe non-ischemic (IRR: 2.18, 4.92, 4.77; p = 0.032) subgroups respectively, compared to first quarter.

CONCLUSION

Highlighting the quarterly variations, we reported distinct utilization trajectories across subgroups based on clinical characteristics. Caregiver availability reducing hospitalization supports revisiting caregiver's role as potential hidden workforce, incentivizing their efforts by designing socially inclusive bundled payment models for post-acute stroke care and adopting family-centered clinical care practices.

[Severity assessment strategies based on administrative data using stroke as an example]

BACKGROUND AND OBJECTIVES

Information on disease severity is relevant for many studies with claims data in health service research, but only limited information is available in routine data. Stroke serves as an example to analyse whether the combination of different information in claims data can provide insight into the severity of a disease.

METHOD

As a first step, a literature search was conducted. Strategies to assess the severity of a disease by means of routine data were examined with regard to approval and applicability to German sickness fund data. In order to apply and extend the identified procedures, the statutory health insurance sample AOK Hessen/KV Hessen (VSH) served as data source. It is an 18.75 % random sample of persons insured by the AOK Hessen, with 2013 being the most recent year. Stroke patients were identified by the ICD-10 GM code I63 and I64. Patients with said diagnoses being coded as a hospital discharge diagnosis in 2012 were included due to an acute event in 2012 (n=944). The follow-up time was one year.

RESULTS

Ten studies covering seven different methods to assess stroke severity were identified. Codes for coma (4.2 % of stroke patients in the SHI sample) as well as coma and/or the application of a PEG tube (9.8 % of the stroke patients) were applied as a proxy for disease severity of acute cases. Taking age, sex and comorbidity into consideration, patients in a coma show a significantly increased risk of mortality compared to those without coma. Three operationalisations were chosen as possible proxies for disease severity of stroke in the further course of disease: i) sequelae (hemiplegia, neurological neglect), ii) duration of the index inpatient stay, and iii) nursing care/ care level 3 for the first time after stroke. The latter proxy has the highest explanatory value for SHI costs.

CONCLUSION

The studies identified use many variables mainly based on hospital information in order to describe disease severity. With the exception of coma, these proxies were neither validated nor did the authors provide more detailed grounds for their use. An identified score for stroke severity could not be applied to SHI data. To develop a comparable score requires a linkage of clinical and administrative data. Since routine data include information from all sectors of care, it should be explored whether these data (for example, the patients' care needs) are suitable to assess disease severity. For validation, separate databases and, optimally, primary patient data are necessary.

Post-stroke depression in Ghana: Characteristics and correlates

BACKGROUND

Poststroke depression (PSD) is prevalent and is an important determinant of functional recovery, quality of life and mortality after stroke. Scanty data on the nature of PSD among stroke survivors in sub-Saharan Africa prompted this study.

OBJECTIVE

To assess the prevalence and predictors of depression in a convenience sample of Ghanaian stroke survivors.

METHODS

We evaluated consecutive stroke survivors encountered at a comprehensive neurology clinic in a tertiary medical center in Ghana. The Center for Epidemiologic Studies Depression Scale (CES-D) and Geriatric Depression Scale (GDS) were both used to screen for depressive symptoms and subjects were considered as depressed if they scored ≥16 on the CES-D scale and >5 on the GDS. Demographic and clinical data on stroke type and severity as well as health-related quality of life indicators were collected. Predictors of stroke-related depression were assessed using a logistic regression model.

RESULTS

Of 200 stroke survivors, mean±SD age was 62.0±14.4years, and 105 (52.5%) patients were men. Among the cohort 78.5% were classified as being depressed by CES-D, 42.5% by GDS, and 36.5% on both CES-D and GDS. In multivariable analyses, for each unit increase on the Modified Rankin scale (i.e. worsening disability), there were higher odds of depression (adjusted OR 1.85; 1.28-2.69, p=0.001), and being divorced (vs. being married) was linked to depression (adjusted 2.82; 1.18-6.71, p=0.02). Stroke survivors with depression demonstrated profound diminutions in the physical, psycho-social, cognitive and eco-social domains of quality of life compared with those without depression (p<0.05).

CONCLUSION

Almost 4 out of 10 stroke survivors in this Ghanaian cohort displayed clinically significant depression. Prospective interventional studies are urgently needed to provide solid evidence-based and culturally tailored interventions to address post-stroke depression particularly in LMICs.

Regional variation in post-stroke multidisciplinary rehabilitation care among veteran residents in community nursing homes

INTRODUCTION

Effective post-acute multidisciplinary rehabilitation therapy improves stroke survivors' functional recovery and daily living activities. The US Department of Veterans Affairs (VA) places veterans needing post-acute institutional care in private community nursing homes (CNHs). These placements are made under the same rules and regulations across the VA health care system and through individual per diem contracts between local VA facilities and CNHs. However, there is limited information about utilization of these veterans' health services as well as the geographic variation of the service utilization.

AIM

The aims of this study were to determine rehabilitation therapy and restorative nursing care utilization by veterans with stroke in VA-contracted CNHs and to assess risk-adjusted regional variations in the utilization of rehabilitation therapy and restorative nursing care.

METHODS

This retrospective study included all veterans diagnosed with stroke residing in VA-contracted CNHs between 2006 and 2009. Minimum Dataset (a health status assessment tool for CNH residents) for the study CNHs was linked with veterans' inpatient and outpatient data within the VA health care system. CNHs were grouped into five VA-defined geographic regions: the North Atlantic, Southeast, Midwest, Continental, and Pacific regions. A two-part model was applied estimating risk-adjusted utilization probability and average weekly utilization days. Two dependent variables were rehabilitation therapy and restorative nursing care utilization by veterans during their CNH stays.

RESULTS

The study comprised 6,206 veterans at 2,511 CNHs. Rates for utilization of rehabilitation therapy and restorative nursing care were 75.7% and 30.1%, respectively. Veterans in North Atlantic and Southeast CNHs were significantly (p<0.001) more likely to receive rehabilitation therapies than veterans from other regions. However, veterans in Southeast CNHs were significantly (p<0.001) less likely to receive restorative nursing care compared with veterans in all other regions, before and after risk adjustment.

CONCLUSION

The majority of veterans with stroke received rehabilitation therapy, and about one-third had restorative nursing care during their stay at VA-contracted CNHs. Significant regional variations in weekly days for rehabilitation therapy and restorative nursing care utilization were observed even after adjusting for potential risk factors.

Poststroke Depression: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

Poststroke depression (PSD) is common, affecting approximately one third of stroke survivors at any one time after stroke. Individuals with PSD are at a higher risk for suboptimal recovery, recurrent vascular events, poor quality of life, and mortality. Although PSD is prevalent, uncertainty remains regarding predisposing risk factors and optimal strategies for prevention and treatment. This is the first scientific statement from the American Heart Association on the topic of PSD. Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association's Manuscript Oversight Committee. Members were assigned topics relevant to their areas of expertise and reviewed appropriate literature, references to published clinical and epidemiology studies, clinical and public health guidelines, authoritative statements, and expert opinion. This multispecialty statement provides a comprehensive review of the current evidence and gaps in current knowledge of the epidemiology, pathophysiology, outcomes, management, and prevention of PSD, and provides implications for clinical practice.

Interactive Voice Response-An Innovative Approach to Post-Stroke Depression Self-Management Support

Automated interactive voice response (IVR) call systems can provide systematic monitoring and self-management support to depressed patients, but it is unknown if stroke patients are able and willing to engage in IVR interactions. We sought to assess the feasibility and acceptability of IVR as an adjunct to post-stroke depression follow-up care. The CarePartner program is a mobile health program designed to optimize depression self-management, facilitate social support from a caregiver, and strengthen connections between stroke survivors and primary care providers (PCPs). Ischemic stroke patients and an informal caregiver, if available, were recruited during the patient's acute stroke hospitalization or follow-up appointment. The CarePartner program was activated in patients with depressive symptoms during their stroke hospitalization or follow-up. The 3-month intervention consisted of weekly IVR calls monitoring both depressive symptoms and medication adherence along with tailored suggestions for depressive symptom self-management. After each completed IVR call, informal caregivers were automatically updated, and, if needed, the subject's PCP was notified. Of the 56 stroke patients who enrolled, depressive symptoms were identified in 13 (23 %) subjects. Subjects completed 74 % of the weekly IVR assessments. A total of six subjects did not complete the outcome assessment, including two non-study-related deaths. PCPs were notified five times, including two times for suicidal ideation and three times for medication non-adherence. Stroke patients with depressive symptoms were able to engage in an IVR call system. Future studies are needed to explore the efficacy of an IVR approach for post-stroke self-management and monitoring of stroke-related outcomes.

Poststroke Rehabilitation and Restorative Care Utilization: A Comparison Between VA Community Living Centers and VA-contracted Community Nursing Homes

BACKGROUND

Effective poststroke rehabilitation care can speed patient recovery and minimize patient functional disabilities. Veterans affairs (VA) community living centers (CLCs) and VA-contracted community nursing homes (CNHs) are the 2 major sources of institutional long-term care for Veterans with stroke receiving care under VA auspices.

OBJECTIVES

This study compares rehabilitation therapy and restorative nursing care among Veterans residing in VA CLCs versus those Veterans in VA-contracted CNHs.

RESEARCH DESIGN

Retrospective observational.

SUBJECTS

All Veterans diagnosed with stroke, newly admitted to the CLCs or CNHs during the study period who completed at least 2 Minimum Data Set assessments postadmission.

MEASURES

The outcomes were numbers of days for rehabilitation therapy and restorative nursing care received by the Veterans during their stays in CLCs or CNHs as documented in the Minimum Data Set databases.

RESULTS

For rehabilitation therapy, the CLC Veterans had lower user rates (75.2% vs. 76.4%, P=0.078) and fewer observed therapy days (4.9 vs. 6.4, P<0.001) than CNH Veterans. However, the CLC Veterans had higher adjusted odds for therapy (odds ratio=1.16, P=0.033), although they had fewer average therapy days (coefficient=-1.53±0.11, P<0.001). For restorative nursing care, CLC Veterans had higher user rates (33.5% vs. 30.6%, P<0.001), more observed average care days (9.4 vs. 5.9, P<0.001), higher adjusted odds (odds ratio=2.28, P<0.001), and more adjusted days for restorative nursing care (coefficient=5.48±0.37, P<0.001).

CONCLUSION

Compared with their counterparts at VA-contracted CNHs, Veterans at VA CLCs had fewer average rehabilitation therapy days (both unadjusted and adjusted), but they were significantly more likely to receive restorative nursing care both before and after risk adjustment.

Incidence and Determinants of Traumatic Intracranial Bleeding Among Older Veterans Receiving Warfarin for Atrial Fibrillation

IMPORTANCE

Traumatic intracranial bleeding, which is most commonly attributable to falls, is a common concern among health care professionals, who are hesitant to prescribe oral anticoagulants to older adults with atrial fibrillation.

OBJECTIVE

To describe the incidence of and risk factors for traumatic intracranial bleeding in a large cohort of older adults who were newly prescribed warfarin sodium.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study at the US Department of Veterans Affairs (VA). Participants included 31 951 veterans with atrial fibrillation 75 years or older who were new referrals to VA anticoagulation clinics (for warfarin therapy) between January 1, 2002, and December 31, 2012. The dates of the core analysis were March 2014 through May 2015, and subsequent ad hoc analyses were performed through December 2015. Patients with comorbid conditions requiring warfarin were excluded.

MAIN OUTCOMES AND MEASURES

The primary outcome was hospitalization for traumatic intracranial bleeding. Secondary outcomes included hospitalization for any intracranial bleeding or ischemic stroke. We used International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify the incidence rates of these outcomes after warfarin initiation using VA administrative data (in-system hospitalizations) and Medicare fee-for-service claims data (out-of-system hospitalizations). Clinical characteristics, laboratory results, and pharmacy data were extracted from the VA electronic medical record. For traumatic intracranial bleeding, Cox proportional hazards regression was used to determine predictors of interest selected a priori based on prior known associations.

RESULTS

The study population comprised 31 951 participants. The mean (SD) patient age was 81.1 (4.1) years, and 98.1% were male. Comorbidities were common, including hypertension (82.5%), coronary artery disease (42.6%), and diabetes mellitus (33.8%). During the study period, the incidence rate of hospitalization for traumatic intracranial bleeding was 4.80 per 1000 person-years. In unadjusted models, significant predictors of traumatic intracranial bleeding included dementia, fall within the past year, anemia, depression, abnormal renal or liver function, anticonvulsant use, labile international normalized ratio, and antihypertensive use. After adjusting for potential confounders, the remaining significant predictors for traumatic intracranial bleeding were dementia (hazard ratio [HR], 1.76; 95% CI, 1.26-2.46), anemia (HR, 1.23; 95% CI, 1.00-1.52), depression (HR, 1.30; 95% CI, 1.05-1.61), anticonvulsant use (HR, 1.35; 95% CI, 1.04-1.75), and labile international normalized ratio (HR, 1.33; 95% CI, 1.04-1.72). The incidence rates of hospitalization for any intracranial bleeding and ischemic stroke were 14.58 and 13.44, respectively, per 1000 person-years.

CONCLUSIONS AND RELEVANCE

Among patients 75 years or older with atrial fibrillation initiating warfarin therapy, the risk factors for traumatic intracranial bleeding are unique from those for ischemic stroke. The high overall rate of intracranial bleeding in our sample supports the need to more systematically evaluate the benefits and harms of warfarin therapy in older adults.

Improving Quality of Life and Depression After Stroke Through Telerehabilitation

OBJECTIVE

The aim of this study was to determine the effects of home-based robot-assisted rehabilitation coupled with a home exercise program compared with a home exercise program alone on depression and quality of life in people after stroke.

METHOD

A multisite randomized controlled clinical trial was completed with 99 people<6 mo after stroke who had limited access to formal therapy. Participants were randomized into one of two groups, (1) a home exercise program or (2) a robot-assisted therapy+home exercise program, and participated in an 8-wk home intervention.

RESULTS

We observed statistically significant changes in all but one domain on the Stroke Impact Scale and the Center for Epidemiologic Studies Depression Scale for both groups.

CONCLUSION

A robot-assisted intervention coupled with a home exercise program and a home exercise program alone administered using a telerehabilitation model may be valuable approaches to improving quality of life and depression in people after stroke.

Literature and art therapy in post-stroke psychological disorders

Stroke is one of the leading causes of morbidity and long-term disability worldwide, and post-stroke depression (PSD) is a common and serious psychiatric complication of stroke. PSD makes patients have more severe deficits in activities of daily living, a worse functional outcome, more severe cognitive deficits and increased mortality as compared to stroke patients without depression. Therefore, to reduce or prevent mental problems of stroke patients, psychological treatment should be recommended. Literature and art therapy are highly effective psychological treatment for stroke patients. Literature therapy divided into poetry and story therapy is an assistive tool that treats neurosis as well as emotional or behavioral disorders. Poetry can add impression to the lethargic life of a patient with PSD, thereby acting as a natural treatment. Story therapy can change the gloomy psychological state of patients into a bright and healthy story, and therefore can help stroke patients to overcome their emotional disabilities. Art therapy is one form of psychological therapy that can treat depression and anxiety in stroke patients. Stroke patients can express their internal conflicts, emotions, and psychological status through art works or processes and it would be a healing process of mental problems. Music therapy can relieve the suppressed emotions of patients and add vitality to the body, while giving them the energy to share their feelings with others. In conclusion, literature and art therapy can identify the emotional status of patients and serve as a useful auxiliary tool to help stroke patients in their rehabilitation process.

Non-motor Factors Associated with the Attainment of Community Ambulation after Stroke

OBJECTIVE

Detect the main predictive non-motor factors related to independent community ambulation after stroke. Furthermore, we propose a scale to estimate the probability of a stroke patient achieving independent community ambulation after 6 months of rehabilitation.

DESIGN AND SETTINGS

Prospective cohort. Subjects treated in a rehabilitation center in a large metropolitan area. Independent community ambulation was evaluated after rehabilitation according to the Hoffer classification. Functional ambulation was assessed at four levels: nonambulatory, nonfunctional ambulation, household ambulation, and community ambulation.

PARTICIPANTS

Patients (n=201) with a moderate disability after stroke.

RESULTS

The average time of hospitalization was 19.3 days. However, only 32.8% of the patients started the rehabilitation program during the first 6 months after stroke. We found that 121 patients achieved community ambulation (60.2%), 40 achieved household ambulation (19.9%), 12 achieved therapeutic ambulation (5.9%), and 28 were non-ambulatory after 6 months of treatment. Based on our final model, a scoring scale was created in order to evaluate the probability of stroke patients achieving independent community ambulation after 6 months of rehabilitation. Higher scores were associated with better chances of community ambulation within 6 months.

CONCLUSIONS

The scale that evaluated these factors proved to have acceptable sensitivity and specificity to establish the prognosis of community ambulation after 6 months of rehabilitation.

Personality type as a predictor for depressive symptoms and reduction in quality of life among stroke survivals

OBJECTIVE

Although poststroke depression (PSD) and reduction in quality of life (QOL) are prevalent among stroke patients, little is known about the contribution of personality traits to such impairments. This study examines whether particular personality traits predict PSD symptoms (PSDS) and reduction in QOL among stroke survivals using Cloninger's biopsychosocial personality model. We hypothesized that harm avoidance (HA), expressing the tendency to respond intensely to adverse stimuli, characterizes stroke survivors at risk for PSDS and reduction in QOL.

METHODS

Hospitalized stroke patients (N = 84, age 63.5 ± 9.7 years) prospectively completed Cloninger's Tridimensional Personality Questionnaire, defining HA dominancy by scoring the three personality dimensions: reward dependence, novelty seeking, and HA. The level of neurologic deficit was evaluated by the National Institutes of Health Stroke Scale. At the 3-month follow-up visit, depressive symptoms and QOL scores were assessed using the Beck Depression Inventory and the Stroke Specific Quality of Life questionnaire.

RESULTS

Regression analyses revealed that higher HA scores independently predicted PSDS and reduction in QOL. After controlling for the relative contribution of stroke type and health-related variables, HA and neurologic deficit were significant risk factors for poststroke negative outcomes.

CONCLUSION

Our findings emphasize the relevance of Cloninger's theory (manifested by individual HA behavior) as a distinctive means to identifying patients at risk for PSDS and lower QOL after stroke. The role of specific psychological and neurologic aspects involved in the mechanism of PSD should be further explored using biopsychosocial models.

Older adult stroke survivors discussing poststroke depressive symptoms with a healthcare provider: a preliminary analysis

PURPOSE

The purposes of this study were to examine the relationship between the poststroke depressive symptoms, older adult stroke survivors' perceptions of the depressive symptoms, and the congruence with an informal caregiver about the presence of depressive symptoms, and comfort talking to the health care provider with whether or not older stroke survivors discussed their depressive symptoms with a health care provider.

METHOD

A cross-sectional study where 44 caregiver/older adult stroke survivor dyads completed questionnaires including the Center for Epidemiologic Studies Depression Scale, Symptom Perception Questionnaire, and reporting of depressive symptoms to the health care provider via one time interview.

RESULTS

Thirty-seven percent (n = 16) of all older stroke survivors reported depressive symptoms to their health care provider. Of the stroke survivors who had high levels of depressive symptoms (CESD ≥ 16; n = 11), seven reported the depressive symptoms to their health care provider. Identifying the symptoms as possible depression and attributing the cause of the depressive symptoms to the stroke were related to stroke survivors reporting the depressive symptoms to a health care provider.

CONCLUSIONS

High functioning, older stroke survivors may benefit from strategies to help them identify when they experience depressive symptoms, in order to be able to play an active role in their recovery by appropriately discussing their symptoms with a health care provider.

Economics of psychosocial factors in patients with cardiovascular disease

Growing evidence supports a causal relationship between cardiovascular disease and psychosocial factors such as mental health and behavioral disorders, acute and chronic stress, and low socioeconomic status. While this has enriched our understanding of the interaction between cardiovascular risk factors, much less is known about its economic implications. In this review, we evaluate the economic impact of psychosocial factors in persons at risk for or diagnosed with cardiovascular disease. Most studies have focused on depression and almost uniformly conclude that patients with cardiovascular disease and comorbid depression use a greater number of ambulatory and hospital services and incur higher overall costs. Additionally, comorbid depression may also reduce employment productivity in patients with cardiovascular disease, further magnifying its economic impact. Recent randomized trials have demonstrated that innovative care delivery models that target depression may reduce costs or at least be cost neutral while improving quality of life. The growing population burden and overlap of cardiovascular disease, comorbid mental illness, and other psychosocial factors suggest that future research identifying cost-effective or cost-saving treatment models may have significant health and economic implications.

Depression, activities of daily living and quality of life in patients with stroke

INTRODUCTION

Stroke patients are dealing with a wide variety of physical and psychological problems influencing their ability to carry out activities of daily living (ADL). The aim of the present study was to examine the relationship between the activity of daily living performances and degree of after stroke depression (ASD), as well as, the quality of life (QOL) in Iranian stroke survivors.

MATERIALS AND METHOD

In a cross sectional study, 40 patients with stroke in two Rehabilitation Centers for Stroke Patients, were recruited consecutively. They were assessed using the Modified Barthel Index, the Beck Depression Inventory-II (BDI-II), and a quality of life questionnaire (SF-36). Data were analyzed using Pearson and Spearman correlation coefficient.

RESULTS

Sixty five and one-half percent (65.5%) of the studied participants were either fully dependent or needed help in ADL. Also, 72.5% of the participants showed mild to severe ASD. There was a significant negative correlation between ADL performances and ASD and also between QOL and ASD. Furthermore a strong correlation was found between ADL and QOL.

CONCLUSION

ADL have a strong relationship with both level of depression and QOL in patients with stroke. It appears that motivating to perform ADL may enhance QOL. Further investigation with a larger sample size is required to better understand the causal relationship of these factors.

Depression increases stroke hospitalization cost: an analysis of 17,010 stroke patients in 2008 by race and gender

Objective. This analysis focuses on the effect of depression on the cost of hospitalization of stroke patients. Methods. Data on 17,010 stroke patients (primary diagnosis) were extracted from 2008 Tennessee Hospital Discharge Data System. Three groups of patients were compared: (1) stroke only (S^O, n = 7,850), (2) stroke + depression (S^+D, n = 3,965), and (3) stroke + other mental health diagnoses (S^+M, n = 5,195). Results. Of all adult patients, 4.3% were diagnosed with stroke. Stroke was more prevalent among blacks than whites (4.5% versus 4.2%, P < 0.001) and among males than females (5.1% versus 3.7%, P < 0.001). Nearly one-quarter of stroke patients (23.3%) were diagnosed with depression/anxiety. Hospital stroke cost was higher among depressed stroke patients (S^+D) compared to stroke only (S^O) patients ($77,864 versus $47,790, P < 0.001), and among S^+D, cost was higher for black males compared to white depressed males ($97,196 versus $88,115, P < 0.001). Similar racial trends in cost emerged among S^+D females. Conclusion. Depression in stroke patients is associated with increased hospitalization costs. Higher stroke cost among blacks may reflect the impact of comorbidities and the delay in care of serious health conditions. Attention to early detection of depression in stroke patients might reduce inpatient healthcare costs.

Depression after stroke and risk of mortality: a systematic review and meta-analysis

Background. Depression after stroke may have great burden on the likelihood of functional recovery and long-term outcomes. Objective. To estimate the association between depression after stroke and subsequent mortality. Methods. A systematic search of articles using PubMed and Web of Science databases was performed. Odds ratios (ORs) and hazard ratios (HRs) were used as association measures for pooled analyses, based on random-effects models. Results. Thirteen studies, involving 59,598 subjects suffering from stroke (6,052 with and 53,546 without depression), had data suitable for meta-analysis. The pooled OR for mortality at followup in people suffering from depression after stroke was 1.22 (1.02–1.47). Subgroups analyses highlighted that only studies with medium-term followup (2–5 years) showed a statistically significant association between depression and risk of death. Four studies had data suitable for further analysis of pooled HR. The meta-analysis revealed a HR for mortality of 1.52 (1.02–2.26) among people with depression after stroke. Conclusions. Despite some limitations, this paper confirms the potential role of depression on post stroke mortality. The relationship between depression and mortality after stroke seems to be related to the followup duration. Further research is needed to clarify the nature of the association between depression after stroke and mortality.

Rivermead mobility index can be used to predict length of stay for elderly persons, 5 days after stroke onset

BACKGROUND

Recovery after acute stroke is expected to continue for a long time but is most rapid during the first few days after onset. Because the cost of hospital care is rising constantly, there is increasing pressure from various administrative bodies to reduce the duration of hospital stay. To select the optimal level of care for elderly patients with stroke-related disability, it is important to be aware of adequate discharge destinations and to have reliable predictors for the length of institutional stay (LOS) (ie in hospital or nursing home).

PURPOSE

The purpose of the study was to find feasible prognostic indicators for the LOS, to be used 5 days after acute stroke, in persons 65 years and older.

METHODS

One hundred fifteen consecutive persons, 65 years and older, were assessed 5 days poststroke for the following: consciousness (Glasgow Coma Scale), language (aphasia/no aphasia), perceptual (Cancellation Tasks and Block Test), emotional (lability/no lability), energy and drive (Montgomery-Åsberg Depression Scale), mental (Mini-Mental State Examination), somatosensory (normal/impaired), and urinary (continent/incontinent) functions; mobility (Rivermead mobility index [RMI]); activities of daily living (Barthel Index); and side of hemiplegia or hemiparesis. In addition, previous living arrangements (alone vs with another person), stroke characteristics, and demographic information were documented. Length of institutional stay was recorded 5 days to 3 months poststroke onset.

RESULTS

Multiple regression survival analyses showed that the factors with the greatest positive impact on short LOS, 5 days poststroke, were the following: no previous stroke; Glasgow Coma Scale ≥ 13 (mild brain injury); and RMI ≥ 4 points, corresponding to the ability to rise from a chair in less than 15 seconds and stand there for 15 seconds with or without an aid.

CONCLUSIONS

In addition to medical appraisal, the RMI ≥ 4 points, a quickly performed test, can be used to predict short LOS for persons with stroke as early as 5 days after stroke onset.

Prevention of poststroke depression: does prophylactic pharmacotherapy work?

BACKGROUND

Given the negative influence of poststroke depression (PSD) on functional recovery, cognition, social participation, quality of life, and risk for mortality, the early initiation of antidepressant therapy to prevent its development has been investigated; however, individual studies have offered conflicting evidence. The present systematic review and meta-analysis examined available evidence from published randomized controlled trials (RCTs) evaluating the effectiveness of pharmacotherapy for the prevention of PSD to provide updated pooled analyses.

METHODS

Literature searches of 6 databases were performed for the years 1990 to 2011. RCTs meeting study inclusion criteria were evaluated for methodologic quality. Data extracted included the antidepressant therapy used, treatment timing and duration, method(s) of assessment, and study results pertaining to the onset of PSD. Pooled analyses were conducted.

RESULTS

Eight RCTs were identified for inclusion. Pooled analyses demonstrated reduced odds for the development of PSD associated with pharmacologic treatment (odds ratio [OR] 0.34; 95% confidence interval [CI] 0.22-0.53; P<.001), a treatment duration of 1 year (OR 0.31; 95% CI 0.18-0.56; P<.001), and the use of a selective serotonin reuptake inhibitor (OR 0.37; 95% CI 0.22-0.61; P<.001).

CONCLUSIONS

The early initiation of antidepressant therapy, in nondepressed stroke patients, may reduce the odds for development of PSD. Optimum timing and duration for treatment and the identification of the most appropriate recipients for a program of indicated prevention require additional examination.

Electronic clinical decision support for management of depression in primary care: a prospective cohort study

OBJECTIVE

To assess the utility of an electronic clinical decision support tool for management of depression in primary care.

METHOD

This prospective study was conducted in a national network of ambulatory practices over a 1-year period (October 2007-October 2008). A clinical decision support tool was embedded into the electronic health record of 19 primary care practices with 119 providers. The main components included (1) the 9-item Patient Health Questionnaire (PHQ-9), with 9 questions paralleling the 9 DSM-IV criteria for the diagnosis of major depressive disorder; (2) a suicide assessment form; and (3) brief patient and provider education. Use of each component was tracked in the electronic health record. Providers completed baseline and postintervention surveys regarding their depression management practices and their perceptions of the clinical decision support tool.

RESULTS

According to electronic health record tracking, the PHQ-9 form was used in 45.6% of the 16,052 adult patients with depression and in 73.7% of the 1,422 patients with new depression. The suicide assessment form was used in 62.0% of patients with possible suicidality. Education modules were rarely used. From before to after the study, providers reported increased use of standardized tools for depression diagnosis (47% to 80%, P < .001) and monitoring (27% to 85%, P < .001). The majority of providers reported often using the PHQ-9 and suicide forms and felt them to be very helpful in patient care, with 85% planning to continue their use after the study.

CONCLUSIONS

The electronic health record-based clinical decision support tool was extensively used and perceived as very helpful for assessment of patients' symptoms but not for provider education. These findings can help guide national efforts incorporating clinical decision support for quality improvement.

Association between mental health conditions and rehospitalization, mortality, and functional outcomes in patients with stroke following inpatient rehabilitation

BACKGROUND

Limited evidence exists regarding the association of pre-existing mental health conditions in patients with stroke and stroke outcomes such as rehospitalization, mortality, and function. We examined the association between mental health conditions and rehospitalization, mortality, and functional outcomes in patients with stroke following inpatient rehabilitation.

METHODS

Our observational study used the 2001 VA Integrated Stroke Outcomes database of 2162 patients with stroke who underwent rehabilitation at a Veterans Affairs Medical Center. Separate models were fit to our outcome measures that included 6-month rehospitalization or death, 6-month mortality post-discharge, and functional outcomes post inpatient rehabilitation as a function of number and type of mental health conditions. The models controlled for patient socio-demographics, length of stay, functional status, and rehabilitation setting.

RESULTS

Patients had an average age of 68 years. Patients with stroke and two or more mental health conditions were more likely to be readmitted or die compared to patients with no conditions (OR: 1.44, p = 0.04). Depression and anxiety were associated with a greater likelihood of rehospitalization or death (OR: 1.33, p = 0.04; OR:1.47, p = 0.03). Patients with anxiety were more likely to die at six months (OR: 2.49, p = 0.001).

CONCLUSIONS

Patients with stroke with pre-existing mental health conditions may need additional psychotherapy interventions, which may potentially improve stroke outcomes post-hospitalization.

Pre-post evaluation of automated reminders may improve detection and management of post-stroke depression

BACKGROUND

Post-stroke depression (PSD) occurs in at least one-third of stroke survivors, is associated with worse functional outcomes and increased mortality, and is frequently underdiagnosed and undertreated.

OBJECTIVE

To evaluate the effectiveness of an electronic medical record-based system intervention to improve the proportion of veterans screened and treated for PSD.

DESIGN

Quasi-experimental study comparing PSD screening and treatment among veterans receiving post-stroke outpatient care one year prior to the intervention (the control group) to those receiving outpatient care during the intervention period (the intervention group); contemporaneous data from non-study sites included to assess temporal trends in depression diagnosis and treatment.

PARTICIPANTS

Veterans hospitalized for ischemic stroke and/or receiving primary care (PC) or neurology outpatient follow-up within six months post-stroke at two (Veterans Affairs) VA Medical Centers.

INTERVENTIONS

We formed clinical improvement teams at both sites. Teams developed PSD screening and treatment reminders and designed tailored implementation strategies for reminder use in PC and neurology clinics.

MAIN MEASURES

Proportion screened for PSD within 6 months post-stroke; proportion screening positive for PSD who received an appropriate treatment action within 6 months post-stroke.

KEY RESULTS

In unadjusted analyses, PSD screening was performed within 6 months for 85% of intervention (N = 278) vs. 50% of control (N = 374) patients (OR 6.2 , p < 0.001), and treatment action was received by 83% of intervention vs. 73% of control patients who screened positive (OR 1.8 p = 0.13). After adjusting for intervention, site and number of follow-up visits, intervention patients were more likely to be screened (OR 4.8, p < 0.001) and to receive a treatment action if screened positive (OR 2.45, p = 0.05). Analyses of temporal trends in non-study sites revealed no trend toward general increase in PSD detection or treatment.

CONCLUSIONS

Automated depression screening in primary and specialty care can improve detection and treatment of PSD.

Selective serotonin reuptake inhibitor treatment and depression are associated with poststroke mortality

BACKGROUND

Studies generally do not examine patients' prestroke depression diagnoses and treatments.

OBJECTIVE

To examine the association of depression diagnosis and prestroke and/or poststroke selective serotonin reuptake inhibitor (SSRI) treatment with poststroke mortality.

METHODS

We conducted a retrospective study of the medical records of a cohort of veterans with a stroke diagnosis between July 31, 2000, and September 30, 2001. Data regarding demographics, comorbidities, depression diagnosis, and treatment were abstracted from automated databases and electronic medical records for 6 months before and 1 year after the stroke index date. The survival rates of veterans who received an SSRI before and/or after the stroke were estimated using Kaplan-Meier survival analysis. Time-dependent Cox proportional hazards regression model was used to assess the association between risk factors and mortality.

RESULTS

Among 870 veterans, 80 died less than 60 days after their stroke. Among the remaining 790, 12% died within 1 year, 26% died by the end of follow-up (May 1, 2007), and more than 62% were alive at the end of follow-up. Veterans were 3 times as likely to die if they had been treated for depression with an SSRI only before their stroke (hazard ratio [HR], 3.12; 95% CI 1.60 to 6.09). In the time-dependent model, SSRI treatment both before and after the stroke was protective compared with no SSRI treatment during the year following the stroke (HR 0.31; 95% CI 0.11 to 0.86). However, the survival curves crossed over and SSRI treatment before and after stroke conferred greater risk at the end of 7 years (HR 1.36; 95% CI 1.00 to 1.87). Depression diagnosis was associated with greater risk of mortality (HR 1.87; 95% CI 1.24 to 2.82).

CONCLUSIONS

Poststroke SSRI treatment was associated with longer survival even though depression diagnosis was associated with earlier mortality in the unadjusted model. After a stroke, SSRI initiation or resumption of treatment should be considered as part of a medication therapy management service, especially if the patient has a history of depression or was taking an SSRI before the stroke.

Medication adherence: WHO cares?

The treatment of chronic illnesses commonly includes the long-term use of pharmacotherapy. Although these medications are effective in combating disease, their full benefits are often not realized because approximately 50% of patients do not take their medications as prescribed. Factors contributing to poor medication adherence are myriad and include those that are related to patients (eg, suboptimal health literacy and lack of involvement in the treatment decision-making process), those that are related to physicians (eg, prescription of complex drug regimens, communication barriers, ineffective communication of information about adverse effects, and provision of care by multiple physicians), and those that are related to health care systems (eg, office visit time limitations, limited access to care, and lack of health information technology). Because barriers to medication adherence are complex and varied, solutions to improve adherence must be multifactorial. To assess general aspects of medication adherence using cardiovascular disease as an example, a MEDLINE-based literature search (January 1, 1990, through March 31, 2010) was conducted using the following search terms: cardiovascular disease, health literacy, medication adherence, and pharmacotherapy. Manual sorting of the 405 retrieved articles to exclude those that did not address cardiovascular disease, medication adherence, or health literacy in the abstract yielded 127 articles for review. Additional references were obtained from citations within the retrieved articles. This review surveys the findings of the identified articles and presents various strategies and resources for improving medication adherence.

Emerging strategies in the treatment of poststroke depression and psychiatric distress in patients

Poststroke depression (PSD) is a common sequela of stroke associated with increased morbidity and mortality among stroke survivors. PSD has been associated with poorer rehabilitative outcomes, longer inpatient stays, inefficient use of medical resources, worsened cognitive decline, and increased suicidality. This article reviews the definition and proposed etiology of PSD as well as current and emerging evidence-based prevention, screening, and treatment modalities. The timely use of prevention and treatment techniques including pharmacologic and nonpharmacologic methods may improve treatment outcomes and enhance the quality of life in stroke patients.

Post-stroke depression: can prediction help prevention?

Depression is common after stroke. Post-stroke depression (PSD) is an independent predictor of poor long-term functional outcome following stroke. PSD has been associated with poor social and rehabilitation outcomes, cognitive impairment and increased mortality. Prevalence varies widely between studies because of differences in patient selection, time, evaluation methods and diagnostic criteria. Approximately a third of stroke survivors may suffer from PSD. Potential confounders include anosognosia, apathy and emotional lability. The identification of risk factors is important to prevent and detect PSD early, and provide appropriate interventions. PSD may be associated with restriction in social activities and dependence in activities of daily living in the chronic phase of stroke. Pharmacologic and rehabilitation strategies are needed to treat PSD. More evidence is required before recommendations can be made about the routine use of antidepressants to prevent PSD.

Racial and ethnic disparities in post-stroke depression detection

OBJECTIVES

Post-stroke depression (PSD) is common among stroke survivors and is associated with increased morbidity and mortality. Little is understood about racial/ethnic differences in PSD detection. This study assessed the racial/ethnic disparities in PSD detection in a national cohort of Department of Veterans Affairs (VA) acute stroke patients.

METHODS

The study included VA patients who: received inpatient care for acute stroke within 2001; survived >60 days post-index hospitalization; had an index stay <365 days; and were confirmed VA healthcare enrollees. PSD was established if a patient had a depression diagnosis in VA or Medicare inpatient or outpatient files, or was dispensed an antidepressant with guideline recommended minimum daily dosage during the 12 months post stroke. A multivariate logistic regression model was fitted to estimate the effects of race/ethnicity on PSD detection, adjusting for sociodemographic and clinical factors.

RESULTS

The study cohort (N = 5825) was comprised of 66% white, 22% black, 7% Hispanic, and 6% for all other racial/ethnic categories. Among these stroke patients, 39% had PSD. Black and 'all other' racial/ethnic categories were significantly less likely to be diagnosed with PSD than non-Hispanic whites, even adjusting for potential risk factors.

CONCLUSION

White, non-Hispanic VA acute stroke patients were more likely to be diagnosed with PSD, even controlling for sociodemographic and clinical characteristics. Whether these findings suggest racial/ethnic differences in symptom endorsement by patients or in symptom recognition by providers is not clear.

Subchronic alpha-linolenic acid treatment enhances brain plasticity and exerts an antidepressant effect: a versatile potential therapy for stroke

Omega-3 polyunsaturated fatty acids are known to have therapeutic potential in several neurological and psychiatric disorders. However, the molecular mechanisms of action underlying these effects are not well elucidated. We previously showed that alpha-linolenic acid (ALA) reduced ischemic brain damage after a single treatment. To follow-up this finding, we investigated whether subchronic ALA treatment promoted neuronal plasticity. Three sequential injections with a neuroprotective dose of ALA increased neurogenesis and expression of key proteins involved in synaptic functions, namely, synaptophysin-1, VAMP-2, and SNAP-25, as well as proteins supporting glutamatergic neurotransmission, namely, V-GLUT1 and V-GLUT2. These effects were correlated with an increase in brain-derived neurotrophic factor (BDNF) protein levels, both in vitro using neural stem cells and hippocampal cultures and in vivo, after subchronic ALA treatment. Given that BDNF has antidepressant activity, this led us to test whether subchronic ALA treatment could produce antidepressant-like behavior. ALA-treated mice had significantly reduced measures of depressive-like behavior compared with vehicle-treated animals, suggesting another aspect of ALA treatment that could stimulate functional stroke recovery by potentially combining acute neuroprotection with long-term repair/compensatory plasticity. Indeed, three sequential injections of ALA enhanced protection, either as a pretreatment, wherein it reduced post-ischemic infarct volume 24 h after a 1-hour occlusion of the middle cerebral artery or as post-treatment therapy, wherein it augmented animal survival rates by threefold 10 days after ischemia.

Brief psychosocial-behavioral intervention with antidepressant reduces poststroke depression significantly more than usual care with antidepressant: living well with stroke: randomized, controlled trial

BACKGROUND AND PURPOSE

Depression after stroke is prevalent, diminishing recovery and quality of life. Brief behavioral intervention, adjunctive to antidepressant therapy, has not been well evaluated for long-term efficacy in those with poststroke depression.

METHODS

One hundred one clinically depressed patients with ischemic stroke within 4 months of index stroke were randomly assigned to an 8-week brief psychosocial-behavioral intervention plus antidepressant or usual care, including antidepressant. The primary end point was reduction in depressive symptom severity at 12 months after entry.

RESULTS

Hamilton Rating Scale for Depression raw score in the intervention group was significantly lower immediately posttreatment (P<0.001) and at 12 months (P=0.05) compared with control subjects. Remission (Hamilton Rating Scale for Depression <10) was significantly greater immediately posttreatment and at 12 months in the intervention group compared with the usual care control. The mean percent decrease (47%+/-26% intervention versus 32%+/-36% control, P=0.02) and the mean absolute decrease (-9.2+/-5.7 intervention versus -6.2+/-6.4 control, P=0.023) in Hamilton Rating Scale for Depression at 12 months were clinically important and statistically significant in the intervention group compared with control.

CONCLUSIONS

A brief psychosocial-behavioral intervention is highly effective in reducing depression in both the short and long term.

Depressive symptoms, physician visits and hospitalization among community-dwelling older adults

BACKGROUND

The relationship between depressive symptoms and health service use among older people is not well understood. In this study we examined the two-way relationships between depressive symptoms and hospitalization and/or physician visits by older adults.

METHODS

In a one-year follow-up study of 973 community-dwelling older adults in the Singapore Longitudinal Aging Studies (SLAS), depressive symptoms (15-item Geriatric Depression Scale score > or =5) were assessed at baseline and one year later. Information on self-reported physician visits and hospitalization were collected bimonthly over one year.

RESULTS

When demographic characteristics, medical comorbidities, functional status and other covariates were controlled for, baseline depressive symptoms were associated with increased episodes of subsequent physician visits during the one-year follow-up (RR,1.34; 95% CI, 1.05-1.70), but not with subsequent hospitalization(s) during the same period. Conversely, participants with five or more physician visits (versus less than 5) over one year were more likely to be depressed at one year (OR, 10.2; 95% CI, 3.36-31.1); hospitalization during this period was also significantly associated with depressive symptoms at one year (OR = 6.43, 95% CI, 2.48-16.6).

CONCLUSION

Depressive symptoms and health service use have reciprocal relationships. Health service use for non-mental illnesses may be optimized by efforts at post-hospitalization interventions to recognize and treat depression in older persons.

Antidepressant therapy in post-stroke depression

BACKGROUND

About 40% of patients with stroke will develop depression at some stage after the acute event. Post-stroke depression (PSD) is associated with a poor prognosis. Depressed patients have more severe deficits in activities of daily living, a worse functional outcome, more severe cognitive deficits and increased mortality as compared to stroke patients without depression.

OBJECTIVE

This review will focus on available controlled trials of treatment for PSD.

METHODS

An unsystematic review of recent studies for the treatment of PSD.

RESULTS

Randomized controlled trials have demonstrated the efficacy of sertraline, citalopram and nortriptyline to treat post-stroke depression. Whether antidepressant medication may help to prevent post-stroke depression and decrease post-stroke mortality will require further controlled studies.

Case-finding algorithm for post-stroke depression in the veterans health administration

OBJECTIVES

Post-stroke depression (PSD) is prevalent, often undiagnosed, and undertreated. The accuracy of detecting patients with post-stroke depression in administrative databases has not been examined.The objective was to validate a case-finding algorithm for post-stroke depression (PSD) among veteran stroke survivors.

METHODS

We conducted a retrospective cohort study of veterans admitted to two local VHA facilities for an inpatient episode of care for acute ischemic stroke. Our cohort included all patients from two medical centers who were identified in the fiscal year (FY) 2001 VHA inpatient database using high specificity stroke ICD-9 codes. FY 2002 VHA and Medicare inpatient, outpatient, and pharmacy data were used to examine the patients' 12-month PSD status by using ICD-9 depression codes and antidepressant use. We assessed our accuracy about patients' PSD from the administrative databases through standardized chart reviews.

RESULTS

Of our 185 subject cohort, 50 (27%) were identified as having PSD. The most sensitive case-finding algorithm for PSD included having an ICD-9 code diagnosis for depression or receiving a prescription for an approved-dosage of antidepressant medication. However, the algorithm of receiving an ICD-9 code for primary or secondary diagnoses of depression revealed the largest positive predictive value.

CONCLUSIONS

A case-finding algorithm using outpatient ICD-9 codes or medication was the most sensitive in identifying cases of PSD. The use of ICD-9 codes alone may be adequate for characterizing a cohort with PSD. Intention for use should be considered when choosing an algorithm to detect PSD.

Impact of Preexisting Depression on Length of Stay and Discharge Destination Among Patients Hospitalized for Acute Stroke

Background and Purpose— There exists limited knowledge regarding the relation between depression and healthcare utilization in stroke patients. The objective of this register-based study was to examine the impact of having preexisting depression at the time of hospital admission for acute stroke on length of hospital stay and discharge destination.

Methods— Data from a general-practice database were linked to those of a hospital database to identify patients hospitalized for stroke and were used to categorize these patients into 3 groups based on preexisting mental health (MH) status at admission, ie, those with preexisting depression, those with another preexisting MH condition, and those without any preexisting MH condition. Multilevel analyses controlling for several potentially important covariates were performed to estimate the associations under study.

Results— Both patients with preexisting depression (n=41) and those with another preexisting MH condition (n=62) did not differ significantly from patients without any preexisting MH condition (n=211) regarding length of hospital stay for acute stroke. Among patients who survived hospitalization, those with preexisting depression had significantly higher odds of being discharged to an institution instead of their home than did patients without any preexisting MH condition. Having another preexisting MH condition had no significant effect on discharge destination.

Conclusions— Having preexisting depression at admission seems to be a relevant factor in determining discharge to institutional care after acute stroke hospitalization. Further research is needed to determine the mechanism(s) through which preexisting depression decreases the chances of being discharged to home.