HONOLULU – Poststroke depression is a common condition that is underdiagnosed and inadequately treated, according to Dr. Linda S. Williams, a neurologist at Indiana University and the Roudebush VA Medical Center, both in Indianapolis.
But it doesn’t have to be this way. "There are many, many treatments, and they’re easy to give. It’s something that should be within the grasp of every provider to do," she said at the International Stroke Conference, sponsored by the American Heart Association.
Dr. Linda S. Williams
Yet many of her fellow neurologists don’t see it this way. Dr. Williams said she faults her specialty for playing a major role in the generally poor management of poststroke depression (PSD).
"I’ve always wanted to write an editorial called, ‘What’s the ‘P’ in ABPN?’ because neurologists are boarded by the American Board of Psychiatry and Neurology, but many neurologists – even though we get some training in psychiatry – don’t want to initiate treatment for depression. We somehow think it’s not our job. That might be fine if you have great communication with the patient’s primary care doctor in an integrated health care system and you can be sure that doctor is going to see that the patient gets started on antidepressant therapy, but I think reality would suggest that’s not very often the case," she said.
"So I strongly feel that whoever detects the depression first should get the patient started on treatment and should make sure the patient is seen again in 6 weeks to see if there has been improvement in symptoms and to figure out who’ll get called if the patient has medication side effects and needs to switch," the neurologist continued.
An estimated 25%-30% of the 700,000 new stroke survivors each year will develop PSD, although it’s unclear how many cases are new onset after the neurovascular event, as opposed to undiagnosed depression present beforehand. Depression is, after all, an independent risk factor for both stroke and ischemic heart disease. In any case, PSD is associated with increased morbidity and mortality and greater health care utilization.
The keys to improved outcomes in PSD are to set up a systematic screening program for all patients beginning about 1 month after a stroke, start treatment promptly once the diagnosis is made, and then monitor symptomatic progress and adjust the antidepressant medication as needed, she said.
Lots of screening tools for depression are available. Dr. Williams said she favors the Patient Health Questionnaire-9 (PHQ-9) because it’s quick – just nine simple questions, it was developed specifically with primary care physicians in mind, and it’s one of the few screening tools that allows a busy nonpsychiatrist to reliably diagnose major depression based upon the results.
She conducted a study in which 316 stroke survivors were assessed for depression using both the PHQ-9 and the gold standard, time-consuming Structured Clinical Interview for DSM-IV Disorders (SCID). One hundred forty-five patients met SCID criteria for major depression. A PHQ-9 score of 10 or more out of a possible 27 had 91% sensitivity and 89% specificity for major depression. A PHQ-2 of 3 or more, in which only the first two of the nine questions are asked, had 83% sensitivity and 84% specificity for the diagnosis.
"Even in stroke patients, I feel pretty confident in using this scale and knowing it’s going to give me an accurate diagnosis," the neurologist said.
That being said, Dr. Williams acknowledged that the diagnosis of PSD is somewhat trickier than for other forms of depression because a stroke may have lingering physical or cognitive effects that can mimic the symptoms of the mood disorder. Conversely, stroke-induced severe right hemisphere damage or aphasia can mask depressive symptoms.
Epidemiologic studies suggest only about half of patients with PSD are diagnosed. It’s easy for busy physicians to forget to screen. That’s why a systematic screening plan is important, she said. An automated electronic reminder system to screen for PSD 1-6 months after a stroke is an effective way to boost detection and treatment rates. Dr. Williams and her coinvestigators developed such a system for primary care physicians and neurologists for inclusion in patients’ electronic medical record within the VA medical system. When the investigators put the automated reminder system to the test in a controlled trial, it boosted screening rates 1-6 months after a stroke by 6.2-fold and treatment rates in screen-positive patients by 2.45-fold, compared with usual care (J. Gen. Intern. Med. 2011;26:852-7).
PSD responds to the same therapies that are effective in nonstroke major depression. The recent literature suggests the proportion of patients with PSD who are on antidepressant therapy has been rising in the past few years; however, the majority of treated patients stop taking their medication after the first several weeks or stay on the initial dose without ever having it titrated upward. It’s crucial to check in with the patient after about 6 weeks of therapy to learn if symptoms are improving; if not, it’s time to switch to an antidepressant from another class, Dr. Williams said.