“Mental health issues post-stroke: Underrecognized and undertreated”

Mental health has been receiving more attention as an important area of concern after stroke. Emotional distress and mood disturbance, including depressive and anxiety symptoms, are common, occurring in approximately one-third of persons who sustained a stroke.^{1, 2} Mental health conditions are the result of a complex interaction of psychological, biological, and social factors that can impact how a patient will adjust in the aftermath of a stroke. Post-stroke depression (PSD) and anxiety (PSA) are highly comorbid and have been associated with greater risk for another stroke, disability, and mortality, decreased participation, and poorer quality of life.^3–7

Despite the high prevalence and documented major consequences on recovery, community re-integration, and quality of life, mental health issues post-stroke remain vastly underrecognized and undertreated. Early detection and proper management are critical to better outcomes in individuals with mental health issues post-stroke. Clinical guidelines for treating post-stroke mood problems include pharmacological and psychotherapeutic approaches.¹ Pharmacotherapy is typically the first line of treatment but may be associated with side effects and risks especially in those with multiple comorbidities and polypharmacy.^{8, 9} Non-pharmacological interventions (such as psychotherapy) also offer promise,¹⁰ while combining pharmacological and psychotherapeutic approaches may be more effective than either treatment alone.¹¹

Despite the availability of various treatment options, most stroke survivors report that their mental health needs are not met or prioritized as part of their recovery and rehabilitation.¹² Although some descriptive studies have explored barriers to receiving mental health care, this has not yet been studied using more rigorous, prospective population-level designs. The study by Tjokrowijoto et al¹³ in this issue is an important contribution to the growing empirical evidence-base illustrating the gaps in mental health care for persons post-stroke. Utilizing data from the Australian Stroke Clinical Registry linked with hospital, primary care billing and pharmaceutical dispensing claims, this study aimed to identify factors associated with receiving mental health treatment post-stroke and examine how mental health treatment affects long-term outcomes such as survival and hospital utilization.

Similar to prevalence rates reported in the literature,^{1, 2}, 39% of respondents self-reported experiencing anxiety or depression at 3–6 months post-stroke.¹³ However, only half of those reporting anxiety or depression received mental health treatment, primarily in the form of antidepressant medication (50%). Only 13% received a combination of psychological management and medication. To think this an isolated problem would be amiss: a nationally representative survey study in the United States (2004–2017) found that approximately two-thirds of persons with stroke who screened positive for depression received no outpatient treatment during a calendar year.¹⁴

Similar to other research,¹⁵ Tjokrowijoto et al¹³ identified men, older adults, and those who had no prior history of mental health treatment as being less likely to receive mental health treatment post-stroke. Requiring interpretive services and holding a health benefits card were barriers to receiving psychological support independent of medication prescribed. The latter may be due to cost (and limited insurance coverage) associated with psychotherapy, whereas the former underscores a well-documented disparity that ethnically/racially, culturally, and linguistically diverse patients are less likely to receive mental health treatment.^{14, 16} Being able to not only identify mental health issues but also provide appropriate treatment in these potentially underserviced populations represents an important next step for risk-reduction and promoting better outcomes post-stroke.

There are a few points to consider regarding this study. First, presence of depression or anxiety was assessed using a single self-reported item, which is not diagnostic and ignores the complexity of mental health issues that might be critical to not only identification but also treatment. Second, the study only assessed mental health at 3–6 months post-stroke. It is important to note that post-stroke mental health issues may vary across the recovery process and have different prognostic consequences.^{1, 2, 6} Mental health issues may occur acutely (within 3 months) or chronically (6 months post-stroke or later).⁵ In the acute and early rehabilitation stage, pathophysiology consists of both biological (e.g., structural changes in the brain) as well as adjustment-related factors. Identifying mental health issues is critical at this stage as it can affect participation in rehabilitation therapies, medication adherence, and, in turn, longer-term outcomes. For example, early-onset PSD is thought to develop in parallel with stroke, possibly due to direct brain injury, inflammatory processes, or acute psychosocial response to stroke, and may remit spontaneously, whereas chronic (‘late-onset’) PSD tends to be more persistent and patients who develop it have a worse functional prognosis.¹⁷ While most PSD occurs in this acute phase, PSA is usually seen in the chronic phase of stroke.¹⁸ A better understanding of the trajectories of mental health issues after stroke is important for informing treatment and further underscores that it is imperative to screen across the care trajectory.

“Of course I’m depressed, I had a stroke!” During the more chronic phases of the stroke recovery trajectory, it becomes more challenging to identify and treat mental health issues. Unfortunately, there is a common assumption –by patients, families, and at times practitioners- that feeling depressed or anxious is to be expected after sustaining a stroke and that mental health issues will resolve spontaneously once a person returns home and integrates back into the community (i.e., “resumes life-as-usual”). Unfortunately, this is often not the case. In fact, new and more significant difficulties may arise particularly as a patient realizes the full extent of functional impairments and associated losses; for example, being unable to return to work or experiencing a significant change in family roles. Because there is often less contact with stroke treatment providers at this stage, it also becomes more difficult to identify and subsequently treat mental health issues. This is only complicated by the reality that somatic symptoms common to mental health issues overlap with symptoms that may be associated with stroke. Yet it is particularly for these types of symptoms (e.g., fatigue, pain, headache, gastrointestinal distress) that patients present to their health care provider, and especially primary health care providers who play a potentially pivotal role in facilitating mental health treatment.¹³ Implementing a simple -and psychometrically sound- screening instrument like the 2-item Patient Health Questionnaire (PHQ-2) could be an effective strategy to identify patients who could be at risk for PSD.¹⁹

Finally, the current study did not observe a reduction in mortality or hospital utilization for those who received mental health treatment; however, as noted by the authors, functional recovery or quality of life -which were not assessed in this study- may have been better indicators of mental health treatment effectiveness. It is well-documented that if left untreated, mental health issues can have a range of detrimental effects on long-term outcomes post-stroke,^{3, 5, 7} but appropriate treatment may mitigate these effects.^{6, 20}

Altogether, this underscores the importance of providing information to the patient, family, and health care providers about mental health post-stroke not only during early rehabilitation but at every stage of the recovery trajectory in order to improve symptom recognition and treatment. Although not all stroke survivors develop mental health issues or pathology, mental health should be a focus of practice for all stroke survivors.

Abbreviations:

PSA

post-stroke anxiety

PSD

post-stroke depression

PHQ-2

2-item Patient Health Questionnaire