Proactive Pharmacist Counseling About Post-Stroke Depression Prevention Can Help Improve Outcomes

Proactive Pharmacist Counseling About Post-Stroke Depression Prevention Can Help Improve Outcomes

Post-Stroke Depression Prevention Post-stroke depression has been recognized for decades, yet the first scientific statement on the condition wasn’t published until December 2016. The report released by the American Heart Association (AHA) delivers some key pieces of information that are vital for pharmacist counseling.

The high incidence of post-stroke depression, the fact that it increases mortality—and that it may be preventable—point to the critical role of patient awareness and education. Pharmacists can help enhance physical and cognitive recovery from a stroke by encouraging patients to talk with their doctor about post-stroke depression prevention.

The Challenge of Post-Stroke Depression

Depression tends to be ignored. Sometimes it’s not recognized because emotional lows are a normal part of everyday life; other times people are embarrassed to admit the depth of the problem or their family and friends tell them to just shake it off. Similar attitudes are evident following a stroke. Patients and their loved ones shrug off symptoms—or don’t even recognize them—because they fully expect stroke-related trauma to cause emotional fallout. But this mindset is a mistake. Patients with post-stroke depression have a higher risk for recurrent vascular events, suboptimal recovery, and mortality, so it’s essential for pharmacists to intervene as they dispense post-stroke medications.

The AHA Scientific Statement reported that multiple studies verify a high prevalence of post-stroke depression:1

  • 31 percent of stroke patients meet the diagnostic criteria for depression within 1 year (compared with 5 to 13 percent in adults without stroke).
  • 23 percent are depressed at 5 years following stroke.
  • Pooled hazard ratio for mortality is 1.52.

Another study published in September 2016 in the New England Journal of Medicine reported results from a Danish cohort of more than 145,000 controls and 135,000 patients with a first-time hospitalization for stroke and no baseline depression. The researchers found the following:2

  • 25 percent developed depression within the first 2 years
  • Risk for incident depression in the first 3 months was increased nearly ninefold.
  • Risk for incident depression during the second year was almost twofold.

Heterogeneity between studies makes it hard to generalize risk factors, but the most consistent predictors of post-stroke depression include:

  • Stroke severity
  • Physical disability
  • Cognitive impairment
  • History of depression

Key Information from AHA Scientific Statement on Post-Stroke Depression

The AHA summarizes the challenge of post-stroke depression by calling it underrecognized, underinvestigated, and undertreated. The scientific statement offers a comprehensive review of the current evidence and provides “implications” for clinical practice, but in nearly every category the authors wrote that no recommendations are possible due to insufficient evidence—a sad conclusion that could be depressing except for the fact that there’s plenty of information in the report to guide patient education and pharmacist outreach.

A brief overview of the scientific statement begins with this information:

  • Pathophysiology – The pathophysiology of post-stroke depression is best described as poorly understood, but the experts believe it includes biological and psychosocial components.
    • Biological causes – Research increasingly points to a physical basis for post-stroke depression. Potential factors being explored include lesion location, inflammation, and genetic influence.
    • Psychosocial factors – Social isolation and a psychiatric history increase the risk for post-stroke depression.
  • Influence on functional outcome – Post-stroke depression is associated with increased cognitive and functional deficits. Depression influences recovery by limiting the patient’s participation in rehabilitation or by directly affecting the biological process of neuroplasticity.

Recognizing depression in stroke patients can be a challenge, depending on the severity of the stroke and symptoms such as flat affect, aprosodic speech, emotional lability, and pseudobulbar affect. As a result, the AHA makes this recommendation: All health care practitioners should have a high index of suspicion for depression, especially at the start of rehabilitation. One simple screening tool, the Patient Health Questionnaire (PHQ-9), consists of nine simple questions and has a high sensitivity for detecting post-stroke depression.3 But if you decide to include a depression assessment during patient counseling, it’s critical to follow up to see if the patient obtained treatment.

Treatment for post-stroke depression:

  • Pharmacologic treatment: A meta-analysis published in November 2016 in Medicine reported that SSRIs and TCAs significantly improved post-stroke depression.4 SSRI use after a stroke also improves motor recovery. However, patients must be carefully evaluated due to the potential for adverse effects.
  • Psychosocial interventions: Various therapies may effectively treat post-stroke depression, including cognitive behavioral therapy, motivational interviewing, home-based therapy, and problem-solving therapy. Some patients also need adjunctive antidepressant medication for optimal benefits from psychological therapies.

Role of Pharmacists in Post-Stroke Depression Prevention

One of the most important pieces of information is that early treatment can help prevention post-stroke depression. This is an exciting and emerging field of research, but so far, clinical trials reviewed by the AHA demonstrate that pre-emptive pharmacological and psychological intervention successfully prevent depression. While future studies will clarify optimal timing and treatment duration, one systematic review published in 2009 found significant improvement when treatment was started in the first month following stroke.5

These studies suggest that it’s worth your time to carefully assess each individual. Knowing that you may help prevent post-stroke depression is motivation to create a pharmacy counseling protocol. The steps to take aren’t new—they’re consistent with your usual patient outreach—but sometimes you need to help pharmacy teams break out of standard, time-pressured pattern to focus energy on a new goal. Here are four simple steps for post-stroke patients:

  • Identify high-risk patients and assess for depression; ask about symptoms such as lack of energy, difficulty concentrating and sleeping, irritability, thoughts of suicide, and feeling sad, anxious, hopeless, worthless, or guilty. Also ask about post-stroke pain syndrome, as chronic pain often causes depression.
  • Educate patients and caregivers about depression—emphasize that depression inhibits stroke rehabilitation and stress the importance of getting treatment.
  • Ask for permission to communicate with physicians and the rehabilitation team so they can develop a treatment plan.
  • Follow-up by phone or the next time they refill a prescription.

Outreach to Prevent or Treat Depression Has Long-Lasting Impact

Following a stroke, patients often have a team of medical specialists helping them rehabilitate, but they may overlook depression because they’re focused on physical and cognitive recovery. Pharmacists have a unique opportunity to intervene and raise awareness, which may prevent depression but at the very least, it will help patients get the treatment they need. In the process, you’ll improve functional outcomes, give them better quality of life, and even instill hope for a long life.

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Show 5 footnotes

  1. “Poststroke Depression: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association,” December 2016, http://stroke.ahajournals.org/content/early/2016/12/08/STR.0000000000000113.full.pdf?download=true
  2. “Depression and Stroke,” September 2016, http://www.jwatch.org/na42297/2016/09/23/depression-and-stroke
  3. “The Patient Health Questionnaire – PHQ-9,” accessed February 2017, http://www.agencymeddirectors.wa.gov/files/AssessmentTools/14-PHQ-9%20overview.pdf
  4. “Efficacy and Feasibility of Antidepressant Treatment in Patients with Post-Stroke Depression,” November 2016, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5106064/
  5. “Interventions for Preventing Depression After Stroke,” June 2009, http://stroke.ahajournals.org/content/40/7/e485
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