ARTICLE IN BRIEF
Investigators reported that one in twelve patients reported thinking about suicide in the past two weeks in a survey. Moreover, the study found that suicidal ideation among stroke patients exceeded that among patients with cancer, diabetes, or myocardial infarction.
Suicidal ideation appears to be strikingly common among stroke patients, indicating the need for routine screening for and treatment of depression.
That was the conclusion of a study looking at suicidal ideation among more than 6 million stroke patients between 2005 and 2010. The study, reported at the International Stroke Conference in Honolulu, Hawaii, in February, found that one in twelve patients reported thinking about suicide in the past two weeks.
Moreover, the study found that suicidal ideation among stroke patients exceeded that among patients with cancer, diabetes, or myocardial infarction.
“Our study is the first that we are aware of that compared the prevalence of suicidal thoughts among stroke survivors with suicidal thoughts in individuals with other conditions such as cancer, heart attack, and diabetes,” lead author Amytis Towfighi, MD, told Neurology Today. “We were struck by the fact that those with stroke were more likely to have suicidal thoughts than those with any of those other conditions.
“In addition, we were intrigued by the finding that such a large proportion of stroke survivors (7.8 percent) endorsed suicidal thoughts in the two weeks before the survey. The individuals in our study could have had their stroke years before the survey, so it was interesting that the prevalence was that high, even years after the event. Our study also found that one third of the individuals with suicidal thoughts had PHQ-9 [Patient Health Questionnaire-9] scores of 10 or less (indicating, at most, mild depression). This suggests that a targeted question regarding suicidal ideation may be necessary, and screening for depression alone may not be sufficient for identifying individuals at risk.”
In the study, Dr. Towfighi and colleagues assessed the prevalence of suicidal ideation among adults 20 years or older who reported a history of stroke and participated in National Health and Nutrition Examination Surveys — a series of cross-sectional surveys of a nationally representative sample of the US population from 2005 through 2010. Suicidal ideation in the past two weeks was determined from item 9 of the PHQ-9: “In the last two weeks how often have you had thoughts that you would be better off dead, or of hurting yourself.”
Socio-demographic factors, health behaviors, and comorbid conditions were examined as potential correlates. Results were compared with those of people with a history of myocardial infarction (MI), diabetes, and cancer.
Between 2005 and 2010, an estimated 6,235,528 adults in the US reported a history of stroke. A total of 400,640 patients (7.8 percent of the total stroke patients) reported having suicidal ideation within the previous two weeks. This was higher than the feelings reported by patients with myocardial infarction (6.2 percent), diabetes (5.2 percent), and cancer (4.1 percent).
They also found that seven variables predicted suicidal ideation: higher depression score, younger age, higher BMI, lower education level, lower poverty index, female sex, and unmarried marital status. “The first four predictors were the most important factors for predicting suicidal thoughts,” Dr. Towfighi said. “The subsequent three factors were equally important.”
She told Neurology Today that, to her knowledge, there are no current US outpatient guidelines recommending screening for depression or suicidal thoughts after stroke. “Our study highlights the importance of screening for depression and suicidal ideation in routine clinical encounters with stroke survivors,” Dr. Towfighi said. “Treatment strategies include mobilizing social support, psychotherapy, and antidepressant medications. The level of neurologists' involvement would likely depend on the health care setting.”
SCREEN FOR DEPRESSION, EXPERTS SAY
Neurologists who reviewed the report for Neurology Today said the risk for depression among stroke patients is confirmed by research and widely recognized by neurologists. And they agreed that the data support screening for depression in patients after stroke and TIA. But they noted the dramatic nature of the findings — especially the comparison of suicidal ideation in other conditions — should be a red alert to clinicians, who should do appropriate follow-up for depression and make psychiatry referrals when appropriate, they said.
“Depression is remarkably under-diagnosed and undertreated,” said Brett Kissela, MD, professor and vice chair of education and clinical services in the department of neurology and rehabilitation medicine at the University of Cincinnati. “Of course stroke is a serious illness causing loss of function, so it's natural to think that people will become depressed,” Dr. Kissela said. “Some people talk about it as a fate worse than death. But in fact there is probably something biological specifically associated with stroke. There is injury to the brain and that increases the risk for depression.”
Neurologist Cheryl Bushnell, MD, director of the Wake Forest Baptist Stroke Center at Wake Forest Baptist School of Medicine, said that that the stroke victims that are at the highest risk are younger patients and women. “I know from my own research that women are more likely to have depression and worse quality of life than men, so this is not surprising,” she told Neurology Today. “In addition, women are more likely to be living alone and less likely to be married, so this makes intuitive sense that women are higher risk.”
She said neurologists should screen for both depression and suicidal thoughts, as well as recognize the factors that would increase the risk, such as pre-stroke mood disorder, female sex, younger age, and the effect stroke has on pre-morbid functioning — such as the inability to work or care for family.
“In addition, prescription of SSRIs [selective serotonin re-uptake inhibitors] is fairly common and comprehensive treatment of depression with counseling is very important,” Dr. Bushnell said. “There is research to support this approach to improve outcomes. I think most neurologists would feel comfortable prescribing depression treatments, but with suicide issues, a psychiatrist and/or clinical psychologist should also be consulted.”
Dr. Kissela said: “If I don't see a treatment response to an SSRI, I will refer to a psychiatrist.”
Nada El-Husseini, MD, assistant professor of neurology/vascular neurology at Duke University Medical Center, and colleagues reported in a paper published in Stroke last year that among subjects with persistent depression, 67.9 percent of those with stroke and 70 percent of those with transient ischemic attacks were not using antidepressants at either three months or twelve months post-stroke.
Dr. El-Husseini added: “In the current study, it would be important to know if the rate of depression and the severity of depression based on PHQ-9 score were compared between individuals with stroke, MI, diabetes, and cancer.”
Future studies should also “differentiate between active and passive suicidal ideations, suicidal attempts, and completed suicide to get the whole picture about `suicidality' post stroke,” she said. “This study re-emphasizes the need for neurologists to ask about suicidality when screening for depression post-stroke, or at the very least, ask about it in those who are depressed.”