Receipt of Mental Health Treatment in People Living With Stroke: Associated Factors and Long-Term Outcomes

Abstract

BACKGROUND: Untreated poststroke mood problems may influence long-term outcomes. We aimed to investigate factors associated with receiving mental health treatment following stroke and impacts on long-term outcomes. METHODS: Observational cohort study derived from the Australian Stroke Clinical Registry (AuSCR; Queensland and Victorian registrants: 2012–2016) linked with hospital, primary care billing and pharmaceutical dispensing claims data. Data from registrants who completed the AuSCR 3 to 6 month follow-up survey containing a question on anxiety/depression were analyzed. We assessed exposures at 6 to 18 months and outcomes at 18 to 30 months. Factors associated with receiving treatment were determined using staged multivariable multilevel logistic regression models. Cox proportional hazards regression models were used to assess the impact of treatment on outcomes. RESULTS: Among 7214 eligible individuals, 39% reported anxiety/depression at 3 to 6 months following stroke. Of these, 54% received treatment (88% antidepressant medication). Notable factors associated with any mental health treatment receipt included prestroke psychological support (odds ratio [OR], 1.80 [95% CI, 1.37–2.38]) or medication (OR, 17.58 [95% CI, 15.05–20.55]), self-reported anxiety/depression (OR, 2.55 [95% CI, 2.24–2.90]), younger age (OR, 0.98 [95% CI, 0.97–0.98]), and being female (OR, 1.30 [95% CI, 1.13–1.48]). Those who required interpreter services (OR, 0.49 [95% CI, 0.25–0.95]) used a health benefits card (OR, 0.73 [95% CI, 0.59–0.92]) or had continuity of primary care visits (ie, with a consistent physician; OR, 0.78 [95% CI, 0.62–0.99]) were less likely to access mental health services. Among those who reported anxiety/depression, those who received mental health treatment had an increased risk of presenting to hospital (hazard ratio, 1.06 [95% CI, 1.01–1.11]) but no difference in survival (hazard ratio, 1.04 [95% CI, 0.58–1.27]). CONCLUSIONS: Nearly half of the people living with mood problems following stroke did not receive mental health treatment. We have highlighted subgroups who may benefit from targeted mood screening and factors that may improve treatment access.

Mental Health Issues Poststroke: Underrecognized and Undertreated

“…Similar to other research, 15 Tjokrowijoto et al 13 identified men, older adults, and those with no prior history of mental health treatment as being less likely to receive mental health treatment poststroke. Requiring interpretive services and holding a health benefits card were barriers to receiving psychological support independent of medication prescribed.…”

“…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 al 13 identified men, older adults, and those with no prior history of mental health treatment as being less likely to receive mental health treatment poststroke. Requiring interpretive services and holding a health benefits card were barriers to receiving psychological support independent of medication prescribed.…”

“…Yet, it is particularly for these types of symptoms (eg, 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 could be an effective strategy to identify patients 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.…”

“…12 While some descriptive studies have explored barriers to receiving mental health care, more rigorous, prospective population-level design studies are lacking. The study by Tjokrowijoto et al 13 in this issue is an important contribution to the growing empirical evidence-base illustrating the gaps in mental health care for persons poststroke. 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 poststroke and examine how mental health treatment affects long-term outcomes such as survival and hospital utilization.…”

“…Like prevalence rates reported in the literature, 1,2 39% of respondents self-reported experiencing anxiety or depression at 3 to 6 months poststroke. 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.…”