Selective serotonin reuptake inhibitor treatment and depression are associated with poststroke mortality.

BACKGROUND: Studies generally do not examine patients' prestroke depression diagnoses and treatments. OBJECTIVE: To examine the association of depression diagnosis and prestroke and/or poststroke selective serotonin reuptake inhibitor (SSRI) treatment with poststroke mortality. METHODS: We conducted a retrospective study of the medical records of a cohort of veterans with a stroke diagnosis between July 31, 2000, and September 30, 2001. Data regarding demographics, comorbidities, depression diagnosis, and treatment were abstracted from automated databases and electronic medical records for 6 months before and 1 year after the stroke index date. The survival rates of veterans who received an SSRI before and/or after the stroke were estimated using Kaplan-Meier survival analysis. Time-dependent Cox proportional hazards regression model was used to assess the association between risk factors and mortality. RESULTS: Among 870 veterans, 80 died less than 60 days after their stroke. Among the remaining 790, 12% died within 1 year, 26% died by the end of follow-up (May 1, 2007), and more than 62% were alive at the end of follow-up. Veterans were 3 times as likely to die if they had been treated for depression with an SSRI only before their stroke (hazard ratio [HR], 3.12; 95% CI 1.60 to 6.09). In the time-dependent model, SSRI treatment both before and after the stroke was protective compared with no SSRI treatment during the year following the stroke (HR 0.31; 95% CI 0.11 to 0.86). However, the survival curves crossed over and SSRI treatment before and after stroke conferred greater risk at the end of 7 years (HR 1.36; 95% CI 1.00 to 1.87). Depression diagnosis was associated with greater risk of mortality (HR 1.87; 95% CI 1.24 to 2.82). CONCLUSIONS: Poststroke SSRI treatment was associated with longer survival even though depression diagnosis was associated with earlier mortality in the unadjusted model. After a stroke, SSRI initiation or resumption of treatment should be considered as part of a medication therapy management service, especially if the patient has a history of depression or was taking an SSRI before the stroke.

Impact of antidepressant dispensing on health service use among veterans with stroke.

OBJECTIVE: To examine the association between dispensing of a selective serotonin reuptake inhibitor (SSRI) antidepressant medication and inpatient and outpatient service use in a cohort of veterans with confirmed acute stroke. DESIGN: Retrospective study. SETTING: Southeastern U. S. Veterans Health Administration (VHA) network, from October 1, 2000, to September 30, 2001. PATIENTS: 785 veterans with confirmed acute stroke. INTERVENTION: VHA and Medicare databases were used to obtain outcome information during the 12 months after the index stroke date. MAIN OUTCOME MEASURES: Number of inpatient admissions, length of inpatient stays, and number of outpatient clinic stops for all causes. RESULTS: Among the study cohort (n = 785), 12% had an SSRI dispensed 30 days or less poststroke, 19% had an SSRI dispensed between 31 and 365 days poststroke, and 69% were not dispensed an SSRI poststroke. After adjusting for risk factors, no significant association was found between time to first SSRI dispensing and inpatient use. However, patients with an early SSRI dispensing were more likely to have a greater number of all-cause outpatient stops compared with patients with later or no SSRI dispensing. Regardless of time to first dispensing, patients dispensed an SSRI had more outpatient clinic stops than patients without the medication. CONCLUSION: SSRI dispensing was not predictive of inpatient use but was a strong predictor of all-cause outpatient clinic stops.

Does prestroke depression impact poststroke depression and treatment?

OBJECTIVES: To 1) describe the prevalence of before the stroke depression (BSD) and poststroke depression (PSD) and 2) serotonin selective reuptake inhibitor (SSRI) treatment patterns. DESIGN: Naturalistic, retrospective cohort design. SETTING: Veterans Healthcare System. PARTICIPANTS: Seven hundred ninety veterans with confirmed stroke during fiscal year 2001. MEASUREMENTS: Diagnosis of depression and dispensing for antidepressants before and after stroke. RESULTS: A depression diagnosis was noted for nearly 10% (N = 74) of veterans before their stroke and nearly 26% afterward (N = 205). Among those with a BSD diagnosis, 75.7% received a PSD diagnosis after their stroke. Only 20.9% of the veterans without a BSD diagnosis received a PSD diagnosis afterward (odds ratio [OR] = 9.5, 95% confidence interval [CI] = 5.4-16.5). Nearly 32% were dispensed a SSRI. Veterans receiving an SSRI before their stroke were more likely to receive one afterward (OR = 31.9, 95% CI: 17.4-58.4). Nearly 48% of those with a BSD diagnosis were dispensed an SSRI < or =30 days if they had a PSD diagnosis < or =30 days, but 48% without a PSD diagnosis were still dispensed an SSRI < or =30 days if they had a BSD diagnosis. Conversely, among those without a BSD diagnosis, 39.4% were dispensed an SSRI < or =30 days if they had a PSD diagnosis but only 7.2% without a PSD diagnosis in < or =30 days with no BSD diagnosis. CONCLUSION: Patients' depression status before the stroke is a significant predictor of PSD and providers' SSRI prescribing behavior but not age. Given the deleterious effects of PSD, physicians may be tending toward prophylaxis or early treatment even before the evidence to support such treatment leads to standard practice recommendations.

Racial and ethnic disparities in post-stroke depression detection.

OBJECTIVES: Post-stroke depression (PSD) is common among stroke survivors and is associated with increased morbidity and mortality. Little is understood about racial/ethnic differences in PSD detection. This study assessed the racial/ethnic disparities in PSD detection in a national cohort of Department of Veterans Affairs (VA) acute stroke patients. METHODS: The study included VA patients who: received inpatient care for acute stroke within 2001; survived >60 days post-index hospitalization; had an index stay <365 days; and were confirmed VA healthcare enrollees. PSD was established if a patient had a depression diagnosis in VA or Medicare inpatient or outpatient files, or was dispensed an antidepressant with guideline recommended minimum daily dosage during the 12 months post stroke. A multivariate logistic regression model was fitted to estimate the effects of race/ethnicity on PSD detection, adjusting for sociodemographic and clinical factors. RESULTS: The study cohort (N = 5825) was comprised of 66% white, 22% black, 7% Hispanic, and 6% for all other racial/ethnic categories. Among these stroke patients, 39% had PSD. Black and 'all other' racial/ethnic categories were significantly less likely to be diagnosed with PSD than non-Hispanic whites, even adjusting for potential risk factors. CONCLUSION: White, non-Hispanic VA acute stroke patients were more likely to be diagnosed with PSD, even controlling for sociodemographic and clinical characteristics. Whether these findings suggest racial/ethnic differences in symptom endorsement by patients or in symptom recognition by providers is not clear.

Geographic variation in poststroke depression among veterans with acute stroke.

This study compared patterns of poststroke depression (PSD) detection among veterans with acute stroke in eight U.S. geographic regions. Department of Veterans Affairs (VA) medical and pharmacy data as well as Medicare data were used. International Classification of Diseases-9th Revision depression codes and antidepressant medication dispensing were applied to define patients' PSD status 12 months poststroke. Logistic regression models were fit to compare VA PSD diagnosis and overall PSD detection between the regions. The use of VA medical data alone may underestimate the rate of PSD. Geographic variation in PSD detection depended on the data used. If VA medical data alone were used, we found no significant variation. If VA medical data were used along with Medicare and VA pharmacy data, we observed a significant variation in overall PSD detection across the regions after adjusting for potential risk factors. VA clinicians and policy makers need to consider enrollees' use of services outside the system when conducting program evaluation. Future research on PSD among veteran patients should use VA medical data in combination with Medicare and VA pharmacy data to obtain a comprehensive understanding of patients' PSD.

Case-finding algorithm for post-stroke depression in the veterans health administration.

OBJECTIVES: Post-stroke depression (PSD) is prevalent, often undiagnosed, and undertreated. The accuracy of detecting patients with post-stroke depression in administrative databases has not been examined.The objective was to validate a case-finding algorithm for post-stroke depression (PSD) among veteran stroke survivors. METHODS: We conducted a retrospective cohort study of veterans admitted to two local VHA facilities for an inpatient episode of care for acute ischemic stroke. Our cohort included all patients from two medical centers who were identified in the fiscal year (FY) 2001 VHA inpatient database using high specificity stroke ICD-9 codes. FY 2002 VHA and Medicare inpatient, outpatient, and pharmacy data were used to examine the patients' 12-month PSD status by using ICD-9 depression codes and antidepressant use. We assessed our accuracy about patients' PSD from the administrative databases through standardized chart reviews. RESULTS: Of our 185 subject cohort, 50 (27%) were identified as having PSD. The most sensitive case-finding algorithm for PSD included having an ICD-9 code diagnosis for depression or receiving a prescription for an approved-dosage of antidepressant medication. However, the algorithm of receiving an ICD-9 code for primary or secondary diagnoses of depression revealed the largest positive predictive value. CONCLUSIONS: A case-finding algorithm using outpatient ICD-9 codes or medication was the most sensitive in identifying cases of PSD. The use of ICD-9 codes alone may be adequate for characterizing a cohort with PSD. Intention for use should be considered when choosing an algorithm to detect PSD.

Identifying veterans with acute strokes with high-specificity ICD-9 algorithm with VA automated records and Medicare claims data: a more complete picture.

Medicare claims data are available to Department of Veterans Affairs (VA) researchers to identify veterans with acute stroke. Our study sought to (1) ascertain whether additional acute stroke cases are identified with Medicare data and (2) assess the use of VA and Medicare inpatient automated data for assigning the stroke date. The study population was veterans living in Veterans Integrated Service Network 8 with an acute stroke diagnosis during fiscal year 2001. High-sensitivity and high-specificity algorithms were applied to VA data sets and matched with Medicare files. We confirmed acute stroke cases and index dates using the VA Computerized Patient Record System (CPRS). VA data identified 582 veterans with acute stroke, but Medicare claims data identified 201 more such veterans. CPRS confirmed 94% of the VA and 77% of the Medicare cases. The median difference between CPRS and automated index dates was 11 days for VA and 4 days for Medicare data. Use of both VA and Medicare data provides a more complete sample of veterans with acute stroke.