Introduction

According to the World Health Organization, since the year 2000, stroke has been the second largest cause of mortality worldwide¹. Stroke is a disease classified by the presence of radiological, clinical, or pathological evidence of brain damage, which can be due to ischemia or hemorrhage in a defined cerebral vascular territory². Around 87% of strokes are ischemic in which blood flow is impaired due to a blood clot, and 10% are hemorrhagic³. Although most research surrounding prevention and intervention occurs in first world countries, more than 85% of strokes occur in low- and middle-income countries⁴. On the other hand, mental health disorders are becoming more common and are expected to increase by 2030⁵.

Mental health is still severely underfunded in many third world countries. In Mexico, only 2% of the total funding in health services is dedicated to mental health⁶, and of that 2%, more than three quarters of the money is dedicated to the maintenance of mental health hospitals⁷. This means services aimed at treating mental health difficulties are typically underfunded which is evidenced by the fact that < 40% of primary care centers have protocols to address mental health disorders⁶. Meanwhile, the prevalence of depression in the Mexican population ranges from 4 to 7.9%⁸. The ability for people to seek mental health assistance is further exacerbated by the stigma that prevails in society toward those seeking mental health care which is often fueled by the media⁷,⁹. However, according to one study, patients can also feel stigma from mental workers themselves⁸.

Depression in post-stroke patients occurs in almost a third of all patients and is considered the most common and important neuropsychiatric complication affecting the quality of life and prognosis of patients¹⁰. Depression has been shown to increase mortality rates by up to 10 times, therefore highlighting the importance of this condition in detrimentally affecting the recovery of patients¹¹.

Despite the plethora of studies highlighting the prevalence and impact of depression in those who have suffered strokes, there is limited research which studies this in developing countries. This is important because there is a lack of information regarding the prognosis of these patients, as mental health services might not be available to most of them. This study aimed to bridge current gaps in knowledge by determining the prevalence and implications of depression for those who have suffered ischemic stroke in a routine vascular clinic evaluation in Mexico.

Material and methods

A prospective cohort with a transversal evaluation was done. Patients with ischemic stroke who arrived to the Neurology Service from the Hospital Universitario “Dr. Jose Eleuterio Gonzalez” in Monterrey, Nuevo Leon, Mexico, from January of 2017 to July 2018 were recruited. The following clinical scales were performed to evaluate severity of stroke and functionality while the patients were at the hospital: the National Institute of Health Stroke Scale (NIHSS)¹², mRs¹³, Barthel¹⁴, and the Trial of Org 10172 in Acute Stroke Treatment (TOAST)¹⁵. The NIHSS scale measures the neurological deficit of the patient. The Rankin scale measures the degree of disability or dependence in daily activities, the Barthel index assesses functional independence, and TOAST is used to classify the etiology of the stroke. The exclusion criteria were patients under 18 years old, history of depression or mental disorders, and aphasia.

The follow-up was completed by presential evaluation and by phone. In the follow-up, the aforementioned clinical scales were used, and two new scales were added: the Hamilton Depression Rating Scale (HDRS; 13) and the SF-36 questionnaire¹⁶. The HDRS is a questionnaire used to assess the severity of depressive symptoms and to evaluate the response to treatment. Patients were categorized as depressed if they scored higher than 8. Patients completed the SF-36 questionnaire in person, and this was used to evaluate their quality of life. Patients with depression were sent to the neuropsychological clinic.

A descriptive analysis of the demographic and clinical variables was conducted. For the categorical variables, a univariate analysis with the exact “X” test was performed. For the categorical and variance variables, a Fisher’s test was conducted. For the continuous nonparametric variables, Mann–Whitney’s test was performed. Finally, a logistic multivariate regression analysis was done to identify independent risk factors. Results are expressed in percentages and medians with standard deviations (±). Statistically significant values are considered to be p < 0.05. SPSS version 20.0 was used to perform all the statistical analyses.

Results

In total, 93 out of 162 eligible patients were evaluated in routine neurovascular clinic and contacted by phone between 3 months and 2 years post-stroke event. The remaining 69 eligible patients could not be contacted or did not come to the presential evaluation. Fifty-six (60.2%) of the patients were male and 27 (29.8%) were female. The average age was 63.5 ± 14.08 ranging from 34 to 91 years. The mean time since the stroke and the clinical or telephonic evaluation was 93 weeks. The most common risk factors for ischemic stroke were high blood pressure, diabetes mellitus, and cardiopathy (Table 1).

More than half of the patients enrolled in this study had minor or moderate impairment defined by a value less than 11 as measured by the NIHSS scale (Table 1) during their hospitalization. Less than 25% of the patients were categorized with a moderate to severe or severe impairment (Table 1).

In the follow-up performed between 3 months and 2 years after the stroke event, more than 85% of patients showed minor or no impairments as measured by the NIHSS scale (Table 1).

The follow-up also showed that 34 patients (36.6%) (Table 2) presented as having a depressive disorder as classified by the HDRS: 28% had mild depression, 3.2% moderate depression, 4.3% severe depression, and 1.1% very severe depression. About 8.6% reported having had suicidal ideation, and 3 patients (3.2%) had thought about how to carry it out (planning). No suicides were carried out. In addition, depressed patients tended to have higher scores in all the HDRS points except for hypochondriasis and insight when compared to non-depressed patients (Table 2).

Meanwhile, the SF-36 scale found that non-depressed patients had higher scores for quality of life than depressed patients. Only 1% of the patients who met the criteria for having depression were receiving treatment at the time of the study. The complete datails of the differences between depressed and non-depressed patients are described in table 2.

All the patients that were diagnosed with depression were sent to be evaluated and treated by psychiatrists.

Discussion

This study found a high prevalence of depressive disorders among ischemic stroke patients in a routine vascular clinic evaluation (36.6%). These findings are in line with results from other studies regarding the prevalence of depression in post-stroke patients¹⁷,¹⁸. It is important to mention that only 1% of the patients that met the criteria for depression in this study were already in treatment, suggesting that many people who suffer stroke do not receive a diagnosis of depression or receive mental health treatment.

One study in Colombia found that post-stroke patients had overall more depression and stress when compared to age-matched controls¹⁹. Indeed, another study involving ischemic stroke, intracerebral hemorrhage, or cerebral venous thrombosis showed that depression and vascular cognitive impairment were common findings appearing in almost half of the patients²⁰.

Depression is a frequent disorder in the Mexican population and stigma toward mental health disorders is prevalent in society²¹,²². This may explain why many participants did not have any previous diagnosis of depression despite scoring highly for symptoms of depression.

This is the first study conducted in Mexico which evaluates depression in post-stroke patients in a routine vascular clinical evaluation which evaluates ischemic stroke only. There is other research that shows a higher amount of depression in patients who have suffered a stroke or vascular disorder (near 50%) compared to this study (36.6%). This difference might be related to the inclusion of different pathologies, and by the different age gap, with a mean age of 56 compared to 63.5²⁰.

Remission of post-stroke depression in the first few months after the stroke event is associated with greater recovery in activities of daily life²³. Therefore, conducting a longer follow-up might have provided a more detailed assessment of the quality of life of our patients.

There are plenty of different treatments for depression, the most used worldwide being pharmacological with SSRIS and TCA²⁴. Other therapies, such as CBT or acupuncture, should also be used as an adjuvant to improve the outcome²⁴,²⁵. Research is now focusing on the role that gut microbiota plays in depression, showing a different path that could also benefit the outcomes of the actual therapy²⁶.

The result from this study highlights the importance of screening for depression in post-stroke patients in the rutinary vascular clinic evaluation even if they do not have clear symptoms of depression, as prevalence is high among these patients.

Nevertheless, this study also has weaknesses. One of them is that the follow-up was not divided by time periods, which might have shown that depression might become common as the patients have to struggle or adapt to their disabilities. In addition, there is no information about the outcomes of the depressed patients that were referred to receive pharmacological therapy.

Conclusions

Depression in post-stroke patients is common in a rutinary vascular clinic evaluation, and more efforts should be made to diagnose and treat this condition in those suffering stroke.