Inequities and Trends in US Adult Poststroke Depression Diagnosis and Treatment

Barriers that exist among patients with poststroke depression are inequities in clinical management by sex, age, and race/ethnicity.

Inequities in clinical management by sex, age, and race/ethnicity, are evidence of barriers in addition to health care access that may exist among patients with poststroke depression, according to study findings published recently in the Journal of Neurology, Neurosurgery, & Psychiatry.

Researchers sought to analyze privately insured individuals in the United States following stroke for rates of treatment and incidence of depression. They hypothesized differences in treatment rates across population subgroups stratified by stroke type and that diagnosis and treatment of poststroke depression would increase longitudinally.

This retrospective cohort study included 831,471 privately insured individuals at least 18 years of age in the US from 2003 to 2020 who experienced first stroke with follow-up for as much as 1 year for depression. Patients with poststroke depression were identified from ICD-9 and -10 codes and treatment was identified by prescriptions for antidepressants. Data was found in the Optum Clinformatics Data Mart, a longitudinal, deidentified commercial and Medicare Advantage claims database. Rates of poststroke depression diagnosed by age, race/ethnicity, and sex were explored using Cox proportional hazards regression analysis and treatment rates were estimated using negative binomial regression analysis.

Researchers classified stroke diagnoses as ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage. No restrictions were placed on study eligibility based on duration or continuity of follow-up. Individuals with prior depression diagnosis were not excluded.

Beneficiaries who were male, ages 18–34, and members of racial/ethnic minorities were less likely to be prescribed an antidepressant.

Researchers found from 2003 to 2020 annual diagnosis and treatment rates increased for poststroke depression (both P <.001 for trend). Women received higher diagnosis rates than men (hazard ratio [HR] 1.53; 95% CI, 1.51-1.55). They noted racial/ethnic minorities received lower diagnosis rates vs White patients (Hispanic HR 0.88; 95% CI, 0.86-0.90), (Black HR 0.76; 95% CI, 0.74-0.78), (Asian HR 0.63; 95% CI, 0.60-0.66). They found diagnosis rates varied by age (18 to 34 [2.2%] years, 35 to 49 [7.3%] years, 50 to 64 [20.2%] years, 65 years and older [70.2%]).

Overall, researchers noted approximately a 13.9% 1-year prevalence rate of poststroke depression which does not match pooled frequency estimates from meta-analyses with a prevalence rate of approximately 30%. This difference may possibly be attributed to identification of depression based on ICD codes in the current study instead of direct measures of depressive symptoms.

Researchers observed women received higher rates of treatment vs men (rate ratio [RR] 1.19; 95% CI, 1.17-1.21). They noted racial/ethnic minorities received lower rates of treatment vs White patients (Hispanic RR 0.96; 95% CI, 0.93-0.99), (Black RR 0.92; 95% CI, 0.89-0.94) (Asian RR 0.85; 95% CI, 0.80-0.90). They found treatment rates higher among older patients (35-49 [RR 1.27] years, 50-64 [RR 1.49] years, 65 years and older [RR 1.23]).

Overall, they noted almost 70% of this patient population were prescribed antidepressants.

Significant study limitations include all data derived from commercial and Medicare Advantage claims not necessarily generalizable, lack of data regarding details of insurance that may affect rates of diagnosis and treatment over time, rates of treatment based on filled prescriptions lacking data on medication adherence, unaccounted for loss to mortality, no exclusion for individuals with prior depression diagnosis, and lack of data on stroke or depression severity. Additionally, limitations include concurrent cognitive symptoms leading to underestimate of depressive symptom true burden, and unaccounted for therapeutic modalities other than antidepressants, such as psychotherapy.

“In this insured population, we identify potential inequities in clinical management of poststroke depression by gender, race/ethnicity, and age that may reflect barriers other than access to health care,” researchers concluded. Poststroke depression diagnoses and treatment rates increased across the study period. The most frequent poststroke depression rates were among women, older, and White beneficiaries. Researchers stated “Beneficiaries who were male, ages 18–34 years, and members of racial/ethnic minorities were less likely to be prescribed an antidepressant.”

References:

Elser H, Caunca M, Rehkopf DH, et al. Trends and inequities in the diagnosis and treatment of poststroke depression: a retrospective cohort study of privately insured patients in the USA, 2003-2020. J Neurol Neurosurg Psychiatry. Published online November 18, 2022. doi:10.1136/jnnp-2022-330179