What percentage of patients with minor stroke require psychiatric follow-up in the chronic phase of stroke?

From the Guidelines

Approximately 20-30% of patients with minor stroke require psychiatric follow-up in the chronic phase of stroke. This need arises because even minor strokes can lead to significant psychiatric complications, including depression, anxiety, and post-traumatic stress disorder. Depression is particularly common, affecting about one-third of all stroke survivors, regardless of stroke severity, as reported in the 2016 guidelines for adult stroke rehabilitation and recovery from the American Heart Association/American Stroke Association 1. Patients with minor strokes may experience these psychiatric issues despite having minimal physical disabilities, as the psychological impact of a stroke can be substantial even when physical recovery appears complete.

Key Considerations

• Early screening for psychiatric symptoms should occur at regular intervals during follow-up visits, typically at 1,3,6, and 12 months post-stroke.
• Treatment may include selective serotonin reuptake inhibitors (SSRIs) such as sertraline (50-200 mg daily) or escitalopram (10-20 mg daily), which have shown efficacy in post-stroke depression.
• Cognitive behavioral therapy is also beneficial, particularly for addressing anxiety and adjustment issues.
• The need for psychiatric follow-up is often underestimated in minor stroke patients because healthcare providers may focus primarily on physical recovery, but addressing mental health is crucial for optimal recovery and quality of life, as emphasized in the 2021 clinical performance measures for stroke rehabilitation from the American Heart Association/American Stroke Association 1.

Psychiatric Complications

• Depression incidence: up to one-third of patients with ischemic stroke, with risks including physical disability, severity of stroke, prestroke depression, and cognitive impairment 1.
• Anxiety and post-traumatic stress disorder can also occur, necessitating comprehensive psychiatric evaluation and treatment.
• Pseudobulbar affect incidence: 10%–48%, with assessment and treatment options including cognitive and emotional therapy, psychotherapy, and support groups 1.

Recommendations

• Regular psychiatric follow-up is essential for patients with minor stroke, given the high prevalence of psychiatric complications and their impact on recovery and quality of life.
• Healthcare providers should prioritize mental health assessment and treatment alongside physical rehabilitation to ensure comprehensive care for stroke survivors.

From the Research

Psychiatric Follow-up in Minor Stroke Patients

• The prevalence of post-stroke depression (PSD) in patients with minor stroke is approximately 29.0% (95% CI, 25.2-32.8) over a 1-year follow-up period 2.
• Female gender, current smoking at stroke onset, mild global cognitive impairment at 14±2 days, and stroke recurrence are independently associated with a high risk of PSD over the 1-year follow-up 2.
• Approximately three in ten patients with first-ever minor ischemic stroke may develop depression during the first year after stroke, suggesting a need for psychiatric follow-up in these patients 2.
• There is no direct evidence on the percentage of patients with minor stroke that require psychiatric follow-up in the chronic phase of stroke, but the high prevalence of PSD and other residual problems suggests that a significant proportion of patients may benefit from follow-up care 2, 3.

Residual Problems and Follow-up Care

• Patients with minor stroke often experience residual problems, including psychological, cognitive, and physical impairments, which can significantly affect their lives 3.
• Follow-up care for minor stroke patients is often variable and medically focused, with a lack of awareness among healthcare providers about the long-term problems experienced by patients 3.
• Patients emphasize the importance of understanding their diagnosis, individualized support regarding stroke risk, and addressing residual problems, highlighting the need for comprehensive follow-up care 3.

Treatment and Outcomes

• Selective serotonin reuptake inhibitors (SSRIs) may be effective in reducing post-stroke disability and improving outcomes, but the evidence is mixed and more research is needed to determine their effectiveness 4, 5.
• SSRIs may reduce the risk of future depression and improve neurological deficit scores, but they may also increase the risk of seizures and bone fractures 5.
• The use of IV thrombolysis in minor strokes is a topic of ongoing debate, with current guidelines advising against its use in patients without clearly disabling symptoms due to a lack of evidence 6.