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Trends and inequities in the diagnosis and treatment of poststroke depression: a retrospective cohort study of privately insured patients in the USA, 2003–2020
  1. Holly Elser1,2,
  2. Michelle Caunca3,
  3. David H Rehkopf4,
  4. Wells Andres1,
  5. Rebecca F Gottesman5,
  6. Scott E Kasner6,
  7. Kristine Yaffe7,
  8. Andrea L C Schneider6,8
  1. 1Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
  2. 2Center for Population Health Sciences, Stanford University, Stanford, California, USA
  3. 3Department of Neurology, University of California, San Francisco, California, USA
  4. 44. Epidemiology and Population Health, Stanford University, Stanford, California, USA
  5. 5National Institute of Neurological Disorders and Stroke Intramural Research Program, National Institutes of Health, Bethesda, Maryland, USA
  6. 6Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
  7. 7Departments of Psychiatry, Neurology and Epidemiology, University of California, San Francisco, California, USA
  8. 8Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
  1. Correspondence to Dr Holly Elser, Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA; Holly.Elser{at}Pennmedicine.upenn.edu

Abstract

Background Depression is a common neuropsychiatric consequence of stroke, but there is little empiric evidence regarding clinical diagnosis and management of poststroke depression.

Methods Retrospective cohort study among 831 471 privately insured patients with first stroke in the USA from 2003 to 2020. We identified diagnoses of poststroke depression using codes from the International Classification of Diseases. We identified treatment based on prescriptions for antidepressants. We used Cox proportional hazards regression analysis to examine rates of poststroke depression diagnosis by gender, age and race/ethnicity. Among individuals who received a diagnosis of poststroke depression, we estimated treatment rates by gender, race/ethnicity and age using negative binomial regression analysis.

Results Annual diagnosis and treatment rates for poststroke depression increased from 2003 to 2020 (both p for trend<0.001). Diagnosis rates were higher in women than men (HR 1.53, 95% CI 1.51 to 1.55), lower among members of racial/ethnic minorities (vs white patients: Asian HR 0.63, 95% CI 0.60 to 0.66; Black HR 0.76, 95% CI 0.74 to 0.78; Hispanic HR 0.88, 95% CI 0.86 to 0.90) and varied by age. Among individuals diagnosed with poststroke depression, 69.8% were prescribed an antidepressant. Rates of treatment were higher in women vs men (rate ratio, RR=1.19, 95% CI: 1.17 to 1.21), lower among members of racial/ethnic minorities (vs white patients: Asian RR 0.85, 95% CI 0.80 to 0.90; Black RR 0.92, 95% CI 0.89 to 0.94; Hispanic RR 0.96, 95% CI 0.93 to 0.99) and higher among older patients.

Conclusions 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 healthcare.

  • depression
  • stroke
  • epidemiology

Data availability statement

Data may be obtained from a third party and are not publicly available.

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Data availability statement

Data may be obtained from a third party and are not publicly available.

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Footnotes

  • Twitter @ElserHolly, @michelle_caunca, @drehkopf, @gottesman_lab, @KristineYaffe, @ASchneiderMDPhD

  • Contributors HE: conceptualised and designed the study, acquired and analysed the data, drafted the manuscript, revised the manuscript critically for important intellectual content, and is accountable for the overall content as guarantor. MC: conceptualised and designed the study, assisted with data interpretation, and revised the manuscript critically for important intellectual content. DR: assisted in data acquisition, assisted with data interpretation, and revised the manuscript critically for important intellectual content. WA: assisted with data interpretation and revised the manuscript critically for important intellectual content. RFG: assisted with data interpretation and revised the manuscript critically for important intellectual content. SK: assisted with data interpretation and revised the manuscript critically for important intellectual content. KY: assisted with data interpretation and revised the manuscript critically for important intellectual content. ALCS: conceptualised and designed the study, assisted with data interpretation and revised the manuscript critically for important intellectual content. All authors provided final approval for the manuscript and have confidence in the integrity of the contributions of their coauthors.

  • Funding Data for this project were accessed using the Stanford Center for Population Health Sciences Data Core. ALCS was supported by the National Institute of Neurological Disorders and Stroke project grant K23NS123340. KY was supported by the National Institute on Aging project grant R35AG071916. RFG was supported by the National Institute of Neurologic Disorders and Stroke Intramural Research Program.

  • Disclaimer The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.