People with mental health problems in later years were less likely to have strokes treated with thrombolysis or thrombectomy, a finding that is likely due in part to less recognition of stroke symptoms, according to a national study from Denmark.
Of more than 19,000 admissions for stroke between 2016 and 2017, reperfusion therapy was applied to 17% of patients, and even fewer in those with comorbid mental illness, regardless of severity:
- Minor mental illness: RR 0.79 (95% CI 0.72-0.86)
- Moderate mental illness: RR 0.85 (95% CI 0.72-0.99)
- Major mental illness: RR 0.63 (95% C 0.51-0.77)
“Upon arrival at the hospital within 4 hours (regardless of the hospital’s level of expertise in stroke), reperfusion therapy was still underutilized,” wrote Julie Mackenhauer, MD, and colleagues from the Danish Stroke Research Center. Aalborg University Clinical Health Services. “We identified lower recognition of stroke symptoms at all steps in the stroke chain. This resulted in delays and lower rates of reperfusion treatment among patients with a history of mental illness, especially among patients with a history of mental illness.” major mental illness.
“However, when a stroke was recognized in the prehospital setting or after hospital arrival, reperfusion treatment was performed just as quickly, and a history of mental illness or mental vulnerability was not a barrier to stroke treatment. acute stroke,” the researchers reported in Race.
His study delves into possible causal paths and mediating factors after a 2018 US study also described lower odds of IV thrombolysis in stroke patients with psychiatric illness.
Mackenhauer and colleagues estimated that total prehospital delays were approximately 67 minutes longer, after adjustment, in stroke patients with a history of severe mental illness compared with their peers without a history of mental illness. The difference widened to 123 minutes among those who had been admitted without an EMS call.
“Longer delays from symptom onset to hospital arrival contributed to patients’ risk of not being eligible for reperfusion therapy,” the authors said. “Stigma related to mental illness may contribute to the observed differences.”
The team acknowledged that the proportion of stroke patients who were called to EMS before arriving at the hospital differs between countries. The rate was a low 31% in this report from Denmark, where there is a strong primary care system that is mostly funded by taxpayers’ money and is freely accessible.
In contrast, half of stroke patients in the US presented by ambulance during the years 1997-2008, a previous study He showed.
Poor public knowledge of stroke has been suggested as a barrier to ambulance use.
“Recognizing stroke symptoms among stroke patients with poor awareness of stroke symptoms is challenging, not only in mentally ill patients. Focal stroke symptoms in addition to other mental symptoms can be difficult for both both patients and caregivers,” Mackenhauer’s team said.
They suggested more widespread use of acute MRI for rapid recognition of stroke.
Mackenhauer and colleagues conducted the present study using Danish registries that captured 19,592 admissions for acute ischemic stroke during the study period. Any mental illness was characterized as minor (18%), moderate (3%), or major (3%).
Major mental illnesses included schizophrenia, bipolar disorder, and major depression requiring hospital care; moderate mental illness included other contacts with psychiatric services; and minor mental illness was any recent prescription of antidepressants or benzodiazepines, or talk therapy in a primary care setting.
People with moderate and severe mental illness tended to be younger and more likely to have a history of prior stroke, be current smokers, live alone, use alcohol or drugs, have below-average income, and receive social assistance.
Between stroke patients with and without a history of mental illness, there were no differences in door-to-needle time, response time, on-scene time, transport time, or time to obtain images among patients who arrived within 4 hours of symptom onset.
The study authors cautioned that their registry-based reporting was subject to possible selection bias, as people with mental illness may have more undetected strokes. The database also lacked some clinical variables and information on patients’ primary care contacts.
Finally, residual confounding remains a potential limitation of the observational study despite statistical adjustment by the researchers, they said.
Disclosures
The study was supported by the regional government and a private foundation.
Mackenhauer and co-authors did not reveal anything.
Please enable JavaScript to view the comments powered by Disqus.
