Andrea Morotti, MD
Stroke and cardiac diseases are major determinants of morbidity and mortality in patients with mental illness.1 Previous studies showed that presence of psychiatric disease independently associated with higher chances of poor outcome after stroke, and one of the mechanisms mediating this association may be the underuse of reperfusion therapies such as intravenous thrombolysis (IVT). Using a large national sample of stroke patients, Dr. Bongiorno and colleagues investigated whether the presence of comorbid psychiatric disease was associated with lower odds of receiving IVT.
Patients were selected using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. The authors focused on the following psychiatric diseases: schizophrenia or other psychoses, bipolar disorder, depression, or anxiety. The association between mental illness and the rate of IVT was investigated using a multivariable regression model.
A total of 325,009 stroke patients met the inclusion criteria for the study, and the presence of any comorbid mental illness was 12.8%. The rate of IVT was 4.4% in patients without mental illness versus 3.6% in those with a diagnosis of mental illness. After adjustment for potential confounders, the presence of any psychiatric disease was independently associated with a lower probability of being treated with IVT for acute ischemic stroke (adjusted odds ratio, 0.80; 95% confidence interval, 0.76–0.85). In subgroups analysis, all psychiatric comorbidities except bipolar disorder were significantly associated with lower chances of receiving IVT (Figure).
The determinants of the underuse of IVT in patients with psychiatric disease remain unknown. Delayed presentation, poor social support or wrong diagnosis of conversion disorder by stroke physicians may be plausible explanations for the observed findings. All these are potentially modifiable factors, suggesting the need for further research and efforts aimed at equalizing stroke care for all patients. In particular, the possibility of conversion disorder or malingering in patients presenting with stroke-like symptoms should not discourage physicians from the use of IVT because this therapy is safe in stroke mimics including functional disorders.2
As acknowledged by the authors, some limitations should be highlighted. First, diagnosis of stroke and mental illness with (ICD-9-CM) codes may have underestimated the prevalence of psychiatric disease. Second, the authors were not able to account for active vs. past diagnosis of psychiatric disease. Finally, no data on medications, stroke location and etiology, and exact reason for exclusion from IVT were available.
In conclusion, this study highlighted psychiatric disease as a barrier to treatment in acute ischemic stroke. Future studies should focus on the mechanisms underlying this interesting association to develop targeted interventions to equalize stroke care.
- Chaddha A, Robinson MSW EA, Kline-Rogers EN, Alexandris-Souphis BSN TR, Rubenfire M. Mental Health and Cardiovascular Disease. Am J med. 2016. doi:10.1016/j.amjmed.2016.05.018.
- Tsivgoulis G, Zand R, Katsanos AH, et al. Safety of Intravenous Thrombolysis in Stroke Mimics: Prospective 5-Year Study and Comprehensive Meta-Analysis. Stroke. 2015;46(5):1281-1287. doi:10.1161/STROKEAHA.115.009012.