Stroke Care Pathway Breaks Down for the Mentally Ill

Because we have no objective damage diagnosis protocols. If doctors can successfully recognize locked-in-syndrome they should be able to do the same for mentally ill. NO EXCUSES ALLOWED.

Stroke Care Pathway Breaks Down for the Mentally Ill

Lower use of reperfusion therapy attributed to lower stroke recognition

by Nicole Lou, Senior Staff Writer, MedPage Today August 19, 2022

People with mental health troubles in recent years were less likely to have strokes treated with thrombolysis or thrombectomy, a finding that is likely in part due to lower recognition of stroke symptoms, according to a nationwide study from Denmark.

Out of over 19,000 stroke admissions from 2016 to 2017, reperfusion therapy was applied to 17% of patients -- and even less 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)

"When arriving at hospital within 4 hours (disregarding hospital level of stroke expertise) reperfusion therapy was still underutilized," wrote Julie Mackenhauer, MD, and colleagues at the Danish Center for Clinical Health Services Research of Aalborg University. "We identified lower recognition of stroke symptoms in all steps of 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 major mental illness."

"However, when stroke was recognized either in the prehospital setting or after hospital arrival, reperfusion treatment was undertaken equally fast, and a history of mental illness or mental vulnerability was not a barrier to acute stroke treatment," the researchers reported in Stroke.

Their study elaborates on possible causal paths and mediating factors after a 2018 study from the U.S. also described lower odds of IV thrombolysis in stroke patients with psychiatric disease.

Mackenhauer and colleagues estimated total prehospital delays being approximately 67 minutes longer, after adjustment, in stroke patients with a history of major mental illness compared with peers with no 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 the 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 having EMS called before hospital arrival differs between countries. The rate was a low 31% in this report from Denmark, where there is a strong primary care system that is mainly funded by taxpayer money and freely accessible.

In contrast, half of U.S. stroke patients presented via ambulance during the years 1997-2008, a previous study showed.

Poor public knowledge about stroke has been suggested as a barrier to ambulance use.

"Recognizing stroke symptoms among stroke patients with low awareness of stroke symptoms is a challenge -- not only in patients with mental illness. Focal stroke symptoms on top of other mental symptoms may be difficult for both the patients and caregivers," Mackenhauer's team said.

They suggested more widespread use of acute MRI for speedy recognition of stroke.

Mackenhauer and colleagues conducted the present study using Danish registries that captured 19,592 acute ischemic stroke admissions during the study period. Any mental illness was characterized as minor (18%), moderate (3%), or major (3%).

Major mental illness included schizophrenia, bipolar disorder, and severe depression requiring inpatient care; moderate mental illness included other contacts with psychiatric services; and minor mental illness was any recent prescription for antidepressants or benzodiazepines, or talk therapy in a primary care setting.

People with moderate and major mental illness tended to be younger and were more likely to have a history of prior stroke, be current smokers, be living alone, use alcohol or drugs, have income below average, and be on welfare.

Between stroke patients with and without a history of mental illness, there were no differences regarding door-to-needle time, response time, on-scene time, transport time, nor in time to imaging among patients arriving within 4 hours from symptom onset.

The study authors cautioned that their registry-based report was subject to potential selection bias as people with mental illness may have more undetected strokes. The database also lacked some clinical variables and information on the patients' contacts with primary care.

Finally, residual confounding remains a possible limitation of the observational study despite statistical adjustment by the investigators, they said.

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  Nicole Lou is a reporter for MedPage Today, where she covers cardiology news and other developments in medicine. Follow

Disclosures

The study was supported by the regional government and a private foundation.

Mackenhauer and co-authors had no disclosures.

Primary Source

Stroke

Source Reference: Mackenhauer J, et al "Disparities in reperfusion therapy and time delays among patients with ischemic stroke and a history of mental illness" Stroke 2022; DOI: 10.1161/STROKEAHA.122.038591.

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