Stroke is responsible for a third of global mortality each year; it represents the second cause of global death in Spain. Post-stroke depression is one of the most described complications; up to 30% of patients who suffer a stroke develop it. The first choice treatment for stroke of ischemic origin is mechanical thrombectomy. Thanks to this type of endovascular intervention, it is possible to reduce the sequelae that this pathology generates, which is why it seemed interesting to know the subsequent impact and its influence on the development of depression. after the stroke.
Main objectiveTo observe the early incidence of depressive states in patients who underwent mechanical thrombectomy as a treatment option.
MethodologyObservational, descriptive, longitudinal, prospective multicenter study with follow-up after 2 weeks of treatment, at one month and at 3 months.
ResultsPatients who underwent mechanical thrombectomy showed decreasing rates of depression. An incidence of depression of 18% is observed at 2 weeks, with a decrease to 10% in the third month (p < 0.084).
ConclusionPerforming a mechanical thrombectomy as a stroke treatment may influence the development of subsequent depression.
El ictus es responsable de un tercio de la mortalidad mundial cada año, representa en España la segunda causa de muerte global. La depresión posterior al Ictus es una de las complicaciones más descritas, hasta un 30 % de los pacientes que sufren un ictus la desarrollan. El tratamiento de primera elección para el ictus de origen isquémico es la trombectomía mecánica, gracias a este tipo de intervención endovascular es posible reducir las secuelas que esta patología genera por lo que pareció interesante conocer la repercusión posterior y su influencia en el desarrollo de la depresión tras el ictus.
Objetivo principalObservar la incidencia temprana de estados de depresión en pacientes a los que se les realizó una trombectomía mecánica como opción de tratamiento.
MetodologíaEstudio observacional, descriptivo, longitudinal, prospectivo multicéntrico con un seguimiento posterior a las 2 semanas del tratamiento, al mes y a los 3 meses.
ResultadosLos pacientes a los que se les realizó una trombectomía mecánica presentaron cifras en descenso en cuanto a la incidencia de depresión. Se observa una incidencia de depresión del 18% a las 2 semanas, con un descenso al 10% en el tercer mes (p < 0,084).
ConclusiónLa realización de una trombectomía mecánica como tratamiento de un ictus puede influir en el desarrollo de una depresión posterior.
Globally, one in six adults suffers a stroke,1 which is responsible for almost 10% of deaths and 5% of disabling illnesses worldwide.2
Strokes are the second leading cause of death globally after coronary heart disease,3 the leading cause of disability, and the most common consequences after suffering this event are physical disability and cognitive impairment.4
Around 85% of strokes are ischaemic. Of these, 40%–50% are caused by occlusion of one of the large blood vessels, 25% are lacunar infarcts, and 5% are embolisms, non-atherosclerotic occlusions, or other blood disorders. The remainder are haemorrhagic.2
Cerebrovascular disease is also responsible for the loss of the majority of disability-adjusted life years,5 significantly affecting the quality of life of both patients and their families.6 Approximately 30% of stroke survivors will require lifelong assistance with activities of daily living.7 Twenty per cent will need assistance with ambulation, and 16% will require institutional care.8
Stroke is considered a traumatic event, and due to its serious consequences, it has become a global health problem over the years, affecting not only physical well-being but also psychological, social, and economic well-being.9
Post-stroke depression is one of the most frequently described complications, with the literature indicating that 30% of stroke patients develop post-stroke depression.10
Depression is associated with greater functional disability, higher mortality, a significantly lower quality of life, and ultimately, a poorer prognosis in post-stroke recovery.10
The level of functional recovery is directly related to the speed and effectiveness of the intervention. Therefore, effective treatment, delivered as quickly as possible, results in fewer or even no functional complications. However, the social stigma associated with this condition and the lifestyle changes it entails, even in the absence of serious sequelae, can lead to persistent emotional, affective, and psychological deficiencies, and the development of depression.11
Studies have observed a similar number of cases of post-stroke depression among patients with both fewer and a greater number of physical sequelae, indicating that the risk of developing depression after a stroke is not solely related to the severity of physical sequelae. Other factors can have a negative impact, and it is thus important to assess and evaluate the possibility of developing a depressive state without discriminating against patients who have recovered their functional status.11,12
Post-stroke depression is defined as a depressive state following the onset of a stroke.10,13 One in three stroke survivors will experience post-stroke depression, which has a significant impact on rehabilitation from potential long-term effects. It is the most common psychiatric problem following stroke,14 making long-term follow-up of susceptible patients crucial.15
Furthermore, post-stroke depression considerably increases the risk of another stroke, and both recurrence and mortality risks are elevated when depression is present. Accurately diagnosing post-stroke depression is very challenging: in the acute phase of stroke, survivors tend not to recognize mood symptoms as depression, but rather attribute them to the stroke's after effects, leading them to denial or somatisation of these symptoms.16
The treatment of choice for ischaemic stroke is mechanical thrombectomy. Early recanalisation of occluded arteries through mechanical thrombectomy restores cerebral perfusion, significantly reducing sequelae. However, no studies have been found that specifically link the possible association between post-mechanical thrombectomy treatment and the onset of depression.17
The objective of this study was to determine the incidence of depression in patients with ischaemic stroke after undergoing mechanical thrombectomy as a treatment option at the Puerta de Hierro University Hospital and the 12 de Octubre Hospital in Madrid during the 2023–2024 period.
MethodAn observational, descriptive, longitudinal, prospective, multicentre study was conducted with follow-up at 2 weeks, 1 month, and 3 months post-treatment.
The target population consisted of patients who underwent mechanical thrombectomy as treatment for ischaemic stroke, and the accessible population consisted of patients who underwent mechanical thrombectomy at the Puerta de Hierro University Hospital (HUPH) and the 12 de Octubre University Hospital in Madrid (HUDO). The sample was recruited over a 6-month period, from December 2023 to May 2024.
The inclusion criteria were: patients who were independent in their activities of daily living before the thrombotic event, absence of a depressive episode prior to the thrombotic event, and patients who, after treatment, had an optimal level of consciousness (Glasgow Coma Scale score of 15) to allow for assessment.
The exclusion criteria were: patients who underwent mechanical thrombectomy as treatment for an ischaemic stroke but whose stroke became haemorrhagic during the procedure, and cases in which mechanical thrombectomy was performed as treatment for an ischaemic stroke but the thrombotic event was not reversed during the procedure, and therefore the cerebral infarction did not resolve.
The primary outcome of the study was depression. It was measured using the Patient Health Questionnaire-9 (PHQ-9), which consists of 9 items. Each item of the PHQ-9 is scored from 0 to 3, with a minimum score of 0 and a maximum of 27, where 0 represents no depression and 27 represents severe depression (Table 1). It has demonstrated validity in detecting post-stroke depression.14,18
PHQ-9 scale: questionnaire.
| During the last 2 weeks, how often have you been affected by any of the following problems? (Use × to indicate your answer) | Not at all | Several days | More than half the days | Every day |
|---|---|---|---|---|
| 1. Little interest or pleasure in doing things | ||||
| 2. Feeling sad, depressed, or hopeless | ||||
| 3. Difficulty falling or staying asleep, or sleeping too much | ||||
| 4. Feeling tired or having little energy | ||||
| 5. Poor appetite, or overeating | ||||
| 6. Feeling bad about yourself (or that you are a failure or have disappointed yourself or your family) | ||||
| 7. Difficulty concentrating on activities, such as reading the newspaper or watching television | ||||
| 8. Moving or speaking so slowly that other people may have noticed. Or the opposite, feeling so nervous and restless that you have been moving more than usual | ||||
| 9. Thoughts that you would be better off dead or of hurting yourself in some way |
Secondary outcomes assessed included functional capacity and quality of life.
The validated Barthel Index was used to measure functional capacity. It consists of ten parameters that measure basic activities of daily living, each assigned a score (0, 5, 10, 15), resulting in a final score ranging from 0 to 100. The total score for maximum independence is 100, and for maximum dependence,0.19
Quality of life was measured using the ECVI-38 instrument, validated in 2005 by Fernández-Concepción. This scale uses a Likert-type response format with five possible responses: 1 indicates no impairment, and 5 indicates extreme impairment. The maximum score is 100 points. A score below 25 indicates no impairment; between 25 and 50, mild impairment; between 50 and 75, moderate impairment; and a score of 75 or higher indicates severe impairment.20
The health variables included in the study were physical exercise (yes/no) and sleep quality, measured using the Oviedo Sleep Questionnaire (OSQ), a brief interview that provides information about the patient's sleep-wake cycle. It consists of 15 items, 13 of which are grouped into 3 subscales: subjective sleep satisfaction (item 1), insomnia (9 items), and hypersomnia (3 items). The other 2 items refer to parasomnias and medication use. Each item is scored from 1 to 5, except for item 1, which is scored from 1 to 7. The insomnia subscale ranges from 9 to 45: higher scores indicate greater insomnia severity and, therefore, poorer sleep quality. The diagnosis of insomnia was established using the COS 2-1, 2-2, 2-3, 2-4, and 7 items, a reliable and validated instrument according to the ICD-10 and DSM-IV diagnostic criteria for patients with depressive disorders.21
Sociodemographic variables considered included age, sex, marital status, dependents, occupation (requiring specialised training), and educational level.
Data collection involved contacting each participant by telephone after providing them with an information sheet and obtaining their signed informed consent. Participants then completed the different scales, and their responses were recorded in a coded database.
Data analysisA consecutive non-probability sampling method was used in both hospitals. Participants were selected as they were admitted for treatment and after verifying that they met the selection criteria.
The final sample size for this pilot study was 60 patients.
A descriptive analysis was performed. Data were imported from an XLSX file, and tables were created to compare the totals for each scale.
Most of the variables collected were nominal or ordinal qualitative variables, and the levels used were taken into account when interpreting the differences. A comparison of proportions was performed using Pearson's or Fisher's exact test when necessary.
Ethical considerationsAll participants received a patient information sheet about the project and signed an informed consent form. The anonymity and confidentiality of the data, as mandated by Spanish Organic Law 3/2018, Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, and the fundamental right of natural persons to the protection of personal data, enshrined in Article 18.4 of the Spanish Constitution, were respected, in accordance with the provisions of Regulation (EU) 2016/679 and the World Medical Association and the Declaration of Helsinki. This study was approved by the Ethics Committees of the Puerta de Hierro University Hospital (213/23) and the 12 de Octubre University Hospital (23/626).
ResultsThe final sample consisted of 60 participants, distributed between centres as follows: 33 (55%) from HUDO, of whom 51.52% were women, and 27 (45%) from HUPH, of whom 40.74% were women. The mean age of the sample was 69 years (±13.54), ranging from 51 to 82 years.
Eighty-five per cent (51) of the sample did not have a skilled profession (both men and women), with 56% of the men being retired, compared to 54% of the women who reported being homemakers (p < .001).
The economic level showed a higher percentage of men with an income exceeding €1000 per month, 53.3% (32), compared to 16.6% (10) for women (p < .001). Approximately 35% (21) of all participants were employed (36% of women and 34% of men).
Regarding educational level, a higher percentage of men (19%) had higher education compared to 7.1% of women, and a higher percentage of women (25%) had no formal education compared to 13% of men.
As for physical activity, 53% (32) did not engage in any type of exercise, with women exhibiting a higher rate of sedentary behaviour, a statistically significant difference (p < 0.001). 31% (10) of the men did not exercise at all, compared to 79% (22) of sedentary women.
Regarding the study's main variable, depression status, measured using the PHQ-9 scale, the incidence of depression was 18% at 2 weeks, decreasing to 12% at one month and 10% at three months (p < .084).
The difference between the sexes was greater in the male group, with the percentage of men showing signs of depression dropping from 16% at the first assessment to 6.3% at the second and 3.1% at the third. In the female group, the decrease was smaller, falling from 21% at the first assessment to 19% at the second, remaining unchanged at the third assessment (p < .001).
Fig. 1 shows the evolution of the PHQ-9 scale score according to sex.
The results related to quality of life show a high and stable percentage of patients with no impairment in their quality of life (83%), very similar to and consistent with the result obtained in the measurement of functional capacity using the Barthel Index, in which 86% of the sample is independent in basic activities of daily living, also stable across the three data collection periods. The evolution of the differences by sex is shown in Fig. 2.
Regarding sleep quality, it was observed that 90% of the patients had sleep rated as normal, maintaining a similar value across the three time points. There are statistically significant sex differences (p < .003), which are shown in Fig. 3: 25% of women present sleep disturbances, compared to 0% of men in the first assessment; in the second and third assessments, 22% of women had sleep disturbances compared to 0% of men.
Discussion
The results of this study focus on the incidence of depressive states in patients with ischaemic stroke who have been treated with mechanical thrombectomy. Other studies have focused on post-stroke depression,12,22 but no studies have been found that differentiate the results by stroke type (haemorrhagic or ischaemic) or by treatment type (fibrinolysis or mechanical thrombectomy).
If we focus on the study's main variable, depressive states, we may observe that many patients frequently responded to item two of the PHQ-9 scale (feeling down, depressed, or hopeless) with a score of 2, meaning they felt this way on more than half of the days. However, the remaining items, such as appetite, sleep, and fatigue, were scored at zero (no days), thus not establishing a depressive state, but a certain collective sadness was detected, partly attributed to the fear of suffering another stroke. This suggests that it may be interesting to introduce variables related to sadness, such as apathy, an aspect that other studies indicate as influential in terms of affective impairment.23 Subclinical apathy is detectable in healthy individuals in three of the possible subtypes (behavioural, social, and emotional), and is frequently associated with different degrees of depression, making its inclusion in future studies important.24
Regarding sex differences in depressive states, numerous studies conclude that post-stroke depression occurs more frequently in women, and although the factors are still to be determined, they are attributed to hormonal causes or the social role that women play in today's society.25 Female sex is identified as a risk factor for both post-stroke depression and major depression, independent of the cerebrovascular event, and is associated with a complex multifactorial relationship, attributing sociocultural, biomedical, and psychological reasons.22 According to some studies, women are up to 20% more likely to suffer from depression compared to men.26
Significant sex differences have been found in the other variables: women have poorer sleep quality, poorer functional status, and consequently, poorer quality of life, which persists at least 3 months after the stroke, as other studies indicate, making them more susceptible to developing post-stroke depression.27
Limitations and future directionsOur findings have limitations related to sample size, and further research is needed to increase the number of participants in the study.
This study determines the incidence of depression after suffering the thrombotic event, and it may be interesting to carry out a longer-term follow-up to observe if there is a development of depressive symptoms after complete recovery from the stroke, when the disease is no longer so present or even when the period of functional rehabilitation to which many of the patients go after suffering this pathology has ended.15
ConclusionIt was observed that undergoing mechanical thrombectomy as a stroke treatment can influence the development of subsequent depression: patients showed a decrease in the incidence of depression, as the detected cases only showed indications of it.
It is important to note that these patients have a less significant functional impact and a considerably better quality of life after the thrombotic event because their recovery is usually better and faster compared to patients who, having suffered a stroke, were not treated in time, or in whom the ischaemic situation could not be reversed, developing more sequelae that frequently become chronic.
Sex differences are notably present in many of the variables measured in the study, revealing a clear vulnerability in women, who show a higher percentage of indications of depression, sleep disturbances, and sedentary lifestyles—risk factors that lead to a greater risk of developing established depression.
Special thanksThank you to all the staff at Puerta de Hierro Majadahonda Hospital and 12 de Octubre Hospital who, behind the scenes, helped recruit the patients included in this research study.
First, I would like to thank SEDENE for their support of my research through the first research award, which has greatly helped to fund this project. I would also like to thank my thesis advisors for their unwavering support and, of course, my family, always.
