Depression and the Use of Selective Serotonin Reuptake Inhibitors in Patients with Acute Intracerebral Hemorrhage

Introduction Depression is a common psychiatric complication associated with stroke. However, while most studies focus on post-stroke depression (PSD) subsequent to ischemic strokes, fewer studies have specifically explored depressive symptoms and the use of selective serotonin reuptake inhibitors (SSRIs) in patients with acute intracerebral hemorrhage (ICH). The aim of our study was to identify the incidence and factors associated with depression in ICH patients and the use of SSRIs as therapy by physicians at a tertiary care hospital in Karachi, Pakistan. Materials and methods A retrospective chart review was conducted to identify patients with ICH through the International Classification of Diseases, Ninth Revision (ICD-9) coding system electronic medical records of Aga Khan University Hospital, Karachi, Pakistan. Patient records spanning a period of five years at the hospital were identified and analyzed by neurology residents. Patients' clinical, laboratory, radiological, and pharmacological data were recorded and analyzed using a structured proforma. Patients with a past history of depression or those who were taking SSRIs at the time of admission were excluded from the analysis. Depression was defined as the presence of five or more symptoms according to the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Results Out of the 458 patients we analyzed, 258 (56%) were men and 200 (44%) were women. The mean age was 59 years. Median National Institutes of Health Stroke Scale (NIHSS) score on admission was 13 (range: 0-42), and the median modified Rankin Scale (mRS) score was 4 (range: 0-6). On neuroimaging, sites of hemorrhage in patients were found to include the basal ganglia/thalamus in 279 (61%) patients, cerebral cortex in 105 (23%), cerebellum in 25 (5%), brain stem in 17 (4%), ventricles in 17 (4%), and multiple sites in eight (2%). We found that 48 (10%) patients had a ventricular extension, and 130 (28%) had midline shift, hydrocephalus, or both. Overall, 103 (22%) patients met the DSM-IV diagnostic criteria for depression. The most common depressive symptoms included tearfulness (67%), sadness (55%), and loss of interest or pleasure in life activities (53%). None of the patients reported suicidal ideation. Only seven patients (2%) were seen by a psychiatrist. The presence of depression was not significantly associated with hemorrhage sites [prabability value (p): 0.55] or the extent of disability (p: 0.09). Among the 103 depressed patients, only 25 (24%) received SSRIs during the hospital stay. A total of 57 (12%) received SSRIs during the hospital stay, of which only 25 had met the DSM-IV diagnostic criteria for depression. The mean duration between the diagnosis of ICH and the start of SSRIs was five days (range 3-25 days). None of the patients received any psychotherapeutic help for depression. At the time of discharge, only 13 (13%) of the 103 patients diagnosed with depression were discharged on SSRIs, while 23 that had not met the DSM-IV diagnostic criteria were discharged on SSRIs. Conclusion The present study demonstrates that depression is not uncommon in acute ICH patients, and it is both underdiagnosed and inadequately treated. Physicians should be trained to accurately identify and effectively treat depressive symptoms in ICH patients. Clear guidelines should be developed to aid the diagnosis and treatment of post-ICH depression in hospital settings.