Post-stroke depression management in the Israeli primary care setting: a retrospective cohort study

OBJECTIVES: To characterise post-stroke depression (PSD) diagnostic and treatment patterns in an outpatient primary care setting, including timing, screening methods, therapeutic interventions and associations with mortality. DESIGN: A retrospective cohort study. SETTING: Maccabi Healthcare Services, the second largest Healthcare Maintenance Organisation in Israel, covering more than 2.7 million citizens between 2016 and 2022. PARTICIPANTS: Participants were adult patients with a new stroke diagnosis between 2016 and 2022 and a subsequent diagnosis of depression according to International Classification of Diseases clinical criteria or antidepressant medication initiation. Patients with a diagnosis of depression or antidepressant treatment prior to stroke were excluded from the study. PRIMARY AND SECONDARY OUTCOMES: Primary outcomes included PSD diagnosis rates, time to diagnosis and treatment, use of screening questionnaires, specialty of the physician making the diagnosis and all-cause mortality. Secondary outcomes included referral rates to mental health services, rehabilitation participation and its impact on mortality. RESULTS: Among 11 499 patients, PSD occurred in 4620 (40.2%) patients. Primary care physicians diagnosed 53.1% of cases based on clinical assessment; only 4.5% of patients underwent Patient Health Questionnaire-2 screening. Most diagnoses occurred in the first year (53.4%). Antidepressants, predominantly selective serotonin reuptake inhibitors (58.3%), were initiated within 30 days in 65.1% of diagnosed patients. Patients with PSD demonstrated higher rehabilitation participation (69.5% vs 48.5%, p<0.001) and paradoxically lower mortality rates (22.1% vs 27.9%, p<0.001). Patients without PSD were older with a greater comorbidity burden. Cox regression identified physiotherapy visits (HR=0.625, p<0.001) and mental health consultations (HR=0.642, p<0.001) as protective factors. CONCLUSIONS: In this cohort, in an outpatient primary care setting, primary care physicians diagnosed the majority of PSD cases, predominantly relying on clinical criteria, without using screening tools. The majority of PSD diagnoses occurred during the first year after stroke (53.1%), suggesting that repeated evaluation might be appropriate during this follow-up period. Early antidepressant treatment and enhanced rehabilitation engagement may positively influence mortality outcomes in patients with PSD. Low utilisation of standard screening tools and mental health referrals represents an area for potential improvement in PSD management.