Psychiatric patients less likely to receive thrombolysis following stroke

Patients with psychiatric diseases are 20 percent less likely to receive intravenous thrombolysis (IVT), an evidence-based therapy for improving outcomes after ischemic stroke, researchers from Johns Hopkins University reported in Stroke.

Principal investigator Roland Faigle, MD, PhD, and colleagues studied 325,009 ischemic stroke admissions from 2007 through 2011 using the Nationwide Inpatient Sample. A total of 12.8 percent had psychiatric disease, defined as secondary diagnoses of schizophrenia or other psychoses, bipolar disorder, depression or anxiety.

IVT was used in 3.6 percent of patients with psychiatric comorbidities and 4.4 percent of those without. In multivariable adjustment for other risk factors, individuals with psychiatric diseases were 20 percent less likely to receive IVT.

When evaluated individually, the presence of schizophrenia or other psychoses was associated with 39 percent reduced odds in receiving that form of treatment. Anxiety (12 percent) and depression (15 percent) were also significantly associated with lower odds of getting IVT.

“The effect size of the observed differences in IVT use associated with psychiatric disease is comparable to disparities in IVT use that have been demonstrated in other vulnerable stroke patients, such as racial minorities,” Faigle and coauthors wrote. “Patients with schizophrenia or psychoses were less likely to receive IVT than those with anxiety or depression. This finding is consistent with reports suggesting that schizophrenia is one of the leading contributors to disability globally and may be the psychiatric disease associated with the greatest impairment.”

The researchers were unable to investigate reasons for the disparity in IVT use but said provider attitudes or bias could have played a role, in addition to the real or perceived unreliability of psychiatric patients in providing their medical history, which factors into eligibility for IVT.

“Faced with diagnostic uncertainty, physicians might be more likely to ascribe stroke symptoms to a preexisting psychiatric disease or a conversion disorder, which may delay stroke diagnosis and preclude consideration of IVT,” Faigle et al. wrote.

Faigle and colleagues suggested future research more closely evaluate the reasons for treatment differences among stroke patients with psychiatric diseases. With this knowledge, hospitals could “develop interventions aimed at facilitating equal stroke care for all,” they wrote.