Background/Aims: Pre-stroke depression has been shown to be associated with worse functional outcomes and depression after stroke. However, it is not currently well understood whether pre-stroke mood disorders (depression, anxiety, psychotic disorders, substance use disorder) are associated with withdrawal of life sustaining treatment (WOLST) after a severe stroke. Methods: This was a retrospective cohort study within the Tufts Vascular Neurology Registry of patients hospitalized with severe acute ischemic stroke (AIS, defined as NIHSS ≥10) or severe nontraumatic intracerebral hemorrhage (ICH, defined as ICH score ≥2) between 2018-2022. Multivariate logistic regression was performed to identify predictors of WOLST. Results: There were 405 patients with severe stroke included in this study. Compared to patients who did not undergo WOLST during hospitalization, those who did were more likely to be older, female, have AIS, experience more severe strokes, and live in areas with higher income inequality (as measured by the GINI index). In an adjusted analysis (basic demographics, stroke type), a pre-stroke mood disorder was associated with WOLST (OR 2.15, 95% CI 1.11-4.15). This finding was robust across multiple models including additional covariates (length of stay, GINI index, and median income by zip code). In models stratified by stroke type (AIS vs. ICH) and adjusted for stroke severity, WOLST was associated with age in both groups and with mood disorder in patients with ICH. The WOLST event rate was higher (19% vs 11%) in the ICH group. Conclusion: Pre-stroke mood disorder was associated with increased rates of withdrawal of care after severe stroke in this patient population. Opportunities to actively treat depression may be useful to include in goals of care discussions to mitigate the potential impact of this factor in decision-making. Consistent with prior studies, we observed a higher proportion of WOLST in older, female, and ICH patients. Future studies regarding the quality and content of goals of care discussions may help elucidate the differing effects of pre-stroke mood disorders on WOLST by stroke type seen in this study.
McHugh et al. (Thu,) studied this question.