Feasibility and effectiveness of treatments for post-stroke depression in elderly inpatients: systematic review

Post-Stroke Depression in Older Adults: An Overview

Detailed data on post-stroke depression (PSD) in older adults are limited in spite of the high vulnerability of this population to stroke. In fact, PSD prevalence in older adults ranges from 16.0 to 43.9%; however, timing and instruments of evaluation often differ significantly across all available studies. The etiology, genetic and inflammatory factors, as well as structural brain alterations, are claimed as part of a multifaceted mechanism of action in PSD onset. Thus, the aim of this narrative review was to further elaborate on the prevalence, etiology, diagnosis, consequences and treatment of PSD in older adults. The consequences of PSD in older adults may be devastating, including a poor functional outcome after rehabilitation and lower medication adherence. In addition, lower quality of life and reduced social participation, higher risk of new stroke, rehospitalization, and mortality have been reported. In this scenario, treating PSD represents a crucial step to prevent these complications. Both pharmacological and non-pharmacological therapies are currently available. The pharmacological treatment utilizes antidepressant drugs, such as selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TAs) and new multimodal antidepressants (NMAs). Non-pharmacological therapies include psychological interventions and non-invasive brain stimulation techniques, while excluding drug administration. In the general population experiencing PSD, SSRIs (sertraline in particular) are the most prescribed, whereas the combination of antidepressants and psychotherapy is underused. Furthermore, about one-third of patients do not receive treatment for PSD. In regard to older adults with PSD, the possibility of more adverse effects or contraindications to antidepressant prescription due to comorbidities may limit the therapeutic window. Although drugs such as citalopram, escitalopram, sertraline, venlafaxine, and vortioxetine are usually well tolerated by older patients with PSD, the few randomized controlled trials (RCTs) specifically considering older adults with PSD have been conducted with fluoxetine, fluvoxamine, reboxetine, citalopram and nortriptyline, often with very small patient samples. Furthermore, data regarding the results of non-pharmacological therapies are scarce. High-quality RCTs recruiting large samples of older adults are needed in order to better manage PSD in this population. In addition, adequate screening and diagnosis instruments, with reliable timing of evaluation, should be applied.

Incidence of Poststroke Depression in Patients With Poststroke Dysphagia

PURPOSE

Poststroke dysphagia and poststroke depression (PSD) can have devastating effects on stroke survivors, including increased burden of care, higher health care costs, poor quality of life, and greater mortality; however, there is a dearth of research examining depression in patients diagnosed with dysphagia after stroke. Thus, we aimed to study the incidence of PSD in patients with poststroke dysphagia to provide foundational knowledge about this patient population.

METHOD

We conducted a retrospective, cross-sectional study of individuals with a primary diagnosis of acute ischemic stroke (AIS) and secondary diagnoses of dysphagia and/or depression using administrative claims data from the 2017 Medicare 5% Limited Data Set.

RESULTS

The proportion of depression diagnosis in patients with poststroke dysphagia was significantly higher than the proportion of depression diagnosis in those without poststroke dysphagia during acute hospitalization: 12.01% versus 9.52%, respectively (p = .003).

CONCLUSIONS

Our results demonstrated that persons with poststroke dysphagia were as, or slightly more, likely to have PSD compared to the general stroke population, and to our knowledge, they establish the first reported incidence of PSD in Medicare patients with dysphagia after AIS. Future research is warranted to further explore the effects of PSD on poststroke dysphagia.

First evidence of protective effects on stroke recovery and post-stroke depression induced by sortilin-derived peptides

Post-stroke depression (PSD) is the most common mood disorder following stroke with high relevance for outcome and survival of patients. The TREK-1 channel represents a crucial target in the pathogenesis of stroke and depression. Spadin and its short analog mini-spadin were reported to display potent antidepressant properties. We investigated the therapeutic effects of mini-spadin in a mouse model of focal ischemia and PSD. To activate TREK-1 and induce neuroprotection a single low dose of mini-spadin (0.03 μg/kg) was intraperitoneally injected 30  min after the onset of ischemia, once a day during 7 days post-ischemia. Then, to inhibit TREK-1 and induce antidepressant effect, the peptide was injected at higher concentration (3 μg/kg) once a day for 4 days/week until the sacrifice of animals. Electrophysiological studies showed that mini-spadin had a biphasic action on TREK-1. At low doses, the channel activity was increased whereas at higher doses it was inhibited. Mini-spadin prevented the loss of body weight and the delayed dopaminergic degeneration in substantia nigra and improved the motor and cognitive ischemia-induced deficits. Moreover, mini-spadin prevented PSD analyzed in the Forced Swim (FST) and Novelty Suppressed Feeding (NSF) tests. Finally, enhanced neurogenesis and synaptogenesis contributed to the beneficial effects of mini-spadin against stroke and PSD. This work reveals the first evidence that the modulation of TREK-1 channels in the early and chronic phases of stroke as well as the stimulation of brain plasticity by mini-spadin could play a key role in its brain protective effects against stroke and its deleterious consequences such as PSD.

Efficacy and tolerability of pharmacotherapy for post-stroke depression: a network meta-analysis

Background

Post-stroke depression (PSD) occurs in approximately one third of stroke survivors, leading to great disability and mortality. As there is no consensus on the optimal pharmacological treatment for PSD, we aimed to evaluate the relative efficacy and tolerability of the available pharmacological interventions.

Materials and Methods

We did a network meta-analysis to incorporate evidence from relevant trials providing direct and indirect comparisons. We searched PubMed, the Cochrane Library Central Register of Controlled Trials, Embase and the reference lists of relevant articles up to March, 2017 for randomized controlled trials (RCTs), for different pharmacotherapies of PSD. For efficacy analysis, the primary outcome was the mean change in Hamilton Depression Scale (HAMD) score between baseline and endpoint. For tolerability analysis, the outcome was presented by the discontinuation for any reason. This study is registered with PROSPERO, number CRD42016049049.

Results

From a total of 869 citations, 15 RCTs with 876 participants were included. 13 drugs were considered. For efficacy, paroxetine ranked the best for HAMD reduction, followed by imipramine, reboxetine, nortriptyline, citalopram and fluoxetine at the end of treatment. However, duloxetine ranked the best at 4-week and 8-week duration for HAMD reduction. For tolerability, paroxetine ranked the best but there is no significant result between any comparisons.

Conclusions

Paroxetine is probably the best option to consider for patients with PSD. To get a quicker relief of depression, duloxetine might be useful for its rapid onset of antidepressant action. The tolerability was comparable among all the antidepressants. But more high-quality RCTs are needed.

Efficacy and feasibility of antidepressant treatment in patients with post-stroke depression

BACKGROUND

Depression greatly impacts the quality of life in most stroke survivors. Therefore, effective treatment of post-stroke depression (PSD) is critically important. However, evidence supporting the effectiveness and feasibility of antidepressant treatment in this population is limited and somewhat confusing.

METHODS

A comprehensive literature search of the Cochrane, PubMed, Web of Science, and Embase databases from inception up to November 2015 was conducted. We reviewed all randomized controlled trials (RCTs) that assigned patients with a clinical diagnosis of PSD to antidepressant or placebo treatment. Reduction in depression rating scale scores and response rate to antidepressants were defined as the efficacy outcomes. Rates of dropout for any reason and for adverse effects were defined as the acceptability outcomes. We also assessed improvements in activities of daily living (ADL) as functional outcomes.

RESULTS

In total, 11 trials consisting of 740 participants were indentified. A significant advantage of antidepressants compared with placebo treatment in PSD was observed in overall pooled effect size analysis (SMD = -0.96; 95% CI = -1.41 to -0.51; P <0.0001). In addition, patients receiving antidepressants presented a much greater improvement in various depressive symptoms than those with placebo (RR = 1.36; 95% CI = 1.01-1.83; P = 0.04). However, antidepressants were less well tolerated than placebo because of some adverse events (RR = 2.72; 95% CI = 1.37-5.43; P = 0.04). Intriguingly, no consistent evidence was found for a positive effect of antidepressants on ADL in our analysis.

CONCLUSIONS

This meta-analysis suggests that antidepressants treatment confers potentially positive effects in patients with PSD as compared with simple placebo treatment. However, this must be carefully considered in light of its possible adverse events in some individual patients.

[Post-stroke depression]

Cerebrovascular diseases are associated with a high incidence of psychiatric disorders. Depressive illness after stroke has been extensively investigated during the last three decades. Post-stroke depression is estimated to occur in 30-35% of the patients during the first year after stroke. Numerous studies have given information on its prevalence, pathogenesis, clinical course, treatment and prevention. Despite the high level of comorbidity, depressive symptoms appear to remain frequently unrecognized and untreated. This has a negative effect on the rehabilitation, quality of live, cognitive function and mortality of stroke patients.

Depression, anxiety and their relationship with chronic diseases: a review of the epidemiology, risk and treatment evidence

OBJECTIVE

To review the evidence for an association between depression and anxiety and the National Health Priority Area conditions -- heart disease, stroke, diabetes mellitus, asthma, cancer, arthritis and osteoporosis -- and for the effectiveness of treatments for depression and anxiety in these settings.

DATA SOURCES

Systematic literature search of systematic reviews, meta-analyses and evidence-based clinical practice guidelines published between 1995 and 2007, inclusive.

DATA EXTRACTION

Each review was examined and summarised by two people before compilation.

DATA SYNTHESIS

Depression is more common in all disease groups than in the general population; anxiety is more common in people with heart disease, stroke and cancer than in the general population. Heterogeneity of studies makes determination of risk and the direction of causal relationships difficult to determine, but there is consistent evidence that depression is a risk factor for heart disease, stroke and diabetes mellitus. Antidepressants appear to be effective for treating depression and/or anxiety in patients with heart disease, stroke, cancer and arthritis, although the number of studies in this area is small. A range of psychological and behavioural treatments are also effective in improving mood in patients with cancer and arthritis but, again, the number of studies is small.

CONCLUSION

The evidence for the association of physical illness and depression and anxiety, and their effects on outcome, is very strong. Further research to establish the effectiveness of interventions is required. Despite the limits of current research, policy and practice still lags significantly behind best evidence-based practice. Models of integrated care need to be developed and trialled.

CNS-active drugs in aging population at high risk of cerebrovascular events: evidence from preclinical and clinical studies

The recovery process following cerebral insults such as stroke is affected by aging and pharmacotherapy. The use of medication including CNS-active drugs has increased in the elderly during recent years. However, surprisingly little is known about how safe they are with respect to severity of sensorimotor and cognitive impairments or recovery of function following possible cerebrovascular accidents. This review examines the experimental and clinical literature, primarily from 1995 onwards, concerning medication in relation to cerebrovascular events and functional recovery. Special attention is directed to polypharmacy and to new CNS-active drugs, which the elderly are already taking or are prescribed to treat emerging, stroke-induced psychiatric symptoms. The neurobiological mechanisms affected by these drugs are discussed.

A pilot study to describe antidepressant prescriptions dispensed to veterans after stroke

BACKGROUND

Stroke is the third leading cause of death in the United States, following only heart disease and cancer. Approximately 500,000 strokes occur each year in the United States. Patients suffering from poststroke depression have higher rates of morbidity and mortality, slower physical recovery, and lower functional status than stroke patients without depression. Depressed stroke patients may benefit from early treatment with an antidepressant.

OBJECTIVES

The objectives of this study were to (1) describe antidepressant-dispensing patterns to veteran patients during the 6-month period before their stroke and 1-year time afterward and (2) examine the association of poststroke antidepressant treatment with mortality.

METHODS

Veteran patients (n=543) with one or more hospital discharges during FY2001 with a primary diagnosis of stroke were identified. The discharge date minus the length of stay indicated the index hospitalization date. Antidepressant prescription dispensing records were obtained from the Veterans Integrated System Network 8 Veteran's Affairs (VA) Pharmacy Benefits Management database.

RESULTS

One-third of eligible veteran patients were dispensed one or more antidepressant prescriptions (n=181) either before or after the index hospitalization. Of these veterans, 146 received an antidepressant after the index hospitalization. More than 80% of veteran patients survived the stroke for 1 year or longer (n=448). Among the veteran patients who were discharged from the index hospitalization alive, those with no antidepressant or an antidepressant dispensed only before the stroke had a higher 1 year all cause mortality rate (8.0%) compared with those who were dispensed a prescription for one or more antidepressants afterward (4.8%).

CONCLUSIONS

Veterans dispensed an antidepressant after their stroke appeared to have benefited. Opportunities to reduce poststroke sequelae and improve recovery may be lost.

An Exploration of Central Nervous System Medication Use and Outcomes in Stroke Rehabilitation

Conroy B, Zorowitz R, Horn SD, Ryser DK, Teraoka J, Smout RJ. An exploration of central nervous system medication use and outcomes in stroke rehabilitation.

OBJECTIVE

To study associations between neurobehavioral impairments, use of neurotropic medications, and outcomes for inpatient stroke rehabilitation, controlling for a variety of confounding variables.

DESIGN

Observational cohort study of post-stroke rehabilitation.

SETTING

Six inpatient rehabilitation hospitals in the United States.

PARTICIPANTS

Patients with moderate or severe strokes (N=919).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Discharge disposition, FIM score change, and rehabilitation length of stay (LOS).

RESULTS

Neurobehavioral impairments and use of many medications, including first-generation selective serotonin reuptake inhibitors, older traditional antipsychotic medications, and anti-Parkinsonian neuro-stimulants, have a statistical association with poorer outcomes, whereas use of the atypical antipsychotic medications has a positive association with improvement in motor FIM scores. Counter-intuitively, use of opioid analgesics is associated with a larger motor FIM score change but not an increase in LOS or reduced percentage of discharge to community. There was significant variation in use of neurotropic medications among the 6 study sites during inpatient stroke rehabilitation.

CONCLUSIONS

There are many opportunities to enhance a stroke survivor's ability to benefit from acute inpatient stroke rehabilitation through improved understanding of associations of neurotropic medications with outcomes for different patient groups.

Evidências da eficácia da eletroconvulsoterapia na prática psiquiátrica

A eletroconvulsoterapia (ECT) consiste em tratamento biológico ainda não amplamente utilizado na prática psiquiátrica, devido aos inúmeros fatores que contribuem para uma resistência acerca do método. Objetivando sustentar, com embasamento científico, o emprego da ECT, agregamos evidências de sua eficácia, indicações, contra-indicações e efeitos adversos, advindas dos principais ensaios clínicos randomizados e meta-análises disponíveis na literatura médica atual sobre o tema (PubMed/MEDLINE, Cochrane).

Update on depression in neurologic illness: stroke, epilepsy, and multiple sclerosis

The risk of depression is increased in chronic neurologic illness and can adversely affect the course of disease. Recent literature is reviewed for depression in stroke, epilepsy, and multiple sclerosis. Depression can share pathophysiologic aspects of the comorbid illness, such as neurotransmitter pathway disturbances, hypothalamus-pituitary-adrenal pathway disturbances, and changes in immunologic function. Depression also can be a psychologic reaction to the burden of the neurologic condition. Risk factors for development of depression are reviewed. Depression and other medical conditions can have shared symptoms (eg, fatigue, psychomotor retardation) that can complicate the diagnosis of depression in neurologic illness. Proper selection of antidepressant treatment is necessary to avoid worsening the neurologic disorder.

Is it safe to use antidepressants after a stroke?

Depression is an important complication of stroke. Although antidepressants are widely used for the treatment of poststroke depression (PSD), prescription is critically influenced by their safety, tolerability and by the impact on co-morbidities. The authors reviewed the literature on the use of antidepressants after stroke. Selective serotonin re-uptake inhibitors are effective and have a good profile of safety and tolerability in PSD. They are, therefore, used as first-line drugs in the treatment of PSD, although potential cardiovascular and cerebrovascular effects, drug-drug interactions and intolerability in a minority of patients have to be considered. Other antidepressants appear to be safe and effective in selected patients. PSD patients should be classified according to their clinical profile for the selection of the drug of choice in particular sub-groups of patients.

Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care: executive summary

BACKGROUND

A panel of experts developed stroke rehabilitation guidelines for the Veterans Health Administration and Department of Defense Medical Systems.

METHODS

Starting from previously established guidelines, the panel evaluated published literature through 2002, using criteria developed by the US Preventive Services Task Force. Recommendations were based on evidence from randomized clinical trials, uncontrolled studies, or consensus expert opinion if definitive data were lacking.

RESULTS

Recommendations with Level I evidence include the delivery of poststroke care in a multidisciplinary rehabilitation setting or stroke unit, early patient assessment via the NIH Stroke Scale, early initiation of rehabilitation therapies, swallow screening testing for dysphagia, an active secondary stroke prevention program, and proactive prevention of venous thrombi. Standardized assessment tools should be used to develop a comprehensive treatment plan appropriate to each patient's deficits and needs. Medical therapy for depression or emotional lability is strongly recommended. A speech and language pathologist should evaluate communication and related cognitive disorders and provide treatment when indicated. The patient, caregiver, and family are essential members of the rehabilitation team and should be involved in all phases of the rehabilitation process. These recommendations are available in their entirety at http://stroke.ahajournals.org/cgi/content/full/36/9/e100. Evidence tables for each of the recommendations are also in the full document.

CONCLUSIONS

These recommendations should be equally applicable to stroke patients receiving rehabilitation in all medical system settings and are not based on clinical problems or resources unique to the Federal Medical System.

Meta-review of high-quality systematic reviews of interventions in key areas of liaison psychiatry

BACKGROUND

When planning and delivering a liaison psychiatry service it is important to have an understanding of the research evidence supporting the use of interventions likely to be delivered by the service.

AIMS

To identify high-quality systematic reviews for all interventions in three defined areas of liaison psychiatry, to summarise their clinical implications and to highlight areas where more research is needed. The three areas were the psychological effects of physical illness or treatment, somatoform disorders and self-harming behaviour.

METHOD

Computerised database searching, secondary reference searching, hand-searching and expert consultation were used to identify relevant systematic reviews. Studies were reliably selected, and quality-assessed, and data were extracted and interpreted by two reviewers.

RESULTS

We found 64 high-quality systematic reviews. Only 14 reviews included meta-analyses.

CONCLUSIONS

Many areas of liaison psychiatry practice are not based on high-quality evidence. More research in this area would help inform development and planning of liaison psychiatry services.

A 2-item screen for depression in rehabilitation inpatients

OBJECTIVE

To generate a brief screening measure to assist frontline rehabilitation health care workers to rapidly and validly screen patients for depressive symptoms.

DESIGN

Case series.

SETTING

Inpatient rehabilitation unit.

PARTICIPANTS

Five hundred patients (age, >/=60y) cognitively able to complete the outcome measure.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The Geriatric Depression Scale (GDS).

RESULTS

Based on the strength of the correlation with the GDS total score, 5 items were selected for model development. A 2-item screen, consisting of items "downhearted and blue" and "worthless," correctly classified 78.4% of patients, with only 3.6% of patients having false-negative classifications. The 2-item screen did not differ significantly in its accuracy or predictive utility from the more inclusive models.

CONCLUSIONS

The identified 2-item screening instrument may be an effective tool for health care staffs to use in their efforts to identify symptoms of depression in older adults on a rehabilitation unit.

Pharmacologic treatment of poststroke depression: a systematic review of the literature

CLINICAL QUESTION/OBJECTIVE: A systematic evaluation of the literature published from 1966 until December 2001 on pharmacologic interventions for poststroke depression (PSD).

DESIGN

Articles were selected from a computer-based search and were independently reviewed by three evaluators using a standardized criteria including internal validity items as well as descriptive and quantitative items.

RESULTS

Fifty studies were preliminarily reviewed and 10 randomized controlled trials (RCTs) were included for systematic analysis.

CONCLUSION

Selective serotonin reuptake inhibitors (citalopram and fluoxetine) may be effective in the treatment of PSD. There is some evidence for a beneficial effect of the tricyclic antidepressant nortriptyline, however, the RCTs for this medication lack sufficient validity, and reports on side effects are contradictory.

Guideline for the management of late-life depression in primary care

OBJECTIVE

To develop a guideline for the primary care management of depression in later life based on best practice.

METHOD

Source material included relevant guidelines, literature reviews and consensus documents coupled with an updated literature review covering 1998-October, 2001. This material was summarised as a series of evidence-based statements and recommendations agreed by consensus.

RESULTS

Good quality evidence exists for the pharmacological and psychological treatment of depressive episode (major depression), although not specifically in primary care. There is some evidence of efficacy of antidepressants in late-life dysthymia and minor depression associated with poor functional status. In depressive episode, current evidence suggests acute treatment for at least six weeks and a continuation period of at least 12 months. Both tricyclic antidepressants and Selective Serotonin Re-uptake Inhibitors are effective in longterm prevention. There is less data on how to manage patients who do not respond in the acute treatment phase. More data is needed on sub-groups of patients with specific co-morbid medical conditions and those who are frail. Collaborative care is effective in older depressed primary care patients.

CONCLUSIONS

There are effective treatments for depression in primary care. More research is needed to address the optimum treatment of depression with medical co-morbidity and to elucidate the role of newer psychological interventions. Collaborative care between primary care and specialist services is a promising new avenue for management.

Role of selective serotonin reuptake inhibitors in psychiatric disorders: a comprehensive review

The selective serotonin reuptake inhibitors (SSRIs) have emerged as a major therapeutic advance in psychopharmacology. As a result, the discovery of these agents marks a milestone in neuropsychopharmacology and rational drug design, and has launched a new era in psychotropic drug development. Prior to the SSRIs, all psychotropic medications were the result of chance observation. In an attempt to develop a SSRI, researchers discovered a number of nontricyclic agents with amine-uptake inhibitory properties, acting on both noradrenergic and serotonergic neurons with considerable differences in potency. A given drug may affect one or more sites over its clinically relevant dosing range and may produce multiple and different clinical effects. The enhanced safety profile includes a reduced likelihood of pharmacodynamically mediated adverse drug-drug interactions by avoiding affects on sites that are not essential to the intended outcome. SSRIs were developed for inhibition of the neuronal uptake pump for serotonin (5-HT), a property shared with the TCAs, but without affecting the other various neuroreceptors or fast sodium channels. The therapeutic mechanism of action of SSRIs involves alteration in the 5-HT system. The plethora of biological substrates, receptors and pathways for 5-HT are candidates to mediate not only the therapeutic actions of SSRIs, but also their side effects. A hypothesis to explain these immediate side effects is that 5-HT is increased at specific 5-HT receptor subtypes in discrete regions of the body where the relevant physiologic processes are regulated. Marked differences exist between the SSRIs with regard to effects on specific cytochrome P450 (CYP) enzymes, and thus the likelihood of clinically important pharmacokinetic drug-drug interactions. Although no clear relationship exists between the clinical efficacy, plasma concentration of SSRIs, nor any threshold that defines toxic concentrations, but therapeutic drug monitoring (TDM) may be useful in special populations, such as in elderly patients, poor metabolizers (PM) of sparteine (CYP2D6) or mephenytoin (CYP2C19), and patients with liver and kidney impairment. Several meta-analyses have reviewed the comparative efficacy of TCAs and SSRIs, and concluded that both TCAs and SSRIs have similar efficacy in the treatment of depression. SSRIs have demonstrated better efficacy and tolerability in the treatment of obsessive compulsive disorder (OCD). They have also been found to be effective in the treatment for social anxiety disorder both in reducing total levels of social anxiety and in improving overall clinical condition. The benefit of SSRIs in anorexia nervosa (AN) is apparently short-term unless medication is given in the context of nutritional or behavioral therapy. No single antidepressant can ever be recommended for every patient, but in a vast majority of patients, SSRIs should be considered as one of the first-line drugs in the treatment of depression.

Suicide in Neurologic Illness

The risk of attempted or completed suicide is increased in patients with migraine with aura, epilepsy, stroke, multiple sclerosis, traumatic brain injury, and Huntington's disease. Contrary to the general perception that the risk of suicide among patients with Alzheimer's disease and other dementing conditions is low, several reports suggest that the risk of suicide in these patients increases relative to the general population. Some patients at risk for neurologic disorders are also at increased risk for suicide; in particular, the risk of suicide is increased among persons at risk for Huntington's disease, independent of the presence or absence of the Huntington's gene mutation. The risk of attempted or completed suicide in neurologic illness is strongly associated with depression, feelings of hopelessness or helplessness, and social isolation. Additional suicide risk factors in persons with neurologic illness include cognitive impairment, relatively younger age (under 60 years), moderate physical disability, recent onset or change in illness, a lack of future plans or perceived meaning in life, recent losses (personal, occupational, or financial), and prior history of psychiatric illness or suicidal behavior. Substance dependence, psychotic disorders, anxiety disorders, and some personality disorders (eg, borderline personality disorder) may also contribute to increased risk of suicide among persons with neurologic illnesses. Identification and aggressive treatment of psychiatric problems, especially depression, as well as reduction of modifiable suicide risk factors among patients with neurologic illness is needed to reduce the risk of attempted and completed suicide in this population.

Determinants and consequences of post-stroke depression

Post-stroke depression (PSD) is a very frequent and important consequence of stroke, but, in spite of the high number of papers aiming to clarify various aspects of this disorder, controversies about its incidence, its (biological or psychological) determinants, its consequences and its treatment still persist. In the present survey we have taken separately into account each of these issues, starting from a critical discussion of the main factors which can affect the estimates of the incidence of PSD. We have then surveyed and updated the debate between proponents of a neuroanatomical and a psychological interpretation of PSD. Our conclusions have been that the most recent evidence does not support Robinson's influential neuroanatomical model, assuming that a left frontal stroke could provoke a major PSD, indistinguishable from the functional forms of major depression. In the section devoted to the consequences of PSD, we have particularly taken into account the problem of the deleterious influence that PSD could have on functional recovery. The available evidence does not allow us to conclude if an improvement of PSD also leads to an improvement of the patient's functional status. As for the therapy of PSD, a pharmacological treatment with selective serotonin reuptake inhibitors has proven effective and safe, whereas psychological methods of treatment of patients and their families have not yet given conclusive results.

Pharmacotherapy of depression in older patients: a summary of the expert consensus guidelines

Depression in older adults increases disability, medical morbidity, mortality, suicide risk, and healthcare utilization. Most studies of antidepressants are conducted in younger adults, and clinicians often have to extrapolate from findings in populations that do not present the same problems as older patients. Older patients often have serious coexisting medical conditions that may contribute to or complicate treatment of depression; they tend to take multiple medications, some of which may contribute to depression or interact with antidepressants; and they metabolize medications slowly and are more sensitive to side effects than younger patients. To address clinical questions not definitively answered in the research literature, the authors surveyed 50 experts on the pharmacotherapy of depressive disorders in older patients. The survey contained 64 questions with 857 options: 618 of the options were scored using a modified version of the RAND 9-point scale for rating appropriateness of medical decisions; for the other 239 options, the experts were asked to write in answers or check a box. The experts reached consensus on 89% of the options rated on the 9-point scale. Categorical rankings (first line/preferred, second line/alternate, third line/usually inappropriate) were assigned to each option based on the 95% confidence interval around the mean rating. Guideline tables indicating preferred treatment strategies were then developed for common and important clinical scenarios. The authors summarize the expert consensus methodology and the experts' recommendations and discuss how they relate to research findings. The experts recommend including both antidepressant medication and psychotherapy in treatment plans for nonpsychotic unipolar major depressive disorder of any severity, as well as for dysthymic disorder or persistent minor depressive disorder. They would also consider using either medication or psychotherapy alone for milder depression. For unipolar psychotic major depression, the treatment of choice is an antidepressant plus one of the newer atypical antipsychotics, with electroconvulsive therapy another first-line option. If the patient has a comorbid medical condition that is contributing to the depression, the experts recommend treating both the depression and the medical condition from the outset. The SSRIs were the top-rated antidepressants for all types of depression, with highest ratings for efficacy and tolerability given to citalopram and sertraline. Paroxetine was another first-line option, and fluoxetine was rated high second line. The preferred psychotherapy techniques for treating depression in older patients are cognitive-behavioral therapy, supportive psychotherapy, problem-solving psychotherapy, and interpersonal psychotherapy. The experts also recommended use of psychosocial interventions (e.g., psychoeducation, family counseling, visiting nurse services) in addition to pharmacotherapy and psychotherapy. Within limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide direction concerning common clinical dilemmas in older patients. They cannot address the complexities of each individual patient's care and can be most helpful in the hands of experienced clinicians.