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

Evaluation and Treatment of Depression in Stroke Patients: A Systematic Review

Those who received early diagnosis and treatment for poststroke depression had lower mortality rates, cognitive impairments, improved long-term disability, a higher quality of life, and lower rates of suicidal thoughts than those who did not. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 standards were used to conduct this systematic review. Until May 1, 2022, a systematic search was conducted utilizing ScienceDirect, Cochrane, PubMed, Google Scholar, and PubMed central databases, which have been used during the previous 10 years. Randomized controlled trials (RCTs), observational studies, systematic reviews, review articles, case reports, clinical studies, and meta-analyses were included in the research, which covered post-stroke depression patients and how to identify and treat them.

There were 545 possibly related titles found in the database search. Finally, each publication was given a quality rating, and 10 studies with a score of higher than 70% were allowed into the review. Because of their brevity and ease of use, they employed the Patient Health Questionnaire-9 (PHQ-9) and PHQ-2 screening instruments in stroke patients. According to pooled studies, the risk of acquiring post-stroke depression (PSD) was lower in participants undergoing pharmacological therapy with selective serotonin reuptake inhibitors (SSRIs), especially after a year. Identifying further features of the PSD process, we believe, is the most pressing need for future study since it might lead to a more precise treatment strategy.

Effects of early motivational interviewing on post-stroke depressive symptoms: A pilot randomized study of the Good Mood Intervention program

AIMS

The aim of this pilot randomized study was to investigate the feasibility of early motivational interviewing, for reducing mood after acute stroke.

BACKGROUND

Depression is a frequent consequence of stroke that can adversely affect recovery.

METHODS

DESIGN: Pilot randomized study. Intervention group patients received 3, individual motivational interviewing sessions by nurses or social workers prior to hospital discharge.

PARTICIPANTS

Adult patients with acute stroke during 2013 to 2014.

BLINDING

Research assistant who collected data was blind to group assignment.

OUTCOMES

Data were collected at 3 time points: baseline, 1-month, and 3-month follow-up. Outcome measures (anxiety, depression, quality of life) were analysed by descriptive statistics.

RESULTS

Forty-eight patients were enrolled, and 79% retention was achieved at 3 months. Eight participants withdrew (16.7%), and 2 were unable to participate (death: 2.1% and new onset aphasia: 2.1%), leaving 38 participants in the final cohort (Intervention: N = 18, Control: N = 20). Anxiety, depression, and quality of life measures did not alter significantly in the study period.

CONCLUSIONS

Carefully designed studies are required to investigate the effectiveness of early motivational interviewing for improving mood after stroke. The therapy can be administered by nurses, but significant resources are required in terms of training and fidelity.

New opinion on the subtypes of poststroke depression in Chinese stroke survivors

AIM

Poststroke depression (PSD) is the most common complication of stroke. However, some stroke survivors with depression cannot meet the diagnostic criteria of PSD. The aim of this study was to propose the new conception of stroke patients with depression and then make them to receive reasonable diagnosis and treatment.

METHODS

We first put forward the opinion that the general PSD should consist of PSD disorder (PSDD) and PSD symptoms (PSDS) according to the Diagnostic and Statistical Manual of Mental Disorder - Fifth Edition (DSM-5) and ZhongDa diagnostic criteria - first edition (ZD-1), respectively. The ZD-1 was established based on the suggestions of 65 Chinese chief doctors considering that the symptoms of PSDS might be different from those of PSDD and the duration of DSM-5 was too strict. Then, 166 stroke inpatients were recruited, and the study was conducted using the diagnosis and classification of PSD to verify the new concept.

RESULTS

A total of 24 (14.46%) and 80 (48.19%) stroke patients were diagnosed with PSDD and PSDS, respectively, according to individual diagnosis criteria. Moreover, patients meeting the diagnostic criteria of PSDD should satisfy the criteria of PSDS first. The distribution frequencies of depressive symptoms were different, which suggested that there might be discrepant depressive symptoms between PSDS and PSDD.

CONCLUSION

The present study proposes new opinion about the classification and diagnosis of depression in stroke survivors. The definition and criteria of PSDS are beneficial to explore phenomenological consistency and provide useful information for early recognition and appropriate interventions.

Selective serotonin reuptake inhibitors (SSRIs) for stroke recovery

BACKGROUND

Stroke is the major cause of adult disability. Selective serotonin reuptake inhibitors (SSRIs) have been used for many years to manage depression. Recently, small trials have demonstrated that SSRIs might improve recovery after stroke, even in people who are not depressed. Systematic reviews and meta-analyses are the least biased way to bring together data from several trials. Given the promising effect of SSRIs on stroke recovery seen in small trials, a systematic review and meta-analysis is needed.

OBJECTIVES

To determine whether SSRIs improve recovery after stroke, and whether treatment with SSRIs was associated with adverse effects.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (August 2011), Cochrane Depression Anxiety and Neurosis Group Trials Register (November 2011), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 8), MEDLINE (from 1948 to August 2011), EMBASE (from 1980 to August 2011), CINAHL (from 1982 to August 2011), AMED (Allied and Complementary Medicine) (from 1985 to August 2011), PsycINFO (from 1967 to August 2011) and PsycBITE (Pyschological Database for Brain Impairment Treatment Efficacy) (March 2012). To identify further published, unpublished and ongoing trials we searched trials registers, pharmaceutical websites, reference lists, contacted experts and performed citation tracking of included studies.

SELECTION CRITERIA

We included randomised controlled trials that recruited stroke survivors (ischaemic or haemorrhagic) at any time within the first year. The intervention was any SSRI, given at any dose, for any period. We excluded drugs with mixed pharmacological effects. The comparator was usual care or placebo. In order to be included, trials had to collect data on at least one of our primary (dependence and disability) or secondary (impairments, depression, anxiety, quality of life, fatigue, healthcare cost, death, adverse events and leaving the trial early) outcomes.

DATA COLLECTION AND ANALYSIS

We extracted data on demographics, type of stroke, time since stroke, our primary and secondary outcomes, and sources of bias. For trials in English, two review authors independently extracted data. For Chinese papers, one review author extracted data. We used standardised mean differences (SMD) to estimate treatment effects for continuous variables, and risk ratios (RR) for dichotomous effects, with their 95% confidence intervals (CIs).

MAIN RESULTS

We identified 56 completed trials of SSRI versus control, of which 52 trials (4059 participants) provided data for meta-analysis. There were statistically significant benefits of SSRI on both of the primary outcomes: RR for reducing dependency at the end of treatment was 0.81 (95% CI 0.68 to 0.97) based on one trial, and for disability score, the SMD was 0.91 (95% CI 0.60 to 1.22) (22 trials involving 1343 participants) with high heterogeneity between trials (I(2) = 87%; P < 0.0001). For neurological deficit, depression and anxiety, there were statistically significant benefits of SSRIs. For neurological deficit score, the SMD was -1.00 (95% CI -1.26 to -0.75) (29 trials involving 2011 participants) with high heterogeneity between trials (I(2) = 86%; P < 0.00001). For dichotomous depression scores, the RR was 0.43 (95% CI 0.24 to 0.77) (eight trials involving 771 participants) with high heterogeneity between trials (I(2) = 77%; P < 0.0001). For continuous depression scores, the SMD was -1.91 (95% CI -2.34 to -1.48) (39 trials involving 2728 participants) with high heterogeneity between trials (I(2) = 95%; P < 0.00001). For anxiety, the SMD was -0.77 (95% CI -1.52 to -0.02) (eight trials involving 413 participants) with high heterogeneity between trials (I(2) = 92%; P < 0.00001). There was no statistically significant benefit of SSRI on cognition, death, motor deficits and leaving the trial early. For cognition, the SMD was 0.32 (95% CI -0.23 to 0.86), (seven trials involving 425 participants) with high heterogeneity between trials (I(2) = 86%; P < 0.00001). The RR for death was 0.76 (95% CI 0.34 to 1.70) (46 trials involving 3344 participants) with no heterogeneity between trials (I(2) = 0%; P = 0.85). For motor deficits, the SMD was -0.33 (95% CI -1.22 to 0.56) (two trials involving 145 participants). The RR for leaving the trial early was 1.02 (95% CI 0.86 to 1.21) in favour of control, with no heterogeneity between trials. There was a non-significant excess of seizures (RR 2.67; 95% CI 0.61 to 11.63) (seven trials involving 444 participants), a non-significant excess of gastrointestinal side effects (RR 1.90; 95% CI 0.94 to 3.85) (14 trials involving 902 participants) and a non-significant excess of bleeding (RR 1.63; 95% CI 0.20 to 13.05) (two trials involving 249 participants) in those allocated SSRIs. Data were not available on quality of life, fatigue or healthcare costs.There was no clear evidence from subgroup analyses that one SSRI was consistently superior to another, or that time since stroke or depression at baseline had a major influence on effect sizes. Sensitivity analyses suggested that effect sizes were smaller when we excluded trials at high or unclear risk of bias.Only eight trials provided data on outcomes after treatment had been completed; the effect sizes were generally in favour of SSRIs but CIs were wide.

AUTHORS' CONCLUSIONS

SSRIs appeared to improve dependence, disability, neurological impairment, anxiety and depression after stroke, but there was heterogeneity between trials and methodological limitations in a substantial proportion of the trials. Large, well-designed trials are now needed to determine whether SSRIs should be given routinely to patients with stroke.

Guidelines for management of ischaemic stroke and transient ischaemic attack 2008

This article represents the update of the European Stroke Initiative Recommendations for Stroke Management. These guidelines cover both ischaemic stroke and transient ischaemic attacks, which are now considered to be a single entity. The article covers referral and emergency management, Stroke Unit service, diagnostics, primary and secondary prevention, general stroke treatment, specific treatment including acute management, management of complications, and rehabilitation.

Epidemiology and treatment of post-stroke depression

Mood depression is a common and serious complication after stroke. According to epidemiological studies, nearly 30% of stroke patients develop depression, either in the early or in the late stages after stroke. Although depression may affect functional recovery and quality of life after stroke, such condition is often ignored. In fact, only a minority of patients is diagnosed and even fewer are treated in the common clinical practice. Moreover, the real benefits of antidepressant (AD) therapy in post-stroke depression have not been fully clarified. In fact, controlled studies on the effectiveness of ADs in post stroke depression (PSD) are relatively few. Today, data available suggest that ADs may be generally effective in improving mood, but guidelines for the optimal treatment and its length are still lacking.

Antidepressant treatment and worsening white matter on serial cranial magnetic resonance imaging in the elderly: the Cardiovascular Health Study

BACKGROUND AND PURPOSE

In some studies, late life depression is associated with white matter lesions on MRI. The effect of different classes of antidepressants on progression of white matter lesions is unknown. Selective serotonergic reuptake inhibitors (SSRIs) may decrease platelet aggregation. We hypothesized that Cardiovascular Health Study participants taking SSRIs would less often have worsening white matter on serial MRI than participants not on antidepressants.

METHODS

Among 1826 participants who were not using an antidepressant at initial MRI scan, we examined the association of worsening in white matter grade from initial to follow-up MRI scans, 5 years apart on average, and antidepressant use between the scans. Logistic regression models were used, controlling for a variety of potential confounding variables.

RESULTS

Use of any antidepressant during the period of study was associated with worsening white matter. In a multivariable model, risk was slightly increased, not reduced, with use of serotonergic agents (OR 1.36, 95% CI 0.87 to 2.12) and was significantly increased with the use of tricyclic antidepressants (OR 1.77, 95% CI 1.07 to 2.94).

CONCLUSIONS

The association between worsening white matter and use of tricyclic antidepressants was an unexpected finding that may relate to indications for use other than depression or to side effects such as hypotension. Protection against worsening was not seen with use of serotonergic agents.

Effects of citalopram and fluoxetine on the corticocerebral blood flow in conscious rabbits

Depression, which is associated with an increased incidence of vascular events, frequently occurs following stroke. Selective serotonin reuptake inhibitory drugs (SSRIs) as antidepressants, are well tolerated, and also seem to be effective in post-stroke depression. The aim of this study was to investigate the effects of the SSRIs citalopram and fluoxetine, on the corticocerebral blood flow (cCBF) in rabbits with unilateral carotid occlusion induced cerebral ischemia. The cCBF was measured by the hydrogen clearance technique. After determination of the mean baseline cCBF, the effects of individual doses (0.1, 0.3 and I mg/kg) of citalopram or fluoxetine on the cCBF were investigated. Following the induction of an impaired cCBF, the changes in cCBF after drug treatments in this condition were likewise measured. The mean arterial blood pressure (MABP) and the heart rate (HR) from the electrocardiogram (ECG) were also determined. Neither citalopram nor fluoxetine influenced the cCBF in the control group. Fluoxetine improved the cCBF only very slightly in the ischemic animals. In contrast, all the doses of citalopram exerted pronounced and dose-dependent cCBF-increasing effects in the animals with unilateral carotid occlusion (maximal mean ACBF: 10, 16 and 27 ml/min/100 g tissue). The HR was decreased in both groups. Only citalopram treatment led to a slight MABP-decreasing effect. Besides enhancement of the serotonergic transmission in the brain, the cCBF-increasing effect of citalopram under ischemic conditions may be of benefit in post-stroke and vascular depression.

Cognitive improvement after treatment of depressive symptoms in the acute phase of stroke

The outcome of antidepressant treatment for depressive symptoms and cognitive impairment at the acute phase of stroke is controversial. We investigated 93 patients, treating with citalopram 36 with severe depressive symptoms (HAM-D: Hamilton Depression Rating Scale >18), whilst 19 patients with mild depressive symptoms, and 38 non-depressed patients, remained untreated. At baseline (two weeks after stroke), patients with severe depressive symptoms had lower scores in total Dementia Rating Scale (DRS) and in the attention and memory DRS subscales, than the non-depressed patients (p<0.001). At the end of the three-month follow-up period, these differences had disappeared, but patients initially with mild depressive symptoms had higher HAM-D scores than the non-depressed patients (p=0.015), and lower scores in DRS attention and memory subscales (p<0.01), than the patients treated with citalopram. Treatment was associated with improved mood, memory and attention, and a placebo-controlled study on the treatment of mild depressive symptoms is warranted.

Depression and Other Mental Health Diagnoses After Stroke Increase Inpatient and Outpatient Medical Utilization Three Years Poststroke

OBJECTIVE

Poststroke depression (PSD) has been linked to negative outcomes, including mortality and decreased functioning. However, the effect of PSD and other mental health conditions on inpatient and outpatient healthcare utilization after stroke has not been examined. The primary objective of this study was to evaluate the relationship between PSD and healthcare utilization after stroke. The secondary objective was to evaluate the relationship between other mental health diagnoses and medical utilization after stroke.

METHOD

We examined 3 years of poststroke healthcare utilization data in a national cohort of veterans with ischemic stroke. Mental health diagnoses were identified with inpatient International Classification of Diseases, 9th Revision codes. Multivariate analysis of variance was used to compare patient characteristics and multivariate linear regression to model utilization in: 1) patients with PSD, 2) patients diagnosed with other mental health conditions poststroke, and 3) patients with no mental health diagnosis.

RESULTS

Of 51,119 veterans identified, 2405 (5%) received a PSD diagnosis and 2257 (4%) received a diagnosis of another mental health condition after their stroke. Patients with PSD had significantly more inpatient hospitalization days and outpatient visits than those without any mental health diagnosis, even after adjusting for the number of mental health clinic visits. Likewise, patients diagnosed with other mental health diagnoses had greater medical utilization than patients without any mental health diagnosis. Both PSD and other mental health diagnoses independently predicted medical utilization.

CONCLUSION

Mental health diagnosis after stroke increases inpatient and outpatient healthcare utilization in the first 3 years poststroke. Additional biologic and psychosocial factors should be investigated.

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.

Clinical practice. Rehabilitation after stroke

A 66-year-old man was suddenly unable to speak, follow directions, or move his right arm and leg. He received tissue plasminogen activator within 90 minutes. Four days later, his speech was limited to effortful answers of yes or no. He could not walk or use his right arm, and self-care tasks required maximal assistance. What advice would you offer him and his family regarding rehabilitation for his disabilities?

Poststroke depression: psychopharmacological considerations

PSD is a common psychiatric complication of stroke. It is often underrecognized and untreated. Numerous studies show that untreated PSD impedes the rehabilitation and recovery process, jeopardizes quality of life, and increases mortality. Successful management of the PSD requires early recognition and initiation of appropriate treatment to facilitate an optimal level of functioning. As active members of the interdisciplinary treatment team, psychiatric consultative-liaison nurses play a pivotal role in facilitating positive treatment outcomes during both the acute and rehabilitation phases in the management of PSD.