Post Stroke Depression: UnderDiagnosed & UnderTreated

Post Stroke Depression: UnderDiagnosed & UnderTreated

This Topic is Posted in Following Four Sections:

    1. Pathophysiology of Post Stroke Depression.
    2. Risk Factors Associated with Post Stroke Depression.
    3. Treatment of Post Stroke Depression (Level of Evidence According to Evidence Based Review of Stroke Rehabilitation).
    4. Prevention of Post Stroke Evidence (Level of Evidence According to Evidence Based Review of Stroke Rehabilitation).

 

(1) Pathophysiology of Post Stroke Depression

  • No consistent findings yet.
  • Lesion Locations: Association found with Left frontal lesions and frontal-lenticulo-capsular-brainstem base lesions and development of post stroke depression.
  • Thus indicating the possible role of anterior frontal lobe damage and the involvement of the frontal-basal ganglia brainstem pathway.

 

Source: Can J Psychiatry. 2010 Jun; 55(6):341-9.

(2) Risk Factors Associated with Post Stroke Depression

  • Female gender
  • Younger age
  • Past history of depression or psychiatric illness
  • Cognitive impairment
  • Severe stroke
  • Early or late physical disability

 

Note: No consistent association between hemisphere of stroke, lesion location, or pathological subtype of depression.

Source: (a) J Stroke. 2016 Sep; 18(3): 244–255. (b) Evidence-Based Review of Stroke Rehabilitation. Ch 18 (Last Updated: September 2016).

(3) TREATMENT OF POST STROKE DEPRESSION:

  1. Heterocyclic Antidepressants: Level 1a evidence that they may improve depression post stroke. Side effects in elderly patients mean that these medications should be used with caution in that population.
  2. SSRIs: Level 1a evidence that SSRIs are effective in the treatment of post-stroke depression. Further placebo studies should be conducted using a blinded administrator and an optimal treatment duration in order to address methodological differences across current studies.
  3. Reboxetine: Level 1b evidence that Reboxetine (noradrenaline reuptake inhibitor) is effective in reducing “retarded” post-stroke depression.
  4. SNRIs: More evidence is required to determine the efficacy of Venlafaxine (Level 4) and Duloxetine (Level 1b) for post-stoke depression.
  5. Methylphenidate: Level 1b evidence that methylphenidate is more effective than placebo in improving both symptoms of depression and functional recovery. Methylphenidate has an earlier onset of action than traditional antidepressants.
  6. Statinslimited Level 2 evidence that statins may improve post-stroke depression and anxiety.
  7. Herbal Preparation- Free and Easy Wanderer Plus (FEWP): Level 1b evidence that FEWP may be as effective as fluoxetine in the treatment of post-stroke depression. 
  8. Omega-3 Fish Oil: Level 1b evidence that fish oil supplementation following stroke has no impact on mood

 

Source (Complete PDF Chapter): Evidence-Based Review of Stroke Rehabilitation.

(4) PREVENTION OF POST STROKE DEPRESSION:

  1. Early Initiation of Antidepressant Therapy: Level 1a evidence that early initiation of antidepressant therapy in non-depressed stroke patients is associated with reduced risk for the development of post-stroke depression. Further study is required to assess both duration of treatment and optimal timing for the initiation of therapy.
  2. Fluoxetine: Level 1a evidence that Fluoxetine is an effective pharmaceutical treatment for preventing post stroke depression (* Note: with level 1b evidence from one RCT that Fluoxetine can also improve functional disabilities.)
  3. Escitalopram: Level 1a evidence that Escitalopram can assist with improving mood among stroke patients (* Note: one RCT revealing a successful prevention of depression compared to problem-solving therapy and a placebo group, and another RCT revealing a prevention of apathy compared to a placebo.)
  4. Sertaline: Mixed evidence regarding the efficacy of Sertraline with level 1b evidence it does not prevent depression any better than a placebo while other level 1b evidence reporting successful prevention of depression compared to placebo.
  5. Milnacipran: Level 1b evidence that Milnacipran may be effective in preventing depression compared to a placebo.
  6. Mirtazapine: Level 2 evidence that Mirtazapine may be effective in preventing depression compared to not receiving pharmacological treatment.

 

Source (Complete PDF Chapter): Evidence-Based Review of Stroke Rehabilitation.


 

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Dr. Harvinder Singh, M.D. (Admin)


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