Clinical Edge

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Management & Prevention of Poststroke Depression

Stroke; ePub 2016 Dec 8; Towfighi, Ovbiagele, et al

The American Heart Association/American Stroke Association has issued a scientific statement on poststroke depression (PSD), which occurs in approximately one-third of stroke survivors and is associated with poor functional outcomes and higher mortality. The statement provides a review of the current evidence and gaps in current knowledge of the epidemiology, pathophysiology, outcomes, management, and prevention of PSD, and provides implications for clinical practice. Among the statement’s findings:

  • Epidemiology: Approximately one third of stroke survivors develop PSD at some point after stroke.
  • Pathophysiology: The pathophysiology of PSD is complex and likely involves a combination of biological and psychosocial factors.
  • Predictors: A multitude of studies have evaluated predictors of PSD, but because of differences in inclusion and exclusion criteria, statistical methods, and inadequate sample sizes for multivariate analyses, generalizability is limited. The most consistent predictors of PSD have been physical disability, stroke severity, history of depression, and cognitive impairment.
  • PSD and functional outcomes: PSD is associated with poorer functional outcomes after stroke. Treatment with fluoxetine was associated with lower PSD occurrence rates and improvement in motor recovery in 1 RCT.
  • PSD and mortality: PSD is associated with higher mortality after stroke.
  • Screening: 24 studies (n=2,907 participants) showed that the CES-D, HDRS, and PHQ-9 had high sensitivity for detecting PSD; however, the studies had several limitations, including generalizability.
  • Management: pharmacotherapy: 12 trials (n=1,121) suggest that antidepressant medications may be effective in treating PSD.
  • Management: psychosocial interventions: 7 trials (n=775) suggest that brief psychosocial interventions may be useful and effective in treatment of PSD.
  • Prevention: pharmacotherapy: 8 trials (n=776) suggest that pharmacological treatment may be effective in preventing PSD.
  • Prevention: psychosocial interventions: 5 trials (n= 1,078) suggest that psychosocial therapies may prevent the development of PSD.

Citation:

Towfighi A, Ovbiagele B, El Husseini N, et al. Poststroke depression: A scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. doi:10.1161/STR.0000000000000113.

Commentary:

PSD is common and this new scientific statement raises our awareness of this important consequence of stroke. Given that over one-third of patients develop depression after a stroke and the fact that such depression affects outcomes, our main takeaway from this statement is that we should have a low threshold for initiating treatment for suspected depression in patients after a stroke. The other interesting conclusion is that both pharmacotherapy and psychosocial interventions may help prevent depression, and the possibility of preventing depression will be an important area of future research. —Neil Skolnik, MD

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