Pharmacological management of post-stroke depression

ABSTRACT

Introduction: Post-stroke depression (PSD) is a common clinical problem affecting approximately one-third of stroke survivors. PSD is associated with poor functional outcome and higher morbidity and mortality rates. Currently, uncertainty remains regarding optimal pharmacological strategies for its prevention and treatment.

Areas covered: This article reviews the state of the current literature on pharmacologic intervention strategies for PSD, providing a summary of the most recent evidence to support pharmacological treatment in PSD.

Expert opinion: Experimental and clinical research have increased our knowledge on PSD, although unanswered questions still remain regarding the best time to begin treatment, the effect of the antidepressants in areas other than emotion, or their capability to reduce mortality in stroke patients, among others.

Currently, though numerous trials and meta-analyses suggest that antidepressants are effective in treating PSD and guidelines recommend their use for PSD, in the daily clinical practice, only a minority of patients are properly assessed and treated. Therefore, though further evidence is needed to clarify the real role of antidepressants in patients with stroke, physicians and other healthcare professionals must be familiar with the pharmacological treatment of PSD, in order to improve the outcome and increase the quality of life of this vulnerable group of patients.

KEYWORDS:

• Stroke
• depression
• treatment
• pharmacotherapy
• post-stroke depression
• antidepressants

Article highlights

• Post-stroke depression (PSD) is the most frequent psychiatric disorder following a stroke, affecting approximately one-third of stroke survivors.

• PSD is a major limiting recovery and rehabilitation in stroke patients and is associated with poor functional outcomes and higher morbidity and mortality. PSD increases all-cause mortality by more than 50%.

• In 1984, the first randomized, double-blind placebo-controlled treatment trial demonstrated that nortriptyline was effective in treating PSD.

• Subsequently, numerous studies and meta-analyses on PSD treatment have been published, though uncertainty remains regarding optimal strategies for PSD treatment. The Guidelines for Healthcare Proffessionals from the American Heart Association/American Stroke Association (AHA/ASA), published in 2017, recommend the use of antidepressant for PSD. However, authors highlight the need for further research to clarify the optimal timing and most efficacious medications for the treatment of PSD.

• Clinical trials of antidepressants in individuals with PSD have shown a beneficial effect, not only in terms of remission of depressed mood, but also in terms of the improvement of cognitive and functional impairment, and long-term survival. Several studies have also supported the use of pharmacological interventions to reduce the likelihood of developing PSD.

• Currently, SSRIs are first-choice pharmacological treatments for PSD due to their relatively better side-effect profile. Tricyclics should be considered as second-line therapy due to their severe side effects and contraindications. The efficacy of drugs other than antidepressants has only been marginally investigated.

• In the coming years, new studies will be published to confirm and possibly increase the indications for the use of antidepressants in PSD. Meanwhile, it is essential that all physicians and health-care professionals caring for patients with stroke receive the appropriate training to assess and treat PSD.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.