Pharmacological management of post-stroke depression: an update of the evidence and clinical guidance

ABSTRACT

Introduction: Post-stroke depression (PSD) is common, serious and of considerable high risk of being chronic. Pharmacological treatment is highly recommended (class I recommendation) based on level B evidence. Still, treatment is often insufficient and the diagnosis can be challenging.

Areas covered: The present paper is an update on pharmacological treatment of PSD and a review of recent clinical guidelines. To put this into perspective, the authors highlight the risk factors that might help clinicians identify patients with PSD, and discuss pharmacological prevention, functional outcome, and safety of antidepressant treatment in stroke patients.

Expert opinion: Although there are still gaps in our knowledge of PSD, the seriousness should not be neglected, and pharmacological treatment should be recommended when relevant. A selective serotonin reuptake inhibitor (SSRI) is first choice, but is not always tolerated or effective. Close follow-up and dose adjustments as well as add-on possibilities are therefore important aspects of treatment as well. Antidepressant treatment prevents PSD but the effect on enhancement of stroke recovery is less clear.

KEYWORDS:

• Antidepressants
• pharmacological treatment
• post-stroke depression
• prevention
• Treatment
• selective Serotonin Reuptake Inhibitors

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 in this manuscript have no relevant financial or other relationships to disclose.

Article highlights

• In the presence of PSD, treatment with a selective serotonin reuptake inhibitor is indicated.

• There is no evidence suggesting that a specific selective serotonin reuptake inhibitor should be preferred.

• Optimal timing regarding treatment initiation, duration and threshold for treatment is largely unknown.

• Treatment with selective serotonin reuptake inhibitors is relatively safe, also in the acute phase. The seriousness of PSD should, however, always be weighed against potential side effects including the risk of bone fractures, GI symptoms, and bleeding complications. There is no evidence of routine treatment; however, evidence shows effect of preventive treatment.

• Newer antidepressants, including the drug vortioxetine, have recently been developed and their potential role in the treatment of PSD is yet to be studied.

This box summarizes key points contained in the article.

List of abbreviations

Mesh: Medical Subject Heading, PSD: Post-stroke depression, SSRI: Selective Serotonin Reuptake Inhibitor, RCT: Randomized Controlled Trial, TCA: Tricyclic Antidepressants, RR: Risk Ratio, HR: Hazard Ratio, CI: Confidence Interval, SNRI: serotonin norepinephrine reuptake inhibitors, AMPA: alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid, NARI: selective norepinephrine reuptake inhibitor, NIHSS: National Institute of Health stroke scale, CNS: central nervous system, GI: Gastrointestinal, mRS: modified Rankin Scale.

Additional information

Funding

This manuscript has not been funded.