- Last edited on February 2, 2024
Post-Stroke Depression
Primer
Epidemiology
- Following a stroke, the onset of depression is acute, usually occurring within 1 day or a few days of the cerebrovascular accident (CVA).[1]
- Approximately 33% of stroke survivors develop PSD at some point, with the frequency being highest in the first year of stroke (and declines thereafter).
Pathophysiology
- The pathophysiology of PSD involves both biological and psychosocial factors, but certain stroke lesions and locations are associated with a higher risk for post-stroke depression.[2]
Localization
- Historically, left-sided strokes were thought to place patients at greater risk for PSD, but newer studies show mixed findings (i.e. - outpatient clinics actually see depression more commonly in right-sided strokes).[3]
- PSD can be longer lasting compared to non-stroke depression due its multifactorial nature, and is more difficult to treat with antidepressants.
Prophylaxis
- The prophylactic use of SSRIs in post-stroke neurological recovery is debated, with an argument to be made that some studies have shown reduced depression post-stroke.[4]
- There is some debate about whether or not the study population is representative of typical stroke populations (e.g., most enrolled individuals had milder forms of stroke)[8]
- Thus, the use of antidepressants as prophylaxis for post-stroke depression has not been routinely recommended.
- A comprehensive risk-benefit analysis should be considered along with a personalized approach to treatment, with monitoring of side effects if antidepressant therapy is pursued.
Treatment
- Citalopram, escitalopram, fluoxetine, and sertraline are the most commonly recommended SSRIs in post-stroke depression.[9][10]
- Paroxetine may also be more effective compared to other antidepressants, though has a greater risk for anticholinergic burden.[11]
- Cognitive-behavioural therapy (CBT) or interpersonal therapy (IPT) are also first line treatments for depressive symptoms post-stroke.[12]
Resources
For Clinicians
Guidelines
References
1)
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
2)
Robinson, R. G., Jorge, R. E., & Starkstein, S. E. (2023). Poststroke Depression: An Update. The Journal of Neuropsychiatry and Clinical Neurosciences, 00-00.
3)
Robinson, R. G., & Spalletta, G. (2010). Poststroke depression: a review. The Canadian Journal of Psychiatry, 55(6), 341-349.
4)
Robinson, R. G., Jorge, R. E., & Starkstein, S. E. (2023). Poststroke Depression: An Update. The Journal of Neuropsychiatry and Clinical Neurosciences, 00-00.
5)
Hankey, G. J., Hackett, M. L., Almeida, O. P., Flicker, L., Mead, G. E., Dennis, M. S., ... & Lung, T. (2020). Safety and efficacy of fluoxetine on functional outcome after acute stroke (AFFINITY): a randomised, double-blind, placebo-controlled trial. The Lancet Neurology, 19(8), 651-660.
6)
Lundström, E., Isaksson, E., Näsman, P., Wester, P., Mårtensson, B., Norrving, B., ... & Hankey, G. J. (2020). Safety and efficacy of fluoxetine on functional recovery after acute stroke (EFFECTS): a randomised, double-blind, placebo-controlled trial. The Lancet Neurology, 19(8), 661-669.
7)
Kwakkel, G., Meskers, C., & Ward, N. S. (2020). Time for the next stage of stroke recovery trials. The Lancet. Neurology, 19(8), 636-637.
8)
Woranush, W., Moskopp, M. L., Sedghi, A., Stuckart, I., Noll, T., Barlinn, K., & Siepmann, T. (2021). Preventive approaches for post-stroke depression: where do we stand? A Systematic Review. Neuropsychiatric Disease and Treatment, 3359-3377.
10)
Woranush, W., Moskopp, M. L., Sedghi, A., Stuckart, I., Noll, T., Barlinn, K., & Siepmann, T. (2021). Preventive approaches for post-stroke depression: where do we stand? A Systematic Review. Neuropsychiatric Disease and Treatment, 3359-3377.