Depression and Stroke

Dr. Robinson started his talk by summarizing the results of a recent study by Rasmussen and colleagues, which demonstrated the incidence of poststroke depression could be significantly reduced by sertraline treatment. This study was particularly interesting in that all the subjects were not depressed on study entry, and so all patients were treated prophylactically.

A treatment effect was present by about week 18, and sertraline treatment also decreased the incidence of adverse events, in particular the occurrence of cardiovascular events. However, an earlier study with mianserin was unable to show any reduction in the rate of poststroke depression relative to placebo, although the rate of depression in the placebo group was fairly low in this study, which may have made it difficult to see any effect of active treatment.

Depression

Depression is the most common psychological problem in the US. Minor Depression can be attributed to normal depressed feelings that arise because of a specific life situation, a side effect of medication, hormonal changes or physical illness, and does not usually require treatment. Major Depression (depressive illness) is a serious condition that result in extreme fatigue, sleep problems and eventually an inability to function. The exact cause is unknown, but it is thought to be a malfunction of brain neurotransmitters, which are chemicals that modulate moods. Major Depression is usually treated with a combination of psychotherapy and antidepressants which moderate or correct chemical imbalances in the brain. The group of antidepressants most frequently prescribed is the selective serotonin reuptake inhibitors (SSRIs) which regulate the neurotransmitter serotonin. Examples: Amitriptyline HCL WELLBUTRIN Wellbutrin SR Fluoxetine Celexa Lexapro Paxil Prozac Remeron Zoloft Effexor XR

When depression is present in stroke patients, it is associated with a significantly worse outcome. A diagnosis of depression 3 months after stroke has been shown to be associated with much poorer functioning at 15 months and a much slower rate of recovery. A diagnosis of depression at 1 month after a stroke has also been demonstrated to be a significant predictor of mortality at both 12 and 24 months. Even more surprising, Dr. Robinson presented some unpublished data that 3 months of SSRI treatment poststroke significantly reduced the death rate, even if the patients were not depressed. There was approximately a 50% increase in survival in SSRI-treated patients, most likely due to a decreased rate of adverse cardiovascular events.

Dr. Robinson next reviewed some of the factors that predict the occurrence of depression following a stroke. A number of factors, including age, the presence of heart disease, and family history, increase the risk of developing depression. Neuroticism scores have also been shown to predict the incidence of depression following a stroke. Conversely, a study by May and colleagues followed patients for 14 years and suggested that previous psychopathology (ie, depression) also significantly increased the likelihood of subsequently having a fatal stroke. Thus, history of depression may increase the risk for later developing a stroke, and having a stroke may increase the risk for developing depression.

There is also considerable debate as to whether stroke location increases the risk for developing depression. A recent meta-analysis by Carson and colleagues was unable to find an association between stroke location and the occurrence of depression. However Dr. Robinson suggested that left-sided location is associated with major depression. An MRI study has also demonstrated that left internal capsule or pallidal lesions were associated with depression, which would be consistent with the hypothesis that lesions affecting the prefrontal circuits on the left side of the brain are correlated with depression.

Dr. Robinson concluded by suggesting that depression may actually increase the risk of developing a stroke, and that the presence of depression following a stroke is associated with a significant decrease in recovery and increased mortality. Finally, he recommended that sertraline (50-150 mg) be given to all patients during the first 2-3 months after a stroke, as it appears to be a safe and effective strategy to reduce the incidence of depression and adverse cardiovascular events during the poststroke period.

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