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More than one third of stroke patients without depression histories develop depressive illness within 2 years of experiencing a stroke, and antidepressants are effective for acute treatment of this depression. However, previous studies have failed to show that antidepressants can prevent poststroke depression. In this randomized controlled trial, researchers examined the efficacy of 12 months’ treatment with the SSRI escitalopram (5–10 mg/day), problem-solving therapy (PST; 6 sessions over 10 weeks, plus 6 booster sessions for the remainder of the year), or pill placebo in 176 nondepressed stroke patients (mean age, 62) with significant medical comorbidity but no life-threatening conditions (or other possibly confounding conditions, e.g., impaired decision making). Participants had experienced stroke within 3 months of enrollment.
Results were adjusted for depression history. Placebo recipients were significantly more likely to develop major or minor depression (22.4%) than were patients treated with either escitalopram (8.5%) or PST (11.9%). Hazard ratios for depression with placebo were 4.5 compared with escitalopram and 2.2 compared with PST (number needed to treat, 7.2 and 9.1). A stricter analysis assumed that all 27 patients who dropped out before beginning treatment had developed depression; here, only escitalopram remained superior to placebo (HR, 2.2). Adverse events and functional outcomes (assessed quarterly) did not differ by group.
Robinson RG et al. Escitalopram and problem-solving therapy for prevention of poststroke depression: A randomized controlled trial. JAMA 2008 May 28; 299:2391.
Comment
This study demonstrates a significant effect of escitalopram and a somewhat less substantial effect of PST in preventing depression, in contrast with previous negative studies that were smaller and underpowered and used slightly younger patients. Other studies of acute treatment of poststroke depression suggest greater efficacy for tricyclic antidepressants than for SSRIs. These older, albeit less tolerable, medications might have provided even greater preventive benefits. Poststroke depression is associated with increased mortality but is difficult to identify. Therefore, preventive strategies may be more efficient than early detection and treatment.