Depression after stroke: a review of the evidence base to inform the development of an integrated care pathway. Part 2: Treatment alternatives.
BACKGROUND
Depression is a common complication of stroke, leading to increased morbidity and mortality. It can impede the process of rehabilitation, and has been associated with poorer outcomes and increased length of stay in hospital. This systematic review was undertaken as a preliminary step to the development of an evidence-based integrated care pathway (ICP) for the management of post-stroke depression (PSD) in a rehabilitation setting, and is divided into two parts. In part 1 we reviewed the frequency of depression in stroke, its impact on functional recovery and the different methods for assessment.


OBJECTIVE
In part 2, we discuss the rationale for treatment of PSD, appraise the evidence for effectiveness of the different antidepressant drugs, and consider whether we can identify a recommended first-line treatment for use in our ICP.


METHODS
Data sources comprised a computer-aided search of published studies on depression in stroke and references to literature used in reviews.


RESULTS
From the few controlled trials of anti-depressant therapy in PSD, both tricyclics and selective serotonin re-uptake inhibitors (SSRIs) appear to be effective, but the latter may be preferable in stroke because of their prompt action and better side-effect profiles. Within the group of SSRIs there is currently no direct evidence to guide the choice of agent. In the absence of firm guidance, sertraline was chosen on theoretical grounds as one of the most potent with minimal sedative effects and no reported interaction with warfarin. Citalopram may offer an appropriate second choice.


CONCLUSIONS
A suggested regimen for the use of sertraline in PSD was put forward. Development of an ICP may help to establish a more consistent approach to assessment and treatment of PSD, and form a basis for future comparison of different treatments as they become available.
Turner-Stokes
Lynne
L
Regional Rehabilitation Unit, Northwick Park and St Mark's Hospital Trust, Harrow, Middlesex, UK. lynne.turner-stokes@kcl.ac.uk
Hassan
Nibras
N
D000928:Antidepressive Agents / Q000627:therapeutic use*; D019091:Critical Pathways; D003866:Depressive Disorder / Q000188:drug therapy* / Q000209:etiology*; D006801:Humans; D017367:Selective Serotonin Reuptake Inhibitors / Q000627:therapeutic use; D020521:Stroke / Q000150:complications*; D000071939:Stroke Rehabilitation; D016896:Treatment Outcome
D000928:Antidepressive Agents; D017367:Selective Serotonin Reuptake Inhibitors