title: Escitalopram and problem-solving therapy for prevention of poststroke depression: a randomized controlled trial.
abstract: BACKGROUND
  Depression occurs in more than half of patients who have experienced a stroke. Poststroke depression has been shown in numerous studies to be associated with both impaired recovery in activities of daily living and increased mortality. Prevention of depression thus represents a potentially important goal.
  
  
  OBJECTIVE
  To determine whether treatment with escitalopram or problem-solving therapy over the first year following acute stroke will decrease the number of depression cases that develop compared with placebo medication.
  
  
  METHODS
  A multisite randomized controlled trial for prevention of depression among 176 nondepressed patients was conducted within 3 months following acute stroke from July 9, 2003, to October 1, 2007. The 12-month trial included 3 groups: a double-blind placebo-controlled comparison of escitalopram (n = 59) with placebo (n = 58), and a nonblinded problem-solving therapy group (n = 59).
  
  
  METHODS
  The main outcome measure was the development of major or minor poststroke depression based on symptoms elicited by the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) and the diagnostic criteria from DSM-IV for depression due to stroke with major depressive-like episode or minor depression (ie, research criteria).
  
  
  RESULTS
  Patients who received placebo were significantly more likely to develop depression than individuals who received escitalopram (11 major and 2 minor cases of depression [22.4%] vs 3 major and 2 minor cases of depression [8.5%], adjusted hazard ratio [HR], 4.5; 95% confidence interval [CI], 2.4-8.2; P < .001) and also more likely than individuals who received problem-solving therapy (5 major and 2 minor cases of depression [11.9%], adjusted HR, 2.2; 95% CI, 1.4-3.5; P < .001). These results were adjusted for history of mood disorders and remained significant after considering possible confounders such as age, sex, treatment site, and severity of impairment in the model. Using an intention-to-treat conservative method of analyzing the data, which assumed that all 27 patients who did not start randomized treatment would have developed depression, and controlling for prior history of mood disorders, escitalopram was superior to placebo (23.1% vs 34.5%; adjusted HR, 2.2; 95% CI, 1.2-3.9; P = .007), while problem-solving therapy was not significantly better than placebo (30.5% vs 34.5%; adjusted HR, 1.1; 95% CI, 0.8-1.5; P = .51). Adverse events, including all-cause hospitalizations, nausea, and adverse effects associated with escitalopram were not significantly different between the 3 groups.
  
  
  CONCLUSIONS
  In this study of nondepressed patients with recent stroke, the use of escitalopram or problem-solving therapy resulted in a significantly lower incidence of depression over 12 months of treatment compared with placebo, but problem-solving therapy did not achieve significant results over placebo using the intention-to-treat conservative method of analysis.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT00071643.
authors.affiliation: Department of Psychiatry, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA. robert-robinson@uiowa.edu
authors.forename: Robert G
authors.initials: RG
authors.lastname: Robinson
authors.forename: Ricardo E
authors.initials: RE
authors.lastname: Jorge
authors.forename: David J
authors.initials: DJ
authors.lastname: Moser
authors.forename: Laura
authors.initials: L
authors.lastname: Acion
authors.forename: Ana
authors.initials: A
authors.lastname: Solodkin
authors.forename: Steven L
authors.initials: SL
authors.lastname: Small
authors.forename: Pasquale
authors.initials: P
authors.lastname: Fonzetti
authors.forename: Mark
authors.initials: M
authors.lastname: Hegel
authors.forename: Stephan
authors.initials: S
authors.lastname: Arndt
mesh_terms: D000368:Aged; D015283:Citalopram / Q000627:therapeutic use*; D003863:Depression / Q000209:etiology / Q000517:prevention & control*; D003866:Depressive Disorder / Q000209:etiology / Q000517:prevention & control*; D039721:Diagnostic and Statistical Manual of Mental Disorders; D004311:Double-Blind Method; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011340:Problem Solving; D011613:Psychotherapy / Q000379:methods*; D017367:Selective Serotonin Reuptake Inhibitors / Q000627:therapeutic use*; D020521:Stroke / Q000150:complications; D000071939:Stroke Rehabilitation
chemical_list: D015283:Citalopram; D017367:Selective Serotonin Reuptake Inhibitors