Too Much and Too Little: Antidepressant Treatment in Stroke Survivors during the First Year

Abstract

Background: Post-stroke depression (PSD) is the most frequent mental illness after stroke, affecting about 30% of stroke survivors and hampering rehabilitation outcome. While current guidelines recommend monitored antidepressant treatment (ADT) in PSD, the limited precision between the use and need of ADT in clinical practice remains underassessed and poorly understood. Methods: Depression according to DSM criteria and ADT was assessed in n = 294 stroke survivors from two German rehabilitation centers about one, six, and twelve months after stroke. At each measurement occasion, PSD and current use of ADT was assessed, leading to four subgroups: PSD (yes/no) and ADT (yes/no). Frequencies of ADT and PSD were examined and analyzed with regard to depression severity (minor/major). Intra-individual trajectories were used to assess the persistence in ADT over-and undertreatment from a longitudinal perspective. Results: After one, 6 and 12 months, 36.7%, 31.1% and 25.5% of stroke survivors fulfilled the criteria for depression. Across all measurement occasions, 53% of depressed stroke survivors did not receive ADT, while 12% of the non-depressed did. ADT between stroke survivors with major or minor depression differed at baseline but not thereafter. Between 15-40% of the depressed without ADT experienced persisting undertreatment and 25-50% the non-depressed with ADT had not fulfilled depression criteria at an earlier time point. Conclusions: Depression occurred in one in three stroke survivors. Among these, only one in two received ADT, irrespective of PSD severity after discharge. In contrast, one in eight stroke survivors without depressive disorder received ADT, about half of them in the absence of earlier PSD. In conclusion, we found evidence of both under-and overtreatment of PSD with ADT, which emphasizes the need for a more stringent implementation of current PSD guideline recommendations.

Efficacy of the use of video games on mood, anxiety and depression in stroke patients: preliminary findings of a randomised controlled trial

“…[ 36 , 37 ]. These data may explain the increased use of antidepressants found in this study (79.31%) compared to previous studies where they only represent 50% of diagnosed patients [ 38 ].…”

Integrative-interpersonal dynamic therapy for poststroke depression (INID): study protocol of a randomised controlled pilot trial

“…Because a discontinuation of antidepressant medication shortly after its start during an ongoing depressive episode is potentially harmful and may lead to further symptom aggravation, 63 existing antidepressant medication will not be changed or conditioned for randomised patients, but recorded and used as a covariate (see the ‘Statistical analysis’ section). With this procedure, the proportion of (pre)medicated patients and changes in regiments 17 can be estimated for a subsequent confirmatory definite trial.…”

“…Open access survivors receive antidepressant drug treatment, and less than 10% receive psychotherapy treatment. [17][18][19] This striking gap is exacerbated by missing treatment guidelines and scarce evidence for standardised psychotherapy treatments for PSD. 11 Moreover, psychotherapists might be reluctant to treat PSD due to an uncertainty how to address stroke-specific challenges, handle medication and often complex comorbid somatic symptoms.…”

“… 11 Moreover, psychotherapists might be reluctant to treat PSD due to an uncertainty how to address stroke-specific challenges, handle medication and often complex comorbid somatic symptoms. 17 20 Taken together, evidence-based, effective and standardised psychotherapeutic interventions are crucial to address the need of adequate treatment for the growing number of stroke survivors experiencing PSD. Moreover, treatment strategies for PSD should address the time-sensitive prevalence after stroke 6 11 21 and bridge the crucial gap between inpatient rehabilitation and the difficult reintegration in survivors’ familiar environment 22 after discharge.…”

Predictors of post-stroke depression: Validation of established risk factors and introduction of a dynamic perspective in two longitudinal studies

“…The optimal timing for PSD screening also remains unclear ( 8 ) as depression may occur up to several years after the stroke and shows a non-linear pattern of emergence ( 10 , 11 ). Previous evidence underlined the need for early identification of PSD risk factors, which represents a promising strategy to address the timing issue and improve treatment use in PSD, which is characterized by both over- and undertreatment ( 12 , 13 ). Moreover, meta-analytic evidence demonstrated that psychosocial interventions and pharmacotherapy are efficacious for prevention of depression after stroke, albeit with an increased risk of nausea and bone fracture for pharmacotherapy ( 14 , 15 ).…”