Prevention and treatment of post-stroke depression and anxiety disorders
THELERITIS CH.

A large percentage of patients with stroke (about 40%) will eventually develop depression. Post-stroke depression is associated with deficits in activities of daily living, poor functional recovery, more cognitive deficits and increased mortality both in the short-term and the long term. Post-stroke depression is often unrecognized and remains untreated. A psychiatric examination of all post-stroke patients, especially of those with considerable disability and a history of depressive disorder should be systematically pursued.

Selective Serotonin Reuptake Inhibitors-(SSRIs) and in particular sertraline and citalopram, are considered to be efficacious and safe for the pharmacological treatment of post-stroke depression. Nortriptyline should be limited to patients resistant to treatment with SSRIs, but clinicians should be aware of the anticholinergic side effects that might occur. With regards to the optimal length of treatment of post-stroke depression, it is recommended that antidepressant treatment should be continued for a period of 4-6 months, which should be followed by a slow withdrawal period.

Psychostimulants (dextroamphetamine and methylphenidate) are considered to be safe and efficacious in the treatment of post-stroke depression; however, more studies are needed to confirm their efficacy. Based on one study, repetitive Transcranial Magnetic Stimulation (rTMS) has been found to be an effective and safe treatment for patients with refractory depression and cerebrovascular disease. There are no adequate randomized controlled trials of ECT in post-stroke depression; nevertheless, based on two retrospective chart studies, ECT might be considered a useful and relatively safe treatment option.

With regards to psychosocial interventions, a care management intervention of depression in patients with recent stroke may result in greater remission of depression and reduction of depressive symptoms than the standard monitoring and care alone. Due to methodological limitations the effectiveness of psychotherapeutic interventions has no empirical support for its effectiveness; however, cognitive-behavioural therapy has shown promising results that should be further explored.

Sertraline and escitalopram have been found efficacious and safe in the prevention of post-stroke depression. On the contrary, there is no evidence to support the routine use of psychotherapy in this domain. Furthermore, it has been reported that religious faith, prayer and spiritual life might protect patients from emotional distress after stroke.

Patients with stroke may also present with anxiety disorders (generalized anxiety disorder and PTSD) co-occuring or not with depression. Even, in these cases antidepressant treatment and psychosocial interventions might help considerably. Encephalos 2008, 45(4):213-219.

Key words: Stroke, post-stroke depression, post-stroke anxiety disorders, treatment, prevention.