Stroke psychiatry — PSD, location myth, capacity (MEQ)

(i) Formulation and location. Concurrent post-stroke depression (depressive disorder due to another medical condition): anhedonia, insomnia, passive SI, rehab withdrawal at 6 weeks — PSD affects roughly one-third of survivors at some point and worsens participation.^[1][2] Correct the junior doctor: lesion location alone is not a reliable diagnostic determinant of PSD (Carson systematic review); left frontal history is teaching colour, not a rule that makes clinical assessment unnecessary.^[3][7] Distinguish from pure apathy or emotionalism if features fit, but here depressive syndrome is primary.

(ii) Assessment. Stroke dossier (territory, disability, dual antiplatelets), collateral, aphasia-adapted MSE, suicide risk, medical drivers of non-engagement, cognitive screen. PHQ-type tools if language allows; otherwise observational/therapy metrics.^[1][7]

(iii) Treatment. Multimodal AHA/ASA-aligned care: rehab psychology/behavioural activation adapted for aphasia; social support; treat pain/sleep.^[1] Antidepressant example: sertraline 25–50 mg oral daily titrate, or escitalopram 5–10 mg oral daily (often 5 mg if older/frail), monitoring bleeding with dual antiplatelets, sodium, falls, QTc (especially escitalopram/citalopram), and early suicide risk; Cochrane supports pharmacological and psychological treatment options with evidence-quality caveats.^[6][7] Trial literacy: Robinson JAMA 2008 showed prevention with escitalopram or problem-solving therapy in non-depressed patients — different question from treating established PSD.^[4] Do not start fluoxetine solely for motor recovery; after FLAME enthusiasm, large pragmatic trials (FOCUS and related AFFINITY/EFFECTS programme) do not support routine fluoxetine for functional outcome — treat mood on psychiatric grounds.^[5]

(iv) Capacity and disposition. House sale is a high-stakes, decision-specific capacity problem: test understanding, retention, weighing, communication with speech support. Nodding or mild aphasia does not prove valid weighing, especially with depression-related hopelessness. Pause major transactions; involve social work/legal substitute pathways under local law; reassess after mood treatment. Disposition: suicide safety plan, stepwise rehab, community CL/GP follow-up, secondary prevention adherence support.^[1][7]