Stroke psychiatry — post-stroke depression, location, fluoxetine (MEQ)

(i) Frequency and cost. Post-stroke depression affects approximately one third of stroke survivors at any one time after stroke, and carries a higher risk of suboptimal recovery, recurrent vascular events, poor quality of life and mortality.^[1] Across 61 studies and 25,488 people, the pooled frequency was 31%.^[2] Depression after stroke was associated with prestroke depression, more severe neurological deficit and physical disability, and was negatively associated with functional outcome.^[7]

(ii) The location claim. Carson's systematic review offered no support for the hypothesis that the risk of depression after stroke is affected by lesion location; the pooled relative risk after left-hemisphere compared with right-hemisphere stroke was 0.95.^[3] Mitchell's structured-interview meta-analysis did find the relative risk of any depressive disorder higher after left (dominant) hemisphere stroke and with aphasia.^[10]

(iii) Screening. The Patient Health Questionnaire-9 (PHQ-9) demonstrated higher diagnostic accuracy when evaluating any type of post-stroke depression and during the first 2 months after stroke.^[9]

The reference standard. The gold standard for confirming a diagnosis of post-stroke depression is a structured psychiatric interview against DSM criteria. The best method for screening patients with aphasia and cognitive impairment is unknown.^[9]

(iv) Treatment. In the 2023 Cochrane review, very low-certainty evidence suggests that pharmacological, psychological and combination therapies can reduce the prevalence of depression after stroke; pharmacological treatment was associated with CNS and gastrointestinal adverse events.^[6] SSRIs have been associated with an increased risk of bleeding complications.^[8]

Prevention is a different question. In non-depressed patients, depression developed in 22.4% on placebo, 8.5% on escitalopram and 11.9% with problem-solving therapy over 12 months.^[4]

Fluoxetine for the arm. In FOCUS, fluoxetine 20 mg daily for 6 months did not improve functional outcome, reduced new depression and increased bone fractures; the results do not support routine fluoxetine either to prevent post-stroke depression or to promote recovery of function.^[5] In AFFINITY, fluoxetine did not improve functional outcome and increased falls, bone fractures and epileptic seizures.^[11]