Постинсультная депрессия

Box 2. Differential diagnosis of post-stroke depression.

Cognitive disorders following stroke Vascular dementia Frontal executive syndrome Memory deficit due to strategic infarctions Post-stroke attention deficit

Disorders of the perception of the self & the environment Anosognosia of hemiplegia Anosognosia of aphasia Affective dysprosodia

Post-stroke motivational syndromes Post-stroke apathy Loss of psychic autoactivation (athymhormia)

Disorders of emotional reactivity Blunted affect Involuntary emotional-expressive disorder Catastrophic reactions

Other post-stroke affective disorders Irritability and mania

Adaptative & post-traumatic disorders following stroke Coping disturbances following stroke Post-stroke personality changes Post-stroke fatigue Post-stroke sleeping disorders

Nevertheless, data from a recent Cochrane review concluded that there is no evidence for a significant effect of psychoactive treatment to prevent PSD, although the overall rate of depression was lower among patients treated with antidepressant drugs.[101]

Hackett et al. evaluated 14 randomized controlled trials that included more than 1500 patients. Data were available from ten pharmaceutical trials and four psychotherapy trials (psychotherapy against standard care or attention control) to prevent depression in patients with stroke. Heterogeneity and variability in evaluation methods, time of assessment, time from stroke onset to entry into the trial, treatment duration, chosen drugs and main outcomes were observed. Drugs assessed were fluoxetine, trazodone, piracetam, mianserin, nortriptyline, maprotiline, indeloxazine and methylphenidate. There was no clear effect of pharmacological therapy on the prevention of depression or other end points. The conclusion of this meta-analysis is that more evidence is required before recommendations can be made about the routine use of preventive treatments after stroke. In addition, authors recommend that antidepressants and psychostimulants should not be used to prevent PSD.[101]

Recently, a randomized controlled trial for the prevention of depression among 176 nondepressed patients was conducted within 3 months following an acute stroke. The authors assessed whether treatment with escitalopram or problem-solving therapy over the first year following acute stroke would decrease the number of depression cases compared with placebo. The use of escitalopram resulted in a significantly lower incidence of depression over 12 months of treatment compared with placebo.[99] Nevertheless, this study caused several controversies, since some issues may limit the generalization of their results. Discrepancies were related to the low mean age of the sample, mainly in the escitalopram-treated group, the unusually high percentage of patients with bilateral white matter lesions (28% of the sample), and the degree of disability, which was low in this series.

Post-Stroke Depression: Can Prediction Help Prevention?: Differential Diagnosis