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(Stroke. 2006;37:1365.)
© 2006 American Heart Association, Inc.

Letters to the Editor

Meta-Analysis of Antidepressant Treatment for Patients With Poststroke Depression

Yan Chen, MPH, PhD, candidate Jeff J. Guo, PhD, Associate Professor

College of Pharmacy, University of Cincinnati Medical Center, Cincinnati, OH

To the Editor:

Because of our pharmacoepidemiologic research focus, we reviewed the recent article by Hackett et al entitled "Management of depression after stroke" in the May 2005 issue of Stroke.¹ The article provided a critical systematic review of antidepressant therapies after stroke based on 7 treatment trials and 9 prevention trials. In Figure 2,¹ the authors compared the antidepressants with placebo in term of average change in depression scores between the baseline and end of treatment. Although there were considerable variations of depression measures as authors mentioned, we believe that it would be more meaningful to provide quantitative overall effectiveness comparisons by using meta-analysis method.^2,3 We retrieved and reviewed the original articles listed in Figure 2. It should be noted that, attributable to the predefined selection criteria in the Hackett et al study, the Robinson et al study⁴ should be included for both treatment and prevention trials because its crossover design did provide the comparisons of the depression scores in the depressed patients between the therapy group and control group. On the other hand, the Lipsey et al⁵ original article did not provide the detail data (the means and standard deviations at the baseline and end of treatment). Therefore, we thought that the overall effects of antidepressant treatment in term of various depression scores would better be estimated by separating the pretreatment and post-treatment instead of calculating the mean differences. Based on the limited data directly from the retrieved articles,^4,6–8 we estimated the overall depression treatment effects. With only respect to the treatment trials, before the administration of any treatments, the overall depression scores in the patients of treatment groups were a little bit higher (more depressed) than the patients in the control groups, but the difference was not statistically significant (weighted mean difference [WMD]=1.01, 95% CI, –0.24 to 2.27, statistical Z score [Z]=1.59, P=0.11; see the Figure). However, after the antidepressant treatments, patients in the treatment groups became statistically less depressed than the patients in the control groups in term of lower depression scores (WMD=–1.88, 95% CI, –3.58 to –0.17, Z=2.16, P=0.03; see the Figure). It indicated that antidepressant treatments were effective in the patients after the stroke in term of reducing the symptoms of depression.

View larger version (20K): [in this window] [in a new window]   Comparison of antidepressant versus placebo for the management of depression after stoke: depression scores of pretreatment and post-treatment, respectively.

In addition, the antidepressant treatment effect should be time-dependent.^9,10 Based on available data published in 3 studies^6–8, we measured WMD between the 2 groups as 0.60 (95% CI, –0.75 to 1.94; Z=0.87, P=0.39) at the beginning of antidepressant treatment. In the middle of treatments (3 weeks in Andersen et al study, 1 month in Fruehwald et al study, and 30 days in Wiart et al study), the WMD became –1.85 (95% CI, –3.55 to –0.14, Z=2.12, P=0.03), which demonstrated that the depression scores of patients in the treatment group became significantly lower than the those of patients in the control group. At the end of treatment, the WMD decreased to –3.06 with 95% CI, –5.12 to –1.0 (Z=2.92, P=0.004). Above meta-analysis data provided an in-depth assessment effect of antidepressants for patients after the stroke.

References

1. Hackett ML, Anderson CS, House AO. Management of depression after stroke. A systematic review of pharmacological therapies. Stroke. 2005; 36: 1092–1097.[Abstract/Free Full Text]
2. Hunter JE, Schmidt FL, Method of Meta-Analysis: correcting error and bias in research findings. Newbury Park, CA: Sage; 1990.
3. Lipsey MW, Wilson DB. Practical meta-analysis (Applied social research methods series; v 49). Thousand Oaks, CA: Sage, 2001.
4. Robinson RG, Schultz SK, Castillo C, Kopel T, Kosier JT, Newman RM, Curdue K, Petracca G, Strakstein SE. Nortriptyline versus fluoxetine in the treatment of depression and in short-term recovery after stroke: a placebo-controlled double-blind study. Am J Psychiatry. 2000; 157: 351–359.[Abstract/Free Full Text]
5. Lipsey J, Robinson RG, Pearlson GD, Rao K, Price TR. Nortriptyline treatment of post-stroke depression: a double-blind study. Lancet. 1984; 1: 297–300.[Medline] [Order article via Infotrieve]
6. Andersen G, Vestergaard K, Lauritzen L. Effective treatment of poststroke depression with the selective serotonin reuptake inhibitor citalopram. Stroke. 1994; 25: 1099–1104.[Abstract]
7. Fruehwald S, Gatterbauer E, Rehak P, Baumhackl U. Early fluoxetine treatment of poststorke depression: a three months double-blind placebo-controlled study with an open-label long-term follow up. J Neurol. 2003; 250: 347–351.[CrossRef][Medline] [Order article via Infotrieve]
8. Wiart L, Petit H, Joseph PA, Mazaux JM, Barat M. Fluoxetine in early poststroke depression: a double-blind placebo controlled study. Stroke. 2000; 31: 1829–1832.[Abstract/Free Full Text]
9. Murray V, Von Arbin M, Bartfai A, Berggren AL, Landtblom AM, Lundmark J, Nasman P, Olsson JE, Samuelsson M, Terent A, Varelius R, Asberg M, Martensson B. Double-blind comparison of sertraline and placebo in stroke patients with minor depression and less severe major depression. J Clin Psychiatry. 2005; 66: 708–716.[Medline] [Order article via Infotrieve]
10. Joliat MJ, Schmidt ME, Fava M, Zhang S, Michelson D, Trapp NJ, Miner CM. Long-term treatment outcomes of depression with associated anxiety: efficacy of continuation treatment with fluoxetine. J Clin Psychiatry. 2004; 65: 373–378.[Medline] [Order article via Infotrieve]

Related Article:

Response to Letter by Chen et al

Maree L. Hackett, Craig S. Anderson, and Allan O. House
Stroke 2006 37: 1367. [Full Text] [PDF]

This Article Full Text (PDF) All Versions of this Article: 37/6/1365    most recent 01.STR.0000222914.83670.05v1 Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Chen, Y. Articles by Guo, J. J. Search for Related Content PubMed PubMed Citation Articles by Chen, Y. Articles by Guo, J. J. Pubmed/NCBI databases Medline Plus Health Information Antidepressants Depression Stroke Related Collections Related Article