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Valley Psychiatry Article www.valleypsychiatry.com

Lexapro and Problem-Solving Therapy for Prevention of Poststroke Depression

Early detection of symptoms and prompt treatment has typically been the best that clinicians treating psychiatric illnesses could hope for. Medication intervention to prevent illness where symptoms are not yet present has been controversial or ineffective.

Of course giving everyone psychiatric medication should theoretically prevent significant amounts of illness. Side effects, cost, and common sense eliminate this type of global approach such from being considered. Yet there are populations that exhibit a sufficiently high risk of developing psychiatric morbidity for which preventive treatment could be beneficial.

A study in the May 26th Journal of the American Medical Association investigated one such high risk population and associated psychiatric illness. Stroke survivors develop depression at a much higher rate than the general population. An estimated 37% of stroke victims develop major or minor depression within the first two years of acute stroke.

They showed that Lexapro, and to a lesser degree, problem-solving therapy, can be safely and effectively used to prevent poststroke depression.

What are the associated risks in developing depression after suffering a stroke? Seven studies cited in the JAMA article demonstrated an increased risk of death in depressed stroke survivors compared to similar groups of non-depressed stroke survivors. Here is a chance to decrease a great deal of potential morbidity as well as mortality.

This study demonstrates that Lexapro can be effectively and safely used to prevent poststroke depression.

The authors of the study randomized 176 patients who were within 3 months of a hemorrhagic or ischemic stroke into one of three groups. Patients were randomly assigned to a treatment group (those aged less than 65 received 10mg/day of Lexapro while those aged 65 and older received 5mg of Lexapro daily), a group that received problem-solving therapy, and finally a placebo group. The two most important exclusion criteria were participants who were already depressed and those possessing severe cognitive deficits.

At the conclusion of the 12 month study, the participants who received placebo were 4.5 times more likely to develop depression than the group that received Lexapro. The problem-solving group had statistically significant protection from depression compared to placebo but the response was not as robust as the Lexapro group. Participants in the placebo group were 2.2 times more likely to become depressed in the year following a stroke than the group that received problem-solving therapy.

The authors calculated that 7.2 acute stroke patients would need treatment with Lexapro to prevent one case of depression. This compares favorably to preventive strategies in cardiology. It has been demonstrated that it takes as many as 40 male patients with hypercholesterolemia being medicated with pravastatin for 5 years to prevent only one myocardial infarction.

The study has limitations that prevent making broader conclusions about how effective Lexapro is in preventing depression in all stroke patients. The mean age of the participants was 62. This is younger than similar studies that have failed to prove that prophylactic treatment with antidepressants prevent poststroke depression. This leaves the question of whether antidepressants are less effective in preventing poststroke depression in older patients.

The study also excluded patients who were already depressed. Presumably these patients would be identified and treated with antidepressants but they could represent a more difficult to treat group of stroke patients that might not respond to either early or preventative treatment with Lexapro.

Stroke patients with neurodegenerative diseases such as Alzheimerís and Parkinsonís disease and those with a high level of cognitive impairment comprise a significant percentage of long term care facility populations. Both of these groups were not included in this study. These patientsí depressive symptoms may be harder to isolate and quantify. Unfortunately it is difficult to imagine there being any extensive studies involving this population.

Despite these weaknesses this study is promising. The most exciting finding is that even in the absence of depressive symptoms, Lexapro has now been shown to prevent subsequent poststroke depression. Although the study did not examine poststroke prevention in moderate to severely cognitively impaired patients the benefits of preventing poststroke depression combined with low potential for adverse reactions make this approach enticing.

Valley Psychiatry Article www.valleypsychiatry.com