Recommended Antidepressant for Post-Stroke Depression
SSRIs (selective serotonin reuptake inhibitors) are the first-line antidepressant treatment for post-stroke depression, with SNRIs as an alternative first-line option. 1, 2, 3
Screening and Diagnosis First
- Screen all stroke patients using the Patient Health Questionnaire-2 (PHQ-2) or PHQ-9 routinely during rehabilitation and follow-up visits 1, 2, 3
- Reassess periodically throughout recovery, as depression can emerge at any time after stroke 1, 2
- Cognitive deficits may prevent patients from recognizing symptoms, so gather information from family members and rehabilitation staff 3
First-Line Pharmacological Treatment
Start an SSRI as the preferred first-line agent due to favorable side effect profiles in stroke patients 2, 3, 4:
- Specific SSRIs recommended include sertraline, citalopram, and fluoxetine 5
- SNRIs (duloxetine, venlafaxine) serve as alternative first-line options, particularly when central post-stroke pain requires concurrent management 1, 2, 5
Treatment Monitoring and Adjustments
- Monitor closely to verify effectiveness, as some patients may not tolerate or respond to initial SSRI choice 1, 2, 4
- Consider dose adjustments and add-on possibilities if initial treatment is insufficient 4
- Watch for medication side effects, especially bleeding risk or intracerebral hemorrhage with antidepressants 3
- Be particularly vigilant in elderly patients on multiple medications 5
Important Clinical Considerations
Do not use prophylactic antidepressants in non-depressed stroke patients due to increased fracture risk and other adverse events 2, 5
- While some research suggests prophylactic fluoxetine or mirtazapine reduces depression incidence 6, 7, current guidelines explicitly recommend against this practice 2, 5
- Treat only diagnosed depression, not as prevention 2
Complementary Non-Pharmacological Approaches
- Combine medication with cognitive behavioral therapy (CBT) for optimal outcomes 2, 3
- Implement structured exercise programs of at least 4 weeks duration as complementary treatment 1, 2, 3
- Provide patient education about stroke and opportunities to discuss illness impact 1, 2
When to Refer
- Consult psychiatry or psychology for mood disorders causing persistent distress or worsening disability despite initial treatment 1, 3
- Specialist involvement is particularly important for treatment-resistant cases 3
Common Pitfalls to Avoid
- Avoid tricyclic antidepressants as first-line agents due to high frequency of contraindications and adverse effects in stroke patients 8
- Don't assume early improvement means treatment is unnecessary—spontaneous recovery during intensive rehabilitation can mask the need for continued antidepressant therapy 9
- The placebo group in one study showed depressive relapse after rehabilitation efforts ended, while fluoxetine-treated patients maintained improvement at 18-month follow-up 9
- Don't overlook co-occurring anxiety, which occurs in approximately 75% of depressed stroke patients and may require concurrent treatment 5