Role of mHealth in overcoming the occurrence of post-stroke depression

Unveiling synergies: Integrating TCM herbal medicine and acupuncture with conventional approaches in stroke management

This review explores the mechanisms and treatment strategies of ischemic stroke, a leading cause of morbidity and mortality worldwide. Ischemic stroke results from the obstruction of blood flow to the brain, leading to significant neurological impairment. The paper categorizes ischemic stroke into subtypes based on etiology, including cardioembolism and large artery atherosclerosis, and discusses the challenges of current therapeutic approaches. Conventional treatments like tissue plasminogen activator (tPA) and surgical interventions are limited by narrow windows and potential complications. The review highlights the promise of acupuncture, which offers neuroprotective benefits by promoting cerebral ischemic tolerance and neural regeneration. Integrating acupuncture with conventional treatments may enhance patient outcomes. Emphasis is placed on understanding the pathophysiology to develop targeted therapies that mitigate neuronal damage and enhance recovery.

Effect of nonpharmacological interventions on poststroke depression: a network meta-analysis

Purpose

To investigate the effects of nonpharmacological interventions (NPIs) on poststroke depression (PSD) in stroke patients.

Methods

Computer searches were conducted on the PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP), and Wanfang databases from their establishment to December 2023. The selection was made using the inclusion and exclusion criteria, and 40 articles were included to compare the effects of the 17 NPIs on patients with PSD.

Results

Forty studies involving seventeen interventions were included. The network findings indicated that compared with conventional therapy (COT), superior PSD improvement was observed for cognitive behavioral therapy (CBT) + acupoint acupuncture (CBTA) (mean difference [MD], -4.25; 95% CI, -5.85 to -2.65), team positive psychotherapy (MD, -4.05; 95% CI, -5.53 to -2.58), music therapy (MT) + positive psychological intervention (MD, -2.25; 95% CI, -3.65 to -0.85), CBT (MD, -1.52; 95% CI, -2.05 to -0.99), mindfulness-based stress reduction (MD, -1.14; 95% CI, -2.14 to -0.14), MT (MD, -0.95; 95% CI, -1.39 to -0.52), acupoint acupuncture + MT (AAMT) (MD, -0.69; 95% CI, -1.25 to -0.14). Furthermore, CBT (MD, -3.87; 95% CI, -4.57 to -3.17), AAMT (MD, -1.02; 95% CI, -1.41 to -0.62), acupressure + MT (MD, -0.91; 95% CI, -1.27 to -0.54), and narrative care + acupressure (MD, -0.74; 95% CI, -1.19 to -0.29) demonstrated superior Pittsburgh Sleep Quality Index (PSQI) improvement compared with COT.

Conclusion

Evidence from systematic reviews and meta-analyses suggests that CBTA improves depression in patients with PSD. Moreover, CBT improves sleep in these patients. Additional randomized controlled trials are required to further investigate the efficacy and mechanisms of these interventions.

The role of NPY signaling pathway in diagnosis, prognosis and treatment of stroke

Neuropeptide Y (NPY), an extensively distributed neurotransmitter within the central nervous system (CNS), was initially detected and isolated from the brain of a pig in 1982. By binding to its G protein-coupled receptors, NPY regulates immune responses and contributes to the pathogenesis of numerous inflammatory diseases. The hippocampus contained the maximum concentration in the CNS, with the cerebral cortex, hypothalamus, thalamus, brainstem, and cerebellum following suit. This arrangement suggests that the substance has a specific function within the CNS. More and more studies have shown that NPY is involved in the physiological and pathological mechanism of stroke, and its serum concentration can be one of the specific biomarkers of stroke and related complications because of its high activity, broad and complex effects. By summarizing relevant literature, this article aims to gain a thorough understanding of the potential clinical applications of NPY in the treatment of stroke, identification of stroke and its related complications, and assessment of prognosis.

Acupuncture for ischemic stroke: where are we now?

Acupuncture is an effective treatment for ischemic stroke (IS) and plays a key role in neurological rehabilitation after IS. Acupuncture can improve the clinical symptoms of various complications after IS, including motor dysfunction, swallowing disorders, speech disorders, cognitive impairment, depression, insomnia, and fatigue. However, the mechanisms underlying the effects of acupuncture in IS remain unclear. Available evidence suggests that acupuncture may exert neuroprotective effects through neuroplasticity (neurogenesis and synaptogenesis), angiogenesis, cell proliferation and apoptosis, and regulation of oxidative stress, inflammation, and immunity. Further studies should be conducted to improve the high-quality evidence-based system of acupuncture intervention for IS, by focusing on the clinical and basic research design, increasing the sample size, standardizing and quantifying the standards of acupuncture operations, using multidisciplinary techniques and methods to systematically explore the key targets of acupuncture intervention for IS, and reveal the efficacy and mechanism of acupuncture in the treatment of IS.

Predictors of post-stroke depression: Validation of established risk factors and introduction of a dynamic perspective in two longitudinal studies

INTRODUCTION

Cerebral insults lead in many cases not only to cognitive impairment but also to disturbed emotionality. After stroke, one in three survivors develops a depression which impacts quality of life and rehabilitation. Meta-analyses have identified five main predictors of post-stroke depression (PSD): history of mental disorder, stroke severity, physical disability, cognitive impairment, and social support. However, these five established variables have never been conjointly investigated in a sample of stroke survivors. Therefore, their independent predictive values remain unclear. Moreover, predictors are most often used as time-invariant factors (status scores), neglecting the intraindividual dynamics after stroke.

METHODS

Our study analyses the data of two prospective longitudinal studies, investigating stroke survivors from two rehabilitation hospitals (N ₁ = 273) and one acute care hospital (N ₂ = 226). Baseline assessments included the five established predictors and depressive symptoms. After 6 months, depressive symptoms were reassessed in both studies (n ₁ = 176, n ₂ = 183), and physical disability and social support were reassessed in study 2. The predictivity of the five predictors and the additional predictivity of intraindividual dynamics for PSD were examined in multiple linear regression analyses.

RESULTS

History of mental disorder was a risk factor for depressive symptoms after stroke at all measurement times (B = 3.32 to 3.97; p < 0.01). Physical disability was a risk factor at all measurement times (B = -0.09 to -0.03; p < 0.05) except 6 months after rehabilitation. Social support was a protective factor (B = -2.69 to -1.91; p < 0.01) outside the acute phase (R ² = 0.15-0.39). Intraindividual changes in physical disability and perceived social support were independent predictors of PSD 6 months after the acute phase (B = -0.08/-0.14; p < 0.01), in addition to status scores on established variables (ΔR ² = 0.08, p < 0.001).

DISCUSSION

History of mental disorder, physical disability, and social support are independent predictors of depressive symptoms in the first year post-stroke, also when considered conjointly. Future studies should control for these variables when investigating new predictors of PSD. In addition, intraindividual changes in known predictors after stroke play a relevant role in the pathogenesis of PSD and should be considered in clinical practice and future research.

Mixed methods evaluation to explore participant experiences of a pilot randomized trial to facilitate self-management of people living with stroke: Inspiring virtual enabled resources following vascular events (iVERVE)

INTRODUCTION

Despite digital health tools being popular for supporting self-management of chronic diseases, little research has been undertaken on stroke. We developed and pilot tested, using a randomized controlled design, a multicomponent digital health programme, known as Inspiring Virtual Enabled Resources following Vascular Events (iVERVE), to improve self-management after stroke. The 4-week trial incorporated facilitated person-centred goal setting, with those in the intervention group receiving electronic messages aligned to their goals, versus limited administrative messages for the control group. In this paper, we describe the participant experience of the various components involved with the iVERVE trial.

METHODS

Mixed method design: satisfaction surveys (control and intervention) and a focus group interview (purposively selected intervention participants). Experiences relating to goal setting and overall trial satisfaction were obtained from intervention and control participants, with feedback on the electronic message component from intervention participants. Inductive thematic analysis was used for interview data and open-text responses, and closed questions were summarized descriptively. Triangulation of data allowed participants' perceptions to be explored in depth.

RESULTS

Overall, 27/54 trial participants completed the survey (13 intervention: 52%; 14 control: 48%); and 5/8 invited participants in the intervention group attended the focus group. Goal setting: The approach was considered comprehensive, with the involvement of health professionals in the process helpful in developing realistic, meaningful and person-centred goals. Electronic messages (intervention): Messages were perceived as easy to understand (92%), and the frequency of receipt was considered appropriate (11/13 survey; 4/5 focus group). The content of messages was considered motivational (62%) and assisted participants to achieve their goals (77%). Some participants described the benefits of receiving messages as a 'reminder' to act. Overall trial satisfaction: Messages were acceptable for educating about stroke (77%). Having options for short message services or email to receive messages was considered important. Feedback on the length of the intervention related to specific goals, and benefits of receiving the programme earlier after stroke was expressed.

CONCLUSION

The participant experience has indicated acceptance and utility of iVERVE. Feedback from this evaluation is invaluable to inform refinements to future Phase II and III trials, and wider research in the field.

PATIENT OR PUBLIC CONTRIBUTION

Two consumer representatives sourced from the Stroke Foundation (Australia) actively contributed to the design of the iVERVE programme. In this study, participant experiences directly contributed to the further development of the iVERVE intervention and future trial design.

The efficacy of therapies for post-stroke depression in aging: An umbrella review

Post-stroke depression (PSD) is a common complication after stroke. PSD is associated with emotional disorders and psychological dependence, which are potential risk factors for stroke recurrence and suicidality. This study aimed to perform an umbrella review of therapies for PSD through a comprehensive literature search. A systematic search was conducted in the PubMed and Web of Science by two independent authors. We examined the Hamilton Depression Scale (HAMD), Activities of daily living (ADL), Neurologic function as efficacy endpoints, and the incidence of adverse events as safety profiles. Seventeen eligible studies, including 267 clinical trials were included in this study. The results showed that High-Frequency Repetitive Transcranial Magnetic Stimulation (HfrTMS), Acupuncture/EA+conventional treatment, Escitalopram, Modified Sini San, Moxibustion, Xiaoyao Formula, Paroxetine, Chinese herbal medicine, Exercise, Citalopram, and Cognitive behavioral therapy are beneficial for improving the depression symptoms of patients with PSD. HfrTMS and Sertraline may have an impact on slowing the scores of activities of daily living or neurologic function. In addition, Acupuncture/EA+conventional, Escitalopram, Citalopram, Sertraline, and Fluoxetine showed no serious adverse events in PSD patients. Our study demonstrated that 11 treatment methods can effectively improve the condition of PSD patients.

Multimorbidity

Multimorbidity (two or more coexisting conditions in an individual) is a growing global challenge with substantial effects on individuals, carers and society. Multimorbidity occurs a decade earlier in socioeconomically deprived communities and is associated with premature death, poorer function and quality of life and increased health-care utilization. Mechanisms underlying the development of multimorbidity are complex, interrelated and multilevel, but are related to ageing and underlying biological mechanisms and broader determinants of health such as socioeconomic deprivation. Little is known about prevention of multimorbidity, but focusing on psychosocial and behavioural factors, particularly population level interventions and structural changes, is likely to be beneficial. Most clinical practice guidelines and health-care training and delivery focus on single diseases, leading to care that is sometimes inadequate and potentially harmful. Multimorbidity requires person-centred care, prioritizing what matters most to the individual and the individual's carers, ensuring care that is effectively coordinated and minimally disruptive, and aligns with the patient's values. Interventions are likely to be complex and multifaceted. Although an increasing number of studies have examined multimorbidity interventions, there is still limited evidence to support any approach. Greater investment in multimorbidity research and training along with reconfiguration of health care supporting the management of multimorbidity is urgently needed.

Accuracy and Validity of a Single Inertial Measurement Unit-Based System to Determine Upper Limb Kinematics for Medically Underserved Populations

Stroke is one of the leading causes of death and disability worldwide, with a disproportionate burden represented by low- and middle-income countries (LMICs). To improve post-stroke outcomes in LMICs, researchers have sought to leverage emerging technologies that overcome traditional barriers associated with stroke management. One such technology, inertial measurement units (IMUs), exhibit great potential as a low-cost, portable means to evaluate and monitor patient progress during decentralized rehabilitation protocols. As such, the aim of the present study was to determine the ability of a low-cost single IMU sensor-based wearable system (named the T’ena sensor) to reliably and accurately assess movement quality and efficiency in physically and neurologically healthy adults. Upper limb movement kinematics measured by the T’ena sensor were compared to the gold standard reference system during three functional tasks, and root mean square errors, Pearson’s correlation coefficients, intraclass correlation coefficients, and the Bland Altman method were used to compare kinematic variables of interest between the two systems for absolute accuracy and equivalency. The T’ena sensor and the gold standard reference system were significantly correlated for all tasks and measures (r range = 0.648—0.947), although less so for the Finger to Nose task (r range = 0.648—0.894). Results demonstrate that single IMU systems are a valid, reliable, and objective method by which to measure movement kinematics during functional tasks. Context-appropriate enabling technologies specifically designed to address barriers to quality health services in LMICs can accelerate progress towards the United Nations Sustainable Development Goal 3.

Development of a Framework for the Implementation of Synchronous Digital Mental Health: Realist Synthesis of Systematic Reviews

BACKGROUND

The use of technologies has served to reduce gaps in access to treatment, and digital health interventions show promise in the care of mental health problems. However, to understand what and how these interventions work, it is imperative to document the aspects related to their challenging implementation.

OBJECTIVE

The aim of this study was to determine what evidence is available for synchronous digital mental health implementation and to develop a framework, informed by a realist review, to explain what makes digital mental health interventions work for people with mental health problems.

METHODS

The SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, and Research type) framework was used to develop the following review question: What makes digital mental health interventions with a synchronous component work on people with mental health problems, including depression, anxiety, or stress, based on implementation, economic, quantitative, qualitative, and mixed methods studies? The MEDLINE, EBM Reviews, PsycINFO, EMBASE, SCOPUS, CINAHL Complete, and Web of Science databases were searched from January 1, 2015, to September 2020 with no language restriction. A Measurement Tool to Assess Systematic Reviews-2 (AMSTAR-2) was used to assess the risk of bias and Confidence in Evidence from Reviews of Qualitative Research (CERQual) was used to assess the confidence in cumulative evidence. Realist synthesis analysis allowed for developing a framework on the implementation of synchronous digital mental health using a grounded-theory approach with an emergent approach.

RESULTS

A total of 21 systematic reviews were included in the study. Among these, 90% (n=19) presented a critically low confidence level as assessed with AMSTAR-2. The realist synthesis allowed for the development of three hypotheses to identify the context and mechanisms in which these interventions achieve these outcomes: (1) these interventions reach populations otherwise unable to have access because they do not require the physical presence of the therapist nor the patient, thereby tackling geographic barriers posed by in-person therapy; (2) these interventions reach populations otherwise unable to have access because they can be successfully delivered by nonspecialists, which makes them more cost-effective to implement in health services; and (3) these interventions are acceptable and show good results in satisfaction because they require less need of disclosure and provide more privacy, comfortability, and participation, enabling the establishment of rapport with the therapist.

CONCLUSIONS

We developed a framework with three hypotheses that explain what makes digital mental health interventions with a synchronous component work on people with mental health problems. Each hypothesis represents essential outcomes in the implementation process.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020203811; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020203811.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.12688/f1000research.27150.2.

Mechanisms of Repetitive Transcranial Magnetic Stimulation on Post-stroke Depression: A Resting-State Functional Magnetic Resonance Imaging Study

We aimed to identify neural mechanisms underlying clinical response to repetitive transcranial magnetic stimulation (rTMS) in post-stroke depression (PSD) by the Resting-state functional magnetic resonance imaging (rs-fMRI). Thirty-two depressed patients after ischemic stroke were randomized in a 1:1 ratio to receive 20 min of 5 Hz rTMS or sham over left dorsolateral prefrontal cortex (DLPFC) in addition to routine supportive treatments. The clinical outcome was measured by the 17-item Hamilton Depression Rating Scale (HDRS-17), while the imaging results were acquired from rs-fMRI, including regional homogeneity (ReHo), fractional amplitude of low-frequency fluctuation (fALFF) and seed-based dynamic functional connection (dFC). HRSD-17 scores were improved in the two groups after treatment (P < 0.01), while greater mood improvement was observed in the rTMS group (P < 0.05). Compared with the sham group, the rTMS group demonstrated regions with higher ReHo and fALFF values locating mainly in the left hemisphere and highly consistent with the default mode network (DMN) (p < 0.05). Using the medial prefrontal cortex (mPFC) and posterior cingulate cortex (PCC) as seeds, significant difference between the two groups in dFC within the DMN was found after treatment, including 10 connections with increased connectivity strength and 2 connections with reduced connectivity strength. The ReHo, fALFF and dFC values within DMN in the rTMS group were negatively correlated with the HDRS scores after treatment (P < 0.05). Our results indicated reductions in depressive symptoms following rTMS in PSD are associated with functional alterations of different depression-related areas within the DMN.

Telehealth Interventions to Support Self-Management in Stroke Survivors: A Systematic Review

Telehealth (TH) intervention is a method to optimize self-management (SM) support in stroke survivors. Objectives of this study included identifying the TH-SM intervention's focus and SM support components, the TH delivery type, and the TH-SM support effects on stroke survivors. Five databases were searched for the years 2005-2020 to identify TH-SM support interventions for stroke survivors. Randomized controlled trials and quasi-experimental, one-group re-post study designs were included. Ten studies were reviewed. TH-SM support focused on post-stroke depression, obesity management, participation, functional mobility, and activities of daily living. The TH delivery type most used in selected studies was messaging. Regarding the SM support components, the education component was used in all studies, and psychological support and lifestyle advice and support were used in 8 out of 10 studies. TH-SM intervention had positive effects in terms of goal achievement for SM behavior, emotional state, and mobility of clinical outcomes, and TH acceptance in stroke survivors. Although the TH-SM-supported intervention effects were not found consistently in all outcomes, this review discovered a positive effect on various SM-related outcomes. In addition, TH delivery types and SM support components showed the possibility of various options to be considered for intervention. Therefore, we suggest that TH-SM supported intervention is a positive alternative for SM support in stroke survivors.

Development of a framework for the implementation of synchronous e-mental health: a protocol for a realist synthesis of systematic reviews

Background: During the COVID-19 pandemic, it has been necessary to deliver mental health care using technologies (e-mental health). But there have been difficulties in its application. Quantitative systematic reviews such as meta-analysis doesn't allow us to fully identify and properly describe this subject. Thus, our study has two main objectives: a) "to determine what evidence is available for synchronous e-mental health implementation"; and b) "to develop a framework informed by a realist analysis for the implementation of synchronous e-mental health". Methods: We will search MEDLINE, EBM Reviews, PsycINFO, EMBASE, SCOPUS, CINAHL Complete, and Web of Science databases from 1st January 2015 to September 2020, with no language restriction. A systematic review with a narrative description and a realist synthesis will be conducted. Primary studies relating to adults with common mental health problems using any type of mobile mental health intervention that includes a synchronic component and communication with a mental health professional will be included. For the analysis, we will make a realist synthesis of the systematic reviews, using a grounded theory approach with an emergent approach to synthesize the information, prioritizing the systematic reviews with a lower risk of bias in the AMSTAR-2 tool. The realist synthesis will be based on the interpretation, integration, and inference of the evaluated elements and the generation of hypotheses to better understand the implementation process of synchronous e-mental health. Finally, we will present the overall assessment in a Summary of Qualitative Findings table. Conclusion: Our results will allow a better understanding of the facilitator and limitations in implementing e-mental health.

Development of a framework for the implementation of electronic interventions in mental health: a protocol for a meta-synthesis of systematic reviews

Background: During the COVID-19 pandemic, it has been necessary to incorporate technologies in the care of mental health problems. But there have been difficulties in the application of technology-based interventions in mental health. Some quantitative systematic reviews don't allow us to fully identify and properly describe this subject. In order to answer the question "how do electronic interventions apply in mental health and what makes the application of any of these interventions work", this study will carry out an overview of systematic reviews, which will make it possible to develop a theoretical framework on the implementation of electronic care in mental health problems. Methods: We will search MEDLINE, EBM Reviews, PsycINFO, EMBASE, SCOPUS, CINAHL Complete, and Web of Science databases from 1st January 2015 to September 2020, with no language restriction. We will follow a qualitative method approach and include systematic reviews that assess primary studies relating to adults with common mental health problems using any type of mobile mental health intervention that includes a synchronic component and communication with a mental health professional. For the analysis, we will make a meta-synthesis of the systematic reviews, using an emergent grounded theory approach to synthesize the information, prioritizing the systematic reviews with the lowest risk of bias in the AMSTAR-2 tool. The meta-synthesis will be based on interpreting, integrating, and inferring the evaluation elements to understand better the e-health implementation process for patients with mental health problems. Finally, we will present the overall assessment in a Summary of Qualitative Findings table. Conclusion: Our results will allow a better understanding of the facilitator and limitations in implementing e-health interventions for mental health problems.

Post-stroke depression: A 2020 updated review

BACKGROUND

Post-stroke depression (PSD) is common and associated with higher mortality, poorer recovery, more pronounced cognitive deficits, and lower quality of life than is stroke without depression. This manuscript will conduct an updated, comprehensive and clinically-useful review of the risk factors, pathophysiology, assessment, prevention, and treatment of PSD.

METHODS

This narrative review summarizes articles obtained on PubMed, Medline, EMBase, Google Scholar and the Cochrane Database. This review prioritized articles with a more robust level of evidence, such as original articles with longitudinal data and/or larger samples, randomized controlled trials, systematic reviews, and metaanalyses.

RESULTS

One hundred twenty-four articles were reviewed, of which 44 (35%) were published before 2016 and 80 (65%) that were published since 2016.

DISCUSSION

Rates of PSD range from 18 to 33%, yet it is vastly underdiagnosed and undertreated. Risk factors for PSD include female sex, history of psychiatric illness, large or multiple strokes, injuries in frontal/anterior areas or in the basal ganglia, stroke occurrence within the past year, poor social support, and pronounced disability. The pathophysiology of PSD is multifactorial and likely involves decreased levels of monoamines, abnormal neurotrophic response, increased inflammation with dysregulation of hypothalamic-pituitary-adrenal axis, and glutamate-mediated excitotoxicity. The evidence for preventive interventions for PSD is somewhat inconsistent and modest. The best treatment for PSD consists of the combination of pharmacological, psychosocial and stroke-focused interventions.

CONCLUSION

PSD is a common, treatable condition that is associated with several negative outcomes. Early detection and proper management are critical to obtain better outcomes in individuals with PSD.

Factors related to post-stroke depression during the first 2 weeks after stroke

Introduction

This study aimed to clarify factors associated with post-stroke depression in patients with acute stroke within 2 weeks of onset.

Method

Eighty-eight patients with stroke were divided into post-stroke depression ( n = 49) and non-post-stroke depression ( n = 39) groups based on their Hamilton Depression Rating Scale scores. We evaluated stroke severity, upper limb function, activities of daily living, frontal lobe/cognitive function, and level of apathy. Activity levels were measured using an ActiGraph GT9X Link system. Mann–Whitney U-tests were used to determine differences between the two groups. Spearman’s rank correlation and logistic regression analyses were also performed.

Results

The post-stroke depression and non-post-stroke depression groups exhibited significant differences in National Institutes of Health Stroke Scale scores at admission and discharge; Functional Independence Measure exercise items, cognitive items, and total items at admission; Fugl-Meyer Assessment scores; and Apathy Rating Scale scores. Logistic regression indicated that Fugl-Meyer Assessment scores were associated with post-stroke depression.

Conclusion

Stroke severity, paralysis, and physical function/activities of daily living ability are associated with post-stroke depression in the acute phase. Our findings suggest that increases in physical impairment severity are associated with increased post-stroke depression risks. Rehabilitation professionals should focus on identifying post-stroke depression in early post-stroke stages.

Comparative efficacy of nine antidepressants in treating Chinese patients with post-stroke depression: A network meta-analysis

BACKGROUND

The efficacy ranking of antidepressants for post-stroke depression (PSD) has not been assessed thoroughly yet due to the lack of network meta-analyses with sufficiently large sample size.

METHODS

Seven databases including PubMed, Embase, CENTRAL, CBM, CNKI, WanFang and VIP were systematically searched for eligible randomized controlled trials (RCTs) regarding nine antidepressants (citalopram, escitalopram, venlafaxine, paroxetine, duloxetine, amitriptyline, doxepin, sertraline and mirtazapine) treating PSD patients. Stata 15 software and R software were utilized for statistical analyses.

RESULTS

51 RCTs were included in this NMA. For the key efficacy outcomes, escitalopram, mirtazapine, sertraline, citalopram, venlafaxine and paroxetine were associated with larger reduction of the Hamilton Depression Scale (HAMD) total score compared with placebo at 2 weeks. Among the nine antidepressants, escitalopram ranked the best while amitriptyline was the least helpful. At 4 weeks, citalopram ranked higher than placebo and the other eight antidepressants. In contrast, amitriptyline and doxepin were associated with minimal reduction of HAMD score. At 8 weeks, changes in HAMD score were significantly greater in nine antidepressants groups compared to placebo group. Besides, mirtazapine ranked higher than citalopram and escitalopram. At endpoint, mirtazapine was related to the highest response rate, followed by venlafaxine and escitalopram, respectively.

LIMITATIONS

No restriction was imposed on doses of every antidepressant.

CONCLUSIONS

Escitalopram was associated with a quicker relief of depression, but mirtazapine was probably the best option when it comes to the efficacy of 8-week treatment duration. Amitriptyline and doxepin were nearly the worst choice regardless of the duration (2, 4 or 8 weeks).

Prescription and predictors of post-stroke antidepressant treatment: A population-based study

OBJECTIVES

Post-stroke depression and pathological crying are common and potentially serious complications after stroke and should be diagnosed and treated accordingly. Diagnosis and treatment probably rely on clinical experience and may pose certain challenges. We aimed to examine prescription and predictors of antidepressant treatment after ischemic stroke in a clinical setting.

MATERIALS AND METHODS

In this registry-based follow-up study, consecutive ischemic stroke patients were identified from the Danish Stroke Registry, holding information on antidepressant treatment during admission in Aarhus County from 2003 to 2010. Information on prescription after discharge was obtained from the Danish Prescription Database. Treatment initiation was analyzed using the cumulative incidence method including death as a competing risk. Multiple logistic regression was used to identify potential predictors of treatment.

RESULTS

Among 5070 consecutive first-ever ischemic stroke patients without prior antidepressant treatment, the cumulative incidence of antidepressant treatment and prescription over 6 months was 35.2% (95% CI: 33.8-36.6). Overall 16.5% (95% CI: 15.5-17.6) started treatment within 14 days corresponding to 48.1% (95% CI: 45.8-50.5) of all treated patients, and the most widely prescribed group of antidepressants was selective serotonin reuptake inhibitors (86%). Increasing stroke severity was associated with higher odds of initiating treatment.

CONCLUSION

Antidepressant treatment in this real-life clinical setting was common and initiated early, in almost half the treated patients within 14 days. Our results suggest that special focus should be given to the severe strokes as they may have a greater risk of requiring treatment.

Mechanisms of Transcranial Magnetic Stimulation Treating on Post-stroke Depression

Post-stroke depression (PSD) is a neuropsychiatric affective disorder that can develop after stroke. Patients with PSD show poorer functional and recovery outcomes than patients with stroke who do not suffer from depression. The risk of suicide is also higher in patients with PSD. PSD appears to be associated with complex pathophysiological mechanisms involving both psychological and psychiatric problems that are associated with functional deficits and neurochemical changes secondary to brain damage. Transcranial magnetic stimulation (TMS) is a non-invasive way to investigate cortical excitability via magnetic stimulation of the brain. TMS is currently a valuable tool that can help us understand the pathophysiology of PSD. Although repetitive TMS (rTMS) is an effective treatment for patients with PSD, its mechanism of action remains unknown. Here, we review the known mechanisms underlying rTMS as a tool for better understanding PSD pathophysiology. It should be helpful when considering using rTMS as a therapeutic strategy for PSD.