Escitalopram and problem-solving therapy for prevention of poststroke depression: a randomized controlled trial.

Full Abstract

CONTEXT:
Depression occurs in more than half of patients who have experienced a stroke. Poststroke depression has been shown in numerous studies to be associated with both impaired recovery in activities of daily living and increased mortality. Prevention of depression thus represents a potentially important goal.

OBJECTIVE:
To determine whether treatment with escitalopram or problem-solving therapy over the first year following acute stroke will decrease the number of depression cases that develop compared with placebo medication. DESIGN, SETTING,

AND PARTICIPANTS:
A multisite randomized controlled trial for prevention of depression among 176 nondepressed patients was conducted within 3 months following acute stroke from July 9, 2003, to October 1, 2007. The 12-month trial included 3 groups:
a double-blind placebo-controlled comparison of escitalopram (n = 59) with placebo (n = 58), and a nonblinded problem-solving therapy group (n = 59).

MAIN OUTCOME MEASURES:
The main outcome measure was the development of major or minor poststroke depression based on symptoms elicited by the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) and the diagnostic criteria from DSM-IV for depression due to stroke with major depressive-like episode or minor depression (ie, research criteria).

RESULTS:
Patients who received placebo were significantly more likely to develop depression than individuals who received escitalopram (11 major and 2 minor cases of depression [22.4%] vs 3 major and 2 minor cases of depression [8.5%], adjusted hazard ratio [HR], 4.5; 95% confidence interval [CI], 2.4-8.2; P < .001) and also more likely than individuals who received problem-solving therapy (5 major and 2 minor cases of depression [11.9%], adjusted HR, 2.2; 95% CI, 1.4-3.5; P < .001). These results were adjusted for history of mood disorders and remained significant after considering possible confounders such as age, sex, treatment site, and severity of impairment in the model. Using an intention-to-treat conservative method of analyzing the data, which assumed that all 27 patients who did not start randomized treatment would have developed depression, and controlling for prior history of mood disorders, escitalopram was superior to placebo (23.1% vs 34.5%; adjusted HR, 2.2; 95% CI, 1.2-3.9; P = .007), while problem-solving therapy was not significantly better than placebo (30.5% vs 34.5%; adjusted HR, 1.1; 95% CI, 0.8-1.5; P = .51). Adverse events, including all-cause hospitalizations, nausea, and adverse effects associated with escitalopram were not significantly different between the 3 groups.

CONCLUSIONS:
In this study of nondepressed patients with recent stroke, the use of escitalopram or problem-solving therapy resulted in a significantly lower incidence of depression over 12 months of treatment compared with placebo, but problem-solving therapy did not achieve significant results over placebo using the intention-to-treat conservative method of analysis.

TRIAL REGISTRATION:
clinicaltrials.gov Identifier:
NCT00071643.

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Author information

Author/s: Robinson, Robert G (RG); Jorge, Ricardo E (RE); Moser, David J (DJ); Acion, Laura (L); Solodkin, Ana (A); Small, Steven L (SL); Fonzetti, Pasquale (P); Hegel, Mark (M); Arndt, Stephan (S);

Affiliation: Department of Psychiatry, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA. robert-robinson(-atsign-)uiowa.edu

Grants: R01 MH-65134 (Agency:United States NIMH)

Journal and publication information

Publication Type: Journal Article; Multicenter Study; Randomized Controlled Trial; Research Support, N.I.H., Extramural

Journal: JAMA : the journal of the American Medical Association (JAMA), published in United States. (Language: eng)

Reference: 2008-May; vol 299 (issue 20) : pp 2391-400

Dates: Created 2008/05/28; Completed 2008/06/03; Revised 2008/10/20;

PMID: 18505948, status: MEDLINE (last retrieval date: 11/6/2008)

Sourced from the National Library of Medicine. Abstract text and other information may be subject to copyright.

Comments and Corrections

CommentIn: JAMA. 2008 Oct 15;300(15):1757-8; author reply 1758-9. (PMID: 18854528)

CommentIn: JAMA. 2008 Oct 15;300(15):1757; author reply 1758-9. (PMID: 18854530)

CommentIn: JAMA. 2008 Oct 15;300(15):1757; author reply 1758-9. (PMID: 18854529)

CommentIn: JAMA. 2008 Oct 15;300(15):1758; author reply 1758-9. (PMID: 18854531)

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MeSH headings (categories)

This article was linked to the MESH Headings shown below.

Aged
Citalopram - therapeutic use
Depression - etiology; prevention & control
Depressive Disorder - etiology; prevention & control
Diagnostic and Statistical Manual of Mental Disorders
Double-Blind Method
Female

Humans
Male
Middle Aged
Problem Solving
Psychotherapy - methods
Serotonin Uptake Inhibitors - therapeutic use
Stroke - complications; rehabilitation

Associated Chemicals: Serotonin Uptake Inhibitors (0) ; Citalopram (59729-33-8)

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