Wieslaw Oczkowski, MD
In patients with stroke, do psychological or pharmaceutical interventions prevent depression?
Studies selected compared psychological therapy with standard care or a pharmaceutical agent with placebo for prevention of depression in patients with stroke. Primary outcome was depression, diagnosed by standard diagnostic criteria or a score above the cutpoint on standard rating scales. Secondary outcomes included change in scores on scales for depression, cognitive functioning, independence in activities of daily living, disability, and psychological distress.
Trial registers of the Cochrane Stroke Group (Oct 2007) and Cochrane Depression, Anxiety, and Neurosis Group (Feb 2008); Cochrane Central Register of Controlled Trials (Issue 1, 2008); 11 other databases; conference proceedings (2007); online clinical trial registers (Aug 2007); and reference lists of book chapters were searched for randomized controlled trials (RCTs). Crossover trials and trials involving treatment of depression in patients with stroke were excluded. 14 RCTs (n = 1515, mean age 55 to 74 y, 56% men) met the selection criteria: 4 trials evaluated psychological interventions and 10 trials (12 comparisons) evaluated pharmaceutical agents. 9 RCTs reported adequate concealment of allocation, and 13 RCTs used blinded outcome assessment.
Meta-analysis showed that psychological interventions reduced risk for meeting the criteria for depression after stroke (Table). In 6 comparisons (n = 444) of pharmaceutical interventions, relative risk reductions in proportion of patients with depression ranged from 4% to 73%, with only 1 RCT (n = 60) showing statistical significance (meta-analysis not done). Psychological interventions resulted in more improvement in psychological distress (2 RCTs, n = 520) but did not differ from standard care for change in independence in activities of daily living (3 RCTs, n = 756). For pharmaceutical interventions, groups did not differ for change in scores for depression (6 comparisons, n = 208), cognitive functioning (3 comparisons, n = 140), independence in activities of daily living (4 comparisons, n = 73), or disability (4 comparisons, n = 87).
Psychological interventions reduce risk for depression after stroke. Evidence is limited on the effectiveness of pharmaceutical interventions.
Psychological interventions vs standard care to prevent depression in patients with stroke*
*Abbreviations defined in Glossary. RRR, NNT, and CI calculated from data in article using a fixed-effects model.
Oczkowski W. Review: Psychological interventions prevent depression after stroke. Ann Intern Med. ;149:JC5–13. doi: 10.7326/0003-4819-149-10-200811180-02013
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Published: Ann Intern Med. 2008;149(10):JC5-13.
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