In a study recently published in the Journal of the American Medical Association, University of Iowa researchers have shown that for people who have suffered a stroke, medical intervention can prevent or at least delay the onset of depression if they are treated with an antidepressant and a form of talk therapy. This is the first study that shows it is possible to prevent a psychiatric disorder in patients without previous illness.

Robert G. Robinson, MD, the study's principal investigator and professor and head of the Department of Psychiatry at University of Iowa Hospitals and Clinics, talks about the study:

What research was done previous to this study regarding stroke and depression?

There's actually quite a line of research, including a number of investigators, that have consistently shown that if you have depression following a stroke, your physical recovery over a period as short as several months and as long as two years, is significantly less than for patients who don't have depression after stroke.

Similarly, if you have a depression following a stroke, your cognitive or intellectual recovery seems to be delayed by at least a year, compared with non-depressed patients.

Perhaps most dramatically, there are four studies in Europe as well as the United States, showing that if you have a depression immediately following a stroke, over a period of up to 10 years, your likelihood of dying during that period is three and one-half times higher than somebody who didn't have depression. So, when you put those together in addition to the emotional pain and suffering associated with depression itself, it's a very strong case, I believe, to try to intervene and prevent the development of these depressions.

How many stroke patients were involved in the study? What did the post-stroke depression study involve for participants?

This was a three-site study. The Burke Hospital in New York, the University of Chicago Hospital, and The University of Iowa participated in this study. It was a multi-site study and we enrolled a total of 176 patients with acute stroke who were randomized to one of three treatments for one year. The three treatments we were comparing were:

• ESO talopram (Lexapro)
• Problem-solving therapy, which is a talk-therapy developed in England and used among patients with depression in the elderly
• Placebo

What were the overall results of the study?

In order to compare these three arms of the study, although patients were randomly assigned to each of the arms, we looked at factors such as age, education, the existence or prior history of depressive disorder. When you control for all of those factors, we found that patients who received placebo—22.4 percent of them developed depression during the one year of treatment, compared with only 8.5 percent of those who received the ESO talopram, and 11.9 percent of patients who received the problem-solving therapy.

So if you look at the likelihood of developing depression, if you were receiving the ESO talopram, you were 4.5 times less likely to develop a depression compared to somebody receiving placebo. And if you had the talk-therapy, you were 2.2 times less likely to develop a depression.

Is there a window of opportunity that is most effective in treating stroke patients before they develop depression?

Nobody studied exactly when the most effective time is. We published an earlier study indicating that if patients are treated within the first month following stroke, their recovery is significantly improved at two year follow-ups. In this study, all patients were enrolled within the first three months, and I would say, based on the data available, that the earlier the better. As soon as a patient can undertake an additional treatment such as this, would be the appropriate time to start.

Why is the prevention of depression so important in the treatment of stroke patients?

These studies have demonstrated that there is very significant consequences of the development of depression. In an earlier treatment trial, where patients were completely different from the ones involved in this study, we show that three months of a treatment with antidepressant medication compared with placebo at seven years' follow-up, the patients who received antidepressants had half the mortality rate of the depressed patients who had received placebo. We doubled the survival rate by providing antidepressant treatment to patients who had a depression following a stroke. It just reinforces this idea that either intervention to treat the depression early on after the stroke or, even better, preventing the development of depression is likely to increase long-term survival rate.

Will all stroke patients from this point on see a mental health specialist as part of their recovery process?

That's an interesting question, of course, and it certainly comes out of the findings from this study. I would say that it's probably not feasible for all stroke patients. There are 700,000 stroke patients a year—new strokes—in the United States according to the American Heart Association and so it's probably unfeasible for all of them to see a mental health specialist. I do think that it's important that all patients following stroke be evaluated for depression, whether it's from their primary care physician, neurologist, or other physicians involved.

I think that prevention of depression, giving all patients who have had an acute stroke antidepressant medication would significantly improve long-term recovery. In fact, in our current study, we calculated that if you were to treat everybody who had a stroke, seven patients would have to be treated to prevent one episode of depression. That's a pretty good return on the use of antidepressants to prevent the devastating consequence of depression following stroke.

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Robert G. Robinson, MD