Management of Depression in Post-stroke Patients

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Session Summary

Although the prevalence of PSD depends upon whether the patients are examined in community settings or acute hospitals, the mean prevalence of major depressive disorder based on pooled data from the world’s literature is 20% during acute poststroke period for major depression and 19% for minor depression. The diagnosis of depression is based on DSM-IV criteria for major or minor depression. There is relatively little effect of physical illness on the manifestations of depressive symptoms. The major risk factors for developing poststroke depression include severity of impairment in activities of daily living, in cognitive function and in social support.

In addition, previous personal history, gender, personality, and negative life events, have also been demonstrated to be associated with the development of poststroke depression. The most controversial risk factor has been lesion location, but a meta analysis of studies examining patients within the first 2 months following stroke have demonstrated a relative risk ratio of 2.3 for patients with left anterior compared with right anterior lesions. Poststroke depression has been demonstrated to effect recovery in activities of daily living, cognitive function and survival. After controlling for other risk factors, patients with acute poststroke depression were 3.7 times more likely to die as early as 12 months and as long as 7 years following stroke compared to nondepressed patients. There have been 8 double blind placebo controlled trials of antidepressants following stroke.

Nortriptyline, citalopram and reboxetine have all been shown to be significantly more effective than placebo in the treatment of poststroke depression. In addition, escitalopram has been demonstrated in a double blind randomized treatment trial to prevent the occurrence of poststroke depression. Patients receiving placebo were 4.5 times more likely to develop depression than patients receiving escitalopram. Antidepressants have also been shown in both depressed and nondepressed patients to improve recovery in cognitive function, activities of daily living and decrease the probability of death.

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Faculty Information

Robert Robinson, MD

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Robert Robinson, MD
Professor and Head of the Department of Psychiatry
The University of Iowa Roy J. and Lucille A. Carver College of Medicine
Iowa City , IA

Dr. Robert G. Robinson is the Paul W. Penningroth Chair and Head of Psychiatry in the Carver College of Medicine at The University of Iowa in Iowa City, Iowa. Dr. Robinson received a B.S. degree in Engineering Physics in 1967 and an M.D. from Cornell University in 1971. He completed a medical Internship at Montefiore Hospital and Albert Einstein Medical Center in Bronx, New York and a year of psychiatry residency at Cornell University Medical Center, Westchester Division in White Plains, New York. Following a two-year research associateship at the National Institute of Mental Health in the Laboratory of Neuropharmacology, he completed residency and fellowship, including a year as Chief Resident, at the Department of Psychiatry and Behavioral Sciences, Johns Hopkins Hospital in Baltimore, Maryland. During that time, he also was a Maudsley Exchange Resident in the Children’s Department of Maudsley Hospital, Denmark Hill, London, England.

Following residency training, Dr. Robinson spent from 1977 to 1990 as a faculty member at Johns Hopkins University, School of Medicine in the Department of Psychiatry and the Department of Neuroscience where he rose to the rank of Professor in 1985. He was also a faculty member of the Psychiatry Department at the University of Maryland Medical School. In 1990 he moved to the University of Iowa in Iowa City, Iowa to become the Head of the Department of Psychiatry in the Carver College of Medicine where he is also a member of the faculty of the graduate program in Neuroscience. In 1996, he became the Paul W. Penningroth Professor and in 2007, the Paul W. Penningroth Chair in Psychiatry.

Dr. Robinson’s research interests include a broad range of neuropsychiatric disorders associated with ischemic brain injury; animal models of mood disorders; the mechanism and emotional and behavioral manifestations of brain asymmetry, mechanism and mood regulation in humans, mood disorders following traumatic brain injury, and the use of transcranial magnetic stimulation in the treatment of depression following stroke or vascular disease.

Throughout his career, Dr. Robinson has received 13 research grants from the National Institute of Health including a Research Scientist Career Award and has had continuous funding from the NIH since 1979. He has trained 36 post-doctoral fellows in his laboratory including 7 who are now full professors.

He has published more than 390 original research articles and chapters and 5 books, including the second edition of a monograph entitled, The Clinical Neuropsychiatry of Stroke which was translated into 3 different languages. His research contributions have included pioneering work in the diagnosis, cause and treatment of neuropsychiatric disorders following stroke, the first demonstration of treatment of depression following stroke, the identification of specific sites of brain injury associated with poststroke depression, mania and anxiety disorder and identification of brain asymmetries in the physiological and behavioral response to brain ischemia. The work led to his receipt of the American Psychiatric Association Award for Research in 1999 as well as the Academy of Psychosomatic Medicine Research Award the same year.

Grant/Research Support:

NIMH

Consultant:

The Ripples Group

Presentation will include discussion of off-label, experimental, and/or investigational use of drugs or devices:

Escitalopram-off-label use as preventive of depression. Fluoxetine-to augment recovery from stroke-off-label.

Learning Objectives

Recognize possible risk factors in post-stroke depression (PSD).
Assess symptoms of PSD
Assess the consequences of PSD on recovery and survival.
Evaluate available controlled trials with Selective Serotonin Reuptake Inhibitors for the treatment of PSD and the effect on recovery.
Identify the treatments which have been shown to be the most effective for PSD.

Continuing Education Credit

Activity Dates: 04/20/2009 - 04/20/2012
ACPE Contact Hours: 1.0
ACPE Number: 0284-0000-09-005-H01-P
Nursing Credit Reminder: Note that ACPE and ACCME credit is accepted for certification renewal.

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ACPE The College of Psychiatric and Neurologic Pharmacists is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This self-study course provides 1.0 contact hours (0.1 CEUs) of knowledge-based continuing education credit from CPNP approved programming. The ACPE universal program number assigned to this course is 0284-0000-09-005-H01-P (1.0 contact hours).

ACPE approved contact hours are accepted for ANCC Certification Renewal (see pages 5 and 6): At least 50% (37.5 hours) of your 75 continuing education hours must be formally approved continuing education hours. Formally approved continuing education hours meet one or more of the criteria listed below:

Continuing nursing education (CNE) approved for nursing contact hours by an accredited provider or approver of nursing continuing education
Continuing medical education (CME) approved for CME hours
Sponsored by organizations, agencies, or educational institutions accredited or approved by the American Nurses Credentialing Center (ANCC) or the Accreditation Council for Continuing Medical Education (ACCME) or the Accreditation Council for Pharmacy Education (ACPE) or the Commission on Dietetic Registration

Course Requirements

This course is provided online at cpnp.org and consists of the speaker audio and slides. A PDF file of the slides is also provided and access is available to participants indefinitely although ACPE credit is available only through the course expiration date.

Participants in this course must complete an examination and achieve a score of 60% or greater. Successful completion of the course also requires the completion of a course evaluation. ACPE statements of credit can be retrieved by participants online at cpnp.org immediately upon successful completion of the course.

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Internet Explorer 6+, Firefox 2+ or Safari 3+
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Recommended:

Internet Explorer 7+, Firefox 3+ or Safari 3+
1280x768 resolution or greater
Adobe Flash Player 10+
Windows XP/2000/Vista and Mac OS 10.4 or better
512MB of RAM for Windows XP or Mac OS
1GB of RAM for Windows Vista

Target Audience

If you are a pharmacist, nurse practitioner or other healthcare professional involved in the medication therapy management of psychiatric and/or neurological patients, we invite you to participate in this online course.

Grant Support

This programming was supported in part by grants from Bristol-Myers Squibb, Forest Laboratories, Inc., Lilly, Schering-Plough, Cyberonics, and Shire.