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NEW Optimizing Activity and Community Participation following Stroke
NEW Optimizing Activity and Community Participation following Stroke

1. Mood and Depression

Note

Multiple mood disorders are associated with stroke. This section addresses the most prevalent disorders. These are defined here and then referred to where appropriate within the recommendations that follow.

Refer to the Definitions and Descriptions included in the Overview for additional information related to this section.

Recommendations and/or Clinical Considerations
1.0 General Recommendations
  1. Individuals who have experienced a stroke should be considered at risk for post-stroke depression, which can occur at any stage of recovery [Strong recommendation; High quality of evidence].  
  2. Individuals with stroke, their family and caregivers should be given information and education about the potential impact of stroke on mood as well as be provided with applicable resources and supports to manage altered mood states following stroke [Strong recommendation; Low quality of evidence].  
  3. Individuals with stroke, their family and caregivers should be provided with the opportunity to talk about the impact of stroke on their lives and mental health at all stages of care [Strong recommendation; Low quality of evidence].  Refer to the CSBPR Stroke Systems of Care Module for further information on Patient and Family Education, and Community Follow-up.
1.1 Screening for Post-Stroke Depression
  1. All individuals with stroke should be screened for post-stroke depression if deemed medically appropriate given the high prevalence of post-stroke depression and the evidence for treating symptomatic depression post stroke [Strong recommendation; Moderate quality of evidence]. Note: ‘Medically appropriate’ excludes individuals with stroke who are unresponsive or who have deficits that interfere with screening for mood disorders. Any pre-stroke mental health or cognitive diagnoses should be taken into consideration during the screening process.
  2. Screening should be undertaken by trained professionals using a validated screening tool [Strong recommendation; Moderate quality of evidence].  
  3. Stroke assessments should include evaluation of risk factors for depression, particularly a history of depression to ensure adequacy of assessment and access to appropriate treatment [Strong recommendation; Low quality of evidence]. Refer to note below for list of risk factors.
  4. For individuals who experience some degree of communication challenge or deficits following stroke, appropriate screening strategies that do not rely on verbal communication should be implemented for possible post-stroke depression to ensure adequate screening and assessment and access to appropriate treatment [Strong recommendation; Low quality of evidence].  

Note: Common risk factors associated with post-stroke depression include increased stroke severity, functional dependence, presence of cognitive impairment, and history of previous depression. Increased functional dependence (e.g. requiring help with activities of daily living) and having a history of pre-stroke depression may be the two most salient risk factors for the development of post-stroke depression. Communication deficits and social isolation may also be considered as possible risk factors for depression. Refer to CSBPR Stroke Systems of Care Module for information on depression in family and informal caregivers of people with stroke.

Section 1.1 Clinical Considerations: Timing of Screening for Post-Stroke Depression 

  1. Screening for post-stroke depression may take place at various stages throughout the continuum of stroke care, especially at transition points, as time of onset for post-stroke depression can vary and include:
    1. At transfer from an inpatient acute setting to an inpatient rehabilitation setting;
    2. From an inpatient rehabilitation setting before return to the community;
    3. During secondary prevention clinic visits;
    4. Following discharge to the community, during follow-up appointments with consulting specialists, and during periodic health assessments with primary care practitioners.
  2. Screening for depressive symptoms could be considered during the initial acute care stay, if deemed medically appropriate, particularly if evidence of depression or mood changes are noted or if risk factors for depression are present, as outlined in section 1.1, iii.
  3. Repeated screening may be required since the ideal timing for screening for post-stroke depression is unclear.
1.2 Assessment for Post-Stroke Depression
  1. Individuals with stroke who have screening results that indicate a risk for depression should be assessed in a timely manner by healthcare professionals with expertise in diagnosis, management and follow-up of depression [Strong recommendation; Moderate quality of evidence].
1.3 Non-Pharmacological Management of Post-Stroke Depression
  1. It is reasonable to consider psychological interventions (such as cognitive-behavioural therapy, interpersonal therapy, problem-solving therapy, motivational interviewing, acceptance and commitment therapy), as one of the first line treatments for depressive symptoms post stroke as a monotherapy, provided individuals with stroke have sufficient cognitive and language skills to actively engage in therapy [Strong recommendation; Moderate quality of evidence].  
  2. Treatment for post-stroke depression may include psychological interventions in combination with antidepressants for appropriate individuals [Strong recommendation; Moderate quality of evidence].  
  3. Supervised exercise, ideally performed at least three times per week, is recommended to reduce depressive symptoms in people post-stroke with mild depressive symptoms [Strong recommendation; High quality of evidence] and moderate depressive symptoms [Strong recommendation; Moderate quality of evidence]. 27

Section 1.3 Clinical Considerations 

  1. Other approaches to adjunctive treatment of post-stroke depression are emerging, with research in very early stages. These may include mindfulness and recreational therapies such as music therapy, and pet therapy. These therapies could be considered on an individual basis at the discretion of the treating healthcare professional in consultation with the individual with stroke and their family if appropriate. 
  2. Other therapies including repetitive transcranial magnetic stimulation, or, for severe refractory depression, electro-convulsive therapy or deep brain stimulation. These have all been suggested in the literature but lack sufficient evidence for routine use and require more research. Note these interventions are not yet available/approved specifically for use in post-stroke depression in Canada.
1.4 Pharmacotherapy for Post-Stroke Depression
  1. Individuals with stroke with mild depressive symptoms or those diagnosed with minor depression may initially be managed by “watchful waiting”  [Strong recommendation; Moderate quality of evidence]. Refer to the Definitions and Descriptions included in the Overview for definition of watchful waiting.
    1. Pharmacological treatment should be considered and started if depression is persistent or worsens and interferes with clinical goals [Strong recommendation; Moderate quality of evidence].  
  2. People diagnosed with a depressive disorder following stroke should be considered for a trial of antidepressant medication [Strong recommendation; High quality of evidence].  
  3. No one drug or drug class has been found to be superior for post-stroke depression treatment.  Side effect profiles, however, suggest that some selective serotonin reuptake inhibitors may be favoured in this patient population [Strong recommendation; Moderate quality of evidence].  
    1. Choice of an antidepressant medication will depend upon symptoms of depression, potential side effects of the medication, patient medical profile, and possible drug interactions with other current medications and medical diagnoses [Strong recommendation; Moderate quality of evidence].  
  4. Response to treatment should be monitored regularly by a health professional.  Monitoring should include evaluation of any changes in the severity of depression, review of potential side effects, and update of ongoing management plans [Strong recommendation; Moderate quality of evidence].  
  5. If a good response is achieved, treatment should be continued for a minimum of 6 to 12 months [Strong recommendation; Moderate quality of evidence].
    1. If the individual’s mood has not improved 2-4 weeks after initiating treatment, assess individual adherence to medication regime. If compliant, then consider increasing the dosage, adding an additional medication, or changing to another antidepressant [Strong recommendation; Moderate quality of evidence].  Refer to CANMAT Mood and Anxiety guidelines on pharmacotherapy. 27
    2. Following the initial course of treatment, ongoing pharmacological treatment could be considered on an individual basis (consider previous history and risk factors for recurrence of depression) [Strong recommendation; Low quality of evidence].  
    3. If a decision is made to discontinue an antidepressant, it should be tapered over one to two months [Strong recommendation; Low quality of evidence].  
  6. Following initial treatment for post-stroke depression, individuals should continue to be monitored for recurrence of depression [Strong recommendation; Low quality of evidence].  

Note: Examples of a ‘good response’ may be indicated by positive changes in thoughts and self-perceptions (e.g., hopelessness, worthlessness, guilt), emotional symptoms (e.g., sadness, tearfulness), neurovegetative symptoms (e.g., sleep, appetite), and improved motivation to carry out daily activities.

Section 1.4 Clinical Considerations 

  1. The involvement and feedback of individuals with stroke, their family and caregivers are an important component of ongoing monitoring for post-stroke mood changes and conditions. 
  2. Counselling and education should include information about potential recurrence of symptoms, emerging symptoms to be aware of, the importance of adherence with prescribed medication regime, and contacting their primary care physician or mental health expert should those signs reappear.
1.5 Prophylactic Treatment for Post-Stroke Depression
  1. While prophylactic pharmacotherapy has been shown to prevent post-stroke depressive symptoms [Strong recommendation; High quality of evidence], its impact on function is less clear. At this time, routine use of prophylactic antidepressants for ALL individuals with stroke is not recommended as the risk–benefit ratio has not been clearly established [Strong recommendation; Moderate quality of evidence].  
  2. Psychological interventions (such as problem-solving therapy, cognitive-behaviour therapy) have been shown to have efficacy for prophylactic treatment for post-stroke depression and should be considered where appropriate [Strong recommendation; Moderate quality of evidence].

Section 1.5 Clinical Considerations 

  1. Further research is required to determine individuals who have experienced a stroke who are at higher risk for mood disorders, choice of antidepressant agents, optimal timing and duration of intervention.
1.6 Other Mental Health States
  1. Screening for anxiety may be considered in individuals with stroke as increased prevalence has been demonstrated following stroke [Strong recommendation; Moderate quality of evidence].
    1. A validated screening tool should be used to detect presence of pre-existing or new anxiety [Strong recommendation; Moderate quality of evidence].
    2. Individuals who have had a stroke with resulting communication limitations should be screened for anxiety using appropriate methods validated with individuals experiencing aphasia [Strong recommendation; Moderate quality of evidence].
  2. Psychological interventions (such as cognitive-behaviour therapy) have been shown to have efficacy for anxiety and should be considered for individuals following stroke [Strong recommendation; Moderate quality of evidence].
  3. Anxiety may appear in people who have experienced a stroke who are not clinically depressed. It also frequently co-exists with depression following stroke. For individuals with stroke with marked anxiety with or without clinical depression, it is reasonable to offer pharmacotherapy [Strong recommendation; Low quality of evidence].
  4. Apathy may appear in people who have experienced a stroke who are not clinically depressed. It also frequently co-exists with depression following stroke. For individuals with stroke with marked apathy, with or without clinical depression, it is reasonable to offer nonpharmacological intervention such as exercise or music therapy [Strong recommendation; Low quality of evidence].
    1. Psychostimulants may be considered in select individuals; however, evidence remains limited [Strong recommendation; Low quality of evidence].
    2. Although evidence is limited in individuals with stroke, psychotherapy may be considered as an adjunct to pharmacotherapy [Strong recommendation; Low quality of evidence].
  5. Pseudobulbar Affect:  In cases of severe, persistent tearfulness, emotional incontinence or lability, a trial of antidepressant medication should be considered [Strong recommendation; High quality of evidence].
    1. Some selective serotonin reuptake inhibitors may be considered over others for this population due to side effect profiles [Strong recommendation; Low quality of evidence].
    2. There is no evidence for non-pharmacologic interventions for this condition [Strong recommendation; Low quality of evidence].
Rationale +-

Post-stroke mood disorders, including depression and anxiety, are highly prevalent among individuals with stroke. Approximately one-third of all individuals who experience stroke will exhibit symptoms of depression at some time following the stroke event (acute, sub-acute and at long-term follow-up).  A substantially increased prevalence of depression following stroke has been reported in up to 24% of individuals with stroke (24% vs. 8% compared to general population). 28 Anxiety and apathy have been reported in 20-30% of people who have experienced stroke, either alone or in combination with a diagnosis of post-stroke depression. 29,30

Severity of functional limitations, stroke severity, cognitive impairment, age of stroke onset, and a previous history of depression have all been identified as important risk factors for the development of post-stroke depression.  Symptoms such as persistent sadness, hopelessness, irritability, and withdrawal from social activities can impede motivation and engagement in rehabilitation. Additionally, mood disorders can complicate the recovery process by affecting cognitive function and overall health outcomes. Post-stroke depression is associated with poorer functional recovery, increased risk for dependence, reduction in social participation, and increased mortality. Early identification and intervention, including psychological support and medication, where appropriate, are essential for managing mood disorders.

Families and caregivers of individuals with stroke are also at risk for depression, with the reported incidence as high as 30% to 60% of caregivers experiencing depressive symptoms.  

Individuals with stroke, family and caregivers stress the importance of healthcare providers recognizing mental health needs, and ensuring access to assessment, management and support throughout stroke recovery, using an individualized approach. They emphasize the connection between mental health, physical health and recovery, and the importance of addressing mental health to optimize outcomes, both for the individual with stroke, their family and caregivers. Knowing that recovery is not a linear or time dependent process, and that different fears, anxieties and emotions can come in waves, consistent follow-up care allows an individual to access or re-access support at the time when it is most needed.

Performance Measures +-

System Indicators

  1. Availability of inpatient and community-based education and resources for individuals with stroke experiencing mood and mental health issues.
  2. Availability of healthcare providers with expertise in mental health as part of all stroke programs.
  3. Proportion of individuals with stroke experiencing mood and or depression following stroke.

Process Indicators

  1. Proportion of individuals with acute stroke with documentation indicating initial screening for post-stroke depression was performed (either informally or using a formal screening tool) in the acute care, rehabilitation, long-term care and community settings (e.g., homecare) setting. (aligns to Accreditation Canada)
  2. Proportion of individuals with acute stroke referred for additional assessment or intervention for a suspected diagnosis of depression.
  3. Proportion of individuals with stroke diagnosed with post-stroke depression who are treated with antidepressants and/or psychotherapy.

Patient-Oriented Indicators   

  1. Changes in depression ratings from initiation of treatment, measured wat regular intervals, transition points and when changes in health status, using standardized depression rating scales.
  2. Changes in quality of life of individuals with stroke who experience changes in mood or depression, measured using a standardized scale and at regular follow-up intervals.
  3. Changes in quality of life of family members caring for individuals with stroke who experience changes in mood or depression, measured using a standardized scale and at regular follow-up intervals.
Implementation Resources and Knowledge Transfer Tools +-

Resources and tools listed below that are external to Heart & Stroke and the Canadian Stroke Best Practice Recommendations may be useful resources for stroke care. However, their inclusion is not an actual or implied endorsement by the Canadian Stroke Best Practices team or Heart & Stroke. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.

Health Care Provider Information

Resources for Individuals with Stroke, Families and Caregivers 

Summary of the Evidence +-

Evidence Table and Reference List 1

Post-stroke depression (PSD) is a common consequence of stroke, although reported estimates may be unreliable given possible under-reporting of unusual mood, and the variability in the methods used to assess and define cases of depression. In a systematic review of 61 prospective, observational studies of post-stroke depression conducted in hospital-, rehabilitation-, and population-based settings, Hackett & Pickles 31 estimated that approximately one-third of all individuals who experience stroke exhibited depressive symptoms at some point following the event (i.e., at acute, sub-acute or long-term follow-up). The overall pooled frequency estimate of PSD was 31% (95% CI 28% to 35%). Ayerbe et al. 32 reported that most cases of PSD develop within the first three months post stroke in a prospective study including 3,689 patients included in the South London Stroke Register. Salinas et al.33 reported that of 1,424 postmenopausal women included in the Women’s Health Initiative who experienced a first-ever stroke, new-onset PSD occurred in 21.4% of participants, an average of 16 months post stroke. Jorgensen et al. 28 reported the incidence of persons developing depression was significantly higher compared with those of the general population matched for age and sex. During a 2-year observation period, the incidence of depression was 25.4% vs. 7.8% (adj hazard ratio [HR]=4.09, 95% CI 4.00-4.18). In the prospective Depression Predictors after Ischemic Stroke study (DEPRESS), Guiraud et al. 34 reported that among 251 patients with new onset stroke, the incidence of depression was 19% at two months and 24.3% at 6 months. Risk factors for the development of PSF include increasing age, living alone, high levels of comorbidity, a history of depression, female gender, physical disability (modified Rankin Scale [mRS] score >2 at discharge), increased initial stroke severity, cognitive impairment and prior history of stroke. 28,32,34,35

The best time to screen formally for the possible presence of PSD is not certain. Although incident rates decline over time and there is a general trend toward improvement in depressive symptomatology during the first-year post stroke, PSD may prove to be persistent for a longer duration for a significant proportion of individuals. Screening for depression should be considered during the acute inpatient stay, at the point of transition to, or during inpatient rehabilitation, upon discharge to the community and during periodic health assessments. Swartz et al.36  describes the feasibility of using the 2-item version of the Patient Health Questionnaire during routine clinical practice using 1,500 outpatients attending a stroke prevention clinic. All patients were able to complete the screen, 89% of whom did so in less than 5 minutes. Karamchandani et al. 37 reported that 70% of patients of patients were eligible for depression screening prior to hospital discharge or transfer to another service. The remaining patients were not eligible due to aphasia, other medical condition, hospice/comfort measures, or prolonged intubation.

The diagnostic accuracies of several PSD screening tools have been examined. Meader et al. 38 included the results of 24 studies and evaluated the performance of 18 previously validated scales. The three best performing scales for the identification of any depression included Center of Epidemiological Studies-Depression Scale (CES-D) with a sensitivity and specificity of 75% and 85%, the Hamilton Depression Rating Scale (HDRS, sensitivity 84%, specificity 83%) and the 9-item version of the Patient Health Questionnaire (PHQ-9, sensitivity 86%, specificity 79%). The best two performing scales for the identification of major depression were HDRS and the PHQ-9. In a Canadian study, Prisnie et al. 39 including 122 outpatients attending a stroke prevention clinic, the diagnostic accuracies of the PHQ-9 and PHQ-2 were evaluated. Using a cut-point of 13, the sensitivity and specificity of the PHQ-9 was 81.8% and 97.1%, and 75.0% and 96.3%, for PHQ-2, using a cut point of 3.

For pharmacological treatment, selective serotonin reuptake inhibitors (SSRIs) are the most frequently used form of antidepressants to treat post stroke depression. In a recently updated Cochrane review, the results of 65 RCTs representing 3,342 participants with post-stroke depression, were included. 40 The treatments evaluated included pharmacological, non-invasive brain stimulation and psychological interventions, and their combinations. Among the 18 trials evaluating pharmacological agents, 12 compared an SSRI (citalopram, fluoxetine, paroxetine and sertraline) with placebo. Other agents assessed included tricyclic antidepressants (TCA), and other varied agents (deanxit, aniracetam, reboxetine, trazodone and nefiracetam). Overall, pharmacological agents were associated with a significant decrease in the number of people meeting the study criteria for depression at end of treatment (RR=0.70, 95% CI 0.55 to 0.88, 8 trials) and decreased the number of people with inadequate response to treatment (RR=0.47, 95% CI 0.32 to 0.70, 6 trials). The level of certainty for both outcomes was very low. While doses and duration of treatment were not summarized, the authors noted that the interventions in most trials were probably not given for an adequate length of time to show maximal or sustained response. In three trials the combination of pharmacological and psychotherapy resulted in a significant reduction in depression scores at the end of treatment (MD=-1.60, 95% CI -2.13 to -1.08). Pharmacological treatment was associated with a significantly increased risk of adverse events (RR=1.55, 95% CI 1.12 to 2.15). In another systematic review Xu et al. 41 included the results from 11 RCTs of patients with a clinical diagnosis of post-stroke depression. Treatment with an antidepressant including SSRIs, (n=7), TCAs (n=3) and other agents (n=2) was associated with a significant reduction in depression scores (SMD=-0.96, 95% CI -1.41 to -0.51, p<0.0001), and better response to treatment (RR=1.36, 95% CI 1.01-1.83, p=0.04), compared with a placebo. 

Non-pharmacological approaches for the treatment of PSD include different forms of psychotherapy, physical activity, non-invasive brain stimulation, and acupuncture. In the same Cochrane review mentioned above, Allida et al. 40 also evaluated psychological interventions, (individual or group cognitive behavioral therapy, delivered in-person or remotely, motivational interviewing, and group psychotherapy) which were assessed in 22 trials. Compared with usual care and/or attention control, psychological interventions significantly decreased the number of individuals meeting the study criteria for depression at end of treatment (RR= 0.77, 95% CI 0.62 to 0.95), an effect similar to that of pharmacological interventions.

Prevention of PSD

Given the high prevalence of PSD and the negative consequences associated with it, there is increased focus on prevention strategies. The same interventions examined in the recent Cochrane review 40 for the treatment of PSD, were also examined as interventions for the prevention of PSD. Allida et al. 42 included 19 RCTs (21 interventions), involving 1,771 participants recovering from stroke without depression at study entry. Compared with placebo, antidepressants significantly reduced the risk of depression at the end of the treatment period (RR=0.50, 95% CI 0.37 to 0.68, 9 trials), but were not associated with a significant reduction in Hamilton Depression Rating Scale scores (MD=0.59, 95% CI -1.46 to 2.63, 4 trials) or improvement in Barthel Index scores (MD=-3.86, 95% CI -9.48 to 1.77, 3 trials). Compared with usual care, psychological therapy was associated with a significantly lower risk of depression (RR=0.68, 95% CI 0.49 to 0.94, 2 trials). No trials were included that examined noninvasive brain stimulation (NIBS), or combinations of interventions. In a pooled analysis based on 776 observations from 12 RCTs, Salter et al. 43  reported the odds of developing PSD were reduced significantly with the use of prophylactic pharmacotherapy (odds ratio [OR]=0.34, 95% 0.22-0.53, p<0.001). Similar effects have been reported in other systematic reviews. 

In a trial that included pharmacological and non-pharmacological study arms with long-term follow-up, Robinson et al. 44 randomized 176 patients without depression to receive escitalopram, problem-solving therapy (PST) or placebo, which was provided for 12 months. At one year, in the per-protocol analysis, adjusted for previous history of mood disorders, patients assigned to the placebo condition were significantly more likely to develop depression compared with those receiving either therapy with escitalopram (adj. HR= 4.5, 95% CI 2.4-8.2) or PST (adj. HR=2.2, 95% CI 1.4-3.5). In a follow-up study, Mikami et al. 45 reported that when escitalopram was discontinued at the end of the study period, persons were more likely to develop major depression and had increased Hamilton Depression Rating Scale (HDRS) scores during the next 6 months, compared with those given placebo or PST. Finally, after a mean duration of 8 years of follow-up, Robinson et al.46 reported that participants who received PST were significantly less likely to have died, compared with the combined group of escitalopram + placebo. Increasing age and the development of depression were found to be significant predictors of mortality.

Treatment of other Mood States 

People with depression may also suffer with a comorbid anxiety disorder, the most common of which is generalized anxiety disorder (GAD). The overall prevalence of anxiety following stroke is 19%-24%, depending on the method used for identification (interview vs. rating scale). 47 Despite the high prevalence of post-stroke anxiety, very few studies have included evaluation of the effectiveness of potential treatments. A Cochrane review 48 identified only 3 RCTs examining pharmacotherapy (paroxetine, buspirone) and a self-help autogenic relaxation CD. While the results from individual trials were positive, the results could not be pooled. The authors concluded there was insufficient evidence to guide treatment. Another systematic review 49 including the results of 14 RCT, of which two included patients with traumatic head injuries. Interventions included in this review were psychotherapy (n=6), pharmacotherapy (n=4), pharmacotherapy + psychotherapy (n=1), exercise therapy (n=2) and other interventions (forest therapy, relaxation CD and acupuncture + alprazolam). Compared with a control group, both psychotherapy interventions and pharmacotherapy were associated with significant reductions in anxiety scores (SMD= −0.41, 95% CI -0.79 to −0.03, 6 trials and SMD= −2.12, 95% CI -3.05 to -1.18, 4 trials, respectively).

Post-stroke apathy is another form of mood disturbance that occurs not infrequently post stroke with estimates of 36% reported, 50 which are comparable to that of post stroke depression. Nonpharmacological treatments that have been evaluated for post stroke apathy include NIBS, music therapy, cognitive therapy, and occupational therapy. In a network meta-analysis, when all interventions were combined in a pooled analysis, including the results from 8 RCTs of 334 patients with neurological conditions (dementia or mild cognitive impairment) and stroke in one trial, nonpharmacological interventions were associated with a significant reduction in Apathy Evaluation Scale (AES)(MD=-6.88, 95% CI −8.50 to −5.26). 51 In direct comparisons with the control condition, all interventions except music therapy were associated with significant reductions in AES scores. Mean differences ranged from -8.25 to cognitive rehabilitation to -4.87 for occupational therapy. In head-to-head comparisons, no active intervention was superior to another. 

Pharmacotherapy can also be used for the treatment of post- stroke emotionalism. In a Cochrane review including 7 RCTs, Allida et al. 52 reported that fluoxetine (20 mg/day for 10 days) was associated with a ≥50% reduction in emotionalism, the primary outcome (RR=0.26, 95% CI 0.09 to 0.77), although data were only available for one small trial with 19 participants. The use of SSRIs was also associated with a significant improvement (reduction) in tearfulness when compared to placebo (RR=0.32, 95% CI 0.12 to 0.86; 3 trials).

Sex & Gender Considerations

While female sex has been consistently identified as a significant risk factor for the development of PSD, there is little research focused on sex differences in treatment. In one of the few trials identified on the topic, The Preventive Effect of Escitalopram on Depression and Related Emotional Disorders in Acute Stroke Patients (EMOTION) trial that included 478 patients, women had a better response to a three-month course of antidepressant medication (10 mg/day escitalopram) compared with men.53

Stroke Resources
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