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October 2008

Two Drugs for Fibromyalgia
Pregabalin (Lyrica) and duloxetine (Cymbalta) are approved in the United States for the treatment of fibromyalgia.

Preventing Poststroke Depression
In a 2008 study by Robinson and colleagues, escitalopram (Lexapro) and problem-solving therapy decreased the likelihood of poststroke depression.

Duloxetine for Elderly Patients with GAD
Due to possible adverse events, duloxetine (Cymbalta) should be a second-line option for elderly patients with generalized anxiety disorder.

In Brief
Switch to Aripiprazole Reduces Cardiovascular Risk in Schizophrenia; SSRIs Are Effective for Treating PMS/PMDD; Statins May Protect Against Dementia

Antidepressants for Social Anxiety Disorder
Sertraline (Zoloft and others), paroxetine (Paxil and others), venlafaxine (Effexor and others), and fluvoxamine (Luvox and others) appear to be the most efficacious antidepressants for the treatment of social anxiety disorder, with escitalopram (Lexapro) a reasonable alternative.

Preventing Poststroke Depression

October 2008

Over 700,000 Americans suffer a stroke each year.1 In combined studies of over 2000 patients, more than one-third of stroke survivors had an episode of depression within 2 years after the stroke.2 (The probability that a stroke victim will become depressed may be related to a gene that encodes a widespread neuroprotective protein—brain-derived neurotrophic factor [BDNF].3)

In two double-blind, placebo-controlled trials, sertraline (Zoloft and others) did not prevent poststroke depression,4-5 and in a third, mianserin* also proved ineffective.6 Taking another "bite at this apple," Robinson and colleagues studied escitalopram (Lexapro) and problem-solving therapy as preventive approaches to poststroke depression.2

One hundred seventy-six patients were enrolled from three different academic centers within 3 months of having a stroke. None was depressed on study entry. Subjects were then assigned at random to receive escitalopram, 5 or 10 mg/day (dependent on age), placebo, or nonblinded problem-solving group therapy.

Patients who received placebo were 4.5 times more likely to become depressed than those who took escitalopram (P < .001). They were also 2.2 times more likely to become depressed than those receiving problem-solving therapy (P < .001). The apparent protective benefits of the antidepressant and the psychotherapy remained even after data were adjusted for history of mood disorder, age, gender, treatment site, and severity of impairment. In a conservative method of data analysis, intention-to-treat, escitalopram showed statistical superiority to placebo, but problem-solving therapy did not.

Using the increasingly popular metric "number needed to treat" (NNT), the authors calculate that 7.2 stroke patients would need to be treated with escitalopram or 9.1 patients with problem-solving therapy to prevent 1 case of depression after stroke.

Depression after stroke is associated with increased mortality.2 Ideally, preventing poststroke depression could improve survival.

Data from this study suggest that both escitalopram and problem-solving therapy decrease the likelihood of poststroke depression, with the SSRI's effect being stronger. Conceivably, a combined approach might provide additional benefit—but this would need to be confirmed prospectively.

In clinical practice, patient preference and treatment availability are important determinants of whether treatment is received and of what type. Given today's knowledge, it makes compelling sense to be concerned about patients who have had a stroke becoming depressed. At the very least, mood symptoms should be monitored. The data from Dr Robinson's group appear to justify offering patients the opportunity of taking antidepressants prophylactically or enrolling in this form of psychotherapy.

*Not available in the United States.

1Thom T, Haase N, Rosamond W, Howard VJ, Rumsfeld J, Manolio T, Zheng ZJ, Flegal K, O'Donnell C, Kittner S, Lloyd-Jones D, Goff DC Jr, Hong Y, Adams R, Friday G, Furie K, Gorelick P, Kissela B, Marler J, Meigs J, Roger V, Sidney S, Sorlie P, Steinberger J, Wasserthiel-Smoller S, Wilson M, Wolf P; American Heart Association Statistics Committee and Stroke Statistics Subcommittee: Heart disease and stroke statistics—2006 update: A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2006;113:e85-e151.

2Robinson RG, Jorge RE, Moser DJ, Acion L, Solodkin A, Small SL, Fonzetti P, Hegel M, Arndt S: Escitalopram and problem-solving therapy for prevention of poststroke depression: A randomized controlled trial. JAMA 2008;299:2391-2400.

3Kim JM, Stewart R, Kim SW, Yang SJ, Shin IS, Kim YH, Yoon JS: BDNF genotype potentially modifying the association between incident stroke and depression. Neurobiol Aging 2008;29:789-792.

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