A psychiatric drug used to treat depressed patients has been shown for the first time to be an effective treatment for the depression that often follows a severe stroke.
Researchers at Johns Hopkins University and the University of Maryland, both in Baltimore, report in the Feb. 11 LANCET that 14 stroke patients treated with the antidepressant drug nortriptyline were significantly less depressed than a similar group of 20 patients given a placebo.
“We feel that the success of nortriptyline in the treatment of post-stroke depression represents a potentially important advance,” says Johns Hopkins psychiatrist John R. Lipsey, who headed the study. He was joined by psychiatrists Robert G. Robinson of Johns Hopkins and Godfrey D. Pearlson, radiologist Krishna Rao and neurologist Thomas R. Price of the University of Maryland.
The patients in the study all suffered a thromboembolic stroke, in which the blood flow in a major vessel to the brain is blocked, resulting in a massive seizure and brain injury. Partial paralysis and speech difficulties often follow these strokes. Each year 400,000 Americans have a thromboembolic stroke. Several recent studies directed by Robinson indicate that between 30 percent and 60 percent of patients who survive a stroke are clinically depressed, not just “down” or “blue.” Their depressions usually last for at least six months. Prior to the study, half of the 34 patients had a major depression, said they experienced little or no pleasure from anything in their lives, felt worthless and often had sleep and eating disturbances.
Over a six-week treatment period, the patients in the study, their families, clinical examiners and nursing staff did not know who was receiving the antidepressant and who was on the placebo.
By the end of the study, patients given nortriptyline had an extremely low overall depression score compared with that for the placebo-treated patients. The depression score for each patient was based on a combination of responses to three standard depression scales.
Contrary to the belief that post-stroke depression is an understandable but usually untreatable psychological reaction, nortriptyline’s effectiveness indicates that there is often a biological component that can be countered with antidepressant drugs.
“Some post-stroke depressions are psychological reactions to the consequences of a stroke and require psychotherapy,” says Lipsey. “But we think the majority of these depressions are due to chemical imbalances in the brain.” Neurotransmitters, the chemicals that facilitate the transmission of messages across brain cells, probably decrease following a severe stroke, he adds. Nortriptyline may act to correct the stroke-induced imbalance of two of these chemicals, noradrenaline and serotonin.
Stroke victims with injuries to the left frontal side of the brain usually have the most severe depressions, but Lipsey’s group studied only six patients with left hemisphere damage alone. They are now examining patients with left-brain damage for their response to nortriptyline. Speech and communication skills are controlled by the left frontal brain.
“Our work requires some replicating studies,” says Lipsey. “But we wanted to convince the general practice physicians who often handle stroke patients that antidepressants are effective in treating post-stroke depression.”
