Comparative Efficacy And Acceptability Of Antidepressant Treatment In Patients With Post-stroke Depression

Objective: Post-stroke depression(PSD)affects approximately one third of stroke survivors.The question of whether and what antidepressant treatment for PSD should be prescribed remains controversial.We aimed to integrate direct and indirect evidence by a network meta-analysis,and to create hierarchies of the efficacy and acceptability of all comparative antidepressants for PSD.This study is in order to provide more reliable evidence-based decisions for clinical application.Method: Electronic databases [MEDLINE,Embase,PsycINFO,Cochrane Central Register of Controlled Trials(CENTRAL),Web of Science] were searched up to January 1,2019.We included only randomised controlled trials that compared antidepressants as monotherapy in patients with PSD during the acute phase.The patients had to have had a stroke diagnosed clinically or by CT scan or MRI and have been subsequently diagnosed with depression.The network meta-analysis was conducted by Stata software.The primary outcome was efficacy,defined as the mean change of the total depression score during the acute phase,with standardized mean difference(SMD)and 95% confidence interval(CI).The secondary outcome was acceptability,defined as risk of all-cause discontinuation,with odds ratio(OR)and 95% CI.Result: We identified 12 suitable trials,with data from 707 participants.11 antidepressants were assessed in the trials,including placebo.For efficacy,all drugs were significantly more effective than placebo apart from sertraline(standardised mean differences [SMD]-0.61 [95% CI-1.47 to 0.25]),nefiracetam(SMD 0.51 [-0.17 to 1.19]),and fluoxetine(SMD 0.46 [-0.35 to 1.27]).SMD,compared with placebo,varied from-6.54(-8.42 to-4.65)for the best drug(reboxetine)to 0.51(-0.17 to 1.19)for the worst drug(nefiracetam).Reboxetine,paroxetine,and doxepin were the most efficacious treatments(ranked in order),the cumulative probabilities of which were 100%,85.7%,and 83.2%,respectively.For acceptability,patients assigned to paroxetine had significantly lower all-cause discontinuation than those assigned to doxepin(OR 0.04 [95% CI 0.00 to 0.73]),citalopram(OR 0.03 [0.00 to 0.78]),and fluoxetine(OR 0.04 [0.00 to 0.89]);all other comparisons were not significant.ORs compared with placebo ranged from 0.09(95% CI 0.00 to 1.83)for paroxetine to 3.42(0.73 to 15.91)for citalopram.With respect to the acceptability rank,paroxetine,placebo,and sertraline were among the most acceptable treatments,the cumulative probabilities of which were 92.4%,63.5%,57.3%.Conclusion: After weighing the efficacy and acceptability,we conclude that paroxetine might be the best choice when starting acute treatment for PSD,and fluoxetine might be the worst choice.