[Post-cerebrovascular stroke depression]

Post-cerebrovascular accident depression (PCVAD) affects 30 to 50% of hemiplegic patients in the first two years post-CVA, and has major physical and social repercussions. Particularly closely studied since the beginning of the eighties, PCVAD is considered a therapeutic entity in its own right by many authors. The clinical picture is one of melancholia in 5 to 25% of cases, and of minor or masked depression (with psychomotor retardation and somatic disorders predominating) in 75 to 95% of cases. Etiopathogenesis varies depending on post-CVA period: during the first few months, the depletion of intra-cerebral neurotransmitters is considered to play a dominant role; subsequently, difficulty in coping with the handicap would appear to be the main factor. The diagnostic scales which may be used are CIM 10 or DSM IV. For quantification, Hamilton's, the MADRS, Zung's or the CESD scales may be used. There is as yet no scale specific to PCVAD. The therapeutic approach still remains empirical, due to the rarity of published studies. Tricyclic antidepressants and inadvisable as first-line treatment due to their anticholinergic effects. Serotoninergic agents are well tolerated, but their efficacy is currently insufficiently documented, despite a recent study. Electroconvulsive therapy (ECT) has been tried, with a certain degree of success, by some authors, but no controlled study is currently available. Personal and familial psychological management would appear necessary but this has not yet been validated. In a preliminary, open-label study in 15 patients presenting with PCVAD, the authors obtained normalization of the MADRS in 10 cases following 6 weeks of treatment with fluoxetine (Prozac). No adverse effects were observed. A multicenter, controlled study is currently ongoing in Bordeaux, France.