Interventions for management of post-stroke depression: A Bayesian network meta-analysis of 23 randomized controlled trials

Linghui Deng, Xuejun Sun, Shi Qiu, Yao Xiong, Yuxiao Li, Lu Wang, Qiang Wei, Deren Wang, Ming Liu, Linghui Deng, Xuejun Sun, Shi Qiu, Yao Xiong, Yuxiao Li, Lu Wang, Qiang Wei, Deren Wang, Ming Liu

Abstract

Post-stroke depression (PSD) is an important complication of stroke, leading to increased disability and mortality. Given that there is no consensus on which treatment is optimal for PSD, we aimed to evaluate the relative efficacies of available pharmacological and non-pharmacological interventions. We conducted a network meta-analysis to incorporate evidence from relevant trials and provide direct and indirect comparisons. We searched PubMed, Cochrane Library Central Register of Controlled Trials, and Embase until November 1, 2016 for randomized controlled trials involving different pharmacological and non-pharmacological PSD treatment interventions. The primary outcome was reduction in the Hamilton depression scale (HAMD) score. This study is registered with PROSPERO (number, CRD42016049049). Of a total of 1,152 studies, 23 randomized trials comprising 1,542 participants were included. Nine PSD treatment interventions were considered. Noradrenaline reuptake inhibitor (NRI) was associated with the highest reduction in the HAMD score, followed by tricyclic antidepressant (TCA), psychotherapy plus antidepressant, and selective serotonin reuptake inhibitor (SSRI). This study indicated that NRIs, SSRIs, and TCAs are associated with a considerable higher HAMD score reduction compared with the control treatment. rTMS is a beneficial therapeutic approach for managing PSD to obtain good response to treatments compared with the control treatment.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Figure 1
Figure 1
PRISMA flow diagram. SSRI = selective serotonin reuptake inhibitor. TCA = tricyclic antidepressant. SNRI = serotonin–norepinephrine reuptake inhibitors. NRI = norepinephrine reuptake inhibitor. TCM = traditional Chinese medicine. rTMS = Repetitive Transcranial Magnetic Stimulation. P + A = psychotherapy plus antidepressants. N + A = nimodipine plus antidepressants. RCT = randomized controlled trial.
Figure 2
Figure 2
Network diagram of eligible comparisons. (A) Network diagram of eligible comparisons for reduction of HAMD score between individual treatment. (B) Network diagram of eligible comparisons for reduction of HAMD score between individual pharmacotherapy. The width of each line is proportional to the number of trials comparing every pair of treatments, and the size of each circle is proportional to the number of randomly allocated participants (sample size). SSRI = selective serotonin reuptake inhibitor. TCA = tricyclic antidepressant. SNRI = serotonin–norepinephrine reuptake inhibitors. NRI = norepinephrine reuptake inhibitor. TCM = traditional Chinese medicine. rTMS = Repetitive Transcranial Magnetic Stimulation. P + A = psychotherapy plus antidepressants. N + A = nimodipine plus antidepressants. FEWP = Free and Easy Wanderer Plus (a kind of Chinese medicine; its original Chinese name is Jia-Wei-Xiao-Yao-San).
Figure 3
Figure 3
Summary results of network meta-analysis. (A) Summary mean difference and credible intervals from network meta-analysis of HAMD score change of individual treatment. Treatments are reported in order of efficacy ranking according to SUCRAs. Comparisons should be read from left to right. The efficacy estimate is located at the intersection of the column-defining treatment and the row-defining treatment. For efficacy (mean overall change in symptoms), an MD below 0 favours the column-defining treatment. To obtain MDs for comparisons in the opposing direction, negative values should be converted into positive values and vice versa. Significant results are in bold and underlined. SSRI = selective serotonin reuptake inhibitor. TCA = tricyclic antidepressant. SNRI = serotonin–norepinephrine reuptake inhibitors. NRI = norepinephrine reuptake inhibitor. TCM = traditional Chinese medicine. rTMS = Repetitive Transcranial Magnetic Stimulation. P + A = psychotherapy plus antidepressants. N + A = nimodipine plus antidepressants. (B) Summary odds ratio and credible intervals from network meta-analysis of response rate and remission rate of individual treatment. Treatments are reported in order of efficacy ranking according to SUCRAs. Comparisons should be read from left to right. The response rate (lower left portion) and remission rate (upper right portion) meta-analytic results are shown for the primary outcome. The response rate and remission rate estimate is located at the intersection of the column-defining treatment and the row-defining treatment. An OR value below 1 favours the column-defining treatment. To obtain ORs for comparisons in the opposing direction, reciprocals should be taken. Significant results are in bold and underlined. SSRI = selective serotonin reuptake inhibitor. TCA = tricyclic antidepressant. TCM = traditional Chinese medicine. rTMS = Repetitive Transcranial Magnetic Stimulation. P + A = psychotherapy plus antidepressants. N + A = nimodipine plus antidepressants. (C) Summary mean difference and credible intervals from network meta-analysis of HAMD score change of individual pharmacotherapy. Drugs are reported in order of efficacy ranking according to SUCRAs. Comparisons should be read from left to right. The efficacy estimate is located at the intersection of the column-defining treatment and the row-defining treatment. For efficacy (mean overall change in symptoms), an MD below 0 favours the column-defining treatment. To obtain MDs for comparisons in the opposing direction, negative values should be converted into positive values and vice versa. Significant results are in bold and underlined. FEWP = Free and Easy Wanderer Plus (a kind of traditional Chinese medicine; its original Chinese name is Jia-Wei-Xiao-Yao-San).

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