A Cochrane review included 52 studies with a total of 4059 stroke patients. The mean age of patients ranged from 55 to 77 years. The mean time since stroke was from 0 to 3 months for 31 trials, the time was not reported for 10 trials but no trials recruited patients from 9 to 12 months after stroke. In 16 trials a diagnosis of depression was not one of the inclusion criteria. The duration of treatment, any SSRI, varied from weeks to months. There were significant benefits of SSRI on both of the primary outcomes: for reducing dependency at the end of treatment, RR was 0.81 (95% CI 0.68 to 0.97) based on one trial (n=223), and for disability score, the SMD was 0.91 (95% CI 0.60 to 1.22; 22 trials, n= 1343). For neurological deficit, depression and anxiety, there were also significant benefits of SSRIs. For neurological deficit score, the SMD was -1.00 (95% CI -1.26 to -0.75; 29 trials, n= 2011). For dichotomous depression scores, the RR was 0.43 (95% CI 0.24 to 0.77; 8 trials, n= 771). For continuous depression scores, the SMD was -1.91 (95% CI -2.34 to -1.48; 39 trials, n= 2728). For anxiety, the SMD was -0.77 (95% CI -1.52 to -0.02; 8 trials, n= 413). There was no statistically significant benefit of SSRI on cognition, death, motor deficits and leaving the trial early. For cognition, the SMD was 0.32 (95% CI -0.23 to 0.86; 7 trials, n= 425). The RR for death was 0.76 (95% CI 0.34 to 1.70; 46 trials, n= 3344). For motor deficits, the SMD was -0.33 (95% CI -1.22 to 0.56; 2 trials, n= 145). The RR for leaving the trial early was 1.02 (95% CI 0.86 to 1.21) in favour of control. There was a non-significant excess of seizures (RR 2.67; 95% CI 0.61 to 11.63; 7 trials, n= 444), a non-significant excess of gastrointestinal side effects (RR 1.90; 95% CI 0.94 to 3.85; 14 trials, n= 902) and a non-significant excess of bleeding (RR 1.63; 95% CI 0.20 to 13.05; 2 trials, n= 249) in those allocated SSRIs. There was no clear evidence from subgroup analyses that one SSRI was consistently superior to another, or that time since stroke or depression at baseline had a major influence on effect sizes. Only 8 trials provided data on outcomes after treatment had been completed; the effect sizes were generally in favour of SSRIs but CIs were wide.
Comment: The quality of the evidence is downgraded by study quality (unclear allocation concealment) and inconsistency (heterogeneity in patients and interventions).
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