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Boon or bane? Using antidepressants after stroke

      Depression affects 1 in every 3 adults within the first six months after a stroke [
      • Hackett M.L.
      • Pickles K.
      Part I: frequency of depression after stroke: an updated systematic review and meta-analysis of observational studies.
      ]. In addition to being common, it increases the burden of illness and hinders recovery from stroke [
      • Parikh R.M.
      • Robinson R.G.
      • Lipsey J.R.
      • Starkstein S.E.
      • Fedoroff J.P.
      • Price T.R.
      The impact of poststroke depression on recovery in activities of daily living over a 2-year follow-up.
      ], so that adequate measures to treat and prevent depression in this population are needed. The results of the fluoxetine in motor recovery of patients with acute ischaemic stroke (FLAME) trial (n = 118) showed that stroke survivors treated with fluoxetine had better motor function than their counterparts treated with placebo for 3 months [
      • Chollet F.
      • Tardy J.
      • Albucher J.F.
      • Thalamas C.
      • Berard E.
      • Lamy C.
      • et al.
      Fluoxetine for motor recovery after acute ischaemic stroke (FLAME): a randomised placebo-controlled trial.
      ]. Three large randomised placebo-controlled trials were subsequently designed to confirm these preliminary findings: the fluoxetine or control under supervision (FOCUS) trial (n = 3127), the assessment of fluoxetine in stroke recovery (AFFINITY) trial (n = 1280), and the efficacy of fluoxetine randomised controlled trial in stroke (EFFECTS) (n = 1500) [
      • AFFINITY Trial Collaboration
      Safety and efficacy of fluoxetine on functional outcome after acute stroke (AFFINITY): a randomised, double-blind, placebo-controlled trial.
      ,
      • EFFECTS Trial Collaboration
      Safety and efficacy of fluoxetine on functional recovery after acute stroke (EFFECTS): a randomised, double-blind, placebo-controlled trial.
      ,
      • FOCUS Trial Collaboration
      Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial.
      ]. The three trials found that daily treatment with 20 mg of fluoxetine for 6 months after acute stroke does not improve functional outcomes, but increases the risk of bone fractures [
      • AFFINITY Trial Collaboration
      Safety and efficacy of fluoxetine on functional outcome after acute stroke (AFFINITY): a randomised, double-blind, placebo-controlled trial.
      ,
      • EFFECTS Trial Collaboration
      Safety and efficacy of fluoxetine on functional recovery after acute stroke (EFFECTS): a randomised, double-blind, placebo-controlled trial.
      ,
      • FOCUS Trial Collaboration
      Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial.
      ]. These findings raised significant concerns regarding the safe use of fluoxetine in this population, but need to be balanced against potential benefits, such as the prevention of depression.

      Keywords

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