Download PDF
Fortschr Neurol Psychiatr 2001; 69(12): 581-591
DOI: 10.1055/s-2001-19183
Originalarbeit
Georg Thieme Verlag Stuttgart · New York

Diagnostik und Therapie der Depression nach Schlaganfall

Post-Stroke Depression: Diagnosis and TherapyW.  Huff1 , S.  Ruhrmann1 , M.  Sitzer2
  • 1Klinik und Poliklinik für Psychiatrie und Psychotherapie, (Direktor: Univ.-Prof. Dr. med. J. Klosterkötter), Klinikum der Universität zu Köln
  • 2Zentrum für Neurologie und Neurochirurgie, Klinik für Neurologie (Direktor: Univ.-Prof. Dr. med. H. Steinmetz), Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main
Further Information

Publication History

Publication Date:
19 December 2001 (online)

Also available at
    Permissions and Reprints

Zusammenfassung

Eine Depression tritt nach Schlaganfall häufig, bei 30 - 40 % der Patienten zumindest vorübergehend auf. In der Literatur hat sich bereits der Begriff einer „Poststroke Depression” (PSD) etabliert. Zur Diagnosestellung bestehen keine einheitliche Kriterien, zumeist erfolgt eine Anlehnung an die Klassifikationsschlüssel des DSM beziehungsweise der ICD. In anderen Fällen wird die Diagnose nur anhand von Depressionsskalen gestellt. Obwohl bekanntermaßen hohe Prävalenzraten bestehen, wird die Depression in der Schlaganfallbehandlung in den meisten Fällen nicht diagnostiziert und verbleibt auch nach Feststellung zumeist unbehandelt. Dabei kann es nach den bisherigen Untersuchungen als gesichert gelten, dass Schlaganfallpatienten, die depressive Symptome entwickeln, einen schlechteren Verlauf, besonders ein schlechteres funktionelles Behandlungsergebnis (motorische Fähigkeiten, selbständige Teilnahmen an den Aktivitäten des täglichen Lebens) zeigen. Dieser Unterschied in der Beeinträchtigung zu einem vergleichbaren nicht-depressiven Schlaganfallpatienten lässt sich auch nach mehreren Jahren noch nachweisen. Für eine sich daraus ergebende Behandlungsnotwendigkeit ist nach dem aktuellen Stand der Literatur sowohl der günstigste Zeitpunkt einer therapeutischen Intervention sowie deren Art und Umfang jedoch noch unklar. Einzelnen Untersuchungen zufolge, die selten unter den Bedingungen einer randomisierten kontrollierten Studie erfolgten, zeigen sich positive Effekte einer frühzeitigen medikamentösen Behandlung. Hier können neben den Psychostimulanzien, die vorwiegend im US-amerikanischen Raum eingesetzt werden, und den konventionellen trizyklischen Antidepressiva besonders die Gruppe der „ Selektiven Serotonin-Wiederaufnahmehemmer” (Selective Serotonin Reuptake Inhibitor, SSRI) mit einem breiten Einsatzspektrum bei älteren Patienten gute klinische Erfolge vorweisen.

Abstract

Depression occurs at least temporarily in up to 30 - 40 % of all patients that have experienced a stroke. In the literature the term of a “Poststroke Depression” (PSD) has already been established. However standardised criteria for this diagnoses do not exist to this day. In most cases the DSM or ICD classification system is applied. Other investigators used various psychiatric rating scales. Even though it is generally acknowledged that there is a high prevalence, the occurrence of depression in combination with a stroke fails in most cases to be diagnosed or is left untreated. The need for treatment is even more pronounced by studies showing that a combination of stroke and depression will result in a less favourable outcome, particularly pertaining to that of functional treatment (motor skills, independent participation in activities of daily life). This difference in impairment between a depressed stroke patient and a not depressed stroke patient could be proven in studies that have been conducted over years. Despite the necessity of treatment that can be concluded from such a finding, the recent literature does not offer consistent information as to the ideal point of time for intervention nor the kind and intensity necessitated. According to singular studies, that have rarely been conducted under controlled conditions, there have been positive outcomes after early treatment. Along with psychostimulants that were most predominantly applied in the USA, as well as conventional tricyclic antidepressants, the group of the “Selective Serotonin Reuptake Inhibitors, SSRIs” have resulted in particularly favourable clinical outcomes.

Literatur

  • 1 Morris P L, Robinson R G, Samuels J. Depression, introversion and mortality following stroke.  Aust N Z J Psychiatry. 1993;  27 443-449
    PubMedGoogle Scholar
  • 2 Kraepelin E. Psychiatrie. Ein Lehrbuch für Studierende und Ärzte II und III. Leipzig 1910
    Google Scholar
  • 3 Bleuler E P. Textbook of psychiatry. New York: Macmillan 1951
    Google Scholar
  • 4 Post F. The significance of affective symptoms in old age. London: Oxford University Press 1962
    Google Scholar
  • 5 Robinson R G. The clinical neuropsychiatry of stroke. New York: Cambridge University Press 1998
    Google Scholar
  • 6 Hosking S G, Marsh N V, Friedman P J. Poststroke depression: Prevalence, course and associated factors.  Neuropsychol Rev. 1996;  6 107-133
    CrossrefPubMedGoogle Scholar
  • 7 Gordon W A, Hibbard M R. Poststroke depression: an examination of the literature.  Arch Phys Med Rehabil. 1997;  78 658-663
    CrossrefPubMedGoogle Scholar
  • 8 Starkstein S E, Robinson R G. Affective disorders and cerebral vascular disease.  Brit J Psychiatry. 1989;  154 170-182
    PubMedGoogle Scholar
  • 9 Bryer J P, Starkstein S E, Votypka V, Parikh R M, Price T R, Robinson R G. Reduction of CSF monoamine metabolites in poststroke depression: a preliminary report.  J Neuropsychiatry Clin Neurosci. 1992;  4 440-442
    CrossrefPubMedGoogle Scholar
  • 10 Herrmann M, Wallesch C W. Depressive changes in stroke patients.  Disabil Rehabil. 1993;  15 55-66
    CrossrefPubMedGoogle Scholar
  • 11 Gainotti G, Azzoni A, Razzano C, Lanzilotta M, Marra C, Gasparini F. The Post-Stroke Depression Rating Scale: a test specifically devised to investigate affective orders of stroke patients.  J Clin Exp Neuropsychol. 1997;  19 340-356
    PubMedGoogle Scholar
  • 12 Hüwel J, Weisner B, Kemmer H, Heyder J. Depressive Verstimmung im Akutstadium nach erstmaligem ischämischen Hirninfarkt.  Nervenarzt. 1998;  69 330-334
    CrossrefPubMedGoogle Scholar
  • 13 Ramasubbu R. Relationship between depression and cerebrovascular disease: conceptual issues.  J Aff Dis. 2000;  57 1-11
    PubMedGoogle Scholar
  • 14 Finkelstein S P, Weintraub R J, Karmouz N, Davar G, Baldessarini R J. Antidepressants drug treatment for post-stroke depression: retrospective study.  Arch Phys Med Rehabil. 1987;  68 276-278
    PubMedGoogle Scholar
  • 15 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.  Arch Neurol. 1990;  47 785-789
    CrossrefPubMedGoogle Scholar
  • 16 Price T R. Affective disorders after stroke.  Stroke. 1990;  21 12-13
    PubMedGoogle Scholar
  • 17 Astrom M, Adolfsson R, Asplund K. Major depression in stroke patients: a 3-year longitudinal study.  Stroke. 1993;  24 976-982
    PubMedGoogle Scholar
  • 18 Sharpe M, Hawton K, Seagroatt V, Bamford J, House A, Molyneux A, Sandercock P, Warlow C. Depressive disorders in long-term survivors of stroke: Associations with demographic and social factors, functional status, and brain lesion volume.  Brit J Psychiatry. 1994;  164 380-386
    PubMedGoogle Scholar
  • 19 Kelly-Hayes M, Paige C. Assessment and psychologic factors in stroke rehabilitation.  Neurology. 1995;  45 (suppl 1) S29-S32
    PubMedGoogle Scholar
  • 20 Polnitzky-Meißner P, Helbig P, Krause M, Ackl N, Ringleb P, Obhof W, Reichert K, Hacke W. Rehabilitation nach Schlaganfall - Kognitive Defizite, Depressivität und Lebenszufriedenheit nach Schlaganfall.  Neurol Rehabil. 1997;  3 223-227
    PubMedGoogle Scholar
  • 21 Shimoda K, Robinson R G. The relationship between social impairment and recovery from stroke.  Psychiatry. 1998;  61 101-111
    PubMedGoogle Scholar
  • 22 Chemerinski E, Robinson R G, Kosier T J. Improved recovery in activities of daily living associated with remission of poststroke depression.  Stroke. 2001;  32 113-117
    CrossrefPubMedGoogle Scholar
  • 23 Eastwood M R, Rifat S L, Nobbs H, Ruderman J. Mood disorder following CVA.  Br J Psychiatry. 1989;  154 195-200
    PubMedGoogle Scholar
  • 24 Schubert D SP, Burns R, Paras W, Sioson E. Increase of medical hospital length of stay by depression in stroke and amputation patients: a pilot study.  Psychother Psychosom. 1992;  57 61-66
    PubMedGoogle Scholar
  • 25 Jonkman E J, de Weerd A W, Vrijens N L. Quality of life after a first ischemic stroke. Long term developments and correlations with changes in neurological deficit, mood and cognitive impairment.  Acta Neurol Scand. 1998;  98 169-175
    PubMedGoogle Scholar
  • 26 Bosworth H B, Horner R D, Edwards L J, Matchar D B. Depression and other determinants of values placed on current health state by stroke patients.  Stroke. 2000;  31 2603-2609
    PubMedGoogle Scholar
  • 27 Morris P L, Robinson R G, Andrezejewski P, Samuels J, Price T R. Association of depression with 10-year post-stroke-mortality.  Am J Psychiatry. 1993 (a);  150 124-129
    PubMedGoogle Scholar
  • 28 Burvill P W, Johnson G A, Jamrozik K D, Anderson C S, Stewart-Wynne E G, Chakera T MH. Prevalence of depression after stroke: the Perth Community Stroke Study.  Br J Psychiatry. 1995;  166 320-327
    PubMedGoogle Scholar
  • 29 Feibel J H, Berk S, Joynt R J. The unmet needs of stroke survivors (abstract).  Neurology. 1979;  29 592
    PubMedGoogle Scholar
  • 30 Labi M LC, Phillips T F, Gresham G E. Psychosozial disability in physically restored long-term stroke survivors.  Arch Phys Med Rehabil. 1980;  61 561-565
    PubMedGoogle Scholar
  • 31 Andersen G. Post-stroke depression and pathological crying: clinical aspects and new pharmacological approaches.  Aphasiology. 1997;  11 651-664
    PubMedGoogle Scholar
  • 32 Ramasubbu R, Robinson R G, Flint A J, Kosier T, Price T R. Functional impairment associated with acute poststroke depression: The stroke data bank study.  J Neuropsychiatry Clin Neurosci. 1998;  10 26-33
    PubMedGoogle Scholar
  • 33 World Health Organization .Tenth Revision of the International Classification of Disease, Chapter V (F): Mental and Behavioural Disorders. Geneva: WHO 1992
    Google Scholar
  • 34 American Psychiatric Association .Diagnostical and Statistical Manual of Mental Disorders, Fourth Edition. Washington D.C.: American Psychiatric Association 1994
    Google Scholar
  • 35 Feighner J P, Robins E, Guze S B, Woodruff R A, Winokur G, Munoz R. Diagnostic criteria for use in psychiatric research.  Arch Gen Psychiatry. 1972;  26 57-63
    CrossrefPubMedGoogle Scholar
  • 36 Kishi J, Robinson R G, Kosier T J. The validity of observed depression as a criteria for mood disorders in patients with acute stroke.  J Affect Disord. 1996;  40 53-60
    CrossrefPubMedGoogle Scholar
  • 37 Harrington C, Salloway S. The diagnosis and treatment of post-stroke depression.  Med Health. 1997;  80 181-187
    PubMedGoogle Scholar
  • 38 Radloff L S. The CES-D Scale: a self report depression scale for research in the general population.  App Psychol Mesas. 1977;  1 385-401
    CrossrefPubMedGoogle Scholar
  • 39 Zung W WK. A self-rating depression scale.  Arch Gen Psychiatry. 1965;  12 63-70
    PubMedGoogle Scholar
  • 40 Brink T L, Yesavage J A, Lum O, Heersema P H, Adey M, Rose T L. Screening tests for geriatric depression.  Clin Gerontol. 1982;  1 37-43
    CrossrefPubMedGoogle Scholar
  • 41 Hamilton M A. A rating scale for depression.  J Neurol Neurosurg Psychiatry. 1960;  23 56-62
    CrossrefPubMedGoogle Scholar
  • 42 Alexopoulos G S, Abrams R C, Young R C, Shamoian C A. Use of the Cornell Scale in nondemented patients.  J Am Ger Soc. 1988;  36 230-236
    PubMedGoogle Scholar
  • 43 Asberg M, Montgomery S A, Perris C, Schalling D, Sedvall G. A comprehensive psychopathological rating scale.  Acta Psychiatr Scand. 1978;  271 (Suppl) 5-27
    PubMedGoogle Scholar
  • 44 Montgomery S A, Asberg M. A new depression scale designed to be sensitive to change.  Br J Psychiatry. 1979;  134 382-389
    CrossrefPubMedGoogle Scholar
  • 45 Robinson R G, Szetala B. Mood change following left hemispheric brain injury.  Ann Neurol. 1981;  9 447-453
    CrossrefPubMedGoogle Scholar
  • 46 Shinar D, Gross C R, Price T R, Banko M, Bolduc P L, Robinson R G. Screening for depression in stroke patients: the reliability and validity of the Center for Epidemiologic Studies Depression Scale.  Stroke. 1986;  17 241-245
    PubMedGoogle Scholar
  • 47 Parikh R M, Eden D T, Price T R, Robinson R G. The sensitivity and specifity of the Center for Epidemiologic Studies in Depression Scale for post-stroke depression.  Int J Psych Med. 1988;  182 169-181
    PubMedGoogle Scholar
  • 48 Agrell B, Dehlin O. Comparison of six depression rating scales in geriatric stroke patients.  Stroke. 1989;  20 1190-1194
    PubMedGoogle Scholar
  • 49 Hermann C, Buss U, Snaith R P. HADS-D Hospital anxiety and depression scale - Deutsche Version. Bern: Huber Verlag 1995
    Google Scholar
  • 50 Herrmann M. Emotional-affektive Veränderungen nach cerebrovaskulären Insulten mit Aphasie. Freiburg: Dissertation 1991
    Google Scholar
  • 51 Robinson R G, Benson F D. Depression in aphasic Patients: frequency, severity and clinical-pathological correlations.  Brain and Language. 1981;  14 282-291
    CrossrefPubMedGoogle Scholar
  • 52 Damecour C, Caplan D. The relationship of depression to symtomatology and lesion site in aphasic patients.  Cortex. 1991;  27 385-401
    PubMedGoogle Scholar
  • 53 Herrmann M, Bartels C, Wallesch C W. Depression in acute and chronic aphasia: symptoms, pathoanatomical-clinical correlations and functional implications.  J Neurol Neurosurg Psychiatry. 1993;  56 672-678
    CrossrefPubMedGoogle Scholar
  • 54 Sutcliffe L M, Lincoln N B. The assessment of depression in aphasic stroke patients: the development of the Stroke Aphasic Depression Questionnaire.  Clin Rehabil. 1998;  12 506-513
    CrossrefPubMedGoogle Scholar
  • 55 Finklestein S P, Weintraub R J, Karmouz N, Askinazi C, Davar G, Baldessarini R J. Antidepressant drug treatment for poststroke depression: retrospective study.  Arch Phys Med Rehabil. 1987;  68 772-776
    PubMedGoogle Scholar
  • 56 Lipsey J R, Robinson R G, Pearlson G D, Rao K, Price T R. Nortriptyline treatment of poststroke depression: a double-blind treatment trial.  Lancet. 1984;  1 297-300
    PubMedGoogle Scholar
  • 57 Kimura M, Robinson R G, Kosier J T. Treatment of cognitive impairment after Poststroke depression.  Stroke. 2000;  31 1482-1486
    PubMedGoogle Scholar
  • 58 Lauritzen L, Bendsen B B, Vilmar T, Bendsen E B, Lunde M, Bech P. Post-stroke depression: combined treatment with imipramine or desipramine and mianserin: a controlled study.  Psychopharmacology. 1994;  114 119-122
    PubMedGoogle Scholar
  • 59 Andersen G, Vestergaard K, Lauritzen L. Effective treament of poststroke depression with the selective serotonin reuptake inhibitor citalopram.  Stroke. 1994;  25 1099-1104
    PubMedGoogle Scholar
  • 60 Mok C K, Mak S K, Leung K S, Au S Y. Use of sertraline (an SSRI) in Chinese elderly stroke patients with depression.  Acta Pharmacologica Sinica. 1998;  19 (Suppl.) 47
    PubMedGoogle Scholar
  • 61 Dahmen N, Marx J, Hopf H C, Röder R, Tettenborn B. Behandlung der frühen Post-Stroke-Depression mit Venlafaxin: Sicherheit, Verträglichkeit und Wirksamkeit in einer offenen klinischen Studie.  Neurol Rehabil. 1999;  5 84-88
    PubMedGoogle Scholar
  • 62 Stahl S M. Essential Pharmacology. New York: Cambridge University Press 2nd ed 2000
    Google Scholar
  • 63 Stamenkovic M, Schindler S, Kasper S. Poststroke depression and fluoxetine (letters to the editor).  Am J Psychiatry. 1996;  153 446-447
    PubMedGoogle Scholar
  • 64 Weinman E, Ruskin P E. Anger attacks in Poststroke depression: response to fluoxetine.  Am J Psychiatry. 1994;  151 1839
    PubMedGoogle Scholar
  • 65 Wiart L, Petit H, Joseph P A, Mazaux J M, Barat M. Fluoxetine in early poststroke depression.  Stroke. 2000;  31 1829-1832
    PubMedGoogle Scholar
  • 66 Erfurth A, Loew M, Wendler G, Floreanu A. Depressive Störungen in der neurologischen Rehabilitation: Therapie mit Paroxetin.  Psychiat Prax. 2001;  28 43-44
    PubMedGoogle Scholar
  • 67 De Leon O A, Furmaga K M, Kaltsounis J. Mirtazepine-induced mania in a case of poststroke depression.  J Neuropsychiatry Clin Neurosci. 1999;  11 115-116
    CrossrefPubMedGoogle Scholar
  • 68 Masand P, Murray G B, Pickett P. Psychostimulants in post-stroke depression.  J Neuropsychiatry. 1991;  3 23-27
    PubMedGoogle Scholar
  • 69 Johnson M L, Roberts M D, Ross A R, Witten C M. Methylphenidate in stroke patients with depression.  Am J Phys Med Rehabil. 1992;  71 239-241
    PubMedGoogle Scholar
  • 70 Lingam V R, Lazarus L W, Groves L, Oh S H. Methylphenidate in treating poststroke depression.  J Clin Psychiatry. 1988;  49 151-153
    PubMedGoogle Scholar
  • 71 Lazarus L W, Winemiller D R, Lingam V R, Neyman I, Hartman C, Abassian M, Kartan U, Groves L, Fawcett J. Efficacy and side effects of methylphenidate for post-stroke depression.  J Clin Psychiatry. 1992;  53 447-449
    PubMedGoogle Scholar
  • 72 Grade C, Redford B, Chrostowski J, Toussaint L, Blackwell B. Methylphenidate in early poststroke recovery: a double-blind, placebo-controlled study.  Arch Phys Med Rehabil. 1998;  79 1047-1050
    CrossrefPubMedGoogle Scholar
  • 73 Masand P, Chaudhary P. Methylphenidate treatment of Poststroke depression in a patient with global aphasia.  Ann Clin Psychiatry. 1994;  6 271-274
    PubMedGoogle Scholar
  • 74 Martensson B, Murray V, von Arbin M, Asberg M, Bartfai A, Malm K. Alternative treatment for poststroke depression (letters to the editor).  Am J Psychiatry. 1997;  154 583-584
    PubMedGoogle Scholar
  • 75 Gonzales-Torrecillas J L, Hildebrand J, Mendlewicz J, Lobo A. Effects of early treatment of post-stroke depression on neuropsychological rehabilitation.  Int Psychogeriatr. 1995;  78 547-560
    PubMedGoogle Scholar
  • 76 Lazarus L W, Moberg P J, Langsley P R, Lingam V R. Methylphenidate and nortriptyline in the treatment of poststroke depression: A retrospective comparison.  Arch Phys Med Rehabil. 1994;  75 403-406
    CrossrefPubMedGoogle Scholar
  • 77 Balunov O A, Sadov O G, Alemasov A Y. Therapy of depression in post-stroke patients.  Alaska Med. 1990;  32 20-29
    PubMedGoogle Scholar
  • 78 Miyai I, Reding M J. Effects of antidepressants on functional recovery following stroke: a double-blind study.  J Neuro Rehab. 1998;  12 5-13
    PubMedGoogle Scholar
  • 79 Grober S E, Hibbard M R, Gordon W A, Stein P N, Freeman A. The psychotherapeutic treatment of post-stroke depression with cognitive behavioral therapy.. In: Gordon WA (ed.). Advances in stroke rehabilitation. Andover: Andover Medical Publishers 1993: 217-241
    Google Scholar
  • 80 Kneebone II . Psychological management of post-stroke depression.  Br J Clin Psychol. 2000;  39 53-65
    CrossrefPubMedGoogle Scholar
  • 81 Lincoln N B, Flannaghan T, Sutcliffe L, Rother L. Evaluation of cognitive behavioural treatment for depression after stroke: a pilot study.  Clin Rehabil. 1977;  11 114-122
    PubMedGoogle Scholar
  • 82 Hibbard M R, Grober S E, Gordon W A, Aletta E G. Modification of cognitive psychotherapy for the treatment of post-stroke depression.  Behav Ther. 1990 (a);  13 15-17
    PubMedGoogle Scholar
  • 83 Hibbard M R, Grober S E, Gordon W A, Aletta E G, Freeman A. Cognitive therapy and the treatment of poststroke depression.  Top Geriatr Rehabil. 1990 (b);  5 43-55
    PubMedGoogle Scholar
  • 84 Watzlawick P, Coyne J C. Depression following stroke: brief, problem-focused family treatment.  Fam Process. 1980;  19 13-18
    CrossrefPubMedGoogle Scholar
  • 85 Hager K, Ziegler K. Stages in coping after stroke.  Z Gerontol Geriatr. 1998;  31 9-15
    CrossrefPubMedGoogle Scholar
  • 86 Murray G B, Shea V, Conn D K. Electroconvulsive therapy for poststroke depression.  J Clin Psychiatry. 1986;  47 258-260
    PubMedGoogle Scholar
  • 87 Currier M B, Murray G B, Welch C C. Electroconvulsive therapy for post-stroke depressed. 
    Google Scholar
  • 88 Martin M, Figiel G, Mattingly G, Zorumski C F, Jarvis M R. ECT-Induced interictal delirium in patients with a history of a CVA.  J Geriatr Psychiatry Neurol. 1992;  5 149-155
    PubMedGoogle Scholar
  • 89 Palomäki H, Kaste M, Berg A, Lönnqvist R, Lönnqvist J, Lehtihalmes M, Hares J. Prevention of poststroke depression: 1 year randomised placebo controlled double blind trial of mianserin with 6 month follow up after therapy.  J Neurol Neurosurg Psychiatry. 1999;  66 490-494
    PubMedGoogle Scholar
  • 90 Rasmussen A, Hindberg I, Mellerup E. Does Sertraline induced platelet dysfunction protect stroke patients against cardiovaskular comorbidity.  Int J Neuropsychopharmacol. 2000;  3 (Suppl 1) 372
    PubMedGoogle Scholar
  • 91 Reding J J, Orto L A, Winter S W, Fortuna I M, DiPonte P, McDowell F H. Antidepressant therapy after stroke: a double-blind trial.  Arch Neurol. 1986;  43 763-765
    PubMedGoogle Scholar
  • 92 Dam M, Tonin P, DeBoni A, Pizzolato G, Casson S, Ermani M, Freo U, Piron L, Battistin L. Effects of fluoxetin and maprotilin on functional recovery in poststroke hemiplegic patients undergoing rehabilitation therapy.  Stroke. 1996;  27 1211-1214
    PubMedGoogle Scholar
  • 93 Robinson R G, Schultz S K, Castillo C, Kopel T, Kosier J T, Newman R M, Curdue K, Petracca G, Stakstein S E. Nortriptyline versus Fluoxetine in the treatment of depression and in short-term recovery after stroke: a placebo-controlled, double blind study.  Am J Psychiatry. 2000;  157 351-359
    CrossrefPubMedGoogle Scholar

Dr. med. W. Huff,MPH 

Klinik und Poliklinik für Psychiatrie und Psychotherapie
Klinikum der Universität zu Köln

Joseph-Stelzmann-Str. 9

50924 Köln

Email: Wolfgang.Huff@t-online.de