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BMJ 2008; 336 doi: (Published 05 June 2008) Cite this as: BMJ 2008;336:1271

Preventing depression after stroke

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More than a third of people who survive stroke develop depression, and these people recover less well and are more likely to die than those without depression. Until now, there have been no effective ways to prevent depression in this vulnerable group, but a double blind, multicentre trial has shown that escilatopram and problem solving therapy can prevent depression after stroke.

The three arm trial randomised 176 people to escilatopram, problem solving therapy, or placebo within three months of stroke. At one year, 11 people taking placebo were diagnosed with major depression and two with minor depression. Of those taking escilatopram, three had major depression and two had minor depression (adjusted hazard ratio 4.5, 95% CI 2.4 to 8.2), and in people receiving problem solving therapy, five were diagnosed with major depression and two with minor depression (2.2, 1.4 to 3.5). The number needed to treat was 7.2 for escilatopram and 9.1 for problem solving therapy. The groups did not differ in terms of adverse events.

The trial did not include people with life threatening comorbid conditions, people with severely impaired verbal comprehension, or those who developed depression early after stroke.

Sequential treatment for Helicobacter pylori is better than triple regimen

Triple regimen—a proton pump inhibitor and clarithromycin, with either amoxicillin or an imidazole—now fails to eradicate Helicobacter pylori in nearly a quarter of people treated for dyspepsia or peptic ulcer in the US. In other parts of the world, failure rates of up to 60% have recently been reported. A systematic review of randomised trials shows that a 10 day sequential treatment regimen—five days of a proton pump inhibitor and one antibiotic (usually amoxicillin), followed by five days of the proton pump inhibitor and two other antibiotics (usually clarithromycin and a 5-nitroimidazole)—is better.

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