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Clinical Atlas Prestige · Evidence-first

Psych VivasConsultation-liaison psychiatry

Psych Vivas · Consultation-liaison psychiatry

Stroke and post-stroke psychiatry — structured clinical viva

Fellowship viva covering PSD epidemiology, Carson location myth, Robinson prevention, FLAME vs FOCUS/AFFINITY/EFFECTS, SSRI monitoring, and capacity.

clinical
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the CL psychiatry registrar. The stroke rehab team refers a 71-year-old man 5 weeks after ischaemic stroke (left MCA, residual aphasia and hemiparesis). Issues: suspected post-stroke depression with passive suicidal ideation; staff citing 'left frontal so he must be depressed'; request for fluoxetine to improve motor recovery; family asking whether he can consent to moving into residential care next week; intermittent crying spells that may be emotionalism. Discuss epidemiology, mechanisms/location myth, assessment with aphasia, treatment and trial evidence, capacity, and prognosis.

Interpretation

Reveal interpretation

Classic CL stroke psychiatry package: possible PSD with suicide risk, aphasia-limited assessment, location myth, inappropriate fluoxetine-for-motor request, emotionalism differential, and residential-care capacity. Lead with syndrome clarity and evidence, not dogma.[1][3][5]

Epidemiology and framing

Reveal model points

State PSD is common — about one-third of survivors experience depression at some time (Hackett Part I order of magnitude).[2] Frame as depressive disorder due to another medical condition when causal link is clinical; cite AHA/ASA Towfighi statement as major English-language scientific statement.[1][9]

Location myth and mechanisms

Reveal model points

Multifactorial biology plus psychosocial disability (Robinson & Jorge; mechanisms literature).[9] Historical left-frontal association is not a reliable sole rule — Carson systematic review is the myth-buster examiners want named.[3]

Assessment

Reveal model points

Aphasia-aware MSE, collateral, therapy engagement, suicide risk, medical drivers, distinguish emotionalism vs depressive syndrome, decision-specific capacity for residential care with supported communication.[1][9]

Treatment and trials

Reveal model points

Multimodal care; SSRI example escitalopram 5–10 mg or sertraline 25–50 mg oral daily start with Na+/bleed/QTc monitoring; psychological therapies; Cochrane treatment synthesis.[8][9] Prevention pearl: Robinson JAMA 2008 escitalopram or PST.[4] Motor recovery: FLAME positive signal but FOCUS/AFFINITY/EFFECTS do not support routine fluoxetine for function — treat depression, not 'the arm' alone.[5][6][7]

Prognosis and close

Reveal model points

PSD affects rehab outcome; plan follow-up, safety netting, shared care; reassess capacity after treatment of depression.[1][2]

References

  1. [1]Towfighi A, Ovbiagele B, El Husseini N, Hackett ML, et al. Poststroke Depression: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Stroke, 2017.PMID 27932603
  2. [2]Hackett ML, Pickles K Part I: frequency of depression after stroke: an updated systematic review and meta-analysis of observational studies Int J Stroke, 2014.PMID 25117911
  3. [3]Carson AJ, MacHale S, Allen K, Lawrie SM, et al. Depression after stroke and lesion location: a systematic review Lancet, 2000.PMID 10963248
  4. [4]Robinson RG, Jorge RE, Moser DJ, Acion L, et al. Escitalopram and problem-solving therapy for prevention of poststroke depression: a randomized controlled trial JAMA, 2008.PMID 18505948
  5. [5]FOCUS Trial Collaboration Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial Lancet, 2019.PMID 30528472
  6. [6]AFFINITY Trial Collaboration Safety and efficacy of fluoxetine on functional outcome after acute stroke (AFFINITY): a randomised, double-blind, placebo-controlled trial Lancet Neurol, 2020.PMID 32702334
  7. [7]EFFECTS Trial Collaboration Safety and efficacy of fluoxetine on functional recovery after acute stroke (EFFECTS): a randomised, double-blind, placebo-controlled trial Lancet Neurol, 2020.PMID 32702335
  8. [8]Allida SM, Hsieh CF, Cox KL, Patel K, et al. Pharmacological, non-invasive brain stimulation and psychological interventions, and their combination, for treating depression after stroke Cochrane Database Syst Rev, 2023.PMID 37417452
  9. [9]Robinson RG, Jorge RE Post-Stroke Depression: A Review Am J Psychiatry, 2016.PMID 26684921