Most stroke survivors can safely take two types of common antidepressants

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Most stroke survivors were able to safely take two types of common antidepressants, according to a preliminary study presented at the American Stroke Association’s International Stroke Conference 2024. The meeting will be held in Phoenix, February. 7-9, and is a world premier meeting for researchers and clinicians dedicated to the science of stroke and brain health.

In people with ischemic (clot-caused) stroke, who start taking an antidepressant called an SSRI (selective serotonin reuptake inhibitor) and/or an SNRI (serotonin and norepinephrine reuptake inhibitor) for general post-stroke depression and anxiety, hemorrhagic (bleeds ) was not at risk of stroke or other serious bleeding. This includes those taking anticoagulation medications. However, the risk of hemorrhagic stroke is increased in stroke patients taking two anti-platelet drugs known as dual anti-platelet therapy or DAPT.

Mental health conditions, such as depression and anxiety, are very common but treatable conditions that can develop after a stroke. Our findings should reassure clinicians that for most stroke survivors, it is safe to prescribe SSRI and/or SNRI antidepressants for the treatment of post-stroke depression and anxiety, which may help optimize their patients’ recovery. However, caution is needed when considering the risk-benefit profile of stroke patients receiving dual anti-platelet therapy because we found an increased risk of bleeding in this group.”

Kent P. Simmonds, DO, Ph.D., lead study author, third-year physical medicine and rehabilitation resident, University of Texas Southwestern Medical Center at Dallas

According to the American Heart Association’s Heart Disease and Stroke Statistics 2024 Update, when considered separately from other cardiovascular diseases, stroke ranks fifth among all causes of death behind heart disease, cancer, Covid-19 and unintentional injuries/accidents. About one-third of stroke survivors develop poststroke depression. If left untreated, depression can affect quality of life and reduce the chances of an optimal poststroke recovery such as returning to normal daily activities without assistance.

The most common class of antidepressants are SSRIs or SNRIs, and they are widely used and effective for treating anxiety and depression. However, they may not be prescribed at all or soon enough after stroke, when the risk of depression or anxiety is particularly high, because of concerns that they may increase the risk of hemorrhagic stroke or other serious types of bleeding.

Researchers have looked at the frequency of severe bleeding in hundreds of thousands of stroke survivors taking different types of SSRI and/or SNRI antidepressants (such as sertraline, fluoxetine, citalopram, venlafaxine). Severe bleeding was defined as bleeding in the brain, gastrointestinal tract; and shock, which occurs when bleeding prevents blood from reaching body tissues.

The researchers also investigated severe bleeding in stroke survivors who took antidepressants along with a variety of blood-thinning drugs used to prevent future blood clots. These blood-thinning medications may include either anticoagulant or antiplatelet medications. Anticoagulants are prescribed as single drugs and include drugs such as warfarin, apixaban, and rivaroxaban. In dual antiplatelet therapy, antiplatelet drugs may be used as a single drug (usually aspirin) or two types of antiplatelet drugs. DAPT contains aspirin and another antiplatelet drug called P2Y12 inhibitors (such as clopidogrel, prasugrel or ticagrelor).

The study found:

  • SSRIs and SNRIs were generally safe to start during the critical early stages of recovery because patients taking these drugs were no more likely to have severe bleeding than stroke survivors who did not take antidepressants. This includes ischemic stroke patients who are also receiving anti-coagulation therapy.
  • The risk of serious bleeding is increased when SSRIs or SNRIs are taken in combination with DAPT treatment (aspirin and blood thinners). However, the overall risk was low because severe bleeding events were rare.
  • In ischemic stroke patients taking antidepressant medications, there was a 15% increased risk of major bleeding when taking medications from classes such as mirtazapine, bupropion, and tricyclics compared with SSRIs/SNRIs.

“Maximizing early rehabilitation after stroke is essential because recovery is somewhat time-dependent, and most functional gains occur in the first few months after stroke,” Simmonds said. “Fortunately, dual antiplatelet therapy is often administered for 14, 30, or 90 days, so, when indicated, physicians may not need to discontinue antidepressant medications for long periods of time. Future studies should investigate the risk of bleeding associated with the use of antiplatelet agents. -Medication for depression and anxiety in patients with hemorrhagic or hemorrhagic stroke.”

According to a 2022 American Heart Association Scientific Statement, social isolation and loneliness are associated with a nearly 30% increased risk of death from heart attack or stroke or both. “Depression can lead to social isolation, and social isolation can increase the likelihood of experiencing depression. The current study helps answer safety concerns about the use of antidepressants to treat mental health problems that can develop after stroke,” said Crystal Wiley Sen, MD, MPH, FAHA, Chair of the Association’s Writing Group for Scientific Statements and a Professor of Clinical Medicine and Chief Administrative Officer for Health Equity, Diversity and Inclusion at University of California San Diego Health. Dr. CenĂ© was not involved in this study.

Study description and design:

  • The previous study included electronic medical record data on 666,150 ischemic stroke patients from more than 70 major US health care centers: 35,631 were taking SSRI/SNRI antidepressant medications and 23,241 were taking other antidepressants; However, the majority (607,278) were not taking any antidepressants.
  • Patients were treated at 70 healthcare centers over 20 years.
  • Patients were identified from electronic medical records from 2003 to 2023.

The study had some limitations. The researchers used statistical methods to adjust for differences between groups that may not account for all important differences between groups. The study also did not account for the dose, duration or number of antidepressants taken by the participants, which could have affected the results.

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