Two common Antidepressants found safe for most stroke survivors.

Most stroke survivors could safely take two common antidepressants, according to a preliminary study to be presented at the American Stroke Association’s International Stroke Conference 2024. The conference will be held February 7-9 in Phoenix.

Among ischemic (blood clot-causing) stroke patients who were started on antidepressants known as SSRIs (selective serotonin reuptake inhibitors) and/or SNRIs (serotonin norepinephrine reuptake inhibitors) for the common post-stroke symptoms of depression and anxiety, hemorrhagic (hemorrhagic) strokes and other serious bleeding did not increase risk. This included those taking anticoagulants. However, stroke patients taking two antiplatelet drugs (also called dual anti-platelet therapy or DAPT) had an increased risk of hemorrhagic stroke.

Psychiatric disorders such as depression and anxiety are very common but treatable conditions that can develop after stroke. Our results reassure clinicians that for most stroke survivors, prescribing SSRI and/or SNRI antidepressants early after stroke to treat post-stroke depression and anxiety is safe and may help optimize patient recovery,” said Dr. David J. H. Harris, M.D., Ph.D., director of the Dallas Kent P. Simmonds, D.O., Ph.D., a third-year resident in physical medicine and rehabilitation at the University of Texas Southwestern Medical Center, said. D., “However, caution should be exercised when considering the risk-benefit profile of stroke patients receiving dual antiplatelet drug therapy.

According to the American Heart Association’s Heart Disease and Stroke Statistics 2024 Update, stroke is the fifth leading cause of death among all causes of death, after heart disease, cancer, COVID-19, and unintentional injury/accident, when separated from other cardiovascular diseases. About one-third of stroke survivors develop post-stroke depression. Left untreated, depression can affect quality of life and decrease the likelihood of optimal post-stroke recovery, including return to normal activities of daily living without assistance.

The most common class of antidepressants are SSRIs or SNRIs, which are widely used and effective in treating anxiety and depression. However, antidepressants may not be prescribed at all or early after the onset of stroke, when the risk of depression and anxiety is particularly high, due to concerns that they increase the risk of hemorrhagic stroke or other serious bleeding.

Researchers examined the frequency of serious bleeding in hundreds of thousands of stroke survivors who took different types of SSRI and/or SNRI antidepressants (sertraline, fluoxetine, citalopram, venlafaxine, etc.). Serious bleeding was defined as intracerebral hemorrhage, gastrointestinal bleeding, and shock.

The researchers also studied serious bleeding in stroke survivors who took a combination of antidepressants and various types of blood thinners used to prevent future blood clots. These blood thinners include anticoagulants and antiplatelet agents. Anticoagulants are prescribed as single agents and include warfarin, apixaban, and rivaroxaban. Antiplatelet agents may be prescribed as a single agent (typically aspirin) or dual antiplatelet therapy, in which two antiplatelet agents are used DAPT includes aspirin and a P2Y12 inhibitor (such as clopidogrel, prasugrel, ticagrelor) and another antiplatelet drug called a P2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor, etc.).

The study found:

• SSRIs and SNRIs were generally safe to start during the critical early stages of recovery, as they were no more likely to develop serious bleeding than stroke survivors not taking antidepressants. This includes ischemic stroke patients receiving anticoagulation therapy.
• When SSRIs or SNRIs were combined with DAPT therapy (aspirin or blood thinners), the risk of serious bleeding increased. However, serious bleeding events were rare and the overall risk remained low.
• In ischemic stroke patients taking antidepressants, the risk of serious bleeding was increased by 15% when taking drugs in classes such as mirtazapine, bupropion, and tricyclics compared to SSRI/SNRIs.

Recovery after stroke is time-dependent, with most functional recovery occurring in the first few months after stroke, so it is important to maximize rehabilitation in the early post-stroke period. “Fortunately, the two-drug antiplatelet combination is often administered for 14, 30, or 90 days, so clinicians may not need to withhold antidepressants for long periods of time if indicated. Future studies should investigate the bleeding risk associated with the use of antidepressants and anxiety medications in patients with hemorrhagic or hemorrhagic stroke.

According to a 2022 American Heart Association scientific statement, social isolation and loneliness are associated with an approximately 30% increased risk of death from heart attack, stroke, or both.

‘Depression can lead to social isolation, and social isolation may increase the likelihood of experiencing depression.’ This study helps answer the question of safety in the use of antidepressants to treat mental health problems that may develop after stroke,” said C. C. C. Harris, chair of the association’s scientific statement writing group and professor of clinical medicine and health equity, diversity, and inclusion at the University of California, San Diego’s Department of Health Care. Chief Administrative Officer, Crystal Wiley Cené, M.D., M.P.H., FAHA, said. Dr. Cené was not involved in this study.

Study details and design:

• This retrospective study collected electronic medical record data on 666,150 ischemic stroke patients from more than 70 large medical centers in the United States: 35,631 were taking SSRI/SNRI antidepressants, 23,241 were taking other antidepressants, and most patients (607 1,278) were not taking antidepressants.
• Patients were treated at 70 medical centers over a 20-year period.
• Patients were identified from electronic medical records from 2003 to 2023.

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