New Study Shows Antidepressants Safe for Stroke Survivors, Even in Early Recovery
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Antidepressant medications are safe for most survivors of ischemic stroke (the most common type of stroke), even during the crucial early recovery period, according to a preliminary study to be presented at the American Stroke Association’s International Stroke Conference 2024.
Because people are at increased risk of major bleeding events soon after they experience a stroke, some clinicians may choose not to prescribe an antidepressant over concerns that these medications may increase that risk further, says the study’s lead author, Kent Simmonds, DO, PhD, a third-year physical medicine and rehabilitation resident at the University of Texas Southwestern Medical Center in Dallas.
This means that some stroke survivors may not get the depression treatment they need, which can negatively impact quality of life, he says. “Unfortunately, this time period (three to six months after a stroke) overlaps with the time when most functional recovery occurs. Our study demonstrates that for most patients, serotonergic antidepressant medications are safe to use, as they were not associated with increased risks of bleeds when started early after a stroke,” says Dr. Simmonds.
Up to 40 Percent of Stroke Survivors Experience Depression
When considered separately from other cardiovascular diseases, stroke ranks fifth among all causes of death, behind diseases of the heart, cancer, COVID-19, and unintentional injuries or accidents, according to the American Heart Association’s Heart Disease and Stroke Statistics 2024 Update.
Unfortunately, people who have a stroke may face another challenging health issue: An estimated 20 to 40 percent of people who have a stroke go on to develop depression, according to Columbia University Irving Medical Center. Depression can negatively impact recovery after stroke in different ways, including poor medication adherence and less participation in rehabilitation.
Studies also show that depression independently increases the chances of another stroke or other cardiovascular event.
Why Some Doctors Are Cautious About Prescribing Antidepressants to Stroke Survivors
The most common classes of antidepressants are SSRIs or SNRIs, but these medications may not be prescribed at all or not soon enough after a stroke, when the risk of depression or anxiety is particularly high, because of concerns they may increase the risk of a hemorrhagic stroke or other serious types of bleeding, according to the authors.
Physiologically, most antidepressant medications work on serotonin, and that presents a potential risk because the neurotransmitter also has a role in blood platelet function, says Simmonds.
Study Included More Than 600,000 Stroke Survivors
To investigate the frequency of serious bleeding in stroke survivors who took different types of SSRI and SNRI antidepressants, researchers identified more than 600,000 ischemic stroke survivors from the electronic medical records of 70 large healthcare centers in the United States.
The SSRI and SNRI antidepressants included:
About 35,000 of the survivors were taking an SSRI or SNRI antidepressant, 23,000 were taking other types of antidepressants, and the remaining participants were not taking any antidepressant.
Investigators also included stroke survivors who took antidepressants combined with different types of blood-thinning medications (either anticoagulants or antiplatelet medications) that are used to prevent future blood clots.
Serious bleeding was defined as bleeding in the brain or digestive tract, and shock, which occurs when bleeding prevents blood from reaching the body’s tissues.
Antidepressants Were Found to Be Generally Safe, Even During Early Stages of Stroke Recovery
Researchers found that SSRIs and SNRIs were generally safe to start during the important early stages of recovery. Stroke survivors who took the medications didn’t have a greater risk of serious bleeding than stroke survivors who did not take an antidepressant. This included ischemic stroke patients who were also taking anticoagulation therapy.
Other key findings included:
- An increased risk of serious bleeding occurred when SSRIs or SNRIs were taken in combination with aspirin and blood thinners, but the overall risk remained low and serious bleeding events were rare.
- Antidepressants from other classes — like Remeron (mirtazapine), Wellbutrin (bupropion), and older tricyclic antidepressants — increased the risk of serious bleeding events by 15 percent compared with antidepressants in the SSRI or SNRI classes.
The authors acknowledged that the retrospective study had some limitations. Although researchers used statistical methods to adjust for differences among the groups, those may not have accounted for all differences between them. The study also didn’t include the dosage, duration, or number of antidepressants taken by participants, which may have affected the results.
Still, these findings should reassure clinicians that for most stroke survivors it’s safe to prescribe SSRI and SNRI antidepressants early after stroke to treat post-stroke depression and anxiety, says Simmonds.
Timely Depression Treatment May Help Stroke Survivors Recover
Historically, much of the research on stroke has focused on either stroke prevention or on reducing mortality, but improvements in acute treatments now mean that most patients survive their stroke but are still affected by high levels of disability, says Simmonds.
Maximizing rehab early after a stroke is essential because recovery is somewhat time-dependent, and most functional gains occur during the first few months after a stroke, he said.
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