A preliminary study to be presented at the 2024 International Stroke Conference of the American Stroke Association found that most stroke survivors could safely take two common antidepressants. The conference, taking place from February 7-9 in Phoenix, is a leading global meeting for researchers and clinicians dedicated to the science of stroke and brain health.
Among individuals with ischemic (clot-caused) stroke, those who started taking an antidepressant known as SSRI (Selective Serotonin Reuptake Inhibitor) and/or SNRI (Serotonin and Norepinephrine Reuptake Inhibitor) did not have an increased risk of hemorrhagic (bleeding) stroke or other severe bleeding. This included individuals taking anticoagulant medications. However, there was an increased risk of hemorrhagic stroke in stroke patients taking a dual antiplatelet therapy (DAPT), which consists of two antiplatelet medications.
Mental health conditions such as depression and anxiety are very common but treatable conditions that can occur after a stroke. Our findings should give doctors confidence that it is safe for most stroke survivors to prescribe SSRI and/or SNRI antidepressants early after a stroke to treat depression and anxiety, which can help optimize their patients‘ recovery. However, caution is advised when considering the risk-benefit profile for stroke patients receiving dual antiplatelet therapy, as we found an increased risk of bleeding in this group.
Kent P. Simmonds, DO, Ph.D., lead author of the study, third-year physical medicine and rehabilitation resident at the University of Texas Southwestern Medical Center in Dallas
According to the 2024 update of the Heart Disease and Stroke Statistics from the American Heart Association, stroke ranks fifth as a cause of death, behind heart disease, cancer, COVID-19, and unintentional injuries. Approximately one-third of stroke survivors develop depression after a stroke. Untreated depression can significantly impact quality of life and decrease the chances of optimal recovery after a stroke, such as returning to normal activities without assistance.
The most common classes of antidepressants are SSRIs or SNRIs, which are often used effectively to treat anxiety and depression. However, they may not be prescribed at all or soon enough after a stroke, when the risk of depression or anxiety is particularly high, due to concerns about increasing the risk of hemorrhagic stroke or other serious bleeding.
The researchers investigated the occurrence of severe bleeding in hundreds of thousands of stroke survivors taking various types of SSRIs and/or SNRIs (such as sertraline, fluoxetine, citalopram, venlafaxine). Severe bleeding was defined as bleeding in the brain and gastrointestinal tract, and shock that occurs when bleeding prevents blood from reaching body tissues.
The researchers also examined severe bleeding in stroke survivors taking antidepressants in combination with various types of anticoagulant or antiplatelet medications used to prevent future blood clots. These medications may include anticoagulants or antiplatelet agents. Anticoagulants are prescribed as single medications and include drugs such as warfarin, apixaban, and rivaroxaban. Antiplatelet agents can be prescribed as a single medication (usually aspirin) or as part of a dual antiplatelet therapy, which consists of aspirin and another antiplatelet agent called a P2Y12 inhibitor (such as clopidogrel, prasugrel, or ticagrelor).
The study found:
- Overall, SSRIs and SNRIs could be safely used in the critical early stages of recovery, as the likelihood of severe bleeding in patients taking these medications was not higher than in stroke survivors not taking antidepressants. This included patients with ischemic stroke receiving anticoagulant therapy.
- An increased risk of severe bleeding occurred when SSRIs or SNRIs were taken in combination with DAPT treatments (aspirin and a blood thinner). However, the overall risk remained low, as severe bleeding events were rare.
- In stroke patients, the risk of severe bleeding increased by 15% when taking antidepressants from classes such as mirtazapine, bupropion, and tricyclic compared to SSRIs/SNRIs.
„Early rehabilitation after a stroke is essential, as recovery is somewhat time-dependent, and most functional gains occur in the first few months after a stroke,“ said Simmonds. „Fortunately, dual antiplatelet therapy is commonly administered over 14, 30, or 90 days, so doctors may not have to forego the use of antidepressants over longer periods if indicated. Future research should explore the bleeding risk associated with the use of antidepressants.“ – depressants and anxiety medications in patients with hemorrhagic or bleeding stroke.“
According to a scientific statement from the American Heart Association in 2022, social isolation and loneliness are associated with about a 30% increased risk of heart attack, stroke, or death from both. „Depression can lead to social isolation, and social isolation can increase the likelihood of depression. The current study helps address safety concerns related to the use of antidepressants to treat mental issues that may occur after a stroke,“ said Crystal Wiley Cené, MD, MPH, FAHA, chair of the writing group for the association’s scientific statement and professor of clinical medicine and Chief Administrative Officer for Health Equity, Diversity, and Inclusion at University of California San Diego Health. Dr. Cené was not involved in this study.
Study details and design:
- The retrospective study included electronic health records of 666,150 patients with ischemic stroke from over 70 major health centers in the United States: 35,631 were taking SSRI/SNRI antidepressants, and 23,241 were taking other antidepressants, but most (607,278) were not taking any antidepressant.
- The patients were treated over a 20-year period in 70 health centers.
- The patients were identified using electronic health records from 2003 to 2023.
The study had some limitations. The researchers used statistical methods to balance differences between groups that may not have accounted for all important differences between the groups. The study also did not consider the dosage, duration, or number of antidepressants taken by participants, which may have influenced the results.
American Heart Association