The concern is that the use of ADs in the selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) classes might increase the risk of hemorrhagic stroke or other serious bleeding events, especially in patients taking anticoagulant (AC) medications.
Those apprehensions led to a new study from the University of Texas Southwestern Medical Center in Dallas. The abstract is scheduled to be presented at the American Stroke Association’s International Stroke Conference 2024, February 7–9, 2024, in Phoenix, Arizona. The researchers found that most stroke survivors were able to safely take the two types of common ADs.
On the other hand, patients taking ADs in combination with dual antiplatelet therapy (DAPT) had an increased risk of bleeding, and ADs from classes other than SSRI or SNRI increased the risk of serious bleeding events by 15% compared with the more commonly used ADs.
“Mental health conditions, such as depression and anxiety, are very common yet treatable conditions that may develop after a stroke. Our results should reassure clinicians that for most stroke survivors, it is safe to prescribe SSRI and/or SNRI antidepressants early after stroke to treat post-stroke depression and anxiety, which may help optimize their patients’ recovery,” said study lead author Kent P. Simmonds, DO, PhD, a third-year physical medicine and rehabilitation resident at the University of Texas Southwestern Medical Center. “However, caution is needed when considering the risk-benefit profile for stroke patients receiving dual antiplatelet therapy because we did find an increased risk of bleeding among this group.”
Background information in the study noted that SSRI/SNRIs are associated with improved stroke recovery, although some clinicians withhold the medications because of bleeding concerns.
The authors explained that their objections were to quantify the association between early initiation of SSRI/SNRIs and adverse bleeding events among acute ischemic stroke (IS) patients, determine bleeding risks among patients receiving anticoagulation or DAPT, and evaluate bleeding risks between AD classes.
To do that, the study team identified more than 666,000 medication-naïve, first-time IS patients from the medical records of 70 healthcare organizations from 2003 to 2023. The more than 600,000 patients without ADs were considered “No AD.” The 35,631 patients who were started on ADs within 3 months of the indexed stroke were classified as “SSRI/SNRI”; those receiving mirtazapine, bupropion, trazodone, or tricyclic ADs—totaling 23,241—were classified as “Other AD.”
The primary outcome was defined as the 1-year risk of major bleeding events such as gastrointestinal/intracranial or shock. Secondary outcomes were considered to be hemorrhagic stroke (HS), fall, and death.
The results indicated that early use of SSRI/SNRIs (vs. No ADs) was not associated with an increased risk of a major bleed for all patients based on 35,557 matched pairs or among patients on AC, with 7,672 matched pairs. “However, concurrent use of SSRI/SNRIs and DAPT was associated with a 29% increased risk of HS (RR: 1.29, 95% CI: 1.11-1.50, n = 8,381 matched pairs),” the study pointed out. “Among patients on ADs, bleed risks were higher for use of ‘Other ADs’ vs. ‘SSRI/SNRIs’ (n = 21,810 matched pairs).”
The authors advised that “SSRI/SNRIs treat post-stroke depression, promote functional recovery and are generally safe to start during the early stages of recovery for patients with IS. However, an increased risk of HS should be considered when starting ADs among patients on DAPT.”
Dr. Simmonds noted that “maximizing rehabilitation 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. Fortunately, dual antiplatelet therapy is often administered for 14, 30 or 90 days, so, when indicated, clinicians may not need to withhold antidepressant medications for prolonged periods of time.”
The authors call for future research to investigate the risk of bleeding associated with the use of ADs and anxiety medications among patients with hemorrhagic or bleeding stroke.
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