SSRIs tricky after haemorrhagic stroke

Treating depression after haemorrhagic stroke poses a Sophie's choice dilemma. Here's what you should know.

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And to start the year we have one of those devil or deep blue sea dilemmas.

US researchers have determined that if you give patients who have had a haemorrhagic stroke SSRIs, you are more likely to effectively treat their depression. But … those same drugs increase their risk of having another cerebral bleed.

The observational cohort study of almost 1300 survivors of intracerebral haemorrhage showed depression was common – occurring in more than 60% of patients. And yes if these patients were commenced on an SSRI they had a 55% higher chance of resolution of their depressive symptoms – but the downside was that they had a 30% increased risk of recurrence. It’s a real Sophie’s choice.

Sure, haemorrhagic strokes are less frequent than ischaemic strokes, but the reality is that they tend to be more deadly.

“Intracerebral haemorrhage represents 10% to 15% of all strokes but accounts for almost half of stroke mortality,” the study authors wrote in JAMA Neurology.

And just having had an intracerebral bleed puts someone at a significantly increased risk of having another.

But, by the same token, depression following this type of stroke is also very common, with the researchers quoting figures around the 55% mark from previous studies, and over 60% in this study. Depression too is associated with significant morbidity and poorer long-term health outcomes – so the finding that SSRIs can effectively treat this comorbidity in post-stroke patients is of significance.

For the record, the study was unable to find any discernible difference between the SSRIs in terms of effectiveness or risk in this cohort.

“We found that no individual SSRI had significantly different effects for association with either [intracerebral haemorrhage] recurrence or post –[intracerebral haemorrhage] depression remission,” they said.

Given the known anti-thrombotic effects of SSRIs the findings are perhaps not all that surprising but they do present a management dilemma.

Fortunately as a result of their study, the researchers were able to identify certain subgroups who appeared more at risk of a recurrent bleed.

“The association between SSRI use and [intracerebral haemorrhage] recurrence had larger effect size within subgroups at higher risk for recurrent haemorrhagic stroke (carriers of theAPOE?2/?4 alleles, patients with lobar [intracerebral haemorrhage], patients with prior [intracerebral haemorrhage], and minority participants),” the researchers wrote.

There was also an increased risk with higher doses of the SSRI.

Overall, this identification of higher risk groups may do little to sway the cautious clinician to prescribe this particular group of antidepressants to patients who have had an intracerebral bleed. But at least forewarned is forearmed.

JAMA Neurol. 2021;78(1):61-67.

This article was first published at Healthed