REVIEW OF: Kubiszewski P et al, JAMA Neurol 2020;e203142. Epub ahead of print.

Depression after strokes is very common, affecting about 50% of stroke patients. Many such patients are treated with SSRIs, which are generally effective but potentially dangerous because they can increase the risk of bleeding due to impaired platelet aggregation. This is especially dangerous in intracerebral hemorrhages (ICHs), which cause half of stroke mortality even though they represent only 10–15% of strokes. A recent study examined the safety of SSRIs in patients who recently had an ICH.

In this longitudinal study, researchers recruited a total of 1,279 patients who were treated for ICH at a single academic hospital from January 2006 to December 2017. Of these patients, 766 were diagnosed with depression and 281 were started on SSRIs. Patients receiving SSRIs were divided into two categories: high or low risk for a recurrent stroke. High risk criteria included: 1) a prior history of any type of stroke; 2) presence of apolipoprotein E2/E4 gene variants; 3) Black or Hispanic race; and 4) lobar ICH, as opposed to deeper tissues such as the basal ganglia, brainstem, and cerebellum.

SSRI use was associated with higher ICH recurrence (hazard ratio [HR] 1.3). 6.1% of high-risk patients on SSRIs had a recurrent ICH vs only 3.8% of those not on SSRIs. In contrast, low-risk patients on SSRIs were not at greater risk for a recurrence than those not on SSRIs (2.9% vs 2.3%). On the positive side, SSRIs were effective at resolving post-stroke depression, with patients on the meds 1.5 times more likely to experience remission. Low doses of SSRIs (< 50% maximum recommended dose) were just as effective as high doses (> 50% maximum recommended dose) and were associated with a lower risk of ICH recurrence (HR 1.25 and 1.61 respectively).

CHPR’s Take
SSRIs are effective in treating post-ICH depression, but for patients at high risk for another stroke, the mood benefits may not be worth the higher risk of having another ICH. A good tip from this study is to keep SSRI dosing low to avoid heightening the risk for stroke ­recurrence.