CPCP: Role of SSRI Therapy in the Poststroke Patient: Here Are the Medical Students!

Yesterday’s Clinical Problems in Consultation Psychiatry (CPCP) is about poststroke depression and it was delivered by top-flight medical students, Andrew Ackell and Perry Wu, both in their third year. As one of them pointed out this is a topic geared for a neuroscience approach to evaluation and treatment.

Incidentally, the theme for the Annual Academy of Psychosomatic Medicine (APM) Meeting 2016 is “Brain, Mind and Body: Why Every PM Psychiatrist Should Care About Neuroscience.” It will be held in Austin, Texas, the live music capital of the world. I may not get there this year, but it reminds me..I saw Lyle Lovett on Austin City Limits once, singing a song about…a cheeseburger, I think. And I see the APM Winter 2016 Newsletter had an interesting item pertinent to the controversy about the name “Psychosomatic Medicine.”

CL Psychiatry in Europe

I think it’s fascinating that European psychiatrists practicing at the interface of medicine and psychiatry actually prefer the name “Consultation-Liaison” rather than “Psychosomatic Medicine” for our specialty. And I expect the poll results of the proposal to rename “Psychosomatic Medicine” in America have been submitted to the APM council. Stay tuned and vote in my little poll in which there still seems to be some interest.

Perry and Andrew tag-teamed the presentation and they raised an issue about treating poststroke depression (PSD) which leads to serious reflection about the right thing to do for patients after they’ve suffered a hemorrhagic stroke. As they pointed out, much of the PSD literature focuses on ischemic stroke. While the work of my former department chairman, Dr. Robert G. Robinson, MD, clearly shows the benefits of treating PSD with antidepressant and even supports the use of prophylactic antidepressant for improving survival, quality of life, and cognitive function, we have nagging doubts about their safety in patients who’ve had hemorrhagic stroke. The medical students did a lot of hard thinking about this and while they stuck to the evidence-based literature, they were also critical of it, which bodes well for patient safety in their future roles as physicians. Andrew’s take on the situation:

“When to start treatment and do you treat a hemorrhagic stroke with an SSRI?…what does the literature say?

A brief review (above link to Brain and Behavior article link) shows that in the major studies showing benefit post-stroke, SSRI’s were initiated either immediately, 5-10 days post-stroke, or even up to 3 months post stroke. The 2012 Cochrane Review which is still the “gold standard” perhaps of evidence based practice here: in their studies people were started on an SSRI from day 0 to up to 3 months post stroke! The Brain Behavior review is more cautious than other papers but it has great references. Follow the references if you’re interested in the topic further.

Another interesting reference is here.

2012 Cochrane Review: Conclusions
“SSRIs appeared to improve dependence, disability, neurological impairment, anxiety and depression after stroke, but there was heterogeneity between trials and methodological limitations in a substantial proportion of the trials. Large, well-designed trials are now needed to determine whether SSRIs should be given routinely to patients with stroke.” (emphasis mine)

2012 Cochrane Review: Implications for Research
There should be subgroup analyses for patients with ischaemic and haemorrhagic stroke, to explore whether SSRIs might increase the risk of recurrent intracranial bleeding in patients with intracerebral haemorrhage, and whether there is a higher risk of haemorrhagic transformation of infarct when SSRIs are given to patients with ischaemic stroke who are also taking anticoagulants. (emphasis mine)

For hemorrhagic strokes, my takeaway is that it’s just not known if there’s a danger in using SSRI’s in hemorrhagic strokes, the data is not there yet. There is a reason to be hesitant (known risk for brain hemorrhage in SSRI use) but also reason for optimism (the Cochrane Review which found better stroke outcomes included both ischemic and hemorrhagic strokes in their inclusion criteria).”

I’m so glad for the upcoming next generation of doctors. Here they are.

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