Is it safe to use antidepressants after a stroke?

[Stroke and depression]

Depression is a frequent complication of stroke and occurs in approximately one in three surviving patients. Depression worsens the course of post-stroke neurological disorders, enhances the physical helplessness of patients, further reduces their quality of life, significantly decreases the effectiveness of therapeutic and rehabilitation measures and increases the risk of death. Antidepressants eliminate or relieve depressive symptoms, mitigate neurological disorders, improve cognitive functions and the general condition of patients, increase the effectiveness of treatment and rehabilitation, diminish the risk of recurrent stroke and decrease mortality. Selective serotonin reuptake inhibitors are the first line antidepressants for post-stroke patients; there is evidence of the effectiveness of other modern antidepressants, as well as tricyclic drugs. Unresolved aspects of this problem that require further well-designed controlled studies include tolerability of antidepressants by patients of late age, the choice of optimal drugs and the duration of therapy.

Brain ischemia changes the long term response to antidepressant drugs in mice

Depression is a frequent but often unrecognized and under treated complication of stroke that has scarcely been investigated in animal models particularly regarding treatment issues. Using the Forced Swim Test (FST) and testing spontaneous motor activity, we studied whether a transient focal cerebral ischemia modifies mice behaviours and antidepressant drug effects. We first evaluated whether FST realized 2 days or 1 week after brain reperfusion may be routinely used in male Swiss mice previously submitted to a 15, 30 or 60-min transient occlusion of the right middle cerebral artery. We then evaluated behavioural changes up to 5 weeks in mice previously submitted to a 15-min ischemia. Behaviours according to the administration of imipramine or fluvoxamine at 1 and 5 weeks after a 15-min ischemia were finally evaluated. Transient ischemia was associated with a decrease in immobility in the FST performed 2 days after reperfusion while no changes were observed in 1 and 5 weeks post-ischemia groups. Changes were related neither to brain ischemia duration nor to infarct volume. At both 1 and 5 weeks after brain ischemia, a dramatic decrease in the antidepressant response to imipramine related to a decrease in climbing behaviour was observed while the effects of fluvoxamine were improved through an increase in both climbing and swimming. Behaviours in the FST were unrelated to any spontaneous motor activity changes. Responses to anti-depressant drugs are strongly modified in mice previously submitted to brain ischemia. Present results underline that not all antidepressant drugs are appropriate after ischemic stroke.

Fluoxetine and sertraline attenuate postischemic brain injury in mice

This study aimed to investigate whether selective serotonin reuptake inhibitors (SSRIs) attenuate brain injury and facilitate recovery following photothrombotic cortical ischemia in mice. Male ICR mice were anesthetized and systemically administered Rose Bengal. Permanent focal ischemia was induced in the medial frontal and somatosensory cortices by irradiating the skull with cold light laser. The animals were treated with fluoxetine or sertraline once a day for 14 d starting 1 h after ischemic insult. Treatment with fluoxetine and sertraline significantly reduced the infarct size. The Evans blue extravasation indices of the fluoxetine- and sertraline-treated groups were significantly lower than that of the vehicle group. Treatment with fluoxetine and sertraline shifted the lower limit of the mean arterial blood pressure for cerebral blood flow autoregulation toward normal, and significantly increased the expression of heme oxygenase-1 (HO-1) and hypoxia-inducible factor-1alpha (HIF-1alpha) proteins in the ischemic region. These results suggest that SSRIs, such as fluoxetine and sertraline, facilitate recovery following photothrombotic cortical ischemia via enhancement of HO-1 and HIF-1alpha proteins expression, thereby providing a benefit in therapy of cerebral ischemia.

CNS-active drugs in aging population at high risk of cerebrovascular events: evidence from preclinical and clinical studies

The recovery process following cerebral insults such as stroke is affected by aging and pharmacotherapy. The use of medication including CNS-active drugs has increased in the elderly during recent years. However, surprisingly little is known about how safe they are with respect to severity of sensorimotor and cognitive impairments or recovery of function following possible cerebrovascular accidents. This review examines the experimental and clinical literature, primarily from 1995 onwards, concerning medication in relation to cerebrovascular events and functional recovery. Special attention is directed to polypharmacy and to new CNS-active drugs, which the elderly are already taking or are prescribed to treat emerging, stroke-induced psychiatric symptoms. The neurobiological mechanisms affected by these drugs are discussed.