Which selective serotonin reuptake inhibitor (SSRI) should be started after a stroke?

SSRI Selection After Stroke

Patients diagnosed with post-stroke depression should be treated with an SSRI, with sertraline being the preferred first-line option due to its favorable safety profile and effectiveness in improving functional recovery. 1, 2

Post-Stroke Depression Management

• SSRIs are the recommended first-line pharmacological treatment for post-stroke depression due to their efficacy in reducing depressive symptoms and favorable side effect profile compared to other antidepressants 1
• Routine screening for depression using structured inventories such as the Patient Health Questionnaire-2 is recommended for all stroke patients 1
• Treatment with antidepressants should be initiated when post-stroke depression is diagnosed, in the absence of contraindications 1

SSRI Selection Criteria

First-Line Option: Sertraline

• Sertraline is the preferred SSRI after stroke due to:
  • Less severe adverse effects and more stable pharmacokinetics compared to other SSRIs 2
  • Associated with improved functional recovery in acute ischemic stroke patients with motor deficits 2
  • Demonstrated efficacy in reducing incident depression in stroke patients 2
  • Well-tolerated in post-stroke depression with minimal side effects 3
  • Improvement in depression symptoms typically occurs within approximately 13 days of treatment initiation 3

Alternative SSRI Options

• Fluoxetine was previously considered for stroke recovery but recent high-quality evidence shows no reliable benefit for promoting recovery after stroke 4
• The concept of enhancing brain plasticity through SSRIs has been suggested by animal studies, but multiple clinical studies of fluoxetine have not shown beneficial effects on functional outcome 1

Dosing Recommendations

• Sertraline: Start with 50 mg daily, which has been shown to be effective and well-tolerated in post-stroke depression 3
• For other SSRIs, follow standard dosing protocols:
  • Duloxetine: Start with 20-30 mg once daily, then increase weekly to goal of 60 mg/day (maximum 120 mg/day) 1
  • Venlafaxine: Start with 37.5 mg once or twice daily, increase by 75 mg each week to maximum of 225 mg/day 1

Safety Considerations

• SSRIs are generally well-tolerated in stroke patients, with most common side effects being benign and transient 5
• Monitor for potential gastrointestinal side effects, which occur more frequently with SSRIs compared to placebo 4
• The absolute risk of intracerebral and intracranial hemorrhage with SSRI treatment is low, though slightly increased compared to non-treatment 5
• Early treatment with sertraline may help prevent incident depression in stroke patients 2

Duration of Treatment

• Treatment should continue for at least 3 months after stroke for optimal recovery benefits 6
• Periodic reassessment of depression, anxiety, and other psychiatric symptoms is useful in the ongoing care of stroke survivors 1

Clinical Pitfalls to Avoid

• Do not use SSRIs solely for the purpose of enhancing motor recovery, as high-quality evidence does not support this practice 4
• Avoid assuming all post-stroke mood changes are depression; screen properly to differentiate from emotional lability or pseudobulbar affect 1
• Do not delay treatment once post-stroke depression is diagnosed, as early effective treatment may positively affect rehabilitation outcomes 1
• Avoid using tricyclic antidepressants as first-line therapy due to their less favorable side effect profile in stroke patients 1