Vascular disease

Stroke recovery: no role for SSRIs, Cochrane Review concludes


SSRIs do not improve recovery after stroke, a new Cochrane Review has concluded.

The findings of the group’s latest systematic review overturn those of its previous meta-analysis, which suggested SSRIs may reduce dependence, disability, neurological impairment, anxiety, and depression after stroke, even in people without depression.

The authors say their previous review included trials at higher risk of bias and they conducted a new review to include the results of the recently published FOCUS trial.

This study, published in 2018, involved more than 3000 stroke patients and  found no benefit on functional outcomes from fluoxetine given daily for 6 months after acute stroke.

When included with other studies of SSRIs in acute stroke, there were 63 eligible trials involving 9168 participants, about half of which had patients with depression. The SSRIs used included fluoxetine, sertraline, paroxetine, citalopram and escitalopram.

However the reviewers found that only three of the trials were at low risk of bias, all of which used fluoxetine. A meta‐analysis of these trials found little or no evidence of effect of SSRI on the primary outcomes of disability and independence.

As expected, there was moderate‐quality evidence that SSRIs reduced the severity of depression, but there was also a higher number of gastrointestinal side effects.

When results from all 63 trials were included there was moderate evidence of a benefit of SSRIs on disability, “but this was almost certainly because the studies at high risk of bias tended to give the positive results,” the review authors said.

They acknowledged that the meta-analysis of the three trials was dominated by the results of the large FOCUS study, whereas the two smaller trials were positive. Further evidence would be available from ongoing trials of SSRIs such as the Australian-led AFFINITY (Assessment of Fluoxetine In Stroke Recovery) study, they said.

But the current review found no reliable evidence that SSRIs should be used routinely to promote recovery after stroke, they concluded.

“Based on our meta‐analysis of the trials at low risk of bias, there is currently no indication for the routine prescription of SSRIs to promote stroke recovery. Fluoxetine reduces the risk of depression, but this is probably not a sufficiently strong rationale to give all people with stroke a six‐month course of the drug.”

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