Depression Outcomes Among Patients Treated With Fluoxetine for Stroke Recovery: The AFFINITY Randomized Clinical Trial

Three-needle electroacupuncture ameliorates depressive-like behaviors in a mouse model of post-stroke depression by promoting excitatory synapse formation via the NGL-3/L1cam pathway

Three-needle electroacupuncture (TNEA) has shown promise as a non-pharmacological treatment for post-stroke depression (PSD). However, the underlying mechanisms of its therapeutic effects remain unclear. In this study, we investigated the potential molecular and synaptic mechanisms by which TNEA ameliorates depressive-like behaviors in a mouse model of PSD. Male C57BL/6 mice were subjected to middle cerebral artery occlusion (MCAO) to induce PSD and subsequently treated with TNEA for three weeks at specific acupoints (GV24 and bilateral GB13). Through a combination of behavioral tests, neuronal activation assessment, synaptic function examination, transcriptomic analysis, and various molecular techniques, we found that TNEA treatment significantly improved anxiety and depressive-like behaviors in PSD mice. These improvements were accompanied by enhanced neuronal activation in the medial prefrontal cortex (mPFC) and primary somatosensory cortex (PSC), as well as the promotion of excitatory synapse formation and transmission function in the mPFC. Transcriptomic analysis revealed that TNEA upregulated the expression of Netrin-G Ligand-3 (NGL-3), a postsynaptic cell adhesion molecule, in the mPFC. Further investigation showed that the extracellular domain of NGL-3 binds to the presynaptic protein L1cam, promoting the formation of Vesicular Glutamate Transporter 1 (vGluT1) puncta on neuronal dendrites. Notably, cortical neuron-specific knockout of NGL-3 abolished the antidepressant-like effects of TNEA in PSD mice, confirming the crucial role of the NGL-3/L1cam pathway in mediating the therapeutic effects of TNEA. These findings provide novel insights into the molecular and synaptic mechanisms underlying the therapeutic effects of acupuncture in the treatment of PSD and highlight the potential of targeting the NGL-3/L1cam pathway for the development of alternative interventions for PSD and other depressive disorders.

Chronic Treatment with Serotonin Selective Reuptake Inhibitors Does Not Affect Regrowth of Serotonin Axons Following Amphetamine Injury in the Mouse Forebrain

A current hypothesis to explain the limited recovery following brain and spinal cord trauma stems from the dogma that neurons in the mammalian central nervous system lack the ability to regenerate their axons after injury. Serotonin (5-HT) neurons in the adult brain are a notable exception in that they can slowly regrow their axons following chemical or mechanical lesions. This process of regrowth occurs without intervention over several months and results in anatomical recovery that approximates the preinjured state. During development, serotonin is a trophic factor, playing a role in both cell survival and axon growth. Additionally, some studies have shown that stroke patients treated after injury with serotonin selective reuptake inhibitors (SSRIs) appeared to have improved recovery. To test the hypothesis that serotonin can influence the regrowth of 5-HT axons, mice received a high dose of para-chloroamphetamine (PCA) to induce widespread retrograde degeneration of 5-HT axons. Then, after a short rest period to avoid any interaction with the acute injury phase, SSRIs were administered daily for 6 or 10 weeks. Using immunohistochemistry in 5-HT transporter-GFP BAC transgenic mice, we determined that while PCA led to a rapid initial decrease in total 5-HT axon length in the somatosensory cortex, visual cortex, or area CA1 of the hippocampus, treatment with either fluoxetine or sertraline (two different SSRIs) did not affect the recovery of axon length. These results suggest that chronic SSRI treatment does not affect the regrowth of 5-HT axons and argue against SSRIs as a potential therapy following brain injury.

Post-Stroke Brain Health Monitoring and Optimization: A Narrative Review

Significant advancements have been made in recent years in the acute treatment and secondary prevention of stroke. However, a large proportion of stroke survivors will go on to have enduring physical, cognitive, and psychological disabilities from suboptimal post-stroke brain health. Impaired brain health following stroke thus warrants increased attention from clinicians and researchers alike. In this narrative review based on an open timeframe search of the PubMed, Scopus, and Web of Science databases, we define post-stroke brain health and appraise the body of research focused on modifiable vascular, lifestyle, and psychosocial factors for optimizing post-stroke brain health. In addition, we make clinical recommendations for the monitoring and management of post-stroke brain health at major post-stroke transition points centered on four key intertwined domains: cognition, psychosocial health, physical functioning, and global vascular health. Finally, we discuss potential future work in the field of post-stroke brain health, including the use of remote monitoring and interventions, neuromodulation, multi-morbidity interventions, enriched environments, and the need to address inequities in post-stroke brain health. As post-stroke brain health is a relatively new, rapidly evolving, and broad clinical and research field, this narrative review aims to identify and summarize the evidence base to help clinicians and researchers tailor their own approach to integrating post-stroke brain health into their practices.

Stroke, depression, and self-harm in later life

PURPOSE OF THE REVIEW

To examine recently published results of randomized placebo-controlled trials investigating the clinical effects of selective serotonin reuptake inhibitors on the prevalence of clinically significant symptoms of depression and suicidal ideation after an acute stroke.

RECENT FINDINGS

The prevalence of poststroke depression varies markedly according to the approach used to define depression, with recently published data suggesting that about one in every three stroke survivors will experience clinically significant symptoms of depression over a period of 12 months. The proportion of stroke survivors with clinically significant symptoms of depression decreases progressively with time, but in 30% of them symptoms persist or recur over 12 months. Routine daily treatment with 20 mg of fluoxetine for 6 months does not affect the prevalence of depression in this population, nor is it effective at treating or preventing poststroke depressive symptoms. Treatment discontinuation, gastrointestinal adverse effects, seizures and bone fractures are more frequent among stroke survivors treated with antidepressants than placebo. Moreover, current data show that thoughts about death or suicide are more frequent among adults who had a stroke than the general population, although recurring suicidal thoughts are uncommon. Routine daily treatment with 20 mg of fluoxetine for 6 months does not change the proportion of people who disclose suicidal thoughts over a period of 12 months after an acute stroke.

SUMMARY

Current evidence raises concerns about the efficacy and safety of antidepressants for the management and prevention of poststroke clinically significant symptoms of depression. It is unclear if these findings can be generalized to people with severe strokes or to stroke survivors with moderate to severe major depressive episodes.

Depressive Symptoms and Risk of Acute Stroke: INTERSTROKE Case-Control Study

BACKGROUND AND OBJECTIVES

Depression has been reported to be a risk factor of acute stroke, based largely on studies in high-income countries. In the INTERSTROKE study, we explored the contribution of depressive symptoms to acute stroke risk and 1-month outcome across regions of the world, within subpopulations and by stroke type.

METHODS

The INTERSTROKE is an international case-control study of risk factors of first acute stroke, conducted in 32 countries. Cases were patients with CT- or MRI-confirmed incident acute hospitalized stroke, and controls were matched for age, sex, and within sites. Standardized questions asked about self-reported depressive symptoms during the previous 12 months and the use of prescribed antidepressant medications were recorded. Multivariable conditional logistic regression was used to determine the association of prestroke depressive symptoms with acute stroke risk. Adjusted ordinal logistic regression was used to explore the association of prestroke depressive symptoms with poststroke functional outcome, measured with the modified Rankin scale at 1 month after stroke.

RESULTS

Of 26,877 participants, 40.4% were women, and the mean age was 61.7 ± 13.4 years. The prevalence of depressive symptoms within the last 12 months was higher in cases compared with that in controls (18.3% vs 14.1%, p < 0.001) and differed by region (p interaction <0.001), with lowest prevalence in China (6.9% in controls) and highest in South America (32.2% of controls). In multivariable analyses, prestroke depressive symptoms were associated with greater odds of acute stroke (odds ratio [OR] 1.46, 95% CI 1.34-1.58), which was significant for both intracerebral hemorrhage (OR 1.56, 95% CI 1.28-1.91) and ischemic stroke (OR 1.44, 95% CI 1.31-1.58). A larger magnitude of association with stroke was seen in patients with a greater burden of depressive symptoms. While preadmission depressive symptoms were not associated with a greater odds of worse baseline stroke severity (OR 1.02, 95% CI 0.94-1.10), they were associated with a greater odds of poor functional outcome at 1 month after acute stroke (OR 1.09, 95% CI 1.01-1.19).

DISCUSSION

In this global study, we recorded that depressive symptoms are an important risk factor of acute stroke, including both ischemic and hemorrhagic stroke. Preadmission depressive symptoms were associated with poorer functional outcome, but not baseline stroke severity, suggesting an adverse role of depressive symptoms in poststroke recovery.

Wishing to die or self-harm after stroke: A planned secondary analysis of the AFFINITY Randomised Controlled Trial

We investigated the cumulative prevalence of self-harm ideation among stroke survivors of the AFFINITY trial. We assessed these thoughts with the last item of the PHQ-9, and functional impairment with the modified Rankin Scale (mRS). Of 1221 participants (age 63.9 ± 12.3 years, 775 men), 11 reported wishing to die or self-harm at baseline. By week 52, 36 of 1159 surviving participants had reported wishing to die or self-harm. Treatment with fluoxetine for 26 weeks did not change the prevalence of these thoughts compared with placebo. Clinically significant symptoms of depression were present in 95 % of participants with recurrent self-harm thoughts. The study was registered with the Australian and New Zealand Clinical Trials Registry, ACTRN12611000774921.

In-hospital predictors of post-stroke depression for targeted initiation of Selective Serotonin Reuptake Inhibitors (SSRIs)

BACKGROUND

Although SSRIs are no longer widely prescribed for post-stroke motor recovery, fluoxetine demonstrated beneficial effects on post-stroke depression (PSD). Given the potential side effects of SSRIs, targeted initiation among individuals at highest risk for PSD warrants consideration. While previous studies have identified stroke severity and psychiatric history as factors associated with PSD, its predictability remains unknown. In this study, we investigate inpatient predictive factors to better identify individuals who might derive the most benefit from targeted initiation of SSRIs.

METHODS

We performed a retrospective analysis of a prospectively-collected registry of adult patients presenting with acute ischemic stroke to a tertiary referral urban academic comprehensive stroke center between 2016-2020. Patients were seen 4-6 weeks post-discharge and administered the PHQ-9 (Patient Health Questionnaire-9) to screen for PSD (PHQ-9 ≥ 5). Demographics, history of depression, stroke severity, and inpatient PHQ-9 scores were abstracted. Logistic regression was used to determine factors associated with PSD and an ROC analysis determined the predictability of PSD in the inpatient setting.

RESULTS

Three hundred seven individuals were administered the PHQ-9 at follow-up (mean age 65.5 years, 52% female). History of depression (OR = 4.11, 95% CI: 1.65-10.26) and inpatient PHQ-9 score (OR = 1.17, 95% CI: 1.06-1.30) were significantly associated with PSD. Stroke severity, marital status, living alone, employment, and outpatient therapy were not associated with PSD. The ROC curve using a positive inpatient PHQ-9 achieved an area under the curve (AUC) of 0.65 (95% CI: 0.60-0.70), while the AUC was 0.72 (95% CI: 0.66-0.77) after adding history of depression.

CONCLUSIONS

History of depression and a positive inpatient PHQ-9 appear to be most strongly predictive of long-term PSD. Initiating SSRIs only in those individuals at highest risk for PSD may help reduce the burden of stroke recovery in this targeted population while minimizing adverse side effects.

Safety and Efficacy of SSRIs in Improving Poststroke Recovery: A Systematic Review and Meta-Analysis

Background

Several studies investigated the role of selective serotonin reuptake inhibitors (SSRIs) in improving poststroke recovery; thus, we have decided to conduct this systematic review and meta‐analysis to investigate the efficacy and safety of SSRIs in poststroke recovery.

Methods and Results

In this meta‐analysis we searched the following databases: PubMed, Cochrane, Scopus, and Google Scholar. The studies were included if they were placebo‐controlled trials in design and reported SSRIs’ effects on poststroke depression, anxiety, disability, dependence, motor abilities, and cognitive functions. The quality of the included studies was assessed using the revised Cochrane risk‐of‐bias tool for randomized trials. The search yielded 44 articles that included 16 164 patients, and about half of the participants were treated with SSRIs. Our results showed that SSRIs had a significant effect on preventing depression (weighted mean difference [WMD], −7.05 [95% CI, −11.78 to −2.31]), treating depression according to the Hamilton Rating Scale for Depression score (WMD, −1.45 [95% CI, −2.77 to −0.14]), anxiety (relative risk, 0.23 [95% CI, 0.09–0.61]), dependence (WMD, 8.86 [95% CI, 1.23–16.48]), motor abilities according to National Institutes of Health Stroke Scale score (WMD, −0.79 [95% CI, −1.42 to −0.15]), and cognitive functions (WMD, 1.00 [95% CI, 0.12–1.89]). On the other hand, no significant effect of SSRIs on disability was observed. Additionally, we found that treating with SSRIs increased the risk of seizures (relative risk, 1.44 [95% CI, 1.13–1.83]), whereas there was no difference in the incidence of gastrointestinal symptoms or bleeding between SSRIs and a placebo.

Conclusions

Our study showed that SSRIs are effective in preventing and treating depression, and improving anxiety, motor function, cognitive function, and dependence in patients after stroke. These benefits were only reproducible with the citalopram subanalysis but not fluoxetine. Further well‐conducted placebo‐controlled trials are needed to investigate the safety and efficacy of citalopram among patients after stroke.

Registration

URL: www.crd.york.ac.uk/prospero/; Unique identifier: CRD42021285766.

Measuring Ambulation, Motor, and Behavioral Outcomes with Post-stroke Fluoxetine in Tanzania: The Phase II MAMBO Trial

We test the safety of fluoxetine post-ischemic stroke in sub-Saharan Africa. Adults with acute ischemic stroke, seen <14 days since new-onset motor deficits, were enrolled from November 2019 to October 2020 in a single-arm, open-label phase II trial of daily fluoxetine 20 mg for 90 days at Muhimbili National Hospital, Dar es Salaam, Tanzania. The primary outcome was safety with secondary outcomes of medication adherence and tolerability. Thirty-four patients were enrolled (11 were female; mean age 52.2 years, 65% < 60 years old; mean 3.3 days since symptom onset). Participants had hypertension (74%), diabetes (18%), and smoked cigarettes (18%). The median National Institutes of Health Stroke Scale score at enrollment was 10.5. The median Fugl-Meyer Motor Scale score was 28.5 (upper extremity 8, lower extremity 17.5). 32/34 participants (91%) survived to 90 days. There were eight serious and two nonserious adverse events. Deaths occurred due to gastrointestinal illness with low serum sodium (nadir 120 mmol/L) with seizure and gastrointestinal bleed from gastric cancer. The average sodium level at 90 days was 139 mmol/L (range 133-146) and alanine transaminase was 28 U/L (range 10-134). Fluoxetine adherence was 96%. The median modified Rankin Scale score among survivors at 90 days was 2 and Fugl-Meyer Motor Scale score was 66 (upper extremity 40, lower extremity 27). Median 90-day Patient Health Questionnaire-9 and Montgomery-Åsberg scores were 3.5 and 4 (minimal depression). Fluoxetine administration for 90 days poststroke in sub-Saharan Africa was generally safe and well-tolerated, but comorbid illness presentations were fatal in 2/34 cases, even after careful participant selection.

Measures Associated With Early, Late, and Persistent Clinically Significant Symptoms of Depression 1 Year After Stroke in the AFFINITY Trial

OBJECTIVE

To determine the sociodemographic and clinical factors associated with early, late and persistent clinically significant symptoms of depression during the first year after a stroke.

METHODS

Cohort study of 1221 men and women recruited within two weeks of stroke onset in Australia, New Zealand and Vietnam. The NIH Stroke Scale (NIHSS) was used to assess the severity of the stroke. Other study measures included age, sex, marital status, living arrangements, function before the stroke, depression before the stroke, modified Rankin Scale (mRS), and treatment with fluoxetine or placebo for 26 weeks. Clinically significant symptoms of depression during the 52 weeks after baseline was the outcome of interest, and its presence was defined by a total PHQ-9 score of 9 or higher at weeks 4, 12, 26 or 52, a clinician diagnosis of depression between assessments, or by pharmacological or psychological treatment of depression during follow up. Participants were classified as not depressed, or as early (initial 12 weeks), late (12 to 52 weeks) or persistent depression (before and after 12 weeks). We used multinomial logistic regression to assess depression risk, with all listed measures entered simultaneously into the model.

RESULTS

The mean age of participants was 63.8 (SD=12.3) years and 775 (63.5%) were male. At baseline, 48 (3.9%) participants had previous treated depression, and 228 (18.7%) had clinically significant symptoms of depression (PHQ-9 ≥ 9). 734 (63.3%) participants showed no evidence of depression in the year following the stroke, 208 (17.9%) had early, 86 (7.4%) late, and 131 (11.3%) persistent depression. Increased stroke severity, as measured by doubling of NIHSS scores, was associated with an increased risk of early (Risk Ratio [RR]=2.08, 95%CI=1.65-2.62), late (RR=1.53, 95%CI=1.14-2.06) and persistent clinically significant symptoms of depression (RR=2.50, 95%CI=1.89-3.32). Similar findings were apparent for the mRS, a measure of functional disability. Past depression was associated with increased risk of persistent clinically significant symptoms of depression (RR=6.28, 95%CI=2.88-13.71), as was being married or partnered (RR=3.94, 95%CI=2.42-6.41). The risk of clinically significant symptoms of depression was higher in Australia and New Zealand than in Vietnam.

CONCLUSION

The severity of neurological and functional deficits increases the risk of post-stroke clinically significant symptoms of depression early and persistently. Depression before stroke, personal relationships and cultural context contribute to mediate depression risk. Interventions that minimise the severity of neurological and functional deficits should decrease the risk of post-stroke clinically significant symptoms of depression.

Efficacy of Fluoxetine for Post-Ischemic Stroke Depression in Tanzania

OBJECTIVE

Post-stroke fluoxetine trials are primarily conducted in high-income countries. We characterize post-ischemic stroke depression in fluoxetine-treated and -untreated study participants in urban Tanzania.

METHODS

Adults (>18 years old) within 14 days of CT-confirmed acute ischemic stroke onset were enrolled at Muhimbili National Hospital, Tanzania. The fluoxetine-treated group took 20mg fluoxetine daily for 90 days in a phase II trial and were compared to fluoxetine-untreated historical controls. The primary outcome was depression at 90 days, measured by the Patient Health Questionnaire-9 (PHQ-9). PHQ-9 scores were compared between fluoxetine-treated and -untreated groups. A score >=9 points was considered to reflect depression. A multivariable linear regression model assessed associations with post-stroke PHQ-9 scores.

RESULTS

Of the fluoxetine-treated (n=27) and -untreated (n=32) participants, the average age was 56.8 years old (39% women, 100% Black/African). The average presentation NIHSS score was 12.1 points and modified Rankin Scale (mRS) score was 3.5. The average mRS score at 90-day follow-up was 2.3. There was no significant difference between 90-day PHQ-9 scores in the fluoxetine-treated (mean=4.1 points, standard deviation=3.2; 11% depression) and untreated (mean=4.4, standard deviation=4.8; 19% depression) groups, p=.69. In the multivariable analysis, older age (β=0.08, p=.03) and higher NIHSS score (β=0.15, p=.04), but neither fluoxetine (β=0.57, p=.59) nor sex (β=-0.51, p=.63), were significantly associated with more depressive symptoms.

CONCLUSIONS

Our findings parallel results from trials from higher income settings that fluoxetine does not significantly improve post-ischemic stroke depression, although our sample size was small. More work is needed to depict the longitudinal nature and treatment of post-stroke depression in Sub-Saharan Africa.

Depression, Anxiety, and Suicide After Stroke: A Narrative Review of the Best Available Evidence

Depression and anxiety each affect around 1 in 3 people during the first year after a stroke. Suicide causes the death of about 3 to 4/1000 stroke survivors during the first 5 years. This narrative review describes the best available evidence for the epidemiology of depression, anxiety, and suicide; their prevention; and the treatment of anxiety and depression. We conclude with directions for future research.