Antidepressants and stroke risk

Recently, a new study was published online in the American Journal of Psychiatry which revealed that there is a link between antidepressant therapy and the increased risk for stroke (http://ajp.psychiatryonline.org/cgi/content/abstract/168/5/511).

Dr. Susan Shur-Fen Gau, MD, PhD, professor and chairperson of the Department of Psychiatry at National Taiwan University and senior author of the study said that the results of their study had shown proof which reinforces their hypothesis on acute exposure to antidepressants, most especially those medications which prevents serotonin transport, and increased stroke risk.

Serotonin

Serotonin is a hormone which operates as a neurotransmitter.  It helps relay messages from one area of the brain to another. It is manufactured in the brain where it carries out its primary function. However, majority of our serotonin supply can be located in our digestive tract and in our blood platelets.

Aside from being a neurotransmitter, it also influences a number of our psychological and physiological body functions. It affects our mood, sexual desire and function, appetite, sleep, memory and learning, regulates body temperature and other social behavior.

Depression

It is a common misconception that depression is associated with feelings of sadness or gloom. The National Library of Medicine clears this out by defining it as more than just a feeling but involves the following symptoms:

• loss of interest of activities previous enjoyed
• a change in weight and/or sleeping habits
• energy loss
• feeling “less valued” in life

According to the NLM, the usual causative factors of depression are genetic, environmental, psychological and biochemical factors. Based on statistics, illness is more common in women. The disparity of depression between males and females can be attributed to coping with menstrual cycles, pregnancy and menopause according to the website of the Mayo Clinic. The NLM also said that it can develop as early as 15 years of age. This can be credited to girls typically reaching puberty before boys. It is believed that the frequent hormonal changes during the stage of puberty greatly increase the risk of developing depression in some women.

Treatment of the disorder includes taking antidepressant medications and undergoing talk therapy. Patients may also do best by using both treatments.

Serotonin and depression

Scientists believe that an imbalance in serotonin levels in our body leads to depression. They identified these problems as decreased production of serotonin by the brain, decreased number of receptor sites which can absorb serotonin, the inability of serotonin to reach these receptor sites and the shortage of tryptophan (the chemical from which it is made from). Aside from depression, if these problems occur a person may experience other mental health illnesses such as obsessive-compulsive disorder, anxiety, panic and even anger.

Antidepressant medications

The most common types of antidepressants are called selective serotonin reuptake inhibitors (SSRIs). These medications block the absorption of serotonin on other areas of the body which results to a higher level of serotonin which can be absorbed by receptor sites in the brain. The most common medications are Fluoxetine (Prozac), Citalopram (Celexa), Sertraline (Zoloft), Paroxetine (Paxil) and Escitalopram (Lexapro).

Antidepressant use and stroke risk

Chi-Shin Wu, MD, from Far Eastern Memorial Hospital and a co-author of the study said that depression is known to be an independent risk factor for stroke but whether treating depression with antidepressants reverses this risk is not known.

The authors said that there are increasing concerns on antidepressant therapy and its effects on the cerebrovascular system. This is a result of the growing body of evidence which had shown that antidepressants, most notably SSRIs, can cause bleeding problems and vasoconstriction of the large arteries of the brain.

Dr. Wu and his co-authors made their study to shed more light on whether antidepressant medications do cause cerebrovascular events. Their study involved 24,214 stroke patients who were enrolled in the National Health Insurance Research Database of Taiwan from the years 1998-2007.

Dr. Wu and his study team evaluated the rates of antidepressant medication use by the stroke survivors within a week, two weeks and for one month. They found out that the stroke patients had a mean age of 68.6 years when they had their stroke. They noted that almost half (48.3%) of the subjects were women and that 8789 (36.3%) stroke patients had mood disorders. They also observed that majority of the subjects (75.9%) had experienced an ischemic stroke.

Dr. Wu and his team said that the risk for a stroke grew by 48% if the use of anti-depressant medication was 2 weeks prior to the stroke. But, they did note that there was no association between stroke and the number of antidepressant prescriptions of the previous year.

They added that there was no link between taking antidepressant medication and stroke risk in the two weeks before the stroke for patients who are already taking 3 to 5 antidepressant prescriptions in the previous year. They did point out that the risk of having a stroke is decreased for patients who were already taking more than 6 antidepressant prescriptions. On the other hand, patients taking 1 to 2 antidepressant medications had a greater risk of stroke. They also emphasized that there is an increased risk of stroke for patients who use SSRIs than other types of antidepressant medications.

The authors of the study stated that their findings are similar with previous studies which had shown that a high inhibition of the serotonin transporter can cause a more potent anti-platelet effect and is more associated with a higher risk of abnormal bleeding in other organ systems.  They also pointed out that patients taking high-potency serotonin inhibitors were associated with a greater risk of having an ischemic stroke. They theorized that this is a result of antidepressant-induced constriction of the blood vessels of the brain.

These results made the study team comment that underlying mechanisms for stroke risk in relation to antidepressant use should be investigated more.  They made this assessment after also finding out that patients who were long-term users of antidepressants may actually be protected against a stroke.

These paradoxical findings need to be further studied. They said that the results may indicate that the frequency of exposure to antidepressant medications changes over time. They also hypothesized that their results might have been influenced by other factors such as emotional distress. They also pointed out that using a database as reference is not a sure fire way of measuring adherence to the medications.

In spite of these limitations, they still believe that the results of their study have a major clinical and public health implication. They suggested that patients start with low doses of antidepressants while monitoring side effects most especially to patients who are at a greater risk of having a cerebrovascular event because stroke risk appears to be more of dose related and more noticeably during the first few prescriptions.

Inconsistent Findings

Patients who were taking low-potency serotonin inhibitors should not rejoice prematurely.  The team pointed out that the use of low-potency serotonin inhibitors is associated with a higher risk for any stroke type.

Dr. Gau repeated their team’s prior recommendation of closely monitoring patients who were newly started on antidepressant medications. She said that antidepressant therapy should be started at low doses and closely monitoring the side effects for initial prescriptions most notably for patients with a higher stroke risk. She added that patients who were at a greater risk for stroke should be advised to use other antidepressant with a decreased affinity of serotonin reabsorption as treatment for their depression.

Reference:

Medscape.com

Nlm.nih.gov

Ajp.psychiatryonline.org

Emedicinehealth.com

Webmd.com

Mayoclinic.com

Fugl-Meyer Assessment after a stroke

There are several words in the English vocabulary that denotes some form of ranking. In terms of number there are the words first, second and third, etc. There are also other words which can denote some form of status between people, objects and things such as good, better, and best, bad, worse and worst, etc.

In the field of stroke recovery, there are also words to denote some form of evaluation which can be used in patients who had just experienced a stroke. Examples of such words are weak or strong, weaker or stronger and others. These words are helpful in giving and determining the current status of a patient. Healthcare providers use them in assessing the difference between the unaffected and affected side of the stroke patient’s body.

However, these words are very subjective and will depend on the judgment of a person. A physician’s assessment of a stroke patient may differ from another member of the stroke rehab team. This may cause a problem since objectivity should always be practiced when assessing a stroke victim.

A complete assessment should be made for the benefit of the stroke survivor which will be used as reference for proper therapeutic management and for the stroke patient’s rehabilitation. Also, the advent of new treatments and rehab options for post-stroke therapy has made measuring recovery after a stroke very important. Aside from establishing the plan of treatment for the stroke patient, such assessments can also prepare the stroke survivor, his or her family and his or her significant other for any anticipated and expected outcomes. A tool currently employed by members of the healthcare team in properly evaluating patients is the Fugl-Meyer Assessment (FMA) for Motor Recovery after a Stroke.

The Fugl-Meyer Assessment (FMA)

The FMA is a stroke-specific and performance-based impairment index. This means that all stroke survivors are considered unique and that a grading system is in place for proper evaluation.  Basically, what it does is it can determine the severity of the stroke, describe motor recovery, plan the post-stroke treatment and evaluate these treatments. It also evaluates the capacity of the stroke survivor to perform activities of daily living (ADL) and pain. Evaluation can be done immediately after a stroke and can be repeated while the stroke patient is already undergoing therapy. It was developed  to be used in both clinical and research setting and is the first quantitative evaluation tool based on the chronological stages of motor and sensory return in hemiplegic (paralysis of either left or right side of the body) stroke patients. It allows the healthcare team to properly measure the motor and sensory recovery of survivors after a stroke (http://physical-therapy.advanceweb.com/Article/The-Fugl-Meyer-Assessment-After-Stroke.aspx).

Aside from motor and sensory functions, it can also assess balance and joint function in post-stroke patients.

A physical therapist, an occupational therapist or any other rehab professional trained on FMA can administer the evaluation on the stroke patient on a one-on-one basis. The person tasked to administer the test shall guide the stroke victim through test through demonstration and by giving out verbal instructions.

It can be applied in any setting – a hospital, a clinic even at the stroke survivor’s home. Most importantly, it does not need any special equipment. Although, it does require a mat or a bed and a number of small objects for assessment of sensation, reflexes and range of motion (ROM).

The test tracks the stroke patient’s progress from the initial day that he or she had the stroke to days, weeks, months or even years post-stroke.

Sections of the evaluation can be administered separately. The FMA is that it usually takes about 30-35 minutes to administer the whole test. A copy of the FMA can be obtained by following the link towards the Institute of Rehabilitation Medicine, University of Gothenburg, in Sweden http://www.neurophys.gu.se/sektioner/klinisk_neurovetenskap_och_rehabilitering/neurovetenskap/rehab_med/fugl-meyer/.

However, certain stroke patients may have difficulty with the assessments and may take longer than usual to finish the test. It had been found that the FMA is quite challenging to administer to aphasic (has problems with speech or language) and severely affected patients post-stroke.  Since it is based on direct observation, stroke victims who need a proxy to complete tasks will not be permitted to undergo the test.

Features and scoring

• Scoring in the FMA is based on direct observation of the stroke survivor’s performance and is based on the ability to complete an item in the test.  Items in the FMA are scored on a 3-point scale.
  • 0 = cannot perform
  • 1 = performs partially
  • 2 performs fully

• The maximum score that a stroke patient can have is 226 points

• There are five domains which is evaluated by the occupational or physical therapist
  • Motor function – this part of the test includes assessing the movement, coordination and reflex action of the shoulder, elbow, forearm, wrist, hand, hip knee and ankle. The score for this test range from 0 (paralysis) to 100 (normal motor function). The total score is divided into:
    • Upper extremity maximum score = 66
    • Lower extremity maximum score = 34
  • Sensory function (evaluates light touch on two surfaces of the arm and leg, and position sense for 8 joints) maximum score = 24
  • Balance (contains 7 tests, 3 seated and 4 standing) maximum score = 14
  • Joint range of motion (8 joints) maximum score = 44
  • Joint pain (maximum score 44)

Depending on the need, each of the five domains of the test can be administered without using the full FMA evaluation. This means that if the therapist wishes only to evaluate upper extremity function, the subsections which specifically deal with assessing upper extremity movement, sensation, joint motion and pain can be performed without having to administer the full test. Also, modified or shortened versions had been developed for these purposes.

References:

Ncbi.nlm.nih.gov

Medicine.mcgill.ca

Rehabmeasures.org

Neurophys.gu.se

Medical-dictionary.thefreedictionary.com

What is Hypertension?

The American Heart Association (AHA) defines hypertension as blood pressure measurements of 140 over 90 or higher. Any readings with levels below 120 over 80 are considered healthy and acceptable. The table below illustrates what category the person is in depending on his blood pressure readings:

What does the number mean?
The two numbers correlate to the pressure of the heart when it beats and contract and the pressure when the heart relaxes between beats. The top number is called the systolic pressure; this is when the heart contracts (like when you squeeze a balloon filled with water). The diastolic pressure or the second number is when the heart relaxes (or when you fill the balloon again with water). The unit of measurement used in measuring blood pressure is millimeters of mercury (mm Hg). Continue reading →

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