Increased frequency of first episode poststroke depression following discontinuation of escitalopram

Abstract

Background and Purpose

To compare escitalopram, problem-solving therapy (PST), and placebo, to prevent poststroke depression during 6 months after discontinuation of treatment.

Methods

We examined for depression, 33 patients assigned to placebo, 34 to escitalopram, and 41 to PST.

Results

After controlling for age, gender, prior mood disorder, and severity of stroke, new onset major depression and Hamilton Depression scores were significantly higher 6 months after escitalopram was discontinued, compared to the PST or placebo groups.

Conclusions

Discontinuation of escitalopram may increase poststroke depressive symptoms.

We previously reported that non-depressed patients given placebo over 1 year following stroke were 4.5 times more likely to develop new onset depression than patients given escitalopram and 2.2 times more likely than patients given PST.¹

In the current study, we examined the frequency of major depression and changes in Hamilton Depression Rating Scale (HDRS)² in this population 6 months following discontinuation of treatment. We hypothesized the preventive benefit of escitalopram and PST compared to placebo would continue after cessation.

Patients and Methods

The patient population was described in detail in prior publications. ¹ Non-depressed patients age 50 to 90 were enrolled within 3 months of an index stroke, from The University of Iowa, the University of Chicago, and Burke Rehabilitation Hospital.

In a randomized controlled design, patients were assigned for 12 months to escitalopram (10 mg/d ≥65 years; 5 mg/d >65 years), placebo, or PST. The PST, developed for treating medically ill patients with depression,³ consisted of 12 sessions in which the patient selected a problem and used a 7-step process to arrive at a course of action.

Using the Structured Clinical Interview for DSM-IV diagnosis (SCID)⁴ and the HDRS, ² patients were assessed for major depression and its severity 6 months after cessation of treatment. Secondary outcome measures included activities of daily living using the Functional Independence Measure (FIM).⁵

Escitalopram, PST, and placebo groups were compared using Kruskal-Wallis test for continuous variables and Fisher’s exact test for categorical variables. Changes in HDRS were compared using a linear regression model with covariates of age, gender, prior history of mood disorder, treatment received (escitalopram versus non-escitalopram), and FIM at 12 months since we assumed these variables might influence the HDRS during the 6-month follow-up.

Results

A total of 33 patients randomized to placebo, 34 to escitalopram, and 41 to PST were examined 6 months after cessation. Baseline characteristics showed no significant intergroup differences (Table 1). Frequency of major depression was 4 cases for escitalopram (11.8%) versus 0 for placebo (Fisher’s exact test; P=0.1139), and 0 for PST (Fisher’s exact test; P=0.0382).

Table 1.

Baseline characteristics of poststroke patients in the placebo, escitalopram, or problem-solving therapy groups

	Placebo (n=33)	Escitalopram (n=34)	Problem-Solving Therapy (n=41)	Test Results	P value
Age, mean(SD), y	67.5 (12.5)	63.7 (13.9)	66.1 (10.6)	Kruskal-Wallis (χ2 (2)=1.90)	0.3870
Male, %	63.6	61.8	48.8	Fisher’s exact	0.3825
Married, %	51.5	55.9	51.2	Fisher’s exact	0.9128
Previous history of depression, %	0	8.8	2.4	Fisher’s exact	0.1942
Education, mean (SD), y	13.3 (3.2)	13.9 (2.6)	14.0 (3.0)	Kruskal-Wallis (χ2 (2)=0.62)	0.7351
Stroke characteristics, %
Large-artery atherosclerosis	30.3	29.4	29.3	Fisher’s exact	1.000
Small-artery occlusion	30.3	20.6	34.1	Fisher’s exact	0.4117
Cardioembolism/Other	30.3	44.1	29.3	Fisher’s exact	0.3627
Left-side lesions	45.5	55.9	34.1	Fisher’s exact	0.1665

The escitalopram group showed significantly increased HDRS scores only at 18 months (Kruskal-Wallis test; χ² (2), 10.05; P=0.0066) (Table 2). Alinear regression model covaried for age, gender, prior history of mood disorder, escitalopram versus non-escitalopram, and severity of stroke as measured by FIM at 12 months showed a beta coefficient for change in HDRS for “escitalopram versus non-escitalopram” of 1.87 (95% CI, 0.41–3.32; P=0.0125). There was no effect of treatment on change in FIM score (beta-0.64, 95% CI 2.23–0.94, p=0.42).

Table 2.

Scores of HDRS, FIM and SFE at Baseline, 12 months and 18 months

	Placebo (n=33)	Escitalopram (n=34)	Problem-Solving Therapy (n=41)	Test Results (Kruskal-Wallis test, χ2 (2))	P value
	Mean (SD)
HDRS score at baseline	5.9 (2.8)	7.1 (3.9)	5.9 (2.9)	2.02	0.3635
--12 months	5.0 (2.8)	5.6 (3.3)	4.7 (3.8)	2.40	0.3010
--18 months	4.5 (2.3)	6.9 (4.6)	4.0 (2.9)	10.05	0.0066
FIM score at baseline	117.4 (10.5)	113.4 (18.6)	113.0 (14.8)	1.21	0.5468
--12 months,	121.6 (4.5)	118.3 (11.6)	121.6 (4.2)	1.45	0.4837
--18 months	121.4 (4.5)	117.4 (13.6)	121.3 (4.7)	3.38	0.1842

HDRS, Hamilton Depression Rating Scale; FIM, Functional Independence Measure.

Discussion and Summary

This study found that non-depressed stroke patients, who discontinued escitalopram after 12 months, were more likely to develop major depression and increased HDRS scores during the next 6 months than patients given placebo or PST.

This study is limited by not including acute stroke patients such as those with severe co-morbid illness. Furthermore, the number of new major depressions were relatively small. Thus, our findings should be considered preliminary.

For clinicians, the most important implication of our finding is that patients, given antidepressants following stroke, may be more prone to develop depressive symptoms than untreated patients once their antidepressants are stopped. They may need to be monitored for depression for at least 6 months. Furthermore, treatment for longer than 1 year may be needed or slow tapering of antidepressants. Since PST effectively prevented poststroke depression and no new depressions occurred after cessation, should PST be the first treatment? Perhaps, but the lack of general availability of PST and administration of 12 therapy sessions will probably limit its use.

Cessation of escitalopram may have led to increased depressive symptoms because drugs like escitalopram produce changes in enzymes involved in synthesis and metabolism of biogenic amines and receptors and neuroplastic changes in hippocampus and prefrontal cortex.^{6, 7} Abrupt withdrawal of escitalopram may have led to neural system dysfunction and depression. Increased depressive symptoms after cessation of antidepressants has been reported in other studies. ^8,9 It is important to remember that antidepressants may improve cognitive¹⁰ and physical recovery¹¹ following stroke.