Does depression lead to stroke?

Depression is the most common condition observed in the present condition. But ‘depression leading to stoke’ terrorizes us all.

Even though this is a commonly occurring disorder, when unattended leads to serious consequences emotionally and physically. It is quite a surprise to know that directly or indirectly the physical body is affected by depression. Yet it is unknown as to why and how there is a connection with the emotion and body.

Brain is an important part of our organ system. When something affects brain such as stroke, it needs the at most attention to avoid risk. Stroke can occur at any age and it is not gender specific. Perhaps it can even occur in an unborn child (inside the womb).

Everyone under goes depression in some point of time, however the severity is very minimal. At the same time, we do observe a lot of people suffering from chronic depression which requires medical attention.

The more we see the illness leading to critical disorder, more is the fear within everyone. So, we must have enough knowledge and awareness to avoid complication. This very question alerts to dig more information on

·       If depression really does have risk of getting stroke?

·       If it does, how?

·       What is the risk factor?

It is generally observed that depression is a common emotional disorder seen post-stroke (post-stroke depression [PSD]). But recent studies were made and observed that patients suffering from stroke had history of depression.

Firstly, lets understand the terms.

Depression

Depression is a medical illness which provide negative impact on emotion that may trigger negative action on oneself or others. It often involves feeling of loneliness, sadness, loss of interest in activities which previously gave happiness, or any negative senses.

Depression is a disorder that affects the mood, body, sleep, eating and thoughts. It is characterized by extent of mood change that intervenes one’s day to day activity.

Symptoms:

·       Loneliness

·       Feeling hopeless or worthless

·       Deprived in energy

·       Irritability

·       Lack of interest in any activity

·       Loss of appetite

·       Suicidal idea

·       Difficulty in sleeping

 

Stroke 

Strokes is caused when there is interruption in the flow of blood to the brain. It is often observed due to blood clot or rupture in the arteries.

There are two types of strokes:

1.    Ischemic stroke: A stroke caused by a clot is called an ischemic stroke (87%).

2.    Haemorrhagic stroke: These are strokes caused by bleeding (13%).

Symptoms:

·       Sudden numbness or weakness in body parts, especially on one side

·       Sudden confusion

·       Sudden trouble talking or understanding speech

·       Sudden issues of vision in one or both eyes

·       Sudden severe headache

·       Inability to balance body, dizziness, or difficulty in walking

Relation between depression and stroke

There are studies stating that about 18-61% of the stroke survivors experienced depression know as post-stroke depression, however the recent studies found out that there were previous episodes of depressions prior to stroke. It is also observed that depression may increase the risk of stroke and fatality due to stroke.

Scientists have found out neurological condition known as pre-stroke depression which enhances the risk of dying from stroke.

There were studies done to prove the link between depression and risk of stroke by performing 4-question test to measure depression levels.

•          “Yes” equals a point

•          “no” equals zero point

•          Values 1 through 4 indicates various degree of depression level

On evaluation for 9 years, the patients who scored above zero had increased risk of stroke by 39% and values of four had 54% higher risk of stroke.

There are a few assumptions and predictions made, which could be the reasons for increasing the risk of stroke due to depression.

1.    Depression causes inflammation throughout the body, due to increase in inflammation markers in the bloodstream. This causes increase in severity of depression, risk of stroke or even lead to fatality.

2.    There are behavioral changes due to depression. When a person under goes depression, they tend to involve in an unhealthy behavior. Such as smoking, reduced healthy eating habits, less exercise, etc. that may lead to increasing the risk of stroke.

When the person fails to take prescribed medication for blood pressure or cholesterol-lowering drugs. The increase in blood pressure and cholesterol are major risk factors for the cause of stroke.

3.    Antidepressant medication used for treating depression may also be the cause

Below is a study showing that depression may leads to stroke and outer outcomes:

·       ‘Depression and risk of stroke: a meta-analysis of prospective studies’ by Jia-Yi Dong, Yong-Hong Zhang, Jian Tong and Li-Qiang Q

 

This study was performed to find the association between depression and risk of stroke.

This study was a meta-analysis study which is community-based or population-based prospective studies. The relevant studies were identified through May 2011

The study was made on 17 prospective studies considering 206,641 participants and 6086 cases confirmed positive association with depression and risk of stroke. Patients with history of depression had 34% higher risk to experience stroke.

To fill the gaps in the meta-analysis, an updated meta-analysis was made by cross referring to medication history of those patients.

In the observational study, it was seen that patients taking medication to treat depression were more likely to have stroke than the once who did not take medication. It was seen that depression medication were prone to have severe depression symptoms and increased risk of stroke.

But we should not be misunderstood to avoid or assume to be unsafe anti-depressants to treat depression. The interaction among some medications and side effects needs close monitoring. And the patient must make sure all the medication details that they take has to be shared to the physician.

Herbal medication for depression should be discussed with physician before trying, since recently one of the scientists discovered that St. John’s wort, over the counter herbal medication for depression was found to be harmful when interaction with other medications.

Antidepressants and stroke

Antidepressant treatment is used to improve stroke outcome; however, it was observed that certain antidepressants (such as selective serotonin reuptake inhibitors [SSRIs]) cause the bleeding by inhibiting aggregation of platelet and increasing the risk of stroke.

There were new studies being conducted to overlook if the antidepressants used by the patients may cause stroke. To know the most common antidepressants prescribed in India, the study conducted was ‘Prescription pattern of antidepressants in five tertiary care psychiatric centres of India’ by Adarsh Tripathi, Ajit Avasthi, Avinash Desousa, Dipesh Bhagabati, Nilesh Shah, Roy Abraham Kallivayalil, Sandeep Grover, J.K. Trivedi, and Naotaka Shinfuku.

The common drugs for depression, fall into the following class of drugs:

•          selective serotonin reuptake inhibitors (SSRIs)

•          serotonin-norepinephrine reuptake inhibitors (SNRIs)

•          tricyclic antidepressants (TCAs)

•          tetracyclic antidepressants

•          dopamine reuptake blockers

•          5-HT1A receptor antagonists

•          5-HT2 receptor antagonists

•          5-HT3 receptor antagonists

•          monoamine oxidase inhibitors (MAOIs)

•          noradrenergic antagonists

The study came up with data for the most used medication for depression. There were about 79.2% of the prescription were SSRI class of drug and escitalopram was the most common prescribed (40%), followed by sertraline (17.6%) and fluoxetine (16.3%).

Since SSRI was the most used class of drugs for depression, many studies were conducted to see the involvement of SSRI drugs in the increase of stroke risk.

The below are the few SSRI drugs prescribed for depression

·       sertraline (Zoloft)

·       fluoxetine (Prozac, Sarafem)

·       citalopram (Celexa)

·       escitalopram (Lexapro)

·       paroxetine (Paxil, Pexeva, Brisdelle)

·       fluvoxamine (Luvox)

Common side effects of SSRIs include:

·       nausea

·       trouble sleeping

·       nervousness

·       tremors

·       sexual problems

Studies were conducted to verify if the antidepressants (SSRI used to treat depressant) increased the risk of stroke are listed below.

1.    ‘Use of Antidepressants and Risk of Incident Stroke: A Systematic Review and Meta-Analysis’ by Trajkova S, D’Errico A, Soffietti R et al.
2.        ‘Risk of first onset stroke in SSRI-exposed adult subjects: Survival analysis and examination of age and time effects’ by Chan C. Huang H, Lin C et al.
3.        ‘Impact of prestroke selective serotonin reuptake inhibitor treatment on stroke severity and mortality’ by Janne Kaergaard Mortensen, Heidi Larsson, Søren Paaske Johnsen, and Grethe Andersen

All these studies observed independent increase in risk of stroke on the use of SSRIs.

In the other hand, one of the studies observed increase in severity and mortality in patients with haemorrhagic stroke within 30 days than ischemic stroke. However, in contradiction the 8-year study observed that SSRI use is more likely to be in ischemic than haemorrhagic.

It is assumed that the mechanism of stroke may be due to cerebral micro bleeding or over correction of haemostasis function.

There are not enough data available to provide a broad view of the mechanism involved in the increase in stroke risk with history of depression. Yet from the available data we can conclude few things. The depression causing inflammation may lead to severity of the condition and lead to risk. Other simple logic is the change in behavior changes that could be the possible reason to increase in risk of stroke.

Other observations were made and found that patients taking antidepressants (especially SSRIS) were more prone to increase in risk of stroke. However, the reason may be depression itself or the antidepressant medication is unclear.

There is inconsistency in the outcome of the study (probability of ischemic or haemorrhagic stroke). This unclear data needs more attention and research.