Treatment with an antidepressant may improve recovery from dysphagia after acute ischemic stroke (AIS).
Results of a prospective, cohort study showed patients with AIS who were prescribed an antidepressant at hospital discharge were nearly three times more likely to recover the ability to eat a full oral diet within 3 months than peers who did not receive an antidepressant.
“This is the first study that demonstrates an independent association between antidepressant intake and improved dysphagia recovery following acute ischemic stroke,” Anel Karisik, MD, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria, wrote.
The study was published online on February 13 in Stroke.
Common and Troubling Complication
Poststroke dysphagia — difficulty swallowing following a stroke — is a common and serious complication, contributing to malnutrition, aspiration, pneumonia, and increased mortality.Beyond its physical consequences, dysphagia can significantly impair quality of life and has been linked to poststroke depression and fatigue, both of which may hinder rehabilitation.
Although antidepressants, particularly selective serotonin reuptake inhibitors (SSRI), have been widely studied for poststroke depression, their effect on dysphagia recovery has remained unclear.
To investigate, researchers analyzed data from patients with AIS enrolled in the STROKE-CARD trial and STROKE-CARD registry, both conducted at the University Hospital of Innsbruck, which serves as a comprehensive stroke center.
Dysphagia was assessed using a standardized three-step protocol, including the Gugging Swallowing Screen, comprehensive clinical swallowing assessments, and fiberoptic endoscopic evaluation when needed.
Swallowing impairment was categorized using the Functional Oral Intake Scale (FOIS), and persistent dysphagia was defined as failure to return to a full oral diet at discharge and at 3 months (FOIS < 7).
Higher Recovery Rate
At hospital admission, 380 of the 2046 patients (19%) had dysphagia. The condition persisted in 290 patients (15%) at discharge and in 95 patients (5%) at 3 months.
Among the 290 patients with dysphagia at discharge — the primary study cohort — antidepressant use increased from 5% before stroke to 28% at discharge and 49% at 3 months (P < .001). SSRI were the most commonly prescribed antidepressant class, accounting for 59% of prescriptions at discharge.
Overall, 195 of the 290 patients (67%) with dysphagia at discharge achieved full oral diet resumption by 3 months, with significantly higher recovery rates in patients discharged on antidepressant medication (79% vs 63%; P = .01).
Among antidepressant subclasses, recovery rates were 83% for SSRI, 71% for serotonin-norepinephrine reuptake inhibitors, 69% for other antidepressants, and 83% for combination therapy. All subclasses showed higher recovery rates than patients without antidepressant therapy (63%).
After adjusting for age, stroke severity, depression, disability and other clinical factors, antidepressant use at discharge remained independently associated with improved dysphagia recovery (adjusted odds ratio, 2.98; P = .002).
The researchers cautioned that the study was observational and not designed to establish causality. Antidepressant intake was not randomized and there was no detailed information on dosing, titration, and adherence.
In addition, swallowing assessments were not formally blinded to antidepressant use, and treatment decisions were made for depressive or psychosocial reasons rather than swallowing impairment.
The researchers called for randomized-controlled trials to validate this “exploratory association and to determine whether antidepressants may have a role as an adjunct to dysphagia rehabilitation.”
A Plausible Mechanism
Reached for comment, Daniel T. Lackland DrPH, professor and director, Division of Translational Neurosciences and Population Studies, Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, said the higher recovery rate and improved odds of recovery with antidepressant therapy after AIS are “important” observations.
Mechanistically, it’s plausible that antidepressants may help with dysphagia recovery, Lackland noted.
“Studies on fluoxetine (Prozac) indicate it may enhance swallowing function by promoting neuroplasticity, increasing neurotrophic factors like brain-derived neurotrophic factor and nerve growth factor, and improving the survival of neurons in damaged brain areas,” Lackland, who wasn’t involved in the study, told Medscape Medial News.
“In addition, there is a strong link between persistent dysphagia and poststroke depression, which can impede rehabilitation. Antidepressants may indirectly support recovery by improving the patient's emotional state and motivation,” he noted.
Lackland agreed that more study before antidepressant therapy can be formerly recommended for poststroke dysphagia.
“While these observational study findings are promising, randomized controlled trials are still needed to definitively determine if antidepressants should be used as a routine adjunct to dysphagia ,” he said.
This study had no commercial funding. The authors and Lackland reported having no relevant disclosures.
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