Sertraline for Treatment of Post-Stroke Anxiety

To the Editor: Approximately 35% of patients with stroke suffer symptoms of anxiety¹ and about 17%–18% severe enough to have a DSM-IV-TR diagnosis of an anxiety disorder.² Poststroke anxiety can lead to significant distress impairment on the subject’s daily functioning, interpersonal relationships and quality of life. There are very few studies on the treatment of poststroke anxiety. In a comparison study of acupuncture versus alprozolam, Wu and Liu (2008)³ found acupuncture to be safe and tolerable with improvement in anxiety but no different than alprazolam with regards to effectiveness. There are no other pharmacological studies on the treatment of poststroke anxiety. Since serotonin-selective reuptake inhibitors (SSRIs) are indicated for several anxiety disorders, we conducted a 16-week pilot study to assess the safety and tolerability of sertraline for the treatment of poststroke anxiety. We chose sertraline because it is well tolerated in the treatment of poststroke depression^4,5 and has minimal drug-drug interactions particularly with warfarin anticoagulation therapy⁶ which is frequently used for secondary prevention of recurrent stroke.

We enrolled 4 subjects (3 females and 1 male) in an open-label flexible dose trial (25-200 mg). All 4 had diagnosis of Anxiety Disorder Secondary to General Medical Condition (stroke). Three had comorbid major depression and the fourth suffered from pathological tearfulness. The range of ages was 37-82 years. Three of them had right-hemispheric strokes and the fourth recurrent brain stem strokes. Time duration since stroke ranged from 1 to 5 years. Using the Clinical Global Impression (CGI) scale to assess severity of anxiety, three subjects were “severely ill” and the 4th “moderately ill”. All subjects were started on sertraline 25 mg. The dose was increased by 25-50 mg during the follow-visits. The decision to increase was based on the clinical judgment of the psychiatrist (VR). The last adjustment was made at week 12 giving a 4 week period to assess the nature/ onset of side-effects and maximum dose effect.

Three subjects tolerated sertraline treatment (two of them were on 100 mg and the third 75 mg) well without no adverse events and were rated as “much improved” on the CGI, Global Improvement Score and also had improvement on both the Clinical Anxiety Scale (mean pretreatment versus posttreatment score = 15.6 versus 2) and Hamilton Depression Rating Scale (mean pretreatment score = 19.67 versus mean posttreatment score = 2.67). One subject withdrew from the study after 4 weeks of treatment secondary to worsening anxiety. Sertraline was started at 25g and after 3 weeks increased to 50 mg. Even though it was unclear if the anxiety was related to the medicine or a symptoms of the illness, the subject chose to withdraw from the study and continue treatment with her primary care physician.

The results of this open label pilot study point toward the need for systematic assessment of the efficacy of antidepressants for poststroke anxiety in randomized controlled trials, given the importance of treating anxiety for reducing poststroke morbidity.