Intracranial haemorrhage and use of selective serotonin reuptake inhibitors

Effects of selective serotonin reuptake inhibitors on platelet functions: a literature review

PURPOSE OF REVIEW

Many epidemiological studies have evidenced an increased bleeding risk associated with selective serotonin reuptake inhibitors (SSRIs), yet the underlying mechanisms remain unclear. This review summarizes data on SSRIs' effects on platelet functions assessed with assays used in clinical practice and highlights the areas that deserve further investigation.

RECENT FINDINGS

Conflicting results of SSRI effects on platelet aggregation were observed irrespectively of the agonist used, the antidepressant drug or the study type. Alike, discrepant results were reported with flow-cytometry-based assays assessing either platelet surface glycoprotein levels, integrin activation, agonist-induced secretion of intraplatelet granule content or membrane anionic phospholipid exposure. Other tests may have detected a platelet function defect in SSRIs samples, however, results were largely inconsistent.

SUMMARY

Critical literature examination unveils very low certainty of evidence on potential SSRI effect on platelet functions. Findings are often inconsistent even when similar methods are used, most likely because of differences in study design, included patients (age, comorbid conditions), SSRIs' type and dose, uncontrolled confounding factors, and statistical analysis power. Further studies are needed to disentangle any intrinsic antiplatelet effect of SSRIs and the multiple confounding factors, mainly the depression control itself and the degree of platelet SERT inhibition.

Is SSRI use a risk factor for intracranial hemorrhage after craniotomy for tumor resection?

Introduction

Prior studies have identified SSRI use as a risk factor for certain adverse bleeding outcomes. However, the risk of significant bleeding from perioperative SSRI use after brain tumor resection remains largely undetermined. This study evaluates if patients taking SSRIs perioperatively have a higher risk of intracranial hemorrhage (ICH) following elective craniotomy for tumor resection.

Methods

Researchers reviewed electronic medical records of patients age 18 and older, who received elective craniotomy for tumor resection between 2010 and 2019. Data collection included subject demographics and relevant medical history. We compared intracranial hemorrhage rates and risks between perioperative SSRI-use cohorts.

Results

Of 1,061 patients, 796 (75%) did not use SSRIs perioperatively while 265 (25%) used SSRIs perioperatively. Among those using perioperative SSRIs, 8 patients (3.0%) experienced an ICH within 1 week and 11 patients (4.2%) had an ICH within 1 month. Similarly, for those who stopped SSRI use perioperatively, we found 31 patients (3.9%) experienced an ICH within 1 week and 40 patients (5.0%) had an ICH within 1 month. Using logistic regression analysis, the relative risk for perioperative SSRI-use and ICH was statistically non-significant at 0.692 (95% CI: 0.260 - 1.839, p = 0.460).

Conclusions

Based on our results, perioperative SSRI use does not appear to result in an increased risk of bleeding within 1 week or month of craniotomy for tumor resection. These results remained consistent when controlled for several additional bleeding comorbidities and demographics between cohorts.

Escitalopram-induced epistaxis: A case report

Selective serotonin reuptake inhibitors (SSRIs) are a group of drugs used to treat various psychiatric disorders such as major depression, generalised anxiety, and obsessive-compulsive syndrome. Although generally safe, SSRIs can lead to various adverse effects, including an increased risk of bleeding due to their effect on platelet activation and aggregation. Unexpected bleeding can occur at different sites, in people of different age groups, and in combination with other medications. The commonly reported risk factors associated with medication-induced bleeding in patients with mental disorders include co-administration of other drugs and liver cirrhosis or failure. We report a relatively less common adverse effect of SSRIs. This is the case of a Middle Eastern man, known to have seasonal allergic rhinitis, who developed self-limiting epistaxis following the use of escitalopram for a depressive disorder. Since a history of seasonal allergy can precipitate bleeding when using SSRIs, risk factors for bleeding associated with SSRIs, excluding the common causes, should be explored for better management and prevention.

Influences of antidepressant medications on the risk of developing hyperlipidemia in patients with depression by a population-based cohort study and on in vitro hepatic lipogenic-related gene expression

BACKGROUND

Depression increases the risk of cardiovascular disease (CVD). The association between antidepressant medications (ADMs) and CVD remains controversial. Hyperlipidemia is a risk factor for CVD. We conducted a nationwide population-based retrospective cohort study to examine depression and ADM use on the risk of developing hyperlipidemia. The effects of ADMs on the expression of lipogenesis-related hepatic genes were also evaluated.

METHODS

We obtained data from the Longitudinal Health Insurance Database of Taiwan on patients with new-onset depression and a comparison cohort without depression. A Cox proportional hazards regression model was used to analyze the differences in the risk of developing hyperlipidemia between these two cohorts. We also examined the influence of ADMs on the expression of lipogenesis-related hepatic genes.

RESULTS

After adjustment for comorbidities and confounding factors, the case group (N = 38,322) had a higher risk for hyperlipidemia than that of the control cohort (N = 38,322) [adjusted hazards ratio (aHR) =1.16]. Patients with depression who did not receive ADM therapy exhibited a significantly higher risk of hyperlipidemia (aHR = 1.61). However, in patients with depression treated with ADMs, the risk of developing hyperlipidemia was significantly lowered compared to the patients without ADMs (all aHR < 0.81). Gene expression analysis indicated that ADMs downregulated the expression of lipogenesis-related hepatic genes.

LIMITATIONS

Unmeasured confounding risk factors for hyperlipidemia might not have been included in the study.

CONCLUSIONS

ADMs reduced hyperlipidemia risk in patients with depression, partly by downregulating the expression of lipogenesis-related genes and improving the patients' lipid profiles. Early diagnosis and management of hyperlipidemia would further facilitate the prevention of CVD.

Serotonergic Antidepressants and Risk for Traumatic Intracranial Bleeding

Background: Serotonergic antidepressants may predispose to bleeding but the effect on traumatic intracranial bleeding is unknown. Methods: The rate of intracranial bleeding in patients with antidepressant medication was compared to patients not antidepressants in a cohort of patients with acute head injury. This association was examined by using a consecutive cohort of head trauma patients from a Finnish tertiary center emergency department (Tampere University Hospital, Tampere, Finland). All consecutive (2010-2012) adult patients (n = 2,890; median age = 58; male = 56%, CT-positive = 22%, antithrombotic medication users = 25%, antidepressant users = 10%) who underwent head CT due to head trauma in the emergency department were included. Results: Male gender, GCS <15, older age, and anticoagulation were associated with an increased risk for traumatic intracranial bleeding. There were 17.8% of patients not taking antidepressants and 18.3% of patients on an antidepressant who had traumatic intracranial bleeding (p = 0.830). Among patients who were taking antithrombotic medication, 16.6% of the patients not taking antidepressant medication, and 22.5% of the patients taking antidepressant medication, had bleeding (p = 0.239). In a regression analysis, traumatic intracranial hemorrhage was not associated with antidepressant use. Conclusions: Serotonergic antidepressant use was not associated with an increased risk of traumatic intracranial hemorrhage.

Safety considerations for prescribing SSRI antidepressants to patients at increased cardiovascular risk

INTRODUCTION

With the development of selective serotonin reuptake inhibitors (SSRI), a relatively uncomplicated treatment of depression and a safer alternative to tricyclic antidepressants was introduced. Any medical treatment has potential safety risks, however, and these risks should also be considered when prescribing SSRIs.

AREAS COVERED

The present review focuses on safety considerations when prescribing SSRIs to patients with previous stroke and myocardial infarction, as depression, and the need for antidepressant treatment, is common in these patients. At the same time, patients with stroke and myocardial infarction may be at increased risk of developing adverse events due to higher age, comorbidity, and co-medication. Specifically, the evidence of the risk of QT prolongation and bleeding versus thrombotic events will be discussed in the present review.

EXPERT OPINION

No medical treatment comes without risk and SSRIs are no exception. Depression, a common complication after vascular events, is a potentially life-threatening condition in itself and relevant and sufficient treatment is imperative. SSRIs are often the first medical treatment choice in the ambulatory setting, also in patients at increased cardiovascular risk. Relevant comorbidity and co-medication, however, should always be taken into account when initiating treatment and when choosing a specific SSRI.

Selective Serotonin Reuptake Inhibitors and Intracerebral Hemorrhage Risk and Outcome

Background and Purpose- Selective serotonin reuptake inhibitors (SSRIs) have a well-established association with bleeding complications and conflicting reports on outcome after stroke. We sought to evaluate whether pre-intracerebral hemorrhage (ICH) SSRI use increased ICH risk and post-ICH SSRI use improved ICH outcome. Methods- Through post hoc analysis of the ERICH study (Ethnic/Racial Variations of Intracerebral Hemorrhage), SSRI use was categorized into no use, pre-ICH only, pre- and post-ICH use (termed "continuous"), and post-ICH only (termed "new"). Using multivariable modeling, associations were sought between pre-ICH SSRI use and ICH risk in the case-control set, and associations between post-ICH SSRI use and 3-month outcome were analyzed in the ICH case set. Exploratory analyses sought to assess influence of race/ethnicity in models. Results- The final study cohort consisted of 2287 ICH cases and 2895 controls. Pre-ICH SSRI use was not associated with ICH risk (odds ratio, 0.824 [95% CI, 0.632-1.074]) nor potentiation of ICH risk with anticoagulant or antiplatelet use. New post-ICH SSRI use was associated with unfavorable modified Rankin Scale score at 3 months after ICH (odds ratio, 1.673 [95% CI, 1.162-2.408]; P=0.006) in multivariable analyses. Additional propensity score analysis indicated a similar trend but did not reach statistical significance (P=0.107). When stratified by race/ethnicity, multivariable modeling demonstrated reduced ICH risk with pre-ICH SSRI use in Hispanics (odds ratio, 0.513 [95% CI, 0.301-0.875]; P=0.014), but not non-Hispanic whites or blacks, and no associations between post-ICH SSRI use and 3-month outcome in any racial/ethnic group. Conclusions- In a large multiethnic cohort, pre-ICH SSRI use was not associated with increased ICH risk, but post-ICH SSRI use was associated with unfavorable 3-month neurological outcome after ICH. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT01202864.

Antidepressant drug use and subdural hematoma risk

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) use may be associated with development of subdural hematoma (SDH).

OBJECTIVES

To estimate SDH risk associated with antidepressant use, including when combined with antithrombotics, or nonsteroidal anti-inflammatory drugs (NSAIDs).

PATIENTS/METHODS

We performed this case-control study based on Danish registries. We included 10 885 incident cases of SDH and 435 379 matched general population controls. We calculated odds ratios (95% confidence interval) adjusted for comorbidity, co-medication, education level, and income (aOR).

RESULTS

We found that current use of SSRIs (aOR1.32 [1.25-1.38]) and non-SSRIs (aOR 1.19 [1.13-1.26]) was associated with a higher SDH risk, compared with non-use of antidepressants. Risks were higher with short duration of current use (eg, <1 month of current use: aOR 2.55 [2.07-3.15] for SSRI, 1.88 [1.46-2.41] for non-SSRIs; >3 years of current use: 1.04 [0.93-1.17] for SSRI and 1.12 [0.98-1.28] for non-SSRIs). Combined use of antidepressants with either antithrombotics or NSAIDs yielded similar ORs to those observed for single use of antithrombotics or NSAIDs. Stronger associations were observed for antidepressants combined with both vitamin K antagonists (VKAs) and NSAIDs (SSRI, VKA, & NSAID: aOR 5.51 [2.70-11-22]; non-SSRI, VKA, & NSAID: 6.81 [2.37-19-60]).

CONCLUSIONS

Antidepressant use was associated with higher risk of SDH that seemed largely restricted to first year of treatment. In absolute terms this risk is judged to be small, given the low SDH incidence rate. With one possible exception (triple use of antidepressants, NSAIDs, and VKAs), risk estimates of SDH for combined regimens of antidepressants with antithrombotics or NSAIDs provided little evidence of interactions.

Treatment Approaches to Lacunar Stroke

Lacunar strokes are appropriately named for their ability to cavitate and form ponds or "little lakes" (Latin: lacune -ae meaning pond or pit is a diminutive form of lacus meaning lake). They account for a substantial proportion of both symptomatic and asymptomatic ischemic strokes. In recent years, there have been several advances in the management of large vessel occlusions. New therapies such as non-vitamin K antagonist oral anticoagulants and left atrial appendage closure have recently been developed to improve stroke prevention in atrial fibrillation; however, the treatment of small vessel disease-related strokes lags frustratingly behind. Since Fisher characterized the lacunar syndromes and associated infarcts in the late 1960s, there have been no therapies specifically targeting lacunar stroke. Unfortunately, many therapeutic agents used for the treatment of ischemic stroke in general offer only a modest benefit in reducing recurrent stroke while adding to the risk of intracerebral hemorrhage and systemic bleeding. Escalation of antithrombotic treatments beyond standard single antiplatelet agents has not been effective in long-term lacunar stroke prevention efforts, unequivocally increasing intracerebral hemorrhage risk without providing a significant benefit. In this review, we critically review the available treatments for lacunar stroke based on evidence from clinical trials. For several of the major drugs, we summarize the adverse effects in the context of this unique patient population. We also discuss the role of neuroprotective therapies and neural repair strategies as they may relate to recovery from lacunar stroke.

Selective Serotonin Reuptake Inhibitor Use and Risk of Gastrointestinal and Intracranial Bleeding

Selective serotonin reuptake inhibitors (SSRIs) are among the most commonly prescribed medications in the United States. Although SSRIs are highly tolerable relative to other antidepressants, they are associated with a number of adverse effects, including increased gastrointestinal tract bleeding and intracranial bleeding. Mechanisms include increased gastric acid secretion and inhibition of serotonin entrance into platelets. Patients with other bleeding risk factors, such as warfarin, clopidogrel, or aspirin use, may be at heightened risk of these adverse effects. The purpose of this article is to review the incidence of gastrointestinal tract bleeding or intracranial bleeding associated with concomitant SSRI use, the proposed mechanisms of, and the potential pharmacokinetic/pharmacodynamic interactions with anticoagulants and antiplatelets. Given the prevalence of SSRI use in the ambulatory setting, osteopathic physicians should be aware of potential drug-drug interactions and the clinical implications of SSRI-associated bleeding risk.

The impact of selective serotonin reuptake inhibitors on the risk of intracranial haemorrhage: A systematic review and meta-analysis

Introduction

Observational studies have suggested increased risk of intracranial haemorrhage (ICrH) in patients receiving selective serotonin reuptake inhibitors (SSRIs). We sought to clarify the impact of SSRIs on ICrH, accounting for study methodology.

Patients and methods

A comprehensive search of Medline, Embase and the Cochrane Library from 1960 to December 2017 identified studies comparing SSRIs with control. The outcomes (first-ever and recurrent ICrH) were meta-analysed using a random effects model.

Results

Twenty-four observational studies and three randomised trials were available for meta-analysis, totalling 4,844,090 patient-years of follow-up. Those receiving SSRIs were more likely to be female (p = 0.01) and have depression (p < 0.001). Compared to controls, SSRI users had a significantly increased risk of ICrH (relative risk (RR) 1.26, 95%CI 1.11-1.42). Although SSRI use was associated with increased ICrH risk in those without previous ICrH (RR 1.31, 95%CI 1.15-1.48), this was not the case in those with previous ICrH (RR 0.95, 95%CI 0.83-1.09). Sensitivity analysis according to the bleeding definition reported demonstrated that although 'haemorrhagic stroke' was associated with SSRIs (RR 1.40, 95%CI 1.13-1.72), intracerebral haemorrhage was not (RR 1.11, 95%CI 0.86-1.42). Additional sensitivity analyses demonstrated a stronger association between SSRIs and ICrH in studies with a high (p < 0.001) compared to low risk of bias (p = 0.09) and with retrospective (p < 0.001) compared to prospective (p=0.31) study designs.

Discussion

Although SSRIs are associated with an increased risk of ICrH, the association is partly accounted for by important biases and other methodological limitations in the available observational data.

Conclusion

Our findings suggest there is insufficient high-quality data to advise restriction of SSRIs because of concern regarding ICrH risk.

Risk of Intracranial Hemorrhage Associated with the Use of Antidepressants Inhibiting Serotonin Reuptake: A Systematic Review

BACKGROUND

Observational studies have suggested an increased risk of intracranial hemorrhage (ICH) associated with selective serotonin reuptake inhibitors (SSRIs) and other antidepressants primarily inhibiting serotonin reuptake.

OBJECTIVES

Our aim was to systematically review the available epidemiologic evidence regarding the risk of ICH associated with SSRIs and antidepressants inhibiting serotonin reuptake.

METHODS

MEDLINE/PubMed and EMBASE were searched for all relevant articles in English, French, or German published before April 2017. Observational studies with SSRIs or any antidepressants classified by strength of serotonin reuptake inhibition as primary exposure, a comparison group, and ICH as outcome were eligible.

RESULTS

Among twelve identified studies (six nested case-control, three cohort, two case-control, one case-crossover), seven assessed the risk of ICH associated with SSRIs (some also including other antidepressants primarily inhibiting serotonin reuptake), two the risk of ICH associated with inhibitors of serotonin reuptake according to the degree of reuptake inhibition, and three addressed both objectives. Four of ten studies showed an increased risk of ICH associated with SSRIs, with the two largest studies suggesting a moderate effect. Three of five studies showed an increased risk of ICH associated with strong inhibitors of serotonin reuptake. Limitations including residual confounding, inclusion of prevalent users, potentially inappropriate study designs, and lack of power may have influenced these results, especially in studies showing no association or a highly increased risk.

CONCLUSION

This systematic review suggests an increased risk of ICH with antidepressants primarily inhibiting serotonin reuptake, such as SSRIs. An increased risk of ICH with strong inhibitors of serotonin reuptake compared with weak inhibitors is also possible but the available evidence is limited. Antidepressants only moderately or weakly inhibiting serotonin reuptake might be preferred in high-risk patients.

Data-mining for detecting signals of adverse drug reactions of fluoxetine using the Korea Adverse Event Reporting System (KAERS) database

Selective serotonin reuptake inhibitors (SSRIs) have become one of the most broadly used medications in psychiatry. Fluoxetine is the first representative antidepressant SSRI drug approved by the Food and Drug Administration (FDA) in 1987. Safety information on fluoxetine use alone was less reported than its combined use with other drugs. There were no published papers on adverse drug reactions (ADRs) of fluoxetine analyzing spontaneous adverse events reports. We detected signals of the adverse drug reactions of fluoxetine by data mining using the Korea Adverse Events Reporting System (KAERS) database. We defined signals in this study by the reporting odds ratios (ROR), proportional reporting ratios (PRR), and information components (IC) indices. The KAERS database included 860,224 AE reports, among which 866 reports contained fluoxetine. We compared the labels of fluoxetine among the United States, UK, Germany, France, China, and Korea. Some of the signals, including emotional lability, myositis, spinal stenosis, paradoxical drug reaction, drug dependence, extrapyramidal disorder, adrenal insufficiency, and intracranial hemorrhage, were not labeled in the six countries. In conclusion, we identified new signals that were not known at the time of market approval. However, certain factors should be required for signal evaluation, such as clinical significance, preventability, and causality of the detected signals.

Risk of Bleeding in Patients on Full-Dose Enoxaparin With Venous Thromboembolism and Selective Serotonin Reuptake Inhibitors

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) are very commonly prescribed agents that are also potent antiplatelet agents.

OBJECTIVE

This study was designed compare the rate of major bleeding events between patients who were treated with low-molecular-weight heparin (LMWH) for venous thromboembolism (VTE) on SSRIs and those not on chronic SSRI therapy.

METHODS

This was a retrospective cohort study of 575 patients with a primary or secondary diagnosis of an acute VTE initiated on full-dose enoxaparin with or without an SSRI between October 1, 2009, and October 1, 2014, in a 443-bed, single tertiary care referral county teaching hospital.

RESULTS

No significant difference was found in the incidence of major bleeding in the SSRI versus non-SSRI group (19.6% vs 17.0%, P = 0.548). Ad hoc analysis demonstrated an elevated risk of major bleeding in patients on escitalopram compared with those on any of the other SSRIs (46.2% vs 15.2%, P = 0.018). Multivariate analysis demonstrated that escitalopram use-OR (95% CI) = 18.85 (1.84-193.6)-was associated with increased major bleeding, and acid suppressive therapy-0.24 (0.07-0.90); P = 0.014-was associated with decreased major bleeding in patients reporting alcohol use.

CONCLUSION

No difference was found in the incidence of major bleeding in patients on LMWH and SSRIs versus those on LMWH but not on SSRIs. However, ad hoc findings showed a significantly higher rate of major bleeding events in patients who received escitalopram and alcohol among patients on full-dose enoxaparin for VTE. These findings merit further exploration.

Preadmission use of selective serotonin reuptake inhibitors and short-term mortality in diabetic patients hospitalized due to stroke

BACKGROUND

Patients with diabetes have an increased risk of stroke with a poor prognosis. Moreover, diabetic patients are at increased risk of depression and therefore likely to use selective serotonin reuptake inhibitors (SSRIs). We examined whether preadmission SSRI use was associated with increased mortality in diabetic patients hospitalized due to stroke.

METHODS

Population-based medical databases were used to identify all first-time stroke-related hospitalizations and subsequent mortality in diabetic patients in Denmark between 2004 and 2012 (n = 12 620). Based on redeemed prescriptions, SSRI use was categorized as current (new or long term), former or nonuse, and absolute 30-day mortality and mortality rate ratios (MRRs) were computed using Cox regression controlling for confounding factors.

RESULTS

Amongst SSRI nonusers, 30-day stroke mortality was 15.8% (10.4% for ischaemic stroke, 41.8% for intracerebral haemorrhage and 27.3% for subarachnoid haemorrhage). Amongst current SSRI users, 30-day stroke mortality was 23.3% (17.1% for ischaemic stroke, 50.7% for intracerebral haemorrhage and 28.6% for subarachnoid haemorrhage). Current SSRI use was associated with increased 30-day stroke mortality compared with nonuse [adjusted MRR 1.3, 95% confidence interval (CI) 1.1-1.5], with the highest risk observed amongst new users (MRR 1.5, 95% CI 1.2-1.8). Overall stroke mortality was driven by increased mortality due to ischaemic stroke, with adjusted MRRs of 1.3 (95% CI 1.1-1.7) for current users and 1.7 (95% CI 1.2-2.4) for new users. Propensity score-matched results were similar and robust across subgroups.

CONCLUSION

In patients with diabetes, preadmission SSRI use was associated with increased mortality following ischaemic stroke, compared with nonuse.

Use of Selective Serotonin Reuptake Inhibitors and Risks of Stroke in Patients with Obsessive Compulsive Disorder: A Population-Based Study

Background

Previous research has suggested a link between antidepressants use and the development of cerebrovascular events, but there has never been any study investigating the risk of stroke in obsessive-compulsive disorder (OCD) patients treated with a selective serotonin reuptake inhibitor (SSRI).

Methods

A retrospective observational cohort study was conducted using data from the National Health Insurance Database of Taiwan between the year of 2001 and 2009. A total of 527 OCD patients with 412 subjects in the SSRI use group and 115 in the non SSRI use group were included. Multivariable Cox proportional-hazards models were used to explore the associations between SSRI use and the occurrence of stroke, controlling for age, gender, concomitant medications, and comorbid medical illnesses.

Results

A total of nineteen OCD patients were diagnosed with new onset of stroke during the follow-up period including six cases in the SSRI group and thirteen in the non SSRI use group. SSRI use was demonstrated to be associated with a decreased risk of stroke (hazard ratio [HR] = 0.30; 95% confidence interval [CI] = 0.10–0.86, P = 0.02). The increase in age-related risk of strokes was 2.55 per decade (HR = 2.55; 95% CI = 1.74–3.75, P<0.001). Alternatively, sex, concomitant use of aspirin and non-steroidal anti-inflammatory drugs, and comorbidities with angina pectoris, diabetes mellitus, hypertension, and hyperlipidemia were not found to be associated with an increased risk for stroke in OCD patients.

Conclusions

Our study showed that SSRI use was associated with decreased risk of stroke in OCD patients. Further investigation into the possible biological mechanisms underlying the relationship between stroke and SSRI use in OCD patients is warranted.

Bleeding risk under selective serotonin reuptake inhibitor (SSRI) antidepressants: A meta-analysis of observational studies

Selective serotonin reuptake inhibitors (SSRIs) have been reported to be potentially associated with an increased risk of bleeding. A meta-analysis of observational studies was conducted to quantify this risk. Case-control and cohort studies investigating bleeding risk under SSRI therapy were retrieved by searching the Medline, Pascal, Google Scholar and Scopus databases. Case-control studies were included if they reported bleeding incidents with and without the use of SSRIs and cohort studies were included if they reported the rate of bleeds among SSRI users and non-users. The main outcome was severe bleeding, whatever the site. Only data concerning SSRI belonging to the ATC class N06AB were used. For both case-control and cohort studies, we recorded the adjusted effect estimates and their 95% confidence intervals (CI). Pooled adjusted odds ratio (OR) estimates were computed for case-control and cohort studies using an inverse-variance model. Meta-analysis of the adjusted ORs of 42 observational studies showed a significant association between SSRI use and the risk of bleeding [OR 1.41 (95% CI 1.27-1.57), random effect model, p<0.0001]. The association was found for the 31 case-control studies (1,255,073 patients), with an increased risk of 41% of bleeding [OR 1.41 (95% CI 1.25-1.60)], as well as for the 11 cohort studies including 187,956 patients [OR 1.36 (95% CI 1.12-1.64)]. Subgroup analyses showed that the association remained constant whatever the characteristics of studies. This meta-analysis shows an increased risk of bleeding of at least 36% (from 12% to 64%) based on the high-level of observational studies with SSRIs use.

Sertraline-induced periorbital purpura: a case report

OBJECTIVE

The incidence of mild to severe levels of spontaneous bleeding due to the usage of selective serotonin reuptake inhibitors (SSRIs) is relatively low. Although the exact mechanism is not known, it is thought that inhibition of the serotonin transporter together with a decrease in platelet serotonin could be responsible for the bleeding. Therefore, the use of SSRIs in conjunction with anti-aggregants may predispose to or exacerbate the risk of bleeding. In this case report, we describe a 44-year-old female patient with a diagnosis of anxiety disorder who spontaneously developed periorbital purpura during treatment with sertraline.

CONCLUSION

Abnormal bleeding after treatment with an SSRI should be kept in mind, and alternative non-SSRI drugs of choice in such cases would be more appropriate. More extensive and comprehensive studies focusing on hemostasis and bleeding disorders are needed for SSRIs such as sertraline.

Risk of intracranial haemorrhage in antidepressant users with concurrent use of non-steroidal anti-inflammatory drugs: nationwide propensity score matched study

OBJECTIVE

To define the risk of intracranial haemorrhage among patients treated with antidepressants and non-steroid anti-inflammatory drugs (NSAIDs), compared with the risk among those treated with antidepressants without NSAIDs.

DESIGN

Retrospective nationwide propensity score matched cohort study.

SETTING

Korean nationwide health insurance database between 1 January 2009 and 31 December 2013.

PARTICIPANTS

Patients who began receiving antidepressants for the first time (index date) without a history of having received a prescription for antidepressants during the preceding year. Patients who had been diagnosed as having cerebrovascular diseases within a year before the index date were excluded.

MAIN OUTCOME MEASURE

Time to first hospital admission with intracranial haemorrhage within 30 days after drug use. Matched Cox regression models were used to compare the risk of intracranial haemorrhage among patients who were treated with antidepressants with and without NSAIDs, after propensity score matching with a 1:1 ratio.

RESULTS

After propensity score estimation and matching in a 1:1 ratio, the cohort used in the analysis included 4,145,226 people. The 30 day risk of intracranial haemorrhage during the entire study period was higher for combined use of antidepressants and NSAIDs than for use of antidepressants without NSAIDs (hazard ratio 1.6, 95% confidence interval 1.32 to 1.85). No statistically meaningful differences were found in risk of intracranial haemorrhage between the antidepressant drug classes.

CONCLUSIONS

Combined use of antidepressants and NSAIDs was associated with an increased risk of intracranial haemorrhage within 30 days of initial combination.

Association between warfarin combined with serotonin-modulating antidepressants and increased case fatality in primary intracerebral hemorrhage: a population-based study

Object

Patients receiving oral anticoagulants run a higher risk of cerebral hemorrhage with a poor outcome. Serotonin-modulating antidepressants (selective serotonin reuptake inhibitors [SSRIs], serotonin-norepinephrine reuptake inhibitors [SNRIs]) are frequently used in combination with warfarin, but it is unclear whether this combination of drugs influences outcome after primary intracerebral hemorrhage (PICH). The authors investigated case fatality in PICH among patients from a defined population who were receiving warfarin alone, with aspirin, or with serotonin-modulating antidepressants.

Methods

Nine hundred eighty-two subjects with PICH were derived from the population of Northern Ostrobothnia, Finland, for the years 1993–2008, and those with warfarin-associated PICH were eligible for analysis. Their hospital records were reviewed, and medication data were obtained from the national register of prescribed medicines. Kaplan-Meier survival curves were drawn to illustrate cumulative case fatality, and a Cox proportional-hazards analysis was performed to demonstrate predictors of death.

Results

Of the 176 patients eligible for analysis, 17 had been taking aspirin and 19 had been taking SSRI/SNRI together with warfarin. The 30-day case fatality rates were 50.7%, 58.8%, and 78.9%, respectively, for those taking warfarin alone, with aspirin, or with SSRI/SNRI (p = 0.033, warfarin plus SSRI/SNRI compared with warfarin alone). Warfarin combined with SSRI/SNRI was a significant independent predictor of case fatality (adjusted HR 2.10, 95% CI 1.13–3.92, p = 0.019).

Conclusions

Concurrent use of warfarin and a serotonin-modulating antidepressant, relative to warfarin alone, seemed to increase the case fatality rate for PICH. This finding should be taken into account if hematoma evacuation is planned.

Effects of selective serotonin reuptake inhibitors versus tricyclic antidepressants on cerebrovascular events: a nationwide population-based cohort study

Depression is a common disorder worldwide and is strongly associated with stroke. Use of antidepressants could potentially decrease the risk of stroke in patients with depression. However, the role of selective serotonin reuptake inhibitors (SSRIs), the most frequently prescribed antidepressant in this era, in the risk of stroke showed inconsistent results. We aimed to assess the association between the use of different types of antidepressants, SSRIs and tricyclic antidepressants (TCAs), and the risk of cerebrovascular events in patients with depression or anxiety. A nationwide population-based cohort study was retrospectively conducted in patients with depression or anxiety who started to take SSRIs and TCAs identified from the Taiwan National Health Insurance claims database (2001-2009). We examined the association between the 2 types of antidepressants and incidence of stroke using a proportional hazard model adjusted for stroke risk factors. Among the 24,662 SSRI and 14,736 TCA initiators, the crude incidence rate for stroke was 10.03 and 13.77 per 100 person-years, respectively. Selective serotonin reuptake inhibitor use was not associated with risk of stroke as compared with TCAs in the time-fixed analysis. After adjusting for baseline propensity scores in the time-varying analysis, SSRI use significantly reduced risk of stroke as compared with TCAs with the adjusted hazard ratio of 0.67 (95% confidence interval, 0.47-0.96). The effect persisted even after considering the antidepressant dosage (hazard ratio, 0.65 [0.42 to 0.99]). In summary, use of SSRIs was associated with a reduced risk for stroke, as compared with TCAs, in this specific disease population.

Predictors for recurrent primary intracerebral hemorrhage: a retrospective population-based study

BACKGROUND AND PURPOSE

Underlying comorbidities, previous strokes, and medication may increase the risk for primary intracerebral hemorrhage (PICH) and its recurrence. The aim of this study was to determine the independent predictors for recurrent PICH.

METHODS

We identified 961 subjects with first-ever PICH from 1993 to 2008 among the population of Northern Ostrobothnia, Finland. Hospital and death records were reviewed and data on drug use were obtained from the national register of prescribed medicines. Kaplan-Meier survival curves and Cox proportional hazards models were used to demonstrate predictors for recurrence of PICH.

RESULTS

Total follow-up time of the 961 patients was 3481 person-years. During the follow-up time, 58 subjects had altogether 68 recurrent PICHs. The annual average incidence of first recurrence was 1.67%. Cumulative 5- and 10-year incidence rates were 9.6% and 14.2%, respectively. In univariable analysis, history of ischemic stroke, diabetes mellitus, and aspirin use were associated with a higher recurrence rate. In multivariable analysis, only previous ischemic stroke (adjusted hazard ratio, 2.22; 95% confidence interval, 1.22-4.05; P=0.009) independently predicted PICH recurrence. Diabetes mellitus tended to increase (adjusted hazard ratio, 2.38; 95% confidence interval, 0.98-5.80; P=0.056), whereas treated hypertension tended to decrease (0.45, 0.20-1.01; P=0.054) the risk for fatal recurrent PICH.

CONCLUSIONS

Previous ischemic stroke independent of confounding factors may increase the risk for PICH recurrence.

Effects of selective serotonin reuptake inhibitors on platelet function: mechanisms, clinical outcomes and implications for use in elderly patients

Among the antidepressants, the selective serotonin reuptake inhibitors (SSRIs) are often preferred to other classes of antidepressants in the treatment of depression in the elderly because of their better safety profile. Most of the known effects of SSRIs, either beneficial or adverse, are linked to their inhibitory action on the serotonin reuptake transporter (5-HTT). This reuptake mechanism is present not only in neurons but also in other cells such as platelets. Serotoninergic mechanisms seem to play an important role in haemostasis, and their importance in this regard has long been underestimated. Abnormal activation may lead to a pro-thrombotic state, as may occur in patients with major depressive disorder, whilst downregulation, as occurs in patients treated with SSRIs, may have two clinical consequences, both of particular interest in the elderly. On the one hand, there may be an increased risk of bleeding; on the other hand, a reduction in thrombotic risk may be possible. Polymorphism in the promoter region of the gene that transcribes the 5-HTT has been shown to have a relevant impact on its function and, in turn, on the beneficial and adverse effects of SSRIs. Bleeding has been a concern since the introduction of SSRIs, with multiple case reports published and communicated to the pharmacovigilance systems. The first epidemiological study was published in 1999 and since then, 34 epidemiological studies from different areas, most of them including elderly patients in their study populations, have been published with a variety of results. Broadly, the epidemiological evidence supports a moderately increased risk of bleeding associated with the use of SSRIs, which may be critically dependent on patient susceptibility and the presence of risk factors. The impairment of primary haemostasis induced by SSRIs may result, as a beneficial counterpart, in a reduction in the thrombotic risk. A small number of clinical trials and an increasing number of epidemiological studies that include elderly patients have been conducted to clarify whether SSRIs reduce the risk of primary and secondary ischaemic disorders. However, the results have been inconclusive with some studies suggesting a preventive effect and others no effect or even an increased risk. Behind such contradictory results may be the role of depression itself as a cardiovascular risk factor and, therefore, a major confounding factor. How to disentangle its effect from that of the antidepressants is the methodological challenge to be overcome in future studies. In this complex scenario, the elderly seem to be at a crossroads, because they are the group in which both the risks and the benefits can be the greatest. Studies performed to date have provided us with some clues that can help orient clinicians in taking the most appropriate course of action. For instance, as the gastrointestinal bleeding risk appears to increase with age, prudent advice in patients with a previous history of upper-gastrointestinal bleeding or peptic ulcer, and in those who take NSAIDs, oral anticoagulants, antiplatelet drugs or corticosteroids, would be to suggest addition of an acid-suppressing agent to the drug regimen in those elderly patients in whom SSRIs are indicated.

[Perioperative adverse events related to antidepressive agents use]

OBJECTIVE

Depression is the most common psychiatric disease, which is treated by the use of antidepressive agents possessing various mechanisms of action. Thus, the use in preoperative period of antidepressive agents is frequent (7% of patients scheduled for surgery). The objective of this review was to update the knowledge on the drug interactions between antidepressive agents and drugs used in perioperative period.

METHODS

(i) Medline and Ovid databases using combination of antidepressive agent and perioperative period as keywords; (ii) national and European epidemiologic database; (iii) expert recommendation and official French health agency; (iv) reference book chapters.

RESULTS

The clinical practice showed a limited risk of adverse event related to antidepressant agents interaction with perioperative used drugs. In the two past decades, few relevant observations of adverse event related with imipramine and monoamine oxidase inhibitors use was reported. The most recent antidepressive agents had no serious adverse interaction. Nevertheless, the serotonin syndrome has to be known as far as it is more and more reported. In case of hypotension, the use of vasopressive agent has to be careful because of excessive response.

Monoamine depletion by reuptake inhibitors

BACKGROUND

Disagreement exists regarding the etiology of cessation of the observed clinical results with administration of reuptake inhibitors. Traditionally, when drug effects wane, it is known as tachyphylaxis. With reuptake inhibitors, the placebo effect is significantly greater than the drug effect in the treatment of depression and attention deficit hyperactivity disorder, leading some to assert that waning of drug effects is placebo relapse, not tachyphylaxis.

METHODS

Two groups were retrospectively evaluated. Group 1 was composed of subjects with depression and Group 2 was composed of bariatric subjects treated with reuptake inhibitors for appetite suppression.

RESULTS

In Group 1, 200 subjects with depression were treated with citalopram 20 mg per day. A total of 46.5% (n = 93) achieved relief of symptoms (Hamilton-D rating score ≤ 7), 37 (39.8%) of whom experienced recurrence of depression symptoms, at which point an amino acid precursor formula was started. Within 1-5 days, 97.3% (n = 36) experienced relief of depression symptoms. In Group 2, 220 subjects were treated with phentermine 30 mg in the morning and citalopram 20 mg at 4 pm. In this group, 90.0% (n = 198) achieved adequate appetite suppression. The appetite suppression ceased in all 198 subjects within 4-48 days. Administration of an amino acid precursor formula restored appetite suppression in 98.5% (n = 195) of subjects within 1-5 days.

CONCLUSION

Reuptake inhibitors do not increase the total number of monoamine molecules in the central nervous system. Their mechanism of action facilitates redistribution of monoamines from one place to another. In the process, conditions are induced that facilitate depletion of monoamines. The "reuptake inhibitor monoamine depletion theory" of this paper offers a novel and unified explanation for the waning of response seen after a reuptake inhibitor is started, independent of a drug or placebo etiology.

Selective serotonin reuptake inhibitors and oral bleeding complications after invasive dental treatment

OBJECTIVE

The purpose of this study was to examine the frequency of oral bleeding complications after invasive dental procedures in patients taking selective serotonin reuptake inhibitor (SSRI) medications.

STUDY DESIGN

In this retrospective cohort study, we included dental patients who had invasive dental treatment and were taking an SSRI medication. Data collected included demographics, medical history, dental visits and procedures, and use of adjunctive measures to control bleeding. Primary outcomes included documentation of return visits or phone calls to the dental clinic or emergency department (ED) for oral bleeding, and oral bleeding or use of blood products for inpatients.

RESULTS

There were 92 patients taking SSRIs who had 145 invasive procedure visits, consisting of extractions, implant surgery, alveoloplasty, periodontal surgery, subgingival scaling and root planning, and biopsy. There were 110 extraction visits yielding a total of 167 extractions. Among all patients, there was 1 return visit to the clinic and 1 telephone call with a chief complaint of oral bleeding.

CONCLUSIONS

The frequency of oral bleeding complications after invasive dental treatment is low to negligible in patients on SSRI medications.

Selective serotonin reuptake inhibitors and gastrointestinal bleeding: a case-control study

Background

Selective serotonin reuptake inhibitors (SSRIs) have been associated with upper gastrointestinal (GI) bleeding. Given their worldwide use, even small risks account for a large number of cases. This study has been conducted with carefully collected information to further investigate the relationship between SSRIs and upper GI bleeding.

Methods

We conducted a case-control study in hospitals in Spain and in Italy. Cases were patients aged ≥18 years with a primary diagnosis of acute upper GI bleeding diagnosed by endoscopy; three controls were matched by sex, age, date of admission (within 3 months) and hospital among patients who were admitted for elective surgery for non-painful disorders. Exposures to SSRIs, other antidepressants and other drugs were defined as any use of these drugs in the 7 days before the day on which upper gastrointestinal bleeding started (index day).

Results

581 cases of upper GI bleeding and 1358 controls were considered eligible for the study; no differences in age or sex distribution were observed between cases and controls after matching. Overall, 4.0% of the cases and 3.3% of controls used an SSRI antidepressant in the week before the index day. No significant risk of upper GI bleeding was encountered for SSRI antidepressants (adjusted odds ratio, 1.06, 95% CI, 0.57–1.96) or for whichever other grouping of antidepressants.

Conclusions

The results of this case-control study showed no significant increase in upper GI bleeding with SSRIs and provide good evidence that the magnitude of any increase in risk is not greater than 2.

Treatment of attention deficit hyperactivity disorder with monoamine amino acid precursors and organic cation transporter assay interpretation

BACKGROUND

This paper documents a retrospective pilot study of a novel approach for treating attention deficit hyperactivity disorder (ADHD) with amino acid precursors of serotonin and dopamine in conjunction with urinary monoamine assays subjected to organic cation transporter (OCT) functional status determination. The goal of this research was to document the findings and related considerations of a retrospective chart review study designed to identify issues and areas of concern that will define parameters for a prospective controlled study.

METHODS

This study included 85 patients, aged 4-18 years, who were treated with a novel amino acid precursor protocol. Their clinical course during the first 8-10 weeks of treatment was analyzed retrospectively. The study team consisted of PhD clinical psychologists, individuals compiling clinical data from records, and a statistician. The patients had been treated with a predefined protocol for administering amino acid precursors of serotonin and dopamine, along with OCT assay interpretation as indicated.

RESULTS

In total, 67% of participants achieved significant improvement with only amino acid precursors of serotonin and dopamine. In patients who achieved no significant relief of symptoms with only amino acid precursors, OCT assay interpretation was utilized. In this subgroup, 30.3% achieved significant relief following two or three urine assays and dosage changes as recommended by the assay results. The total percentage of patients showing significant improvement was 77%.

CONCLUSION

The efficacy of this novel protocol appears superior to some ADHD prescription drugs, and therefore indicates a need for further studies to verify this observation. The findings of this study justify initiation of further prospective controlled studies in order to evaluate more formally the observed benefits of this novel approach in the treatment of ADHD.

The use of antidepressants and the risk of haemorrhagic stroke: a nested case control study

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Selective serotonin re-uptake inhibitors (SSRI) are associated with an increased risk of bleeding disorders at a number of sites. It is currently unclear whether they increase the risk of haemorrhagic stroke, with conflicting results reported.

WHAT THIS STUDY ADDS

We found no association between SSRI use and haemorrhagic stroke. The large number of patients involved in the study allowed us to rule out any substantial effect. The results were similar in people with and without a previous history of cerebrovascular events.

AIM

To investigate whether selective serotonin re-uptake inhibitor (SSRI) use is associated with an increased risk of haemorrhagic stroke in a cohort of antidepressant users.

METHODS

We conducted a case control study, nested within a cohort of antidepressant users in the United Kingdom General Practice Research Database. A cohort of 365,195 patients prescribed either an SSRI or tricyclic antidepressant between 1992 and 2006 was identified. Three hundred and fifty-seven cases of haemorrhagic stroke were observed and 1631 control patients without haemorrhagic stroke were selected.

RESULTS

The primary analysis showed no evidence of an association between current SSRI or TCA use and haemorrhagic stroke. Current use of an SSRI compared with no use at the time of haemorrhagic stroke was associated with an adjusted odds ratio of 1.11 (95% confidence interval (CI) 0.82, 1.50). For current tricyclic use the equivalent odds ratio was 0.73 (0.52, 1.02). There was no evidence that prior cerebrovascular events modified the effect of either SSRIs or TCAs.

CONCLUSIONS

We found no evidence that SSRIs are associated with an increased risk of haemorrhagic stroke, regardless of prior history of cerebrovascular events.

Use of serotonergic drugs and the risk of bleeding

We assessed several classes of serotonergic drugs in order to evaluate whether they constitute a risk factor for hospitalization for bleeding (gastrointestinal, intracranial, or in the female genital tract). A case-control study was conducted using data from the PHARMO record linkage system (RLS). The study population comprised 28,289 cases and 50,786 matched controls. Current use of antidepressant drugs was associated with all three types of bleeding, whereas antipsychotic drugs were associated with an increased risk of gastrointestinal and intracranial bleeding. Current use of ergoline derivatives increased the risk of female genital tract bleeding. The risks of gastrointestinal and intracranial bleeding were higher in new users of antidepressant and antipsychotic drugs as compared with those who were already receiving these drugs. No clear association was found between the degree of affinity for the serotonin (5-HT) transporter or the 5-HT(2A) receptor and the risk of any of the three types of bleeding. The association between antipsychotic drugs and gastrointestinal bleeding may warrant further research, in view of the fact that this association was rather unexpected.

[SSRI - treatment and bleeding. What risks do we take?]

Treatment with selective serotonin reuptake inhibitors (SSRI) increases the risk of gastrointestinal bleeding. The combination with non-steroidal anti-inflammatory drugs (NSAIDs) further augments this hazard. Particular precaution is also necessary in patients on platelet aggregation inhibitors, with a known bleeding disorder or preceding gastrointestinal lesions. The incidence of bleeding events apart from the gastrointestinal tract, e.g. intracerebral hemorrhages, is not cumulated under SSRI treatment. This also applies for the combination of SSRI and coumarin or aspirin. Prescribing doctors have to be aware of the bleeding risks of SSRI and should explain this to their patients. High-risk patients have to be followed up closely and an SSRI with a low potential for drug interaction should be used. The prescription of gastroprotective agents and a change of the antidepressant should be considered in particular cases. We provide a literature survey and recommendations for the clinical routine.

Risk of ischemic stroke associated with antidepressant drug use in elderly persons

Competing hypotheses have been formulated about a possible association between selective serotonin reuptake inhibitors (SSRIs) and ischemic stroke. However, the relationship between antidepressant drug use and ischemic stroke is still unclear. The aim of the study was to assess the association between the use of different types of antidepressants and the risk of ischemic stroke in elderly outpatients. A population-based, nested, case-control study was conducted in persons 65 years and older in the Integrated Primary Care Information database (1996-2005). Cases were all patients with a validated first ischemic stroke. Controls were matched on year of birth, sex, and index date. Exposure to antidepressants was divided in current, past, and nonuse and further categorized by type (SSRI, tricyclic, and other antidepressants), dose, and duration. Conditional logistic regression was used to compare the risk of ischemic stroke between users of antidepressants and nonusers. Overall, 996 incident ischemic strokes were identified. Current use of SSRIs was associated with a significantly increased risk as compared with nonuse (odds ratio, 1.55; 95% confidence interval, 1.07-2.25) in elderly patients, particularly when used for less than six months. No associations were observed for current use of tricyclic and other antidepressant drugs. To summarize, compared with nonuse, only SSRI use seems to be associated with an increased risk of ischemic stroke in elderly patients, particularly as a short-term effect.

Hemorrhagic stroke associated with antidepressant use in patients with depression: does degree of serotonin reuptake inhibition matter?

OBJECTIVE

This study aimed to determine whether the degree of serotonin (5-HT) reuptake inhibition affects risk of hemorrhagic stroke associated with antidepressant use in patients with depression.

METHOD

A population-based, nested case-control study was performed using a managed care medical claims database. Ninety two depressed patients with a diagnosis of hemorrhagic stroke were identified and matched with 552 controls by age, sex, and year of index date of depression (IDD). Diagnoses of depression, hemorrhagic stroke, and other medical comorbidities were identified using ICD-9 codes. Antidepressants were classified as high, medium, or low reuptake inhibition based on their affinities for the 5-HT reuptake transporter, determined using their respective equilibrium dissociation constants (K(D); high: K(D) < 1 nM; medium: 1 <or= K(D) < 10 nM; low: K(D) >or= 10 nM). Conditional logistic regression analysis was performed to estimate the crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) of the risk of hemorrhagic stroke.

RESULTS

Compared to non-users of antidepressants, risk of hemorrhagic stroke did not significantly differ between patients who had ever used antidepressants with high (OR = 0.82; 95% CI = 0.44-1.55), medium (OR = 0.93; 95% CI = 0.37-2.31), or low (OR = 0.38; 95% CI = 0.11-1.41) 5-HTT inhibition.

CONCLUSION

Risk of hemorrhagic stroke associated with antidepressant use may not be related to an antidepressant's degree of 5-HT reuptake inhibition. Given the limitations of this study, additional studies are needed to confirm these findings.

Effect of selective serotonin reuptake inhibitors on platelet activation: can they prevent acute myocardial infarction?

In recent years a large body of evidence from several longitudinal studies has emerged suggesting that depression is an independent risk factor for cardiovascular disease (CVD) and that the association between depression and increased CVD risk is not merely due to negative mood-driven behavior related with depression. Even though the underlying mechanisms are not well understood, several hypotheses and explanations have been proposed such as increased activation of the hypothalamic-pituitary-adrenal axis, abnormalities in the sympathoadrenal system, or abnormalities in platelet function. Platelet function abnormalities, including increased platelet reactivity, may predispose patients with depressive disorders to clotting diatheses and may explain their vulnerability to CVD. Serotonin secreted by platelets induces both platelet aggregation and coronary vasoconstriction. Even though serotonin itself is only a weak platelet agonist, it markedly enhances platelet reactions to a variety of other agonists. Several studies have shown that selective serotonin reuptake inhibitors (SSRIs) reduce platelet and whole blood serotonin concentrations after repeated doses, and could therefore exert an inhibitory effect on platelet activation. For that reason, it was hypothesized that SSRIs could have a protective effect against myocardial infarction (MI). Results from three currently available epidemiological studies assessing the risk of MI in patients treated with antidepressants, including SSRIs, are controversial with respect to a potential beneficial effect of SSRIs on CVD risk in depressed patients. However, there is evidence that exposure to SSRIs does not substantially increase the risk of CVD in patients. A recent randomized, double-blind, placebo-controlled, multicenter trial that evaluated the safety and efficacy of the SSRI sertraline in patients with major depression and acute MI or unstable angina suggested that sertraline is well tolerated and effective. Further epidemiological studies or longer-term clinical trials may shed more light on this issue, and answer the question conclusively, whether the effect of SSRIs on platelets or another mechanism translates into a decreased risk of CVD in depressed patients.

Medically serious adverse effects of newer antidepressants

Although safer than tricyclic antidepressants and monoamine oxidase inhibitors, the newer antidepressants may be associated with certain medically serious adverse effects, of which cardiovascular adverse effects, seizures, abnormal bleeding, hyponatremia, and agranulocytosis are discussed in this review. Data regarding the incidence and risk factors are summarized, and strategies for reducing the risk of these adverse effects and managing them are suggested. Identification of risk factors, appropriate antidepressant choice, and, when possible, careful monitoring may substantially reduce the incidence of these adverse effects and the morbidity associated with them.

Epidemiology and treatment of post-stroke depression

Mood depression is a common and serious complication after stroke. According to epidemiological studies, nearly 30% of stroke patients develop depression, either in the early or in the late stages after stroke. Although depression may affect functional recovery and quality of life after stroke, such condition is often ignored. In fact, only a minority of patients is diagnosed and even fewer are treated in the common clinical practice. Moreover, the real benefits of antidepressant (AD) therapy in post-stroke depression have not been fully clarified. In fact, controlled studies on the effectiveness of ADs in post stroke depression (PSD) are relatively few. Today, data available suggest that ADs may be generally effective in improving mood, but guidelines for the optimal treatment and its length are still lacking.

Antidepressant treatment and worsening white matter on serial cranial magnetic resonance imaging in the elderly: the Cardiovascular Health Study

BACKGROUND AND PURPOSE

In some studies, late life depression is associated with white matter lesions on MRI. The effect of different classes of antidepressants on progression of white matter lesions is unknown. Selective serotonergic reuptake inhibitors (SSRIs) may decrease platelet aggregation. We hypothesized that Cardiovascular Health Study participants taking SSRIs would less often have worsening white matter on serial MRI than participants not on antidepressants.

METHODS

Among 1826 participants who were not using an antidepressant at initial MRI scan, we examined the association of worsening in white matter grade from initial to follow-up MRI scans, 5 years apart on average, and antidepressant use between the scans. Logistic regression models were used, controlling for a variety of potential confounding variables.

RESULTS

Use of any antidepressant during the period of study was associated with worsening white matter. In a multivariable model, risk was slightly increased, not reduced, with use of serotonergic agents (OR 1.36, 95% CI 0.87 to 2.12) and was significantly increased with the use of tricyclic antidepressants (OR 1.77, 95% CI 1.07 to 2.94).

CONCLUSIONS

The association between worsening white matter and use of tricyclic antidepressants was an unexpected finding that may relate to indications for use other than depression or to side effects such as hypotension. Protection against worsening was not seen with use of serotonergic agents.

Risk of cerebrovascular events associated with antidepressant use in patients with depression: a population-based, nested case-control study

BACKGROUND

Given the widespread use of antidepressants and the negative consequence of cerebrovascular events (CVEs), an evaluation of the risk of CVEs associated with antidepressants is warranted.

OBJECTIVE

To examine the association between the use of an antidepressant and risk of CVEs among patients diagnosed with depression.

METHODS

A case-control study was performed using a managed care medical claims database from 1998 through 2002. A total of 1086 cases with CVEs were identified and matched with 6515 controls by age, sex, and the year of the index date of depression. Case patients were categorized by stroke type: hemorrhagic stroke, ischemic stroke, and other CVEs. Diagnoses of depression, CVEs, and other medical comorbidities were identified based on International Classification of Diseases, Ninth Revision, codes. Patients were defined as current users (antidepressant ended < or =30 days before CVE), recent users (31-60 days before CVE), past users (61-90 days before CVE), and remote/nonusers (> or =91 days before CVE or nonuse). Cox proportional hazards regression analysis was conducted to estimate the risk of CVEs associated with antidepressant use.

RESULTS

A 24% increased risk of a CVE was noted in patients with current exposure to selective serotonin-reuptake inhibitors (SSRIs; adjusted hazard ratio [HR] 1.24; 95% CI 1.07 to 1.44), 34% increased risk for current exposure to tricyclic antidepressants (HR 1.34; 95% CI 1.10 to 1.62), and 43% increased risk for current exposure to other antidepressants (HR 1.43; 95% CI 1.21 to 1.69). The risk of ischemic stroke in current SSRI users was significantly higher (HR 1.55; 95% CI 1.00 to 2.39) compared with remote/nonusers.

CONCLUSIONS

Current users of antidepressants may be at increased risk of a CVE. Clinicians should consider the relationship of antidepressants with the occurrence of CVEs when determining the risk-benefit profile of pharmacologic treatment in patients with depression, particularly those with existing risk factors for a CVE.

Selective Serotonin Reuptake Inhibitors and Risk of Hemorrhagic Stroke

BACKGROUND AND PURPOSE

Selective serotonin reuptake inhibitors (SSRI) are widely prescribed. Several reports have observed an increased bleeding risk associated with SSRI use, which is hypothesized to be secondary to their antiplatelet effect.

METHODS

We tested the hypothesis that SSRIs increase the risk for or potentiate the risk of hemorrhagic stroke associated with antiplatelets and anticoagulants.

RESULTS

In multivariate analysis, we found no increased risk associated with SSRI use for intracerebral hemorrhage (odds ratio=1.1, 95% CI: 0.7 to 1.8; P=0.63) or subarachnoid hemorrhage (odds ratio=0.6, 95% CI: 0.4 to 1.0; P=0.054). In addition, potentiation of risk with warfarin or antiplatelets was not observed.

CONCLUSIONS

Further studies with larger populations would be needed to exclude a small increase in intracranial hemorrhage risk with SSRI use.

Antidepressant prophylaxis for poststroke depression: a meta-analysis

Given the high incidence of poststroke depression, its serious sequelae, and inherent problems with diagnosis, prophylactic use of antidepressants may be a viable management strategy in patients experiencing stroke. The purpose of this study was to assess the prophylactic effects of antidepressants in nondepressed patients with stroke. A meta-analysis of randomized placebo-controlled trials evaluating the prophylactic effects of antidepressants in nondepressed patients with stroke was conducted. Literature searches in MEDLINE, PubMed, CINAHL, PsycINFO, EMBASE, Cochrane library, and CNKI from 1950 to August 2006 were used to identify the relevant studies. Outcome measures included the occurrence rate of newly developed poststroke depression cases and severity of depressive symptoms as indicated by mean depression rating scale scores. The effect size was presented as rate difference or weighted mean difference. From 10 randomized clinical trials, a total of 703 nondepressed patients after stroke were identified. The pooled occurrence rate of newly developed poststroke depression cases in the intervention and control groups were 12.54 (41/327) and 29.17% (91/312), respectively (pooled rate difference=-0.17, 95% confidence interval: -0.26 to -0.08). Prophylactic effects of antidepressants were not related to duration of use {coefficient of Pearson's correlation [gamma]=0.57, P=0.11}. In conclusion, antidepressant prophylaxis is associated with a significant reduction in the occurrence rate of newly developed poststroke depression, suggesting antidepressants may be considered along with other vascular preventive strategies in the management of stroke patients.

SSRIs and the Risk of Abnormal Bleeding

Considerable research is needed to fully understand the interactions of SSRIs and hematological functioning. Adequate studies of platelet function in patients taking SSRIs are lacking. The risk of bleeding with SSRI treatment appears to be low, and the occurrence of bleeding is usually minor when it does occur. However, the risk does exist and must be considered in any patient taking SSRIs who develops abnormal bleeding or bruising not otherwise explained by an appropriate assessment to determine the etiology. Routine monitoring of patients taking SSRIs should probably include questions about bruising or bleeding, particularly in patients with blood dyscrasias and in older patients taking medications that affect platelet function. Caution should be exercised before starting patients with preexisting bleeding risks on SSRIs, including patients taking NSAIDs, aspirin, or other drugs that may impair coagulation.

Clinical impact of selective serotonin reuptake inhibitors therapy with bleeding risks

The selective serotonin reuptake inhibitors (SSRIs) are extensively used for the treatment of multiple psychiatric conditions. In vitro and ex vivo data with these agents indicate they may have varying degrees of antiplatelet activity via multiple receptors. Reports of bleeding in patients receiving SSRIs appeared soon after their introduction. A review of the literature suggests SSRI therapy may increase the risk of bleeding especially with concomitant aspirin or nonsteroidal anti-inflammatory agents. Clinicians should exercise caution when prescribing these agents in high risk patients and maintain awareness of the potential contribution of SSRIs to unexplained bleeding episodes.