the Bleeding Risks of SSRIs: What Patients Need to Know

Regarding the bleeding issues associated with SSRIs?

Dear Dr.
Wu,
A few years ago, I sought treatment for anxiety and obsessive thinking.
Initially, I tried several medications, but eventually, I was able to live and work normally on Paroxetine HCl Hemihydrate 20mg, as prescribed, taking one tablet at bedtime.
However, I often only take half a tablet when I feel okay, and sometimes I forget to take it until I feel heavy-headed during the day, at which point I take another half tablet at night.
I have somewhat treated it like a supplement or a mental vitamin.
Since I am a carrier of hepatitis B, I am very cautious with medications.
Recently, due to a skin issue, I inadvertently took a small amount of steroids (which are contraindicated for hepatitis B carriers), prompting me to review my medications.
In my search, I came across a piece of medical information: https://www.cgmh.org.tw/cgmn/category.asp?id_seq=1712009#.YgsJXFVBzZ4 (the article mentions the following:)
Moreover, with the increasing research on the use of SSRIs for "promoting recovery of motor function after stroke," the bleeding side effects of SSRIs have also gained attention and discussion among neurologists.
A study published this year in the renowned medical journal JAMA Neurology found that SSRIs significantly increase the risk of cerebral hemorrhage, especially when used in conjunction with anticoagulants, which heightens the risk further.
The most common time for this increased risk is within the first month of treatment.
Patients are advised that if they are using anticoagulants for stroke prevention, it may increase the risk of hemorrhagic stroke.
I sometimes have bruises, but I usually think I bumped into something; occasionally, I am unsure if I did (though it doesn't happen often).
My platelet counts are normal when I have blood tests for hepatitis B.
However, I was alarmed to learn that SSRIs could increase the risk of hemorrhagic stroke (the recent news has been quite frightening).
I would like to ask how to correctly interpret the content mentioned in the medical journal? Are there alternative medication suggestions? (If I am just looking for something akin to a mental vitamin...) Thank you for taking the time to respond.

Mi Ya, 40~49 year old female. Ask Date: 2022/02/15

Dr. Wu Enliang reply Psychiatry

Hello, if you are not taking anticoagulants, non-steroidal anti-inflammatory drugs, or aspirin at the same time, you really don't need to worry too much.
You can discuss this further with your doctor during your next appointment.
Dr.
Wu Enliang

Reply Date: 2022/02/15

More Info

Understanding the bleeding risks associated with Selective Serotonin Reuptake Inhibitors (SSRIs) is crucial for patients, especially those with underlying health conditions such as hepatitis B or those taking other medications that may increase bleeding risks. SSRIs, including Paroxetine (the medication you are currently taking), are commonly prescribed for anxiety and depression. However, recent studies have raised concerns about their potential to increase the risk of bleeding, particularly in the context of certain medical conditions and concurrent medications.

The research you referenced from JAMA Neurology highlights that SSRIs can elevate the risk of intracranial hemorrhage, particularly when used alongside anticoagulants. This is particularly concerning in the first month of treatment, which is when the risk appears to be most pronounced. The mechanism behind this increased risk is thought to be related to the way SSRIs affect serotonin levels in platelets. Serotonin plays a role in platelet aggregation, and by inhibiting its reuptake, SSRIs may impair the ability of platelets to clump together effectively, which is essential for normal blood clotting.

For patients like yourself, who have a history of hepatitis B and are cautious about medication interactions, it is essential to communicate openly with your healthcare provider about all medications you are taking, including over-the-counter drugs and supplements. If you are not taking anticoagulants or non-steroidal anti-inflammatory drugs (NSAIDs), the bleeding risk associated with SSRIs is generally considered to be lower. However, it is still important to monitor for any unusual bruising or bleeding and to report these to your doctor.

If you are considering SSRIs merely as a "mental vitamin" or for mild anxiety, it may be worth discussing alternative treatments with your healthcare provider. Non-pharmacological approaches such as cognitive-behavioral therapy (CBT), mindfulness practices, or lifestyle modifications (like exercise and diet) can be effective for managing anxiety and may not carry the same risks as SSRIs. Additionally, if you find that your symptoms are manageable without medication, it may be appropriate to reduce or discontinue your SSRI under medical supervision.

In summary, while SSRIs can be effective for treating anxiety and depression, it is vital to understand their potential risks, especially concerning bleeding. Regular follow-ups with your healthcare provider can help ensure that your treatment plan is safe and effective. If you have any concerns about your current medication or its effects, do not hesitate to bring them up during your next appointment. Your health and safety should always come first, and your doctor can provide personalized advice based on your specific situation.

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