SSRI Risks: Insights on Anxiety Treatment and Stroke

Questions related to SSRIs?

Dear Dr.
Lin,
A few years ago, I sought treatment for anxiety and obsessive thoughts.
Initially, I tried several medications, but eventually settled on taking Paroxetine HCl Hemihydrate 20mg, as prescribed, one tablet at bedtime.
However, I often only take half a tablet when my condition feels stable, 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 adopted the mindset of treating it like a supplemental vitamin for mental health.
Due to my chronic Hepatitis B carrier status, I am very cautious with medications.
Recently, I inadvertently consumed a small amount of steroids for a skin issue (which is contraindicated for Hepatitis B carriers), prompting me to review my medications.
In the process, I came across a medical article that discussed recent findings: https://www.cgmh.org.tw/cgmn/category.asp?id_seq=1712009#.YgsJXFVBzZ4.
The article mentions that there has been increasing research on the use of SSRIs in promoting recovery of motor function after a stroke, and the bleeding side effects of SSRIs have gained attention among neurologists.
A study published this year in the well-known medical journal JAMA Neurology found that SSRIs significantly increase the risk of intracerebral hemorrhage, especially when combined with anticoagulants, with a higher risk observed during the first month of treatment.
Patients are cautioned that using SSRIs alongside anticoagulants may increase the risk of hemorrhagic stroke.
I sometimes experience bruising, which I attribute to minor bumps, but I am not always sure if that is the cause (it doesn't happen frequently).
My platelet counts have been normal during Hepatitis B monitoring.
However, I was alarmed to learn about the increased risk of hemorrhagic stroke associated with SSRIs (the recent news has been quite frightening).
I would like to ask how to correctly interpret the findings mentioned in the medical journal, and if there are alternative medication recommendations, especially if I am only looking for something akin to a mental health vitamin.
Thank you for taking the time to respond.

LIN U, 40~49 year old female. Ask Date: 2022/04/08

Dr. Lin Mianzhang reply Psychiatry

Hi there! Regarding the article you mentioned that cites the study from JAMA Neurology, it can be found here: https://jamanetwork.com/journals/jamaneurology/fullarticle/2588683.
Upon closer examination of that article, you will find that although SSRIs generally increase the risk of intracranial hemorrhage, this increased risk is primarily observed during the first month of treatment.
After one month of treatment, the risk does not show a significant difference compared to the control group.
Therefore, if you do not have related risk factors, such as a coagulation disorder, use of anticoagulants, or a history of stroke, you can take this medication with peace of mind.
As for occasional bruising, it depends on whether you experienced this phenomenon before starting the medication or if it appeared afterward.
If it occurs only occasionally and is not accompanied by other bleeding symptoms, it can be monitored without too much concern.
Wishing you safety and good health!

Reply Date: 2022/04/08

More Info

When it comes to understanding the risks associated with Selective Serotonin Reuptake Inhibitors (SSRIs) like Paroxetine, especially in the context of anxiety treatment and potential stroke risks, it's essential to consider several factors. SSRIs are commonly prescribed for anxiety disorders and have been shown to be effective in managing symptoms. However, recent studies, including one published in JAMA Neurology, have raised concerns about the potential for SSRIs to increase the risk of intracranial hemorrhage, particularly in the first month of treatment and when combined with anticoagulants.

Understanding the Risks
1. Increased Bleeding Risk: The research indicates that SSRIs can elevate the risk of brain bleeding, especially when used alongside anticoagulants. This is particularly concerning for individuals with pre-existing conditions that may predispose them to bleeding, such as liver disease (like your Hepatitis B carrier status) or those who have a history of stroke. The increased risk is primarily observed during the initial month of treatment, which is crucial to note.

2. Monitoring Symptoms: You mentioned experiencing occasional bruising, which can be a common side effect of SSRIs due to their impact on platelet function. If you notice an increase in bruising or any other unusual bleeding, it’s important to discuss this with your healthcare provider. Regular monitoring of your blood parameters, including platelet counts, is a good practice, especially given your medical history.

3. Medication Adherence: It’s also important to adhere to the prescribed dosage of your medication. Taking half a dose or skipping doses can lead to fluctuations in serotonin levels, potentially exacerbating anxiety symptoms. SSRIs typically require consistent dosing to maintain stable blood levels and therapeutic effects.

Alternative Medications
If you are concerned about the risks associated with SSRIs, you might consider discussing alternative medications with your physician. Some options include:
- SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors): These medications can also be effective for anxiety and may have a different side effect profile. However, they can also increase blood pressure and heart rate, which may not be ideal given your concerns about heart palpitations.

- Non-SSRI Options: Other classes of medications, such as buspirone or certain atypical antipsychotics, may be considered for anxiety management without the same bleeding risks associated with SSRIs.

Conclusion
In summary, while SSRIs like Paroxetine can be effective for anxiety treatment, it’s crucial to weigh the benefits against the potential risks, especially in the context of your medical history. Regular communication with your healthcare provider is essential to ensure that your treatment plan is safe and effective. If you feel uncomfortable with your current medication or have concerns about side effects, don't hesitate to bring these issues up during your next appointment. Your mental health is important, and finding the right balance in your treatment is key to achieving a better quality of life.

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