October 19, 2012 — The journal Neurology has published a study associating the use of SSRI antidepressants with bleeding in the brain and stroke. Although the risk is relatively small, it raises concerns about prescribing SSRIs to people with other risk factors for bleeding and stroke — for example, people taking blood-thinning medications such as Pradaxa or warfarin.
Selective serotonin reuptake inhibitors, or SSRI antidepressants, and have been used by millions of people in the U.S. over the last few decades. The most popular SSRIs include Prozac (fluoxetine), Celexa (citalopram), Lexapro (escitalopram), and Zoloft (sertraline). Other research has linked these medications to an increased risk of gastrointestinal bleeding, especially in the first few months, due to a blood-thinning effect. However, until now, experts did not know whether this risk extended to cerebral hemorrhage.
The Canadian researchers conducted a meta-analysis of 16 studies published in medical literature. The studies involved more than 500,000 people. They found a 51% increased risk of intra-cranial bleeding and a 42% increased risk of intra-cerebral bleeding (bleeding inside the brain) associated with people who used SSRIs, compared to people who did not.
Bleeding in the brain is a relatively rare condition, and even a 40-50% increased risk translates to relatively few extra cases numerically. However, the increased risk may be significant for people who have had a hemorrhagic stroke in the past, or are taking a blood-thinner, or have another risk factor. Patients who took an SSRI plus a blood-thinning medication were 56% more likely to have a stroke compared to people who only used blood-thinning medications.
The researchers wrote:
“We believe clinicians might consider alternate classes of antidepressants in patients with intrinsic risk factors for intracerebral hemorrhage, such as those receiving long-term oral anticoagulation, individuals with previous intracranial bleeding, and patients with cerebral amyloid angiopathy or severe alcohol abuse.”
The researchers also cautioned that people should not be deterred from using an SSRI if they have a clinical reason to use the medication. The increased risk of stroke is small for most people. However, the study does shed more light on the bleeding risks associated with SSRIs. It also highlights the importance of prescribing antidepressants selectively depending on a patient’s unique risk factors for stroke and bleeding.