SSRIs and Bleeding Risk: Exploring the Role of The Consultant Psychiatrist

Thursday, November 10, 2022

11:00 AM – 12:30 PM

Location: Room 206-207

CE: 1.5 CME

Lead Speaker(s)

Jon Levenson, MD, FACLP (he/him/his)

Director of Undergraduate Medical Education in Consult-Liaison Psychiatry
Columbia University Irving Medical Center
New York, New York

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Speaker(s)

Gregg Robbins-Welty, MD, MS

Chief Resident for CL Psychiatry; Internal Medicine & Psychiatry Resident Physician
Duke University Hospital
Durham, North Carolina

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Andrea DeSimone, DO

Chair, Department of Psychiatry
Bayhealth Medical Center
Millsboro, Delaware

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Fíona Fonseca, MBBChBAO, MS (they/them/theirs)

Consultation-Liaison Psychiatry Fellow
Mayo Clinic
Rochester, Minnesota

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Moderator/Discussant(s)

Daniel McFarland, DO (he/him/his)

Director of Psycho-Oncology
University of Rochester
New York, New York

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Abstract: Consultation-liaison psychiatrists are frequently asked whether Selective Serotonin Reuptake Inhibitors (SSRIs) should be discontinued, not started, continued, or modified in patients at substantial risk of bleeding. Colleagues may be concerned about bleeding from gastrointestinal abnormalities, surgical procedures, thrombocytopenia, platelet function abnormalities, hemorrhagic strokes, and other conditions related to risk of bleeding. Although SSRIs roughly double the odds of gastrointestinal bleeding, the absolute risk remains low. But the risk of bleeding increases with medical or surgical complexity and when patients are taking other medications known to impact platelets and other hemostatic mechanisms.

The consultant psychiatrist is often tasked with portraying the risk of bleeding stemming from initiation or continuation of antidepressant therapy while weighing the need to treat anxiety or depression pharmacologically in various medically or surgically complex settings. This task requires not only understanding the relationship between SSRIs and bleeding but also the concomitant risk of bleeding posed by concomitant medical/surgical scenarios. Clinicians may have strong opinions regarding risk and/or efficacy of SSRIs and antidepressants. A paucity of applicable data and the intersectionality of myriad clinical factors leave little high-quality data to drive these decisions. CL psychiatrists are obligated to factor these considerations into their recommendations to stop, continue, or initiate SSRI therapy in the face of elevated risk of bleeding.

The first panel presentation by Dr. Jon Levenson reviews a case of escitalopram discontinuation in the setting of acute leukemia and thrombocytopenia highlighting the consultants concern for patient benefit from antidepressant therapy and bleeding risk. Dr. Levenson will present several questions regarding clinical concerns and practice patterns so that audience members can view their colleagues’ practice patterns. The following presentation, to be given by Dr. Gregg Robbins-Welty, will provide an overview of bleeding mechanisms answering questions about how bleeding occurs secondary to SSRI therapy and the contributing risk of key disease states. Audience participations questions will test knowledge of bleeding mechanisms and disease-related bleeding risk. Dr. Fiona Fonseca will discuss currently available literature regarding bleeding risk from SSRIs and other antidepressant medications, and proposed strategies to mitigate bleeding risk (e.g., switching to bupropion or mirtazapine). Polling questions will gauge audience opinions or consensus regarding treatment options and recommendations. The fourth presentation by Dr. Daniel McFarland, a board-certified hematologist and CL psychiatrist, provides the hematologist perspective on bleeding states and risk assessment, and will discuss the fundamental elements to taking a bleeding history. This adjunctive information provides a contextual framework from which to consider bleeding risk and interdisciplinary collegial discussion regarding this frequently encountered clinical question for the CL psychiatrist. The final panelist, Dr. Andrea DeSimone, will discuss the specific topics of polypharmacy, drug-drug interactions, and situations when patients are on additional antiplatelet therapies.

Learning Objectives:

This symposium will review data and conceptual issues that inform stopping, starting, continuing, or modifying antidepressants, namely selective serotonin reuptake inhibitor (SSRI), in patients who are at risk of bleeding.
instill comprehension of various mechanisms of bleeding and how SSRIs can augment risk of bleeding, and how the CL psychiatrist can conduct a bleeding history with at-risk patients
Obtain a general understanding of bleeding risk from epidemiologic data including differences in relative and absolute risk as well as individual risk from the coupling of multiple risk factors.