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SSRIs increase risk of bleeding and death in surgery


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Yet another possible negative effect on general physical resilience.




SSRIs Linked to Odds of Surgery Survival

By Crystal Phend, Senior Staff Writer, MedPage Today April 29, 2013



  • Surgery while on an elective serotonin reuptake inhibitor (SSRI) antidepressant appears to carry higher risks of mortality and other adverse events.
  • Note that bleeds and early readmission to the hospital also occurred more often among patients receiving SSRIs.
Surgery while on a selective serotonin reuptake inhibitor (SSRI) antidepressant appears to carry higher risks of mortality and other adverse events, a large observational study showed.


Patients on SSRIs in the perioperative period had 20% higher odds of dying in the hospital after elective major surgery (95% CI 1.07 to 1.36) compared with all other patients, Andrew D. Auerbach, MD, MPH, of the University of California San Francisco, and colleagues found.


Bleeds and early readmission to the hospital also occurred more often among those patients, the group reported online in JAMA Internal Medicine.


Adjustment for potential confounders and propensity matching didn't explain the associations, but the observational results couldn't prove causality, the group cautioned.



Sorting out whether patient factors or the drugs themselves are responsible and figuring out what to do about it would take prospective studies "to allocate patients randomly to strategies of early discontinuation of SSRI therapy (e.g., weeks before surgery), holding SSRI therapy closer to the time of surgery, and not holding SSRI therapy at all (e.g., usual care)," the authors added.


Those trials would no doubt be expensive because of the large size required to power those comparisons, but it would be money well spent given how commonly used the antidepressants are and the potential risks posed, the group suggested.


The findings shouldn't change practice for now other than alerting internists, anesthesiologists, and surgeons to a potential bleeding risk, Marko Mrkobrada, MD, and Daniel G. Hackam, MD, PhD, both of Western University in London, Ontario, argued in an accompanying invited commentary.


The overall mortality rate was low, at 0.6%, so the numbers needed to treat to cause a death or readmission were about 1,000 in the propensity-matched analysis.


"Even if a causal relationship exists, the number needed to harm is quite large, and thus the attendant increase in absolute risk for the average patient would be very small," Mrkobrada and Hackam wrote.


Abruptly stopping antidepressants can lead to symptoms of dizziness, nausea, insomnia, hyperarousal or fatigue, myalgia, imbalance, anxiety, and irritability. And "anecdotal data suggest that discontinuation of therapy can lead to increased sensitivity to postoperative pain," the commentators noted.


The retrospective study included 530,416 adults who had major surgery from 2006 through 2008 at 375 U.S. hospitals participating in the voluntary Perspective database for quality and healthcare utilization monitoring.


Pharmacy data indicated that 14% took an SSRI in the perioperative period, most commonly sertraline (Zoloft).


Aside from the elevated mortality risk in that group, other risks were higher as well:

  • Readmission at 30 days (HR 1.22, 95% CI 1.18 to 1.26)
  • Bleeding (HR 1.09, 95% confidence interval 1.04 to 1.15)
  • Transfusion count (HR 1.10, 95% CI 1.08 to 1.13)
  • Length of stay (adjusted rate ratio 1.02, 95% CI 1.02 to 1.03)
Risk of ventricular arrhythmia was lower among the SSRI users compared with the rest of the cohort (HR 0.89, 95% CI 0.83 to 1.96).


Results were similar comparing SSRI use to patients with no other antidepressant use; the only significant difference seen for SSRIs versus other antidepressants was longer length of stay.


"Looking only at patients with a diagnosis of depression or those receiving antidepressants, the risk for mortality was attenuated, but higher risk of bleeding, readmission, and higher length of stay persisted," the researchers noted, supporting a lack of confounding by indication.


Results excluding patients who only got the SSRIs after surgery were almost the same as in the overall analysis.


The SSRI users tended to be sicker than other patients on a number of measures, but the results controlled for those differences. Additional adjustment for concomitant use of anticoagulants, thromboembolism prevention treatments, nonsteroidal anti-inflammatory medications, aspirin, and surgery type had little impact on the associations.


Nevertheless, the commentators cautioned that substantial residual confounding likely remained.



Limitations were use of administrative data for length of stay, electronic billing data for medication measures, and inability to determine how long SSRIs may have been held before surgery among those who got them only postoperatively.


The study was supported by a grant from the National Heart, Lung and Blood Institute.


The researchers and commentators reported having no conflicts of interest to disclose.


Primary source: JAMA Internal Medicine

Source reference:

Auerbach AD, et al "Perioperative use of selective serotonin reuptake inhibitors and risks for adverse outcomes of surgery" JAMA Intern Med 2013; DOI: 10.1001/jamainternmed.2013.714.


Additional source: JAMA Internal Medicine

Source reference:

Mrkobrada M, Hackam DG "Selective serotonin reuptake inhibitors and surgery: To hold or not to hold, that is the question" JAMA Intern Med 2013; DOI: 10.1001/jamainternmed.2013.718.





SSRI Antidepressants Increase Surgical Risks Of Bleeding And Death

Commonly prescribed selective serotonin reuptake inhibitors could complicate surgeries through hemorrhage, hospitalreadmission, and death.

By Cindy del Rosario | Apr 29, 2013 medicaldaily.com


Selective serotonin reuptake inhibitors (SSRIs) -- a popular class of antidepressants which includes Zoloft, Paxil, and Prozac -- could increase the risk of bleeding, readmission to the hospital, and even death.



While a handful of studies have linked SSRIs to increased risk of hemorrhaging in both surgical patients and ambulatory patients, the study, led by Dr. Andrew Auerbach, a professor of medicine at the University of California, San Francisco, is the largest of its kind to date.


As detailed in JAMA Internal Medicine, researchers analyzed data that included 530,416 patients ages 18 and older across 375 U.S. hospitals, who underwent major surgery from 2006-2008. They compared rates of adverse outcomes in patients who took SSRIs before or after surgery (13.7 percent of total sample), as well as outcomes in those diagnosed with depression.


Patients taking SSRIs were more likely to have obesity, chronic pulmonary disease, and hypothyroidism, which are conditions that could complicate surgery. However, after adjusting for these factors, patients taking SSRIs were more likely to die in the hospital, more likely to experience bleeding, and more likely to be readmitted at 30 days.


However, doctors caution against patients deciding to withhold SSRI therapy before or after surgery, because doing so also has negative consequences of its own.


Abrupt withdrawal of SSRI treatment could result in "discontinuation syndrome," which may lead to imbalance, dizziness, nausea, or fatigue. For those using SSRIs as an analgesic, withdrawing treatment could cause pain.


Considering the rate of surgery in the U.S. is an astounding 21 397 operations per 100 000 persons in 2004, minimizing surgical risks is an important task. However, it may mean more awareness and monitoring of those on SSRIs, instead of abrupt discontinuation of the drug before surgery.


Internists, anesthesiologists, and surgeons should be aware of potential bleeding risks in patients receiving SSRIs in the perioperative setting." wrote Dr. Marko Mrkobrada and Dr. Daniel G. Hackam in an accompanying editorial. "Overall, however, we do not believe the evidence base has evolved sufficiently to confirm that patients should routinely have their SSRI therapy tapered or discontinued before surgery."

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

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Alto I have noticed that I can bleed/bruise easily and years back I did not.


It also takes alot more time for wounds to heal.


During my hysterectomy I was told I lost alot of blood.


What about iron supplements? Is it low on AD's?

Intro: http://survivingantidepressants.org/index.php?/topic/1902-nikki-hi-my-rundown-with-ads/


Paxil 1997-2004

Crossed over to Lexapro Paxil not available

at Pharmacies GSK halted deliveries

Lexapro 40mgs

Lexapro taper (2years)


Imipramine and Celexa

Now Nefazadone/Imipramine 50mgs. each

45mgs. Serzone  50mgs. Imipramine

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I don't know, Nikki. Ask Dr. Google to find something about it.

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

All postings © copyrighted.

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  • 3 weeks later...

This explains why I could never stem the blood when I cut myself shaving without one of those clotting sticks you get from the pharmacy.


Actually, I don't recall cutting myself shaving since I came off zoloft. Always just assumed I was careless. Interesting ...

February 2004 - mid 2005 - 50 mg zoloft.


Mid 2005 - lexapro 20mg (3 months) Discontinued SSRIs for a few months - withdrawal.


20mg paxil towards end of 2005 for few weeks - borderline psychosis - lasted until Nay 2006.


Restarted sertraline in early 2006, ending up on 200mg. Down to 100mg in 2009 - stabilised at that dose for a couple of years.


Updosed to 150mg for a few weeks in 2012, before a psychiatrist put me back down to 100mg (no taper!)


Too fast taper off zoloft 100mg between May/June 2012 and September/October. Withdrawal started end of December 2012.


Tried to reinstate zoloft March 2012 50 mg - worsened.


Stemetil 5mg during an acute phase of labyrinthitis/vertigo in early 2011. Haven't taken since mid 2012.

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  • 2 weeks later...

I would like to know how long after you have been off the drugs the risk remains.

While I at the same time sensing some things are forever changed my "sense" is no replacement

for proper study by science.

Had a car accident in 85
Codeine was the pain med when I was release from hosp continuous use till 89
Given PROZAC by a specialist to help with nerve pain in my leg 89-90 not sure which year
Was not told a thing about it being a psych med thought it was a pain killer no info about psych side effects I went nuts had hallucinations. As I had a head injury and was diagnosed with a concussion in 85 I was sent to a head injury clinic in 1990 five years after the accident. I don't think they knew I had been on prozac I did not think it a big deal and never did finish the bottle of pills. I had tests of course lots of them. Was put into a pain clinic and given amitriptyline which stopped the withdrawal but had many side effects. But I could sleep something I had not done in a very long time the pain lessened. My mother got cancer in 94 they switched my meds to Zoloft to help deal with this pressure as I was her main care giver she died in 96. I stopped zoloft in 96 had withdrawal was put on paxil went nutty quit it ct put on resperidol quit it ct had withdrawal was put on Effexor... 2years later celexa was added 20mg then increased to 40mg huge personality change went wild. Did too fast taper off Celexa 05 as I felt unwell for a long time prior... quit Effexor 150mg ct 07 found ****** 8 months into withdrawal learned some things was banned from there in 08 have kept learning since. there is really not enough room here to put my history but I have a lot of opinions about a lot of things especially any of the drugs mentioned above.
One thing I would like to add here is this tidbit ALL OPIATES INCREASE SEROTONIN it is not a huge jump to being in chronic pain to being put on an ssri/snri and opiates will affect your antidepressants and your thinking.

As I do not update much I will put my quit date Nov. 17 2007 I quit Effexor cold turkey. 


There is a crack in everything ..That's how the light gets in :)

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Alto I have noticed that I can bleed/bruise easily and years back I did not.It also takes alot more time for wounds to heal.During my hysterectomy I was told I lost alot of blood.What about iron supplements? Is it low on AD's?


Even before ADs, I bruised easily.  I'm not sure about the bleeding because my doctor had me on low dose aspirin for years, which slows blood clotting considerably.  I no longer take the aspirin plus I take Vitamin K-2 and no longer have any problems at all with bruising. (Vitamin K-2 is also essential to bone health, which is why I started taking it.)


Another reason to mistrust mainstream medicine: near total ignorance of vitamins and nutrition. :angry:

Psychotropic drug history: Pristiq 50 mg. (mid-September 2010 through February 2011), Remeron (mid-September 2010 through January 2011), Lexapro 10 mg. (mid-February 2011 through mid-December 2011), Lorazepam (Ativan) 1 mg. as needed mid-September 2010 through early March 2012

"Never attribute to malice that which is adequately explained by stupidity." -Hanlon's Razor

Introduction: http://survivingantidepressants.org/index.php?/topic/1588-introducing-jemima/


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Please note that I am not a medical professional and my advice is based on personal experience, reading, and anecdotal information posted by other sufferers.


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