Report points to limited benefits of SSRIs in elderly patients

Selective serotonin reuptake inhibitors (SSRIs) may increase risk of clotting problems

Marisa Wexler, MS avatar

by Marisa Wexler, MS |

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Use of certain anti-depressants may increase the risk of life-threatening clotting problems in elderly people with Parkinson’s disease, a new report highlights.

The study, “Deep venous thrombosis and hyponatremia associated with citalopram use for behavioral symptoms in Parkinson’s disease: a case report,” was published in BMC Geriatrics.

Psychiatric problems ranging from anxiety to hallucinations are common among people with Parkinson’s. Selective serotonin reuptake inhibitors, or SSRIs, are a class of antidepressant widely used to help manage these issues, though evidence for their efficacy in people with Parkinson’s is limited.

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A researcher at the University of Tabuk in Saudi Arabia described the case of an 86-year-old woman who went to the university hospital’s emergency department due to swelling in her leg, generalized weakness, and an altered mental state.

The woman had a known diagnosis of Parkinson’s disease, as well as diabetes, high blood pressure, and osteoporosis (weakened bones). She was taking a handful of medicines (gliclazide, metformin, valsartan, and atorvastatin) to help manage these issues, though she was not on any specific treatment for Parkinson’s.

About a month before going to the emergency department, the woman had been prescribed the SSRI citalopram (sold as Celexa and generics) to help manage psychiatric problems including agitation, hallucinations, and difficulty sleeping. Owing to side effects of excessive fatigue, she had stopped taking this medication two days before she went to the hospital.

Deep vein thrombosis

Upon examination at the hospital, the woman was found to have abnormally low levels of sodium (salt) in her blood, and clinicians identified a deep vein thrombosis (DVT) in her leg. A DVT is a large clot that blocks blood flow, which can cause serious — sometimes fatal — problems.

The patient was treated with a high-sodium liquid infusion and with a clot-thinning medicine called warfarin. Her other medicines were paused for the duration of her stay in the hospital.

After two days in the hospital, her sodium levels had normalized. When the patient was discharged from the hospital, she restarted some of her earlier medications, and also started taking apixaban (an anti-clotting therapy) and donepezil, which is approved to help ease memory loss and confusion in Alzheimer’s disease.

At follow-up about a month later, her blood sodium levels were still normal, and her cognitive state had improved markedly.

Taking these findings collectively, clinicians hypothesized that low sodium levels (hyponatremia) may have contributed both to DVT and to the changes in the patient’s mental state. They noted that the patient’s sodium levels had been normal before she started taking citalopram, and prior reports have suggested that SSRI antidepressants may alter sodium levels in some patients, particularly older individuals.

Sodium levels crucial

“Close monitoring of sodium levels is crucial when treating older adults with SSRIs, especially when SSRIs are combined with other medications that may affect sodium levels … to avoid synergistic effects and the serious consequences of hyponatremia,” the scientist noted, adding “This case highlights the uncertainty, limited efficacy, and reduced tolerability of SSRIs when used for neuropsychiatric symptoms related to” Parkinson’s disease.

The researcher noted that other classes of psychiatric medications — particularly dopaminergic agonists and cholinesterase inhibitors — may be more helpful than SSRIs for managing psychiatric issues in Parkinson’s, and other interventions such as talk therapy also may be helpful.

“First-line therapy for these symptoms should focus on non-pharmacologic measures, followed by dopaminergic agonists … or cholinesterase inhibitors,” they wrote.