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Association between selective serotonin reuptake inhibitors and upper gastrointestinal bleeding: population based case-control study

BMJ 1999; 319 doi: (Published 23 October 1999) Cite this as: BMJ 1999;319:1106

Rapid Response:

Association between SSRIs and upper GI bleeding

EDITOR.. De Abajo et al concluded that selective serotonin reuptake
inhibitors are associated with an increased risk of upper GI bleeding
particularly when combined with non-steroidal anti-inflammatory drugs, and
appeared to demonstrate a convincing association between degree of
selectivity and relative risk.
However we have concerns that important factors have been overlooked.
Although patients with alcoholism were excluded it is known that heavy
drinkers are generally poorly identified in general practice. It is
possible therefore that a number of gastrointestinal bleeds secondary to
alcohol misuse have not been identified in this study.
Futhermore, depression is associated with a number of painful conditions
such as menstrual disorders2, arthritis 3 and back pain 4. Theseconditions
frequently lead patients to self-medicate with over the counter
analgesics, which is likely to include substantial use of non-steroidal
anti-inflammatory drugs. GPs lack awareness of the prevalence of self-
medication with non-steroidals 5, though de Abajo et al consider
theirprescription data complete. The UK general practice research database
would therefore be unable to identify the use of over-the counter non-
steroidals in a substantial group of patients, specifically those with
depression associated with pain. Therefore undue bias may be placed on the
role of the antidepressant in the aetiology of gastrointestinal bleeding.
Prospective studies are required, taking into account such confounding
variables, before a causal relationship between selective serotonin
reuptake inhibitors can be demonstrated.

Tim Dickinson SpR in General Adult Psychiatry
Saj Malhi S HO in Psychiatry

Susan Painter S HO in Psychiatry

Jonathon Pyott S HO in Psychiatry

Avleen Sawhney S HO in Psychiatry

Aylesbury Vale Healthcare NHS Trust.

1 de Abajo FJ, Rodriguez LA, Montero D. Association between selective
serotonin reuptake inhibitors and upper gastrointestional bleeding:
population based case-control study. BMJ 1999; 319:1106-9

2 Bancroft J, Rennie D, Warner P. Vulnerability to perimenstrual mood
change: the relevance of a past history of a depressive disorder.
Psychosom Med 1994; 56(3); 225-31

3 Abdel-Nasser AM, Abd El-Azim S, Taal E, El-Badawy SA, Rasker JJ,
Valkenburg HA. Depression and depressive symptoms in rheumatoid arthritis
patients: an analysis of their occurrence and determinants. Br J Rheumatol
1998; 37(4): 391-7

4 Waxman R, Tennant A, Helliwell P. Community survey of factors
associated with consultation for low back pain. BMJ 1998; 317: 1564-7

5 Pal B. GPs lack awareness of non-steroidal anti-inflammatory drugs
available over the counter. BMJ 1996; 313: 116

Competing interests: No competing interests

29 October 1999
Valerie Cahill