Hemorrhages during Escitalopram—Venlafaxine— Mirtazapine Combination Treatment of Depression
Bibliographic record
Abstract
Dear Editor: Selective serotonin reuptake inhibitors (SSRIs) may cause bleeding (1-3), probably by increasing platelet release of serotonin, which increases platelet aggregation. I report on a patient who experienced bleeding during treatment for depression when escitalopram, venlafaxine, and mirtazapine were combined but not when the same drugs were used alone. Case Report A man, aged 60 years, with major depressive disorder had been treated for 12 months with many antidepressants, both alone and in combination, with mild improvement. All SSRIs had been used alone at maximum dosage. The maximum dosages of venlafaxine alone and mirtazapine alone (which increase serotonin and norepinephrine) had also been used. The patient improved with escitalopram 20 mg daily. Two months later, because his depressive symptoms persisted, venlafaxine and mirtazapine were added to escitalopram. His mirtazapine dosage was 15 mg daily, and his venlafaxine dosage was 150 mg daily. One week later, the patient noted mild hemorrhages from his nose and rectum. These progressively worsened during the following 3 weeks, but not to the point of requiring emergency treatment. The patient then spontaneously gradually reduced the dosages of mirtazapine, venlafaxine, and escitalopram. Mirtazapine was reduced to 7.5 mg daily, venlafaxine to 100 mg daily, and escitalopram to 15 mg daily. In 1 week, the bleeding decreased. He continued weekly tapering the medications to escitalopram 5 mg daily, venlafaxine 37.5 mg daily, and mirtazapine 7.5 mg daily after 3 weeks. During tapering, the amount of nose and rectal blood loss progressively decreased; it stopped when the final dosages were reached. As well, the patient's depression remitted. He experienced no serotonin syndrome. This patient has also been taking omeprazole 20 mg daily for stomach ulcers he developed years ago, as well as, for some years, the antihypertensive irbesartan (an angiotensin II receptor inhibitor) 300 mg daily. The onset of hemorrhages when mirtazapine and venlafaxine were added to escitalopram and the dosage-response relation between bleeding and dosages of these drugs suggest a causal link: Because previous treatments with escitalopram, venlafaxine, and mirtazapine, used alone, did not cause hemorrhages, it appears that this drug combination may have caused them. Escitalopram and venlafaxine (by blocking serotonin reuptake) and mirtazapine (by increasing serotonin release) may have increased serotonin to levels not reached with previous treatments, leading to hemorrhage by platelet aggregation. …
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.009 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.002 | 0.002 |
| Open science | 0.002 | 0.000 |
| Research integrity | 0.005 | 0.005 |
| Insufficient payload (model declined to judge) | 0.002 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".