Letters to the Editor
Re: Hemorrhages During Escitalopram–Venlafaxine– Mirtazapine Combination Treatment of Depression
Dear Editor: The publication of Dr Benazzi’s case report (1) is somewhat worrying. Although the report does not suggest that the treatment in this case is routine or normal practice, the concluding statement that “clinicians should take care when combining several antidepressants that increase serotonin” appears to condone the treatment outlined in the paper. Apart from the fact that all treatment algorithms for resistant depression recommend lithium augmentation prior to combined antidepressants, which in most cases come well down the list of strategies, given the limited evidence base for this intervention, and putting aside the fact that, when recommended, the combination of antidepressants refers to 2 antidepressants, to add 2 antidepressants at once to an already- prescribed antidepressant is to court disaster. That nasal and rectal bleeding were the only consequences of this dangerous cocktail could be viewed as fortunate. What level of hemoglobin this patient bled down to is not revealed in the report, and it must be presumed that this was checked and was not of great concern. What is of concern is the risk that this report will encourage this sort of prescribing.
References
1. Benazzi F. Hemorrhages during escitalopram–venlafaxine–mirtazapine combination treatment of depression. Can J Psychiatry 2005;50:184.
Andrew Al-Adwani, MRCPsych
North Lincolnshire, UK
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