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 Table of Contents    
CASE REPORT
Year : 2012  |  Volume : 34  |  Issue : 4  |  Page : 391-393  

Suicidality and Suicide Attempt in a Young Female on Long-Term Sertraline Treatment


1 Department of Clinical & Experimental Pharmacology, Calcutta School of Tropical Medicine, Kolkata, West Bengal, India
2 Senior Research Fellow, National Institute of Cholera and Enteric Diseases, Kolkata, West Bengal, India
3 Department of Pharmacology, Calcutta Medical College, Kolkata, West Bengal, India

Date of Web Publication7-Mar-2013

Correspondence Address:
Ranjita Santra
Department of Clinical and Experimental Pharmacology, Calcutta School of Tropical Medicine, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0253-7176.108230

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   Abstract 

A 22-year-old woman who was on sertraline 50 mg oral tablets once daily for 2 years for treatment of major depression took 30 such tablets (1500 mg) in a fit of rage, with a suicidal intent. She presented to the Emergency Department of a Tertiary Care Hospital with tachycardia, tachypnea, hypertension, tremors, agitation, confusion, vomiting, and hyperthermia. The patient was admitted and treated symptomatically, and sertraline therapy was discontinued. The unwanted effects subsided within 48 h and she recovered uneventfully within 72 h. This case report describes an unsuccessful attempt of suicide with sertraline overdose in a patient on long-term sertraline therapy and underlines the importance of close monitoring of such patients.

Keywords: Selective serotonin reuptake inhibitor, sertraline, suicidality


How to cite this article:
Santra R, Chaudhuri PR, Dhali D, Mondal S. Suicidality and Suicide Attempt in a Young Female on Long-Term Sertraline Treatment. Indian J Psychol Med 2012;34:391-3

How to cite this URL:
Santra R, Chaudhuri PR, Dhali D, Mondal S. Suicidality and Suicide Attempt in a Young Female on Long-Term Sertraline Treatment. Indian J Psychol Med [serial online] 2012 [cited 2019 Jul 23];34:391-3. Available from: http://www.ijpm.info/text.asp?2012/34/4/391/108230


   Introduction Top


The risk for suicide in patients with major depression and bipolar disorders is 15%, and the risk is highest in the early stages of the illness. [1] However, suicidal ideation, thoughts, and behavior - collectively termed as suicidality, and suicidal acts have long been linked to antidepressant usage. [2] Selective serotonin reuptake inhibitors (SSRIs), including sertraline, are believed to increase suicidality risks, [3],[4] although controversies do exist regarding the existence of any such real risk. [5] Case reports highlighting attempts of suicide are available. [6] However, despite a diligent search, we could not find any report of sertraline-associated suicidality from India. We report here a case of suicide attempt by a young woman who was on sertraline treatment for 2 years.


   Case Report Top


A 22-year-old unmarried woman with a history of major depressive disorder and suicidal ideation presented to the emergency department of a tertiary care hospital with palpitation, hurried breathing, tremors, restlessness, agitation, confusion, and a few bouts of vomiting. In a fit of rage, she consumed 30 tablets of 50 mg sertraline. She was rushed to the hospital and was admitted in the intensive care unit. On admission, she had a pulse rate of 112/min, blood pressure (BP) (lying) 150/90 mm Hg, respiration rate 22/min, temperature (oral) 104°F, and exaggerated reflexes. She was restless and communicative. She had been undergoing treatment for the last 2 years for major depressive disorder in the psychiatry outpatients' department (OPD) of the same hospital, with 50 mg sertraline once daily along with 0.25 mg clonazepam as and when required. She revealed no history of suicidal attempt. On mental status examination, she was conscious, oriented to person but not to time and place, and had poor attention and concentration span. Her speech was incoherent and reduced to whispering. Then, she had an episode of vomiting and, subsequently, had three more episodes after an interval of 2 h. Laboratory investigations such as complete hemogram, serum urea and creatinine, liver function tests, random blood glucose, electrocardiogram, and arterial blood gas analysis were all within normal limits.

Sertraline treatment was suspended. She was treated with 2L of 5% Dextrose Normal Saline (DNS) infusion, frusemide 1 ampoule i.v. inj., ondansetron 1 ampoule (4 mg) i.m. inj., and cold compressions. Her pulse, BP, and temperature were monitored hourly. Her vitals improved within 48 h, with pulse rate becoming 76/min and BP 128/78 mm Hg. She became afebrile also. She started taking food orally. On the 3 rd day, the mental status examination showed that her cognition had improved, she was well oriented to time, place, and person; and had a fair level of attention and concentration. Her memory was intact; psychomotor activity was normal; and speech was coherent and goal-directed. The patient was discharged with advice to report for follow-up in the psychiatry OPD. On probing during a predischarge counseling session on the third day, the patient admitted that during the last 2 years she had often been perturbed with suicidal ideation and thoughts, although this was the first time she attempted suicide.


   Discussion Top


Depression in itself is a strong predictor of suicide. There has been a longstanding concern that antidepressants may induce worsening of depression with the emergence of suicidality during the early phases of treatment. [2] Ever since the introduction of the SSRIs, concerns emerged regarding the risk of developing suicidal ideation along with their use. However, controversies mounted as diverging reports supporting and refuting of such concerns continued to pour in. [3],[4],[5] In regard to the risk of suicidality, regulatory agencies such as United States - Food and Drug Administration (US-FDA) or The Medicines and Healthcare products Regulatory Agency (MHRA) (United Kingdom) responded from time to time to the changing information base. The current position on the matter is that there seems to be no increase in the suicidality risk in sertraline-treated adult patients. [7],[8] However, the latest (May 2007) advisory from US-FDA [9] warns against an increased risk of suicidal thinking and behaviors with all antidepressant medications, including sertraline, in young adults aged 18-24 years during initial treatment (generally the first 1-2 months). As a regulatory mandate by both FDA and MRHA, the manufacturers of sertraline are required to warn against the dangers of suicidal thoughts and behavior and to include such warning in the package inserts and patient information leaflets. The Current Index of Medical Practice, India, [10] mentions under Precaution Clause for sertraline: "Monitor for signs of clinical worsening, suicidality and unusual changes in behavior especially during the initial treatment period or when there are dosage adjustments."

In the present case, the 22-year-old woman who was on sertraline treatment for 2 years for major depression took a heavy dose of sertraline with suicidal intent. She revealed that while she was always adherent to the treatment, on several occasions in the past 2 years suicidal thoughts had occupied her mind. She thus clearly demonstrated suicidality with the impulsive consumption of an over dosage of sertraline. It is important to note that contrary to common belief, the suicide attempt in this case occurred after 2 years of treatment with sertraline. To the best of our knowledge, this is the foremost case of sertraline-associated suicidality to be reported from India.

How sertraline or other antidepressants may cause suicidality remains unclear. It could be due to worsening of the primary disease-paradoxical suicide; [1] or it may be attributed to the drug itself. [11] Patients often describe feelings of hopelessness and despair that may develop after starting treatment with an antidepressant that may lead to suicidality. Only careful and frequent monitoring of all patients, particularly children, adolescents, and young adults who are put on long-term treatment with sertraline and other antidepressants, with focus on appearance of suicidal thoughts and behaviors, may detect such tendency, and appropriate measures may then be taken accordingly.

 
   References Top

1.Healy D. A failure to warn. Int J Risk Saf Med 1999;12:151-6.  Back to cited text no. 1
    
2.Healy D, Alfred G. Antidepressant drug use and the risk of suicide. Int Rev Psychiatry 2005;17:163-72.  Back to cited text no. 2
    
3.Fergusson D, Doucette S, Glass KC, Shapiro S, Healy D, Hebert P, et al. Association between suicide attempts and selective serotonin reuptake inhibitors: Systematic review of randomised controlled trials. BMJ 2005;330:396.  Back to cited text no. 3
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4.Tranter R, Healy H, Cattell D, Healy D. Functional effects of agents differentially selective to noradrenergic or serotonergic systems. Psychol Med 2002;32:517-24.  Back to cited text no. 4
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5.Simon GE, Savarino J, Operskalski B, Wang PS. Suicide risk during antidepressant treatment. Am J Psychiatry 2006;163:41-7.  Back to cited text no. 5
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6.Caracci G. Unsuccessful suicide attempt by sertraline overdose. Am J Psychiatry 1994;151:147.  Back to cited text no. 6
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7.Levenson M, Holland C. Statistical Evaluation of Suicidality in Adults Treated with Antidepressants (PDF) (2006-11-17). Overview for December 13, 2006. Meeting of Psychopharmacologic Drugs Advisory Committee (PDAC). US- FDA: USA; p. 75-140. Retrieved 2008-07-11. Available from: http://www.fda.gov/ohrms/dockets/ac/06/briefing/2006-4272b1-01-FDA.pdf. [Last accessed on 2012 Feb 24].  Back to cited text no. 7
    
8.Vanderburg DG, Batzar E, Fogel I, Kremer CM. A pooled analysis of suicidality in double-blind, placebo-controlled studies of sertraline in adults. J Clin Psychiatry 2009;70:674-83.  Back to cited text no. 8
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9.FDA Proposes New Warnings About Suicidal Thinking, Behavior in Young Adults Who Take Antidepressant Medications, 2007. Available from: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2007/ucm108905.htm. [Last accessed on 2012 Feb 24].  Back to cited text no. 9
    
10.Available from: http://www.cimsasia.com/India/drug/info/sertraline/?q=sertraline%20suicidality and type=brief and mtype=generic. [Last accessed on 2012 Feb 23].  Back to cited text no. 10
    
11.Akiskal HS, Benazzi F. Psychopathologic correlates of suicidal ideation in major depressive outpatients: Is it all due to unrecognized (bipolar) depressive mixed states? Psychopathology 2005;38:273-80.  Back to cited text no. 11
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