Treatment of SSRI Overdose
The treatment of SSRI overdose primarily involves discontinuation of all serotonergic agents and providing hospital-based supportive care with continuous cardiac monitoring. 1
Clinical Manifestations
- SSRI overdose presents with a spectrum of symptoms ranging from mild (nausea, vomiting, mydriasis, hypersalivation, and hyperthermia) to severe manifestations of serotonin syndrome 1, 2
- Serotonin syndrome is characterized by mental status changes, neuromuscular hyperactivity, and autonomic hyperactivity 1, 3
- Advanced symptoms include fever, seizures, arrhythmias, and unconsciousness, which can be potentially fatal 1, 4
- QT prolongation is a particular concern with citalopram overdose 5, 1, 4
Treatment Algorithm
Immediate Management
- Discontinue all serotonergic agents immediately 1, 3
- Provide hospital-based supportive care with continuous cardiac monitoring 1, 3
- Do not induce emesis 3
- Consider oral activated charcoal for recent ingestions, though specific clinical benefit is not established 3
Pharmacological Management
- Administer cyproheptadine, a serotonin antagonist, for serotonin syndrome 1, 4
- Use intravenous benzodiazepines for seizures 3
- Implement external cooling measures for hyperthermia (>104°F/40°C) 3
Monitoring and Supportive Care
- Monitor vital signs, particularly temperature and cardiac rhythm 1, 4
- Provide supportive care for autonomic instability 1
- Continue cardiac monitoring, especially for patients with citalopram overdose due to risk of QT prolongation and torsades de pointes 5, 1, 4
Special Considerations
- SSRIs have a more favorable safety profile in overdose compared to tricyclic antidepressants, but deaths have been reported with very large ingestions 5, 6, 2
- Avoid combination of SSRIs with MAOIs as this significantly increases serotonin syndrome risk 1
- Exercise caution with other serotonergic drugs, including opioids and stimulants 1
- Be vigilant for delayed reactions, especially when multiple agents are involved 7
Common Pitfalls to Avoid
- Failure to recognize serotonin syndrome, which can progress rapidly 1
- Administering additional serotonergic medications during treatment 1, 7
- Inadequate temperature monitoring and management in severe cases 1
- Relying solely on physical restraints for agitation, which can worsen hyperthermia 1
- Underestimating the severity of symptoms in patients with delayed presentation 4
- Failing to monitor for cardiac complications, particularly with citalopram overdose 5, 4