Can Sertraline Cause Tremor?
Yes, tremor is a well-documented side effect of sertraline and other SSRIs, occurring both at therapeutic doses and in overdose situations. 1, 2
Evidence from FDA Labeling and Guidelines
The FDA-approved prescribing information for sertraline explicitly lists tremor as one of the common treatment-emergent adverse events, alongside sweating, nervousness, insomnia or somnolence, dizziness, and gastrointestinal disturbances. 2 This represents the highest-quality regulatory evidence confirming tremor as a recognized side effect.
Multiple clinical guidelines corroborate this finding:
- The American Family Physician guidelines identify tremor as a commonly reported adverse effect with second-generation antidepressants, including sertraline. 1
- The American Academy of Child and Adolescent Psychiatry guidelines note that tremors are characteristic symptoms of serotonin syndrome, which can occur when sertraline is combined with other serotonergic medications. 3
- Pediatric guidelines document tremors as part of the neonatal withdrawal syndrome in infants exposed to SSRIs including sertraline during pregnancy. 3
Clinical Context and Mechanisms
Tremor associated with sertraline can occur in two distinct contexts:
As a direct side effect at therapeutic doses: Tremor appears as a common adverse event during routine treatment, typically mild to moderate in severity. 1, 2
As part of serotonin syndrome: When sertraline is combined with other serotonergic agents, tremor becomes part of a more serious constellation of symptoms including mental status changes (confusion, agitation), neuromuscular hyperactivity (clonus, hyperreflexia, muscle rigidity), and autonomic hyperactivity (hypertension, tachycardia, diaphoresis). 3 This represents a medical emergency requiring immediate discontinuation of all serotonergic agents and supportive care. 3
Overdose Presentations
In sertraline overdose, tremor is among the most common presenting signs. A prospective study of 40 sertraline overdoses found tremor to be one of the most frequently reported abnormalities in isolated sertraline ingestion. 4 The FDA overdose data similarly lists tremor among common overdose symptoms, along with somnolence, vomiting, tachycardia, nausea, dizziness, and agitation. 2
Drug Interactions That Increase Tremor Risk
Lithium combination: When sertraline is given with lithium, a pharmacodynamic interaction can lead to increased tremor even though sertraline does not affect lithium clearance. 5 This represents a specific clinical scenario where tremor risk is amplified.
Important Clinical Pitfalls
- Don't dismiss tremor as benign: While isolated tremor may be a tolerable side effect, evaluate for other signs of serotonin syndrome, particularly if the patient is taking multiple serotonergic medications. 3
- Consider conversion disorder in the differential: One case report documented a patient on sertraline presenting with tremor and other symptoms initially thought to be serotonin syndrome but ultimately diagnosed as conversion disorder. 6 However, serotonin syndrome must be ruled out first given its potential severity.
- Monitor high-risk populations: Polypharmacy, older age, and high doses increase the risk of drug-induced tremor. 7
Management Approach
If tremor develops on sertraline:
- Assess for serotonin syndrome features (mental status changes, autonomic instability, neuromuscular hyperactivity). 3
- Review all medications for serotonergic agents, particularly MAOIs, other SSRIs/SNRIs, tramadol, dextromethorphan, and illicit drugs. 3, 2
- If tremor is isolated and mild, consider dose reduction or reassurance with continued monitoring. 1
- If serotonin syndrome is suspected, immediately discontinue all serotonergic agents and provide supportive care with continuous cardiac monitoring. 3
- Drug-induced tremor typically resolves after discontinuation of the offending medication, though persistent tremor (tardive tremor) can rarely occur. 7