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Can Sertraline Induce Parkinson's Disease?

Key Words: Parkinson's Disease • Sertraline

TO THE EDITOR: Extrapyramidal side effects of sertraline and other selective serotonin reuptake inhibitors (SSRIs) have been noted extensively in the literature.¹ These actions are thought to be secondary to the inhibitory effects of serotonin on dopamine neurotransmission within the central nervous system.² To our knowledge, there are no reported cases in which SSRI-induced parkinsonism did not resolve upon termination of the medication. We report on a patient who developed irreversible Parkinson's disease shortly after initiation of treatment with sertraline.

Case Report

Mr. A. is a 70-year-old White, recently retired college professor with no previous neurological or psychiatric history who presented with feelings of depression and anxiety associated with hypersomnia and anhedonia. Full remission of these symptoms was achieved with sertraline (100 mg qhs) and alprazolam (1 mg bid). Within 2 months of beginning sertraline, Mr. A. noticed development of a resting tremor in his left hand and a deterioration of his handwriting. Upon examination he was noted to have cogwheel rigidity bilaterally. At this point the sertraline was discontinued, and some partial improvement was noted, without full disappearance of the symptoms. Mr. A. was referred to a neurologist for a full evaluation. The diagnosis of Parkinson's disease was confirmed and carbidopa/levodopa was started.

The depressive symptoms returned and another trial of sertraline was attempted concurrently with the carbidopa/levodopa. The parkinsonism again worsened and the sertraline was stopped. Soon after, relief from the depressive symptoms was attained with nortriptyline and trazodone. Over the next 3 years the Parkinson's Disease has slowly but steadily progressed with symptoms of gait disturbance, tremor, rigidity, and cognitive deficits.

DISCUSSION

A likely explanation of this case is that sertraline simply unmasked a developing Parkinson's disease. Gonul and Aksu³ have reported a case describing extrapyramidal symptoms induced by fluvoxamine therapy in a 61-year-old woman. In this patient, Parkinson's disease developed after an 11-month symptom-free period, following the discontinuation of fluvoxamine. Gonul and Aksu suggested that SSRI-induced parkinsonism may represent a vulnerability to future Parkinson's disease. However, an alternative explanation for both Gonul and Aksu's case and our case is that the SSRI triggered an irreversible destructive process in the brain in a predisposed patient, thus leading to Parkinson's disease. We cannot know whether this illness would have developed in our patient if the SSRI had never been started. A recent study has demonstrated that SSRIs can induce neuroanatomical changes in the thalamus.⁴ Systematic studies are needed to address whether SSRI's can induce Parkinson's disease.

REFERENCES

1. Lambert MT, Trutia C, Petty F: Extrapyramidal adverse effects associated with sertraline. Prog Neuropsychopharmacol Biol Psychiatry 1998; 22:741–748[Medline]
2. Di Rocco A, Brannan T, Prikhojan A, et al: Sertraline induced parkinsonism. A case report and in-vivo study of the effect of sertraline on dopamine metabolism. J Neural Transm 1998; 105: 247–251
3. Gonul AS, Aksu M: SSRI-induced parkinsonism may be an early sign of future Parkinson's Disease. J Clin Psychiatry 1999; 60:410[Medline]
4. Gilbert AR, Moore GJ, Keshavan MS, et al: Decrease in thalamic volumes of pediatric patients with obsessive-compulsive disorder who are taking paroxetine. Arch Gen Psychiatry 2000; 57:449–456[Abstract/Free Full Text]

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