Serotonin Syndrome Risk – A Case Example

When I’ve had students with me, they will often ask about multiple serotonin related drugs and risk of serotonin syndrome.  A classic example of this is a patient on an SSRI and Tramadol.  This combination is used frequently in practice.

Serotonin syndrome is very serious, but extremely rare.  We should never exclude anything, but if I have a patient on Zoloft 25 mg daily and is taking a prn Ultram 50 mg once or twice a week, serotonin syndrome is not going to be the first thing on my radar to say the least.

Now take this example of a patient on Zoloft 200 mg daily and Effexor 400 mg daily.  My concern for serotonin is obviously much greater and we would need to thoroughly investigate why those high doses (and why this combination) is necessary and if we’ve had to ramp up to these doses on both medications, have they really been effective?  Given the Effexor/Zoloft combo above, my level of concern for Serotonin Syndrome risk would be much higher than simply on a low dose SSRI and Tramadol.  Side effects could also certainly be more prevalent on these higher doses.

Have you seen a case of serotonin syndrome?

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  1. Felicia

    Yes, serotonin syndrome ruined a year of my life. I am a 30 year old healthy female. My psychiatrist had me on effexor XR 150 QD and Wellbutrin SR 300 qd. She diagnosed me almost a year into our treatment with bipolar disorder! My BP and pulse was always high, couldn’t concentrate, did bad in school, always slept, was disorderly to say the least, not myself.
    I took myself off of wellbutrin first, then lamictal, and haven’t had a manic episode since.
    I have to repeat my third year of pharmacy school and she and the school refused to accept that the meds had a huge impact on me.
    I failed one class by less than 1% and the other by less than 2% . That is automatic dismissal from the school and I had to beg my way back in. I am now trying to get a private loan for this year and am finding it almost impossible.
    I share this because I wonder how prevalent this is? I see high doses of “serotonin ” drugs all the time as I work in a pharmacy.

    • Sam

      A few years ago, I was taking 6 different drugs affecting serotonin. As the naive (older)teenager that I was, I was experimenting with LSD. The Paxil I was taking in combination with the high dosage of LSD led to severe serotonin syndrome. I was having a seizure every few minutes, maybe 12 in that first two hours. After the first one my parents called EMS and I was in and out of concioussness and laying in the ER completely unaware of what was happening. I was constantly reminded I was having seizures but had no idea what that meant or who was even telling me. When it started to sregister what they were saying, I cried. The only person I could recognize was my best friend. Due to the obscene amount of seizures, I couldn’t speak, or write, or control fine movement at all. When I woke up a day and a half later in a hospital room I didn’t know where I was or what had happened and I couldn’t control my arms well at all and speaking was still off the table. I wasn’t myself for two weeks, which was a blessing in disguise because we were told I might’ve been like that permanently. I did get a teddy bear out of all of it though.

      • Kayla

        Wishing the best for you

    • Olivia

      I suffered a near fatality due to Serotonin Syndrome. I was losing motor skills for weeks and unable to function in most of the world. My first red flag was anger but more like rage. I told my psychiatrist about this but he was unconcerned. The symptoms changed and became more severe. I was confused and thought it may have something to do with my brain working differently. It coincided with my starting a new project and it seemed like my brain was functioning differently. The symptoms worsened rapidly and I called an ambulance for fear of losing autonomous bodily functions. By the arrival of the ambulance I could not walk and before I made it to the ER I was in the state of consciousness known as Stupor. I did not know the exact state until later research. I was eventually unable to move or speak then I lost the ability to comprehend language. It was the most terrifying 2 hours of my life. When I came out of it I did not know my name. It took hours until I was near lucid. I begged to see a neurologist but they refused. A psychiatrist did asked me if I ever thought I was God but never my medications. They wanted to keep me another night because of an irregular heart rhythm. My state of consciousness was never discussed. It was going to happen again. I could feel my consciousness start to change. A dizziness was involved. That led me to the stupor realization. I checked myself out AMA and may have saved my life. At home I researched my symptoms and causes of Stupor and found serotonin syndrome. I was prescribed by the same psychiatrist 6 medications linked to the condition and the dosage of 2 increased just before the rage incident. I most likely would have been kept on the same drug regiment in the ER and death could have easily occurred. The diagnosis by the ER. Acute encephalopathy. Dementia basically and my state consciousness caused by possibly taking 1/4 more a pill of seroquel. I said maybe I took that but was unsure. I did not take any of the other medications prior. Thank god. I quit everything cold turkey. A patient who arrives in the state of stupor is an automatic for a review by a neurologist. I asked my psychiatrist to prescribe me a serotonin antagonist but he instead prescribed a benzo. Which can raise serotonin as well. Moron. I will never take another psych med again. The field is riddled with psychiatrists searching for something to throw a med at. My suggestion is to go to a drug interaction site and maintain a list of everything you take. Some meds may not be obvious serotonin raisers and I guarantee most psychiatrists don’t even know. Gabbapentin for example. It is so often missed that hospitals have a cover their ass term, Hospital Induced Delirium.

      • Claire Nelson

        Thank you for sharing your story. I had a horrific experience with SSRIs myself. I had a C-section and my doctor kept upping my Zoloft script. I ended up becoming unable to communicate, read or do math. Once I was hospitalized, the “doctors” refused to listen to me about the poisoning I was describing. They held me for 4 days refusing to give my husband and the rest of my family any details of my whereabouts. It was hands down the most traumatic experience of my life. Pfizer is evil.

        • Amber

          I was prescribed Prozac at 10mg daily for major depressive disorder. I am 44 years old in relatively good health and was a store manager of a local retail chain. I was also on probation. After 3 weeks I became extremely irritable and started to have serious muscle spasms along with rigidity. At first they thought I tore a rotator cuff and then the spasms started to travel to all other parts of my body. I was quickly referred to a local neurologist as they were so severe I could not use the affected parts for days/weeks at a time and they were affected ting multiple parts at once. This has made me unable to drive, feed myself bathe or do pretty much anything by myself and there were no days were I was not in excruciating pain for the first 5 months. (I stopped taking the prozac at week 3). I still have them but I can somewhat use the affected parts during the episodes, they are only happening once or twice a week now and only last 2 to 4 days instead of 5 to 9 so it is improving. It has been 8 months now and I am going to prison s probation doesn’t understand that it affects everything and makes me unable to do things like drive, I have lost my job and my home. Has anyone else experienced this? All MRI, cat scans everything comes back normal. The only abnormal is my sedimentation and wbc counts are through the roof .

      • Lauren

        Thank you for posting your experience. It is very helpful.

    • Andrew Mcdougall

      They refused to accept that the meds/syndrome had an effect on you.
      The GP that ‘diagnosed me, then refused to actually diagnose me.
      Refusing to accept the extremes of the effects.
      I hope you are ok. You likely know it takes at least 6 months to get back to ‘base level’,they don’t !

  2. Dustin

    As a teenage I had a bout of depression and seen my PCP for treatment. We started on Prozac because of it’s success rate with teens. Over the course of several weeks I became increasingly outspoken, aggitated and aggressive over minor issues that would normally warrant no reaction. I felt fine, even great, but felt like everyone was getting on my case and annoying me. My mother, with no medical education, realized the change and called the doctor. The symptoms she described suggested Serotonin Syndrome. After stopping the meds I eventually returned to normal. I don’t remember much of those weeks. Just the aggressive nature.

  3. Bill

    A case I recall was a patient receiving Sertraline 200mg per day and was started on zyvox 600mg twice a day. Developed unusual symptoms of confusion, grasping at the air, hallucinations within 2 days. What was interesting was this was brought to our attention by a physical therapist who remarked that the patient was no longer making progress and was in fact getting worse. Stopped the zyvox and patient improved to baseline within one day. Good collaboration!

  4. andy Deel

    I have been taking 200 mg of sertraline for the last 12 years. Because of events in my life that caused me to have chronic anxiety in 2011 that has continued to the present day I also taking 1 mg of clonazepam 3 times a day which was changed to Xanax 0.5 mg 3 times a day. Last year my PCP added Duloxetine 30 mg once a day then insisted I see a Psychiatrist to start managing my medication, which I did. She kept me on my regular meds but she raised my Duloxetine from 30 mg a day to 120 mg a day. I had no Idea that the problems I was about to have during the next year would have anything to do with Serotonin Syndrome. I have never heard of such a thing until my Psychiatrist suddenly retired and I was contacted by a therapist to see if I wanted to continue my sessions with her. She wanted to go over my medication list and when we did she was clearly upset and immediately informed me of how to slowly come off the Duloxetine. That’s when I learned of Serotonin Syndrome. However she did not question me on any possible problems I may have had during that past year so I have been left to research for myself. I am a 61 yr. old male and I didn’t complain much because of my age and my general skeletal health problems I already have. But I have been through a lot more than I ever should have with the different symptoms that some I still am experiencing. So confused right now on how to move forward with my health. I am changing my PCP for many reasons but what’s next.

    • Kayla

      Thank you for sharing your story. Self Advocacy is a skill a lot of us need.

  5. Tori Hill

    I was put on Prozac about 2 years ago, I started out at 20 mg I think, and made my way up to 60. I stopped taking it, I didn’t give it time to work. Then, feeling bad one day a few months later I decide to pick it back up, but started where’s I left off. 60 mg of Prozac was way to much to not build back up to and I took one dose. My whole body started to tingle as if it was “asleep” like when you sit on your foot or something. Everything from my head to toe, even my lips, tingled for weeks non-stop. So even now, 2 years later, I cannot take any kind of SSRI without tingling for weeks. Even birth control, and big fluctuations in my hormones make me tingle. Idk if it will ever go away and no doctor has much to tell me about it.

    • Martha

      I’m not a professional, but some types of tingling can be treated by a med called Neurontin. I won’t want to take it to tolerate other meds, but for thr hormone fluctuations that just happen, maybe your doctor would consider it with you? It helps me with similar symptoms from other causes.

      • Annetta

        Neurontin increases serotonin, so one needs to be careful taking it with SSRIs, as that can cause serotonin syndrome.

    • Sherri

      I had recently started 10mg of lorazepam and have had reactions since day 1. My body is numb and I feel like I am high. My mouth is dry and I have absolutely no energy, I cannot walk around my house. Today took the cake. I was in group, and felt a sudden wave a nausea and ran to the bathroom. Had cold sweats, couldn’t breath, my heart felt like it was racing, barely could walk, and felt this way for about 4 hours after. Even now, 8 hours after I cannot keep my eyes open. Needless to say, I am done taking it

      • Melissa Toni Ortiz

        Hi Sherri,

        I recently started taking citalopram, as I told my doctor that I felt like I needed something for my anxiety. I felt okay the first day, and then the second day I had the same symptoms that you had except I had about 5-6 major panic attacks. It was so severe that I called the emergency services twice and headed to the emergency room and was blown off by the doctors and nurses. They just assumed that I “couldn’t handle” the side effects from SSRIs. I took 10 mg both days and still had the worse side effects I ever felt. It’s been almost three weeks and I’m still having side effects. I hope I can return to normal soon.

        • Trinity

          Did it improve? I took Lexapro for 4 days and no I’ve been diagnosed with Supraventricular Tachycardia. I’ve never had to go to the ER until 4 weeks ago after taking it. High blood pressure which I never had before the medicine and high pulse

          • Sally

            I had the same thing happen after restarting Celexa. I woke up with a pulse of 180 and after several days of that was at the ER twice. No one believe it was because of the Celexa. My doctor insisted I try lexapro even though I tried to explain my concern. I took it today and my heart rate went to 154 and it also caused high BP which I never have. I’m done with these meds—- I can’t afford to continue to go to the ER. I’m hoping to find a way to control my anxiety without the meds and pray this all stops. My heart goes out to everyone having these experiences.

      • Rave

        Lorazepam, or Ativan, is a semi potent benzodiazepine. It actually has nothing to do with serotonin and in fact Ativan is sometimes given for SS.
        Additionally, 10mg of Ativan a day is WAY over the max FDA dose of 6mg/day and most max out at 4mg/day. I’m guessing you meant 1mg. Regardless this is obviously not the benzo for you, I’d suggest stopping it.

  6. Cindy Smith

    I was diagnosed with serotonin syndrome in 2013. Sense then my doctor has been trying to keep me away from certain drugs. But every now and then I still have tremors and can’t sleep is there anything I can do to prevent this. I don’t want to be put on any more medications. But I not sure whats causing this

    • Alex


      Are you still having tremors? I had seritonin syndrome back in January with horrible tremors and jerking. It’s definitely gotten better, but even now I still struggle to fall asleep because of the jerking. There’s nothing online saying how long these symptoms can last!

  7. Leigh Ramirez

    I was put on sertraline in the beginning of February. It immediately made me feel sick—headache and stomach problems. The headaches got worse and so I started having to take migraine medication and I had tramadol to take for the pain. I had told my doctor that I had a history of migraines, and that I had these medications but rarely took them as I had been migraine free for almost 3 years. I was unaware of the dangers of taking these medications together and had emailed my doc about my headaches. I was told to increase my dose of sertraline. I ended up with serotonin syndrome, in complete terror. I was in so much pain, constant seizures, hallucinations, extreme paranoia, uncontrollable tremors and the headaches became so unbearable I often only thought of slicing my throat if I could think of anything besides the pain.
    I was so terrified and I couldn’t trust any doctor. I am about 2 months since my last dose of sertraline and I am finally starting to feel like myself again. My anxiety is worse than it ever was before I started taking this poison, I now have spells of vertigo, my thyroid is still not functioning properly, my short term memory is getting better but was awful, cognitive recall of words had become very difficult especially with my second language, and I have had daily intrusive thoughts about harming myself. I wish I could go back in time and has never had taken this poison. It has made my life very difficult but I am getting though it. I pray no one ever had to go through what I have.

    • Mary Gold

      Have you had your thyroid checked , via a blood test
      To see if you are overthyroid or underthyroid
      Some of the symptoms you mention are associated with abnormal thyroid function.

    • John

      How are you now? I hope you are better

  8. Christian Domey

    I took fluoxetine which was prescribed by a psychiatrist. I took this drug for 5 days and I nearly died. The sensation from my body, the unsteady state of my body, profuse sweating with serious hotness, my eyes were with pains and blurry vision, racing heartbeat, high bp, confusion, and can’t feel for food. I’m in my 4th day and only God knows when this symptoms will go away totally.
    I actually thought I was sick of some unusual sickness. God help me in this.

  9. Tana C Brooks

    I nearly died of Serotonin Syndrome 2 weeks ago today. Many prescribed drugs led to it. I’m upset at doctors, pharmacies, etc, right now and will fight to make changes regarding Serotonin Syndrome awareness. My fear is: what are the long term effects, how long will they go on for me, etc. I’m still quite sick and scared. I’m educating my doctors instead of them educating me!

    • Yvonne

      Hi Tana,

      I am just coming to the realization that I have been given a combination of medication that can cause Serotonin Syndrome. How could doctors and pharmacists not know this and continue prescribing this combo? I have been taking the same medication for 4 years, we expect doctors to be educated in stuff like this, however it is the opposite, and you’re right…we are left to educate them. I am now worried what kind of long term affects this will have.

    • Amber A

      I would like to help do this. I can’t believe so few people know about it. I’ve been blown off as having anxiety attacks and been treated horribly. Is it a political issue, medical board, where does one start?

    • Fabian

      I hope you are doing better. I wish you all the best.

  10. Dana

    My son had allergic reactions to things ever since he was an infant. When my son was a teenager, he got into drugs. We did not know for sure which ones or at what level at that time, but once we knew, we scrambled to get him into rehab for 30 days. Once he was done with rehab and came home, he had a prescription for Prozac and one other medication that I can’t recall, a mood stabilizer (this was 16 years ago.) He went back to High School, and seemed to do ok for about a week. Then I was contacted by the school because something was wrong and I raced over to find him mumbling and grinding his teeth, shivering, and unable to walk. I contacted his doctor who told me to bring him over immediately. By the time we got there, only minutes later, he was posturing and seizing. The doctor took a blood sample and administered a shot, then admitted him to the hospital for 2 days. I was beside myself, just sure that he had relapsed with an illegal drug. But nope, the blood work came back clean and the doctor said it was serotonin reuptake syndrome, and that since my son was apparently so sensitive that he should not take any SSRIs. He has had some mental health difficulties since then, but has never been back on mental health meds. He says that he doesn’t remember much about it, just that he was terrified and couldn’t speak or get his muscles to move. Hell of a way to learn that this was even a possibility

  11. Michael J Browy

    I suddenly started losing control of my body when I am stressed or overheated. I just realized that literally ALL the medications I am prescribed can cause serotonin syndrome including a Buprenorphine transdermal patch which is VERY susceptible to heat. My wife has seen me go into this state and described it like I had late stage Parkinson’s! My treatment luckily saved me by applying cool damp compressed to my head and neck. I was unable to walk because my legs felt like lead, I had severe tremors and couldn’t control my hands or speak. My speech was unintelligible. I explained what happens to my doctor and we never discussed heat induced serotonin syndrome due to my medication regimen! That is my self diagnosis and while my medications help immensely with my diagnosis of major depressive disorder with panic/anxiety disorder I now know that I cannot be exposed to high temperatures for extended periods of time.



  1. Drugs That Cause Hyperthermia - Can You Name Them? - Med Ed 101 - […] Serotonin toxicity (syndrome) caused by serotonin reuptake inhibitors, monoamine oxidase inhibitors, dextromethorphan, tramadol, tapentadol, linezolid, SNRI’s, and St. Johns…

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Written By Eric Christianson

March 29, 2015

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