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Brazilian Journal of Psychiatry

Print version ISSN 1516-4446On-line version ISSN 1809-452X

Rev. Bras. Psiquiatr. vol.22 n.4 São Paulo Dec. 2000 

carta ao editor

The safety of fluoxetine overdose: a case report



A crucial point in the choice of antidepressants is their safety in overdose. A retrospective epidemiological review1 showed that the overall rate of deaths per million of tricyclic antidepressants prescriptions was 34.14 — 13.48 for monoamine oxidase inhibitors (MAOI), 6.19 for atypical drugs and 2.02 for selective serotonin reuptake inhibitors (SSRI). Tricyclic drug overdoses produce confusion, convulsions, hypotension, tachycardia, conduction delays and anticholinergic blockade manifestations. Patients may progress to coma, and cardiac arrhythmia may lead to death. The use of newer and more specific antidepressants may contribute to the safety in the treatment of suicidal patients.2


Case report

A 24 year-old female patient with major depression was admitted to the emergency room 9 hours after an ingestion of 2,800 mg of fluoxetine. This is a university service, part of the medical school and residence program. The patient was confused, with nausea and intense epigastric pain. Her electrocardiogram (EKG) showed an accelerated rhythm without any other abnormalities. She stayed in for clinical observation, with EKG monitoring and receiving intravenous (IV) fluids for 36 hours. 24 hours after the admission she was no longer confused. Gait instability was still present at that time, persisting for 72 hours after the overdose. Liver and renal function tests were within normal limits. She was treated with intensive dynamic psychotherapy for 3 weeks (antidepressant medications had been discontinued on admission, 40mg/day has been prescribed before the overdose). As the patient remained depressed, 40 mg/day of fluoxetine were reintroduced under supervision. Depression remitted after 3 weeks of fluoxetine. After that, a psychiatrist followed up the patient for a year and then the medication was discontinued. She continued to receive psychodinamically-oriented therapy for a year more, showing complete remission.



Suicide is a common event related to psychiatric disorders. Depression disorder is strongly associated with suicide, 30% to 70% of suicidal patients have this diagnostic.3 Antidepressants use must be carefully prescribed to these patients, taking into account the safety at overdose.

The report illustrates the safety of fluoxetine on massive overdose. Some authors describe fluoxetine safety at overdose, if used alone,4 but others report death when fluoxetine is used alone.5

Heterocyclic antidepressants and MAOIs have significant antidepressant effects but are particularly unsafe on drug overdoses. This observation must be taken into account when choosing antidepressant drugs for severely depressed patients with significant suicidal risk.

A single case report is an useful tool to understand rare events. But no further conclusions can be drawn from limited information. In this case, the fluoxetine safety prevented the patient death but there was a need for hospitalization. Suicidal depressed patients must be under intensive care by their psychiatrists; the antidepressant choice plays a fundamental role, but is only part of the whole treatment.



Marcelo F. Mello
Departamento de Psiquiatria e Psicologia Médica
da Unifesp/EPM
Hospital do Servidor Público Estadual

R. Jorge Coelho, 157 apt. 21
01451-020 São Paulo, SP, Brasil



1. Henry JA, Sener EK, Alexander CA. Relative mortality from overdose of antidepressants. BMJ 1995;310(6974):221-4.

2. Rudolph RL, Derivan AT. The safety and tolerability of venlafaxine hydrochloride: analysis of the clinical trial database. J Clin Psychopharmacol 1996;16(3 Suppl 2):54S-59S; discussion 59S-61S.

3. Goodwin FK, Runk BL. Suicide intervention: integration of psychosocial, clinical, and biomedical traditions. In: Jakobs D, editor. Suicide and clinical practice. Washington (DC): American Psychiatric Press; 1992.

4. Barbey JT, Roose SP. SSRI safety in overdose. J Clin Psychiatry 1998;59(Suppl 15):42-8.

5. Kincaid RL, McMullin MM, Crookham SB, Rieders F. Report of a fluoxetine fatality. J Anal Toxicol 1990;14(5):327-9.

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