Antidepressant Toxicity Clinical Presentation

  • Author: Jeena Jacob, MD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Feb 8, 2010
 

History

Clinical symptoms of antidepressant toxicity often progress rapidly and unpredictably, and, many times, patients present asymptomatically or minimally symptomatic and progress to life-threatening cardiovascular and neurologic toxicity within an hour.

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Physical

  • CNS findings
    • Early manifestations include altered mental status, delirium, psychotic behavior, delirium and agitation (from anticholinergic effect), and hallucinations. These symptoms can later proceed rapidly to lethargy, stupor, and coma.
    • Seizures are usually generalized and often occur within 1-2 hours of ingestion. Seizures occurs in 4% of patients with overdose and in 13% of fatal cases. CNS depression and seizures result from mixed effects including those of neuronal fast sodium channel blockade; reuptake inhibition of monoaminergic neurotransmitters; and blockade of H1-histamine, muscarinic, GABA, and NMDA-glutamate receptors.
    • Myoclonus and/or choreoathetosis should not be confused with or treated as seizures.
    • Other findings include ileus; urinary retention; hyperthermia; and dry, flushed skin from anticholinergic effect.
  • Cardiac findings
    • Hypotension as a result of dysrhythmias or alpha-adrenergic blockade with a possible, lesser role played by cardiac conduction abnormalities and direct myocardial depression, autonomic neuron neurotransmitter depletion (caused by reuptake blockade), and capillary leakage
    • Dysrhythmias
    • Conduction block
    • Slowed ventricular conduction and resulting dysrhythmias from blockade of fast sodium channels
    • Tachycardia caused by muscarinic anticholinergic effects
    • Hypertension (early) caused by inhibition of norepinephrine reuptake
  • Pulmonary findings
    • Acute lung injury
    • Hypoventilation
    • Aspiration pneumonitis secondary to CNS depression
    • Acute respiratory distress syndrome (ARDS)
    • Hypoxia caused by hypoventilation, aspiration, and capillary leakage
  • Anticholinergic findings
    • Tachycardia
    • Hypothermia
    • Agitation (early)
    • CNS depression
    • Mydriasis
    • Dry skin and/or mucous membranes
    • Hyperthermia
    • Decreased gastric motility/ileus
    • Urinary retention
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Causes

Tricyclic antidepressant toxicity can be caused by either an acute ingestion or a chronic ingestion. Acute ingestions most often occur in patients who are chronically on this class of medications. Toxicity secondary to chronic ingestions usually presents with symptomatology that is an exaggeration of the usual side effects of tricyclics.

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Contributor Information and Disclosures
Author

Jeena Jacob, MD  PharmD, Medical Toxicology Fellow, Rocky Mountain Poison and Drug Center, Denver, CO

Jeena Jacob, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Theodore I Benzer, MD, PhD  Assistant Professor in Medicine, Harvard Medical School; Director of Clinical Operations, Director of Toxicology, Chair of Quality and Safety, Department of Emergency Medicine, Massachusetts General Hospital

Theodore I Benzer, MD, PhD is a member of the following medical societies: Alpha Omega Alpha and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

David C Lee, MD  Research Director, Department of Emergency Medicine, Associate Professor, North Shore University Hospital and New York University Medical School

David C Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Michael J Burns, MD  Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center

Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD  Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Eric Legome, MD, and Craig Smollin, MD, to the development and writing of this article.

References

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Toxicity, antidepressant. ECG shows the terminal R wave in aVR and the widened QRS complex associated with tricyclic antidepressant (TCA) toxicity.
 
 
 
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