Behavioral Health Red Flag Series: Antidepressants

It is important for providers to be aware of “red flag” symptoms associated with medication adverse events and to use every visit as an opportunity to do a quick check for potentially severe medication side effects, even if the visit is not medication focused. This is the first in a series of articles focused on identifying and addressing “red flag” symptoms.

Medication: Antidepressants (such as fluoxetine, sertraline and citalopram)

Concern: Serotonin Syndrome

Presentation: Triad Symptoms (mental status changes, neuromuscular and/or autonomic hyperactivity) – Usually appear rapidly, especially within 24 hours of starting new medications or dose increases.

Mental Status Changes Neuromuscular Autonomic Hyperactivity
Agitation Tremors Rapid changes in blood pressure
Akathisia (excessive restlessness) Hyperreflexia Tachycardia
Anxiety Slow continuous horizontal eye movements Hyperthermia
Disorientation “Babinski’s sign” Flushed skin/sweating
Loss of consciousness Dilated pupils


Severity Presentation Recommended Action
Mild Tremors, hyperreflexia, mild agitation, mild anxiety Patient should self monitor for any changes in symptoms.   Provider should refer patient for immediate follow up assessment with the prescribing provider.
Moderate – Severe Autonomic findings or moderate to severe mental status changes/neuromuscular changes, Immediately refer patient to emergency care.


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