Psychiatry and Clinical Psychopharmacology

Atomoxetine induced suicidal ideation: case report

Psychiatry and Clinical Psychopharmacology 2014; 24: Supplement S347-S347
Read: 572 Published: 17 February 2021

Atomoxetine (ATX), a specific noradrenaline reuptake inhibitor (SNRI), is one of the first line for treatment options for Attention deficit hyperactivity disorder (ADHD). It is proposed as a safe alternative for ADHD patients with co-morbid Anxiety or Tic Disorders. The most commonly reported side effects are decreased appetite, dizziness, fatigue, nausea and vomiting, which can be easily managed. Rarely, ATX can cause serious side effects, including hepatotoxicity and suicidal thoughts/actions. In this paper, our aim is to present a case with ADHD and comorbid Post Traumatic Stress Disorder (PTSD) who developed suicidal ideation during ATX treatment. Typically grown16-year-old teenage girl, was consulted to our department from another mental healthcare center. She had been suffering from inattention, self-organization and time management problems. In addition, she had experienced sexual abuse by her cousin, when she was 15 years old. She had şashbacks, avoidance behaviors, insomnia, nightmares and mood lability since then, but never had a plan or intent of suicide. ATX 18 mg/day was started and titrated to 36 mg/day a week later. At the 8th day of the treatment, her mother realized that she developed suicidal thoughts, saying “I want to die”, “I will cut myself” for the first time, and ATX treatment was stopped by her mother at day 10. No suicide attempt occurred, and suicidal ideations vanished just after her mother has discontinued the drug. After a while, she applied to our clinic and she was diagnosed as having ADHD-inattention subtype and PTSD. DSM-IV Criteria, K-SADS, Conners Rating Scale for Parents, Stroop Test TBAG Form tools were used to diagnose. Total blood count, hepatic and thyroid functions, anti streptolysin-O, electrocardiograms were found to be normal. Aripiprazole 2.5 mg was begun and titrated to 5 mg in a week. At the end of first month, she began to feel, and sleep well; her mood was slightly regulated. On the other hand, ADHD symptoms and related impairments persisted. After 3 months of Aripiprazole treatment, OROS Methylphenidate 54 mg/day was added on the treatment. Her inattention problem and school performance improved hastily. Significant improvement for performance on the Stroop World-Color Test was observed. She never had suicidal ideation after our combination treatment since 5 months. ATX is announced to be safe in general; rare but a very serious adverse effect of the medication is suicidality. FDA has issued a black box warning for suicidal behavior/ideation of ATX in children in 2005. Adolescents diagnosed with ADHD and/or PTSD tend to commit suicide more frequently compared to healthy population, however in our case the absence of suicide attempts or thoughts prior to ATX treatment supports the idea that this treatment might induce it. Family history should be questioned specifically for suicide or any affective disorders including bipolar or depression. ATX can be useful in treating ADHD and comorbid anxiety symptoms, but clinicians should be careful about suicidal ideations or unusual behaviors at the beginning of treatment. It is also important that parents should be informed about these.

EISSN 2475-0581