To the Editor: In reference to a case report published in the Journal by Vermeulen (1), I wish to make several points that call into question the conclusion drawn about paroxetine by the author. In all three cases cited in the report, concomitant medications and/or alcohol ingestion significantly complicated the clinical picture and likely played a major role in morbidity and mortality. In Case 1, diphenhydramine and dextromethorphan were both collected at autopsy. Furthermore, the patient had been prescribed regular trifluoperazine. In Case 2, blood ethanol levels of 0.25 % were collected upon admission to the hospital. Dilantin was also administered in the emergency department. The patient had been prescribed an amalgamation f regular medications, including fluoxetine and sertraline in addition to paroxetine. In Case 3, postmortem i ipramine and desipramine levels were consistent with lethal concentrations. The patient's regular medications included Fiorinal. Butalbital, amajor component ofFiorinal, may lead to acute barbiturate poisoning and to respiratory depression and coma. Several important points regarding the clinical presentations must also be made. In Case 2, no paroxetine was detected in admission blood samples. Also in Case 2, charcoal was not administered until 5 h after hospital admission. This certainly runs counter to the standards of immediate postoverdose upportive measures. In all three cases, paroxetine dosage information (and number of pills ingested) was sorely lacking. Based on this information, I feel that the author's conclusion that "paroxetine was directly involved in the cause of death " was a very spurious one indeed
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