Abstract Background We present the case of a 52-year-old woman with depression who developed extrapyramidal symptoms (mainly parkinsonism) and suicidal ideation while on fluoxetine. Methods The patient underwent neurological and neuroimaging examination. Results The patient's neurological and neuroimaging examinations were normal and there was no other cause of extrapyramidal symptoms. The patient showed remission of the aforementioned symptomatology when fluoxetine was discontinued. Conclusions This case shows that fluoxetine can be associated with extrapyramidal symptoms, and this may have an aggravating affect on clinical depression progress and the emergence of suicidal ideation.</p

A Rothschild

Athanasia Papadopoulou

Athanassios Douzenis

Christos Christodoulou

D Fergusson

D Gunnell

D Ratan

DM Coulter

Emmanouil Rizos

H Jick

I Schillevoort

J Tiihonen

JK Crundwell

Kalliopi Tournikioti

LB Marangell

Lefteris Lykouras

M Teicher

MH Teicher

MR Lavin

MS Hamilton

R Gibbsons

R Leo

RS Diler

W Wirshing

Xenia Gonda

English

PubMed

Springer - Publisher Connector

Extrapyramidal side effects and suicidal ideation under fluoxetine treatment: a case report

Abstract Background We present the case of a 52-year-old woman with depression who developed extrapyramidal symptoms (mainly parkinsonism) and suicidal ideation while on fluoxetine. Methods The patient underwent neurological and neuroimaging examination. Results The patient's neurological and neuroimaging examinations were normal and there was no other cause of extrapyramidal symptoms. The patient showed remission of the aforementioned symptomatology when fluoxetine was discontinued. Conclusions This case shows that fluoxetine can be associated with extrapyramidal symptoms, and this may have an aggravating affect on clinical depression progress and the emergence of suicidal ideation.</p

Douzenis Athanassios

Gonda Xenia

Tournikioti Kalliopi

Rizos Emmanouil

Papadopoulou Athanasia

Christodoulou Christos

Lykouras Lefteris

Directory of Open Access Journals

Annals of General Psychiatry

CASE REPORT Open Access
Extrapyramidal side effects and suicidal ideation
under fluoxetine treatment: a case report
Christos Christodoulou1*, Athanasia Papadopoulou1, Emmanouil Rizos1, Kalliopi Tournikioti1, Xenia Gonda2,
Athanassios Douzenis1, Lefteris Lykouras1
Abstract
Background: We present the case of a 52-year-old woman with depression who developed extrapyramidal
symptoms (mainly parkinsonism) and suicidal ideation while on fluoxetine.
Methods: The patient underwent neurological and neuroimaging examination.
Results: The patient’s neurological and neuroimaging examinations were normal and there was no other cause of
extrapyramidal symptoms. The patient showed remission of the aforementioned symptomatology when fluoxetine
was discontinued.
Conclusions: This case shows that fluoxetine can be associated with extrapyramidal symptoms, and this may have
an aggravating affect on clinical depression progress and the emergence of suicidal ideation.
Background
Extrapyramidal symptoms (EPSs) are an uncommon side
effect of serotonin reuptake inhibitors (SSRIs). Concomi-
tant use with antipsychotic medication or the presence
of other risk factors (age, gender) increase the vulner-
ability to EPSs [1]. The most common EPS associated
with SSRIs seems to be akathisia, followed by dystonia
and parkinsonism. Fluoxetine is the SSRI most asso-
ciated with extrapyramidal reactions in the majority of
cases [2,3]. Even, in adolescents treated with fluoxetine,
EPSs have been reported [4]. The symptoms are reversi-
ble with dose reduction, drug discontinuation, or by the
addition of another agent, such as anticholinergic
agents, b-blockers or benzodiazepines [5,6]. EPSs, and
especially akathisia, have been associated with the emer-
gence of suicidal ideation and suicidal acts in patients
receiving fluoxetine [7,8], however, a clear relationship
between fluoxetine and emerging suicidality is not cer-
tain [9].
We present the case of a female receiving fluoxetine
who, after approximately 1 month of therapy, developed
severe EPSs, mainly parkinsonism, with simultaneous
emergence of suicidal ideation.
Case presentation
A 52-year-old married woman presented to the emer-
gency department of the Psychiatric Clinic of ‘Attikon’
General Hospital in Athens with depressive symptoms.
The symptoms had begun 1 month prior to the referral
to our hospital, and included: depressive mood, insom-
nia, early morning waking, loss of appetite and psycho-
motor retardation. At that time she visited a private
psychiatrist, and was given antidepressant therapy with
fluoxetine, 60 mg per day and alprazolam 1.5 mg daily
for 4 weeks with no significant improvement. During
her examination, she was obviously very depressed and
anxious with no psychotic symptoms and she reported
suicidal ideation for the last 10 days.
Her neurological examination revealed severe rigidity
and bradykinesia. Her face was like a ‘mask’ and her
facial movements were almost non-existent. She was
speaking at low volume but she had no rest or move-
ment tremor, and no severe instability. Clinically,
although her treatment did not include any antipsycho-
tic drugs, her appearance did not differ from typical
antipsychotic-induced parkinsonism. Her husband had
observed reduced facial expression for the last 2 weeks.
The patient herself associated her suicidal ideation with
the subjective sensation of a progressive movement dis-
ability. Her medical history revealed no neurological* Correspondence: christo.christodoulou@gmail.com1Second Department of Psychiatry, Athens University Medical School,
‘Attikon’ General Hospital, Athens, Greece
Christodoulou et al. Annals of General Psychiatry 2010, 9:5
http://www.annals-general-psychiatry.com/content/9/1/5
© 2010 Christodoulou et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
diseases. A magnetic resonance imaging (MRI) scan
showed no abnormal findings.
It was recommended that fluoxetine treatment be
stopped and alprazolam continued.
Results
At 1 week later the improvement of her rigidity and
bradykinesia was impressive. Her facial expression was
almost normal. The emotional distress was reduced and
surprisingly her suicidal ideation diminished with fluox-
etine withdrawal. At that time she was given another
class of antidepressant, showing significant improvement
of her depression.
Discussion
Considerable controversy exists regarding the relation-
ship between fluoxetine and the emergence of suicidal
ideation. Our patient had no neurological history. EPSs,
mainly parkinsonism, had appeared in the last 2 weeks
while she had been under medication with fluoxetine.
Several reports published in the 1990s suggested that
fluoxetine could be responsible for suicidal ideation or
behaviour [7,10-12]. More recent studies have suggested
this relationship as well. In a case-control analysis an
association has been found between SSRIs and suicide
events [13]. Moreover, a systematic review of rando-
mised controlled trials supports the relationship between
the use of SSRIs and the increased risk of suicidal beha-
viour. According to this review, such risk may be under-
estimated due to a number of methodological
limitations of the published reports [14].
By contrast, the results of a recent cohort study based
on a large sample do not support the hypothesis that
treatment with SSRIs increases the risk of suicide [15].
In another matched case-control study, the risk of suici-
dal behaviour was reported to be similar among users of
amitriptyline, fluoxetine and paroxetine [16]. Also, a
nationwide cohort study in Finland found that fluoxe-
tine was associated with a lower risk of suicide among
different classes of antidepressants. Moreover, the
results of the same study indicate that the current use
of any antidepressant among suicidal patients was asso-
ciated with increased risk of attempted suicide by self-
poisoning, but with a decreased risk of completed sui-
cide and death. The latter could be attributed to the
fewer cardiovascular and cerebrovascular side effects of
SSRI medication [17]. Finally, a meta-analysis of rando-
mised control trials of SSRIs conducted by pharmaceuti-
cal companies indicated that there is evidence of
increased risk of non-fatal self-harm in adults treated
with SSRIs but no evidence of increased risk of suicidal
thoughts [18].
Akathisia or dysphoric extrapyramidal reactions may
be a contributing factor to the emergence of suicidal
ideation during treatment with fluoxetine [19]. In our
case, parkinsonism and restlessness (but no akathisia)
were prominent in the clinical picture of the patient.
EPSs may have accidentally appeared in our patient, or
an underlying organic disorder may have predisposed
her to EPSs. However, an MRI scan revealed no abnor-
mal findings that could explain a possible vulnerability
to side effects. After stopping fluoxetine, the patient’s
extrapyramidal symptomatology improved dramatically
as did her suicidal thoughts. This report suggests that
severe EPSs, and in particular parkinsonism due to the
implicated movement disability, cause distress, which in
turn may cause suicidal ideation.
Conclusions
It is possible that SSRI as monotherapy could be the
cause of EPSs and subsequent suicidal ideation. Psychia-
trists must be aware of this side effect and be prepared
for clinical features characterised by movement disor-
ders in patients treated with SSRIs.
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompany-
ing images. A copy of the written consent is available
for review from the Editor-in-Chief of this journal.
Author details
1Second Department of Psychiatry, Athens University Medical School,
‘Attikon’ General Hospital, Athens, Greece. 2Department of Clinical and
Theoretical Mental Health, Kutvolgyi Clinical Center, Semmelweis University,
Faculty of Medicine, Budapest, Hungary.
Authors’ contributions
CC made substantial contributions to the conception and design of the
present study, and was also involved in drafting and revising the manuscript
and gave final approval for the manuscript to be published. AP was
codesigner of the present study and made substantial contributions in the
acquisition, analysis and interpretation of the data. ER made substantial
contributions in drafting the manuscript and revising it critically for
intellectual content. KT contributed to the clinical evaluations and
manuscript drafting. XG and AD made substantial contributions in revising
the manuscript. LL made substantial contributions in drafting the manuscript
and revising it critically for intellectual content, and gave final approval for
the manuscript to be published. All authors read and approved the final
manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 4 November 2009
Accepted: 18 January 2010 Published: 18 January 2010
References
1. Schillevoort I, van Puijenbroek EP, de Boer A, Roos RA, Jansen PA,
Leufkens HG: Extrapyramidal syndromes associated with selective
serotonin reuptake inhibitors: a case-control study using spontaneous
reports. Int Clin Psychopharmacol 2002, 17:75-79.
2. Coulter DM, Pillans PI: Fluoxetine and extrapyramidal side effects. Am J
Psychiatry 1995, 152:122-125.
Christodoulou et al. Annals of General Psychiatry 2010, 9:5
http://www.annals-general-psychiatry.com/content/9/1/5
Page 2 of 3
3. Leo R: Movements disorders associated with serotonin selective
reuptake inhibitors. J Clin Psychiatry 1996, 57:449-454.
4. Diler RS, Yolga A, Ausi A: Fluoxetine-indused extrapyramidal symptoms in
an adolescent: a case report. Swiss Med Wkly 2002, 132:125-126.
5. Leo R: Movement disturbances associated with the use of selective
serotonin-reuptake inhibitors. Ann Pharmacother 1998, 32:712-714.
6. Lavin MR, Mendelowitz A, Block SH: Adverse reaction to high-dose
fluoxetine. J Clin Psychopharmacol 1993, 13:452-453.
7. Rothschild A, Locke C: Reexposure to fluoxetine after serious attempts by
three patients: the role of akathisia. J Clin Psychiatry 1991, 52:491-493.
8. Wirshing W, van Putten T, Rosenberg J, Marder S, Ames D, Hicks-Gray T:
Fluoxetine, akathisia, and suicidality: Is there a causal connection?. Arch
Gen Psychiatry 1992, 49:580-581.
9. Crundwell JK: Fluoxetine and suicidal ideation-a review of the literature.
Int J Neurosci 1993, 68:73-84.
10. Teicher M, Glod C, Cole J: Emergence of intense suicidal preoccupation
during fluoxetine treatment. Am J Psychiatry 1990, 147:207-210.
11. Teicher MH, Glod CA, Cole JO: Antidepressant drugs and the emergence
of suicidal tendencies. Drug Safety 1993, 8:186-212.
12. Ratan D: Fluoxetine and suicidal ideation. J Clin Psychopharmacol 1997,
17:61-62.
13. Marangell LB, Dennehy EB, Wisniewski SR, Bauer MS, Miyahara S, Allen MH,
Martinez M, Al Jurdi RK, Thase ME: Case-control analyses of the impact of
pharmacotherapy on prospectively observed suicide attempts and
completed suicide I bipolar disorder: findings from STEP-BD. J Clin
Psychiatry 2008, 69:916-922.
14. Fergusson D, Doucette S, Granley Glass K, Shapiro S, Healy D, Hebert P,
Hutton B: Association between suicide attempts and selective serotonin
reuptake inhibitors: systematic review of randomised controlled trials.
BMJ 2005, 19:1-7.
15. Gibbsons R, Brown C, Hur K, Marcus S, Bhaumik D, Mann J: Relationship
between antidepressants and suicide attempts: an analysis of the
veteran health administration data sets. Am J Psychiatry 2007, 164:1044-
1049.
16. Jick H, Kaye J, Jick S: Antidepressant and the risk of suicidal behaviours. J
Am Med Assoc 2004, 292:338-343.
17. Tiihonen J, Lönnqvist J, Wahlbeck K, Klaukka T, Tanskanen A, Haukka J:
Antidepressants and the risk of suicide, attempted suicide, and overall
mortality in a nationwide cohort. Arch Gen Psychiatry 2006, 63:1358-1367.
18. Gunnell D, Saperia J, Ashby D: Selective serotonin reuptake inhibitors
(SSRIs) and suicide in adults: meta-analysis of drug company data from
placebo controlled, randomized controlled trials submitted to the
MHRA’s safety review. BMJ 2005, 330:1-5.
19. Hamilton MS, Opler LA: Akathisia, suicidality, and fluoxetine. J Clin
Psychiatry 1992, 53:401-406.
doi:10.1186/1744-859X-9-5
Cite this article as: Christodoulou et al.: Extrapyramidal side effects and
suicidal ideation under fluoxetine treatment: a case report. Annals of
General Psychiatry 2010 9:5.
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Crossref

Background: We present the case of a 52-year-old woman with depression who developed extrapyramidal symptoms (mainly parkinsonism) and suicidal ideation while on fluoxetine.Methods: The patient underwent neurological and neuroimaging examination.Results: The patient's neurological and neuroimaging examinations were normal and there was no other cause of extrapyramidal symptoms. The patient showed remission of the aforementioned symptomatology when fluoxetine was discontinued.Conclusions: This case shows that fluoxetine can be associated with extrapyramidal symptoms, and this may have an aggravating affect on clinical depression progress and the emergence of suicidal ideation. © 2010 Christodoulou et al; licensee BioMed Central Ltd

Christodoulou C

Papadopoulou A

Rizos E

Tournikioti K

Gonda Xénia

Douzenis A

Lykouras L

Semmelweis Repository

CASE REPORT Open AccessExtrapyramidal side effects and suicidal ideationunder fluoxetine treatment: a case reportChristos Christodoulou1*, Athanasia Papadopoulou1, Emmanouil Rizos1, Kalliopi Tournikioti1, Xenia Gonda2,Athanassios Douzenis1, Lefteris Lykouras1AbstractBackground: We present the case of a 52-year-old woman with depression who developed extrapyramidalsymptoms (mainly parkinsonism) and suicidal ideation while on fluoxetine.Methods: The patient underwent neurological and neuroimaging examination.Results: The patient’s neurological and neuroimaging examinations were normal and there was no other cause ofextrapyramidal symptoms. The patient showed remission of the aforementioned symptomatology when fluoxetinewas discontinued.Conclusions: This case shows that fluoxetine can be associated with extrapyramidal symptoms, and this may havean aggravating affect on clinical depression progress and the emergence of suicidal ideation.BackgroundExtrapyramidal symptoms (EPSs) are an uncommon sideeffect of serotonin reuptake inhibitors (SSRIs). Concomi-tant use with antipsychotic medication or the presenceof other risk factors (age, gender) increase the vulner-ability to EPSs [1]. The most common EPS associatedwith SSRIs seems to be akathisia, followed by dystoniaand parkinsonism. Fluoxetine is the SSRI most asso-ciated with extrapyramidal reactions in the majority ofcases [2,3]. Even, in adolescents treated with fluoxetine,EPSs have been reported [4]. The symptoms are reversi-ble with dose reduction, drug discontinuation, or by theaddition of another agent, such as anticholinergicagents, b-blockers or benzodiazepines [5,6]. EPSs, andespecially akathisia, have been associated with the emer-gence of suicidal ideation and suicidal acts in patientsreceiving fluoxetine [7,8], however, a clear relationshipbetween fluoxetine and emerging suicidality is not cer-tain [9].We present the case of a female receiving fluoxetinewho, after approximately 1 month of therapy, developedsevere EPSs, mainly parkinsonism, with simultaneousemergence of suicidal ideation.Case presentationA 52-year-old married woman presented to the emer-gency department of the Psychiatric Clinic of ‘Attikon’General Hospital in Athens with depressive symptoms.The symptoms had begun 1 month prior to the referralto our hospital, and included: depressive mood, insom-nia, early morning waking, loss of appetite and psycho-motor retardation. At that time she visited a privatepsychiatrist, and was given antidepressant therapy withfluoxetine, 60 mg per day and alprazolam 1.5 mg dailyfor 4 weeks with no significant improvement. Duringher examination, she was obviously very depressed andanxious with no psychotic symptoms and she reportedsuicidal ideation for the last 10 days.Her neurological examination revealed severe rigidityand bradykinesia. Her face was like a ‘mask’ and herfacial movements were almost non-existent. She wasspeaking at low volume but she had no rest or move-ment tremor, and no severe instability. Clinically,although her treatment did not include any antipsycho-tic drugs, her appearance did not differ from typicalantipsychotic-induced parkinsonism. Her husband hadobserved reduced facial expression for the last 2 weeks.The patient herself associated her suicidal ideation withthe subjective sensation of a progressive movement dis-ability. Her medical history revealed no neurological* Correspondence: christo.christodoulou@gmail.com1Second Department of Psychiatry, Athens University Medical School,‘Attikon’ General Hospital, Athens, GreeceChristodoulou et al. Annals of General Psychiatry 2010, 9:5http://www.annals-general-psychiatry.com/content/9/1/5© 2010 Christodoulou et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.diseases. A magnetic resonance imaging (MRI) scanshowed no abnormal findings.It was recommended that fluoxetine treatment bestopped and alprazolam continued.ResultsAt 1 week later the improvement of her rigidity andbradykinesia was impressive. Her facial expression wasalmost normal. The emotional distress was reduced andsurprisingly her suicidal ideation diminished with fluox-etine withdrawal. At that time she was given anotherclass of antidepressant, showing significant improvementof her depression.DiscussionConsiderable controversy exists regarding the relation-ship between fluoxetine and the emergence of suicidalideation. Our patient had no neurological history. EPSs,mainly parkinsonism, had appeared in the last 2 weekswhile she had been under medication with fluoxetine.Several reports published in the 1990s suggested thatfluoxetine could be responsible for suicidal ideation orbehaviour [7,10-12]. More recent studies have suggestedthis relationship as well. In a case-control analysis anassociation has been found between SSRIs and suicideevents [13]. Moreover, a systematic review of rando-mised controlled trials supports the relationship betweenthe use of SSRIs and the increased risk of suicidal beha-viour. According to this review, such risk may be under-estimated due to a number of methodologicallimitations of the published reports [14].By contrast, the results of a recent cohort study basedon a large sample do not support the hypothesis thattreatment with SSRIs increases the risk of suicide [15].In another matched case-control study, the risk of suici-dal behaviour was reported to be similar among users ofamitriptyline, fluoxetine and paroxetine [16]. Also, anationwide cohort study in Finland found that fluoxe-tine was associated with a lower risk of suicide amongdifferent classes of antidepressants. Moreover, theresults of the same study indicate that the current useof any antidepressant among suicidal patients was asso-ciated with increased risk of attempted suicide by self-poisoning, but with a decreased risk of completed sui-cide and death. The latter could be attributed to thefewer cardiovascular and cerebrovascular side effects ofSSRI medication [17]. Finally, a meta-analysis of rando-mised control trials of SSRIs conducted by pharmaceuti-cal companies indicated that there is evidence ofincreased risk of non-fatal self-harm in adults treatedwith SSRIs but no evidence of increased risk of suicidalthoughts [18].Akathisia or dysphoric extrapyramidal reactions maybe a contributing factor to the emergence of suicidalideation during treatment with fluoxetine [19]. In ourcase, parkinsonism and restlessness (but no akathisia)were prominent in the clinical picture of the patient.EPSs may have accidentally appeared in our patient, oran underlying organic disorder may have predisposedher to EPSs. However, an MRI scan revealed no abnor-mal findings that could explain a possible vulnerabilityto side effects. After stopping fluoxetine, the patient’sextrapyramidal symptomatology improved dramaticallyas did her suicidal thoughts. This report suggests thatsevere EPSs, and in particular parkinsonism due to theimplicated movement disability, cause distress, which inturn may cause suicidal ideation.ConclusionsIt is possible that SSRI as monotherapy could be thecause of EPSs and subsequent suicidal ideation. Psychia-trists must be aware of this side effect and be preparedfor clinical features characterised by movement disor-ders in patients treated with SSRIs.ConsentWritten informed consent was obtained from the patientfor publication of this case report and any accompany-ing images. A copy of the written consent is availablefor review from the Editor-in-Chief of this journal.Author details1Second Department of Psychiatry, Athens University Medical School,‘Attikon’ General Hospital, Athens, Greece. 2Department of Clinical andTheoretical Mental Health, Kutvolgyi Clinical Center, Semmelweis University,Faculty of Medicine, Budapest, Hungary.Authors’ contributionsCC made substantial contributions to the conception and design of thepresent study, and was also involved in drafting and revising the manuscriptand gave final approval for the manuscript to be published. AP wascodesigner of the present study and made substantial contributions in theacquisition, analysis and interpretation of the data. ER made substantialcontributions in drafting the manuscript and revising it critically forintellectual content. KT contributed to the clinical evaluations andmanuscript drafting. XG and AD made substantial contributions in revisingthe manuscript. LL made substantial contributions in drafting the manuscriptand revising it critically for intellectual content, and gave final approval forthe manuscript to be published. All authors read and approved the finalmanuscript.Competing interestsThe authors declare that they have no competing interests.Received: 4 November 2009Accepted: 18 January 2010 Published: 18 January 2010References1. Schillevoort I, van Puijenbroek EP, de Boer A, Roos RA, Jansen PA,Leufkens HG: Extrapyramidal syndromes associated with selectiveserotonin reuptake inhibitors: a case-control study using spontaneousreports. Int Clin Psychopharmacol 2002, 17:75-79.2. Coulter DM, Pillans PI: Fluoxetine and extrapyramidal side effects. Am JPsychiatry 1995, 152:122-125.Christodoulou et al. Annals of General Psychiatry 2010, 9:5http://www.annals-general-psychiatry.com/content/9/1/5Page 2 of 33. Leo R: Movements disorders associated with serotonin selectivereuptake inhibitors. J Clin Psychiatry 1996, 57:449-454.4. Diler RS, Yolga A, Ausi A: Fluoxetine-indused extrapyramidal symptoms inan adolescent: a case report. Swiss Med Wkly 2002, 132:125-126.5. Leo R: Movement disturbances associated with the use of selectiveserotonin-reuptake inhibitors. Ann Pharmacother 1998, 32:712-714.6. Lavin MR, Mendelowitz A, Block SH: Adverse reaction to high-dosefluoxetine. J Clin Psychopharmacol 1993, 13:452-453.7. Rothschild A, Locke C: Reexposure to fluoxetine after serious attempts bythree patients: the role of akathisia. J Clin Psychiatry 1991, 52:491-493.8. Wirshing W, van Putten T, Rosenberg J, Marder S, Ames D, Hicks-Gray T:Fluoxetine, akathisia, and suicidality: Is there a causal connection?. ArchGen Psychiatry 1992, 49:580-581.9. Crundwell JK: Fluoxetine and suicidal ideation-a review of the literature.Int J Neurosci 1993, 68:73-84.10. Teicher M, Glod C, Cole J: Emergence of intense suicidal preoccupationduring fluoxetine treatment. Am J Psychiatry 1990, 147:207-210.11. Teicher MH, Glod CA, Cole JO: Antidepressant drugs and the emergenceof suicidal tendencies. Drug Safety 1993, 8:186-212.12. Ratan D: Fluoxetine and suicidal ideation. J Clin Psychopharmacol 1997,17:61-62.13. Marangell LB, Dennehy EB, Wisniewski SR, Bauer MS, Miyahara S, Allen MH,Martinez M, Al Jurdi RK, Thase ME: Case-control analyses of the impact ofpharmacotherapy on prospectively observed suicide attempts andcompleted suicide I bipolar disorder: findings from STEP-BD. J ClinPsychiatry 2008, 69:916-922.14. Fergusson D, Doucette S, Granley Glass K, Shapiro S, Healy D, Hebert P,Hutton B: Association between suicide attempts and selective serotoninreuptake inhibitors: systematic review of randomised controlled trials.BMJ 2005, 19:1-7.15. Gibbsons R, Brown C, Hur K, Marcus S, Bhaumik D, Mann J: Relationshipbetween antidepressants and suicide attempts: an analysis of theveteran health administration data sets. Am J Psychiatry 2007, 164:1044-1049.16. Jick H, Kaye J, Jick S: Antidepressant and the risk of suicidal behaviours. JAm Med Assoc 2004, 292:338-343.17. Tiihonen J, Lönnqvist J, Wahlbeck K, Klaukka T, Tanskanen A, Haukka J:Antidepressants and the risk of suicide, attempted suicide, and overallmortality in a nationwide cohort. Arch Gen Psychiatry 2006, 63:1358-1367.18. Gunnell D, Saperia J, Ashby D: Selective serotonin reuptake inhibitors(SSRIs) and suicide in adults: meta-analysis of drug company data fromplacebo controlled, randomized controlled trials submitted to theMHRA’s safety review. BMJ 2005, 330:1-5.19. Hamilton MS, Opler LA: Akathisia, suicidality, and fluoxetine. J ClinPsychiatry 1992, 53:401-406.doi:10.1186/1744-859X-9-5Cite this article as: Christodoulou et al.: Extrapyramidal side effects andsuicidal ideation under fluoxetine treatment: a case report. Annals ofGeneral Psychiatry 2010 9:5.Publish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central yours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralChristodoulou et al. Annals of General Psychiatry 2010, 9:5http://www.annals-general-psychiatry.com/content/9/1/5Page 3 of 3

Extrapyramidal side effects and suicidal ideation under fluoxetine treatment: A case report

Antidepressant and the risk of suicidal behaviours.

Antidepressant drugs and the emergence of suicidal tendencies. Drug Safety

Antidepressants and the risk of suicide, attempted suicide, and overall mortality in a nationwide cohort. Arch Gen Psychiatry

Association between suicide attempts and selective serotonin reuptake inhibitors: systematic review of randomised controlled trials. BMJ

Ausi A: Fluoxetine-indused extrapyramidal symptoms in an adolescent: a case report. Swiss Med Wkly

Cite this article as: Christodoulou et al.: Extrapyramidal side effects and suicidal ideation under fluoxetine treatment: a case report. Annals of General Psychiatry

Emergence of intense suicidal preoccupation during fluoxetine treatment.

Fluoxetine and extrapyramidal side effects.

Fluoxetine and suicidal ideation-a review of the literature.

Fluoxetine and suicidal ideation.

Hicks-Gray T: Fluoxetine, akathisia, and suicidality: Is there a causal connection?. Arch Gen Psychiatry

Leufkens HG: Extrapyramidal syndromes associated with selective serotonin reuptake inhibitors: a case-control study using spontaneous reports. Int Clin Psychopharmacol

Locke C: Reexposure to fluoxetine after serious attempts by three patients: the role of akathisia.

Movement disturbances associated with the use of selective serotonin-reuptake inhibitors. Ann Pharmacother

Relationship between antidepressants and suicide attempts: an analysis of the veteran health administration data sets.

Selective serotonin reuptake inhibitors (SSRIs) and suicide in adults: meta-analysis of drug company data from placebo controlled, randomized controlled trials submitted to the MHRA’s safety review. BMJ

SH: Adverse reaction to high-dose fluoxetine.

Thase ME: Case-control analyses of the impact of pharmacotherapy on prospectively observed suicide attempts and completed suicide I bipolar disorder: findings from STEP-BD. J Clin Psychiatry

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Extrapyramidal side effects and suicidal ideation under fluoxetine treatment: a case report

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