Bipolar Me

What’s Serotonin Syndrome? And How Do I Avoid It?

This week, I sent my husband to the pharmacy to pick up a prescription for me. The pharmacist told him to call me and put us all on the phone together. The prescription was for tramadol, a pain pill that I needed for a foot injury.

What the pharmacist wanted to know was whether I was aware of the possibility of serotonin syndrome. Of course, I said I was. At least I thought I was. After all, I had been on SSRIs for literally decades, and I’d heard the term before.

The pharmacist filled my scrip and included an informational leaflet on serotonin syndrome. I read it over, and that’s when I realized how little I really knew about the condition. But the thought occurred to me that it must be a fairly common thing, since they had leaflets about it on hand. (I found out it’s considered rare to uncommon, but handing out information seems wise nonetheless.)

I guess it shouldn’t have surprised me that a rare illness provokes such concern, given the number of people who take SSRIs—26 to 30 million in the US. There are approximately 4.5 million who take tramadol. I couldn’t find stats on how many people take both. Tramadol is a mild opioid that also affects serotonin receptors, so it is likely to amplify the effects of SSRIs.

And there’s the problem. The combination of the two drugs, or SSRIs and other drugs, can have the effect of increasing your serotonin without your realizing it.

In addition to reading the information sheet, which name-dropped tramadol as a particularly dangerous pairing with SSRIs, I decided to look it up online as well. I’m pretty particular about what online sources I use. (I use Wikipedia only to look up people’s bios, and I rely on sites like Mayo Clinic and Harvard Health for medical info.)

Too much serotonin causes serotonin syndrome. The effects of the increased dose include both physical and mental symptoms, from the mild (shivering and mild tremors) to the serious (coma and even death). Body temperature can become dangerously high. Cedars-Sinai lists possible effects as:

Seizures

Tremors

Muscle twitching or jerking

Restlessness or agitation

Sweating, nausea, vomiting, or diarrhea

Dilated pupils

Confusion

Rapid heart rate or blood pressure changes

High fever

I am pleased to report that I haven’t experienced any of the symptoms of serotonin syndrome (though some, like confusion and shivering, might be hard to spot in my case. I get confused easily when I’m trying to write and have to stop to take a phone call, and I always feel cold.) I am also pleased to report that I am weaning off the tramadol, taking one-half twice or three times a day rather than a whole one four times per day.

Still, just because I haven’t suffered much, if any, ill effects from the combination of tramadol and serotonin is no reason to take the chance of serotonin syndrome lightly. Other high-risk combinations with SSRIs include other SSRIs, MAOI inhibitors, some opioids, migraine meds, OTC cough medicine that contains dextromethorphan, St. John’s wort, some antibiotics or anti-nausea meds, and stimulants. A health care professional or pharmacist can explain these interactions in more detail.

Anyway, I’m not bashing SSRIs, as so many people are these days. They have saved my life and done the same for countless others. Are they overprescribed? Almost certainly, but so are antibiotics.

What I’m saying is to know the real dangers, educate yourself about them, and be careful.