Understanding Serotonin Syndrome
Instructor: Dr. Dawn-Elise Snipes
Executive Director: AllCEUs Counselor Education
Podcast Host: Counselor Toolbox, Happiness Isn’t Brain Surgery
~ Define Serotonin Syndrome
~ Explore the drug interactions that often cause serotonin syndrome
~ Explore risk factors for serotonin syndrome
~ Learn about treatment for serotonin syndrome
Understanding SOME of the Serotonin Receptors
Ways Serotonin is Increased
~ Increase in serotonin synthesis
~ L-Tryptophan (esp. supplementation)
~ Reduction in serotonin breakdown
~ MAOIs: Isocarboxazid (Marplan) and phenelzine (Nardil)
~ Increase serotonin release
~ Amphetamines (ADHD medication, MDMA)
~ Anorectics (appetite suppressants (dexadrine))
~ Anti-migraine medications such as triptans (Axert, Amerge, Imitrex), carbamazepine (Tegretol) and valproic acid (Depakene)
Ways Serotonin is Increased
~ Stimulation of Post Synaptic Receptors
~ Buspirone
~ Lithium
~ Pain medications such as opioid pain medications including codeine (Tylenol with codeine), fentanyl (Duragesic), hydrocodone meperidine (Demerol), oxycodone (Oxycontin, Percocet, Percodan) and tramadol (Ultram).

Ways Serotonin is Increased
~ Serotonin Reuptake Inhibitor
~ SSRI Antidepressants (Paxil, Prozax, Zoloft)
~ Ultram (SSRI + mu-receptor activation)
~ Trazadone (SARI: Serotonin Agonist and Reuptake Inhibitor)
~ Tricyclic Antidepressants (i.e. Elavil (amitriptyline), Tofranil (imipramine), and Pamelor (nortriptyline ))
~ Serotonin and norepinephrine reuptake inhibitors (SNRIs), antidepressants such as duloxetine (Cymbalta) and venlafaxine (Effexor)
~ Bupropion (Wellbutrin, Zyban) antidepressant and tobacco-addiction medication. Norepinephrine-dopamine reuptake inhibitor (NDRI)


Other Drugs That Act To Raise Serotonin
~ Illicit drugs, including LSD, Ecstasy, cocaine and amphetamines
~ NOTE: Research is unclear about the ability of cannabis to trigger serotonin syndrome in combination with other drugs
~ Herbal supplements, including St. John's wort (SSRI), 5-HTP, SAM-e, kava, ginseng and nutmeg, preworkout with stimulants
~ Over-the-counter cough and cold medications containing dextromethorphan (Delsym, Any cough or cold medicine ending in DM, others)
~ Anti-nausea medications such as granisetron, metoclopramide (Reglan), droperidol (Inapsine) and ondansetron (Zofran)
~ Linezolid (Zyvox), an antibiotic
~ Ritonavir (Norvir), an anti-retroviral medication used to treat HIV/AIDS

CAN Identify
~ C = Cognitive changes including agitation, confusion, euphoria, insomnia, hypomania and hallucinations
~ A= Autonomic changes including tachycardia, fever, arrhythmias, sweating, dilated pupils
~ N= Neuromuscular changes including tremor, rigidity, incoordination, seizures, diarrhea, nausea, vomiting

Other Symptoms
~ Headache
~ Shivering and goose bumps

Life Threatening Stage
~ In severe cases, serotonin syndrome can be life threatening. If you experience any of these symptoms, you or someone with you should seek medical attention immediately:
~ High fever (which can cause brain and organ damage)
~ Seizures
~ Irregular heartbeat
~ Unconsciousness

Risk Factors
~ There is an increased risk of serotonin syndrome if the person:
~ Recently started taking or increased the dose of a medication known to increase serotonin levels.
~ They take more than one drug known to increase serotonin levels.
~ They take herbal supplements known to increase serotonin levels.
~ They use an illicit drug known to increase serotonin levels.
Important Notes
~ Serotonin syndrome may appear after one dose
~ 60% of patients present within 1 to 6 hours after initial administration
~ Many cases resolve within 24 hours of the removal of serotonergic drugs
~ Se
~ Even if a patient isn’t on an antidepressant, he or she may be at risk for serotonin syndrome by combining over the counter medications and/or illicit drugs
~ Abuse of DXM is becoming increasingly popular among youth which can put them at risk of serotonin syndrome
~ Some patients also fail to tell their doctors about herbs, illicit drugs or drugs prescribed by other providers they are taking which, again, puts them at increased risk.
~ Alcohol does increase serotonin, so someone who is on the brink of serotonin syndrome who drinks, or who is taking an antidepressant and drinks can precipitate a crisis.
References and More Information
~ Volpi-Abadie, J., Kaye, A. M., & Kaye, A. D. (2013). Serotonin Syndrome. The Ochsner Journal, 13(4), 533–540.
~ Frank, C. (2008). Recognition and treatment of serotonin syndrome. Canadian Family Physician, 54(7), 988–992.
~ http://www.mayoclinic.org/diseases-conditions/serotonin-syndrome/diagnosis-treatment/treatment/txc-20305697
~ Boyer, E., Shannon, M. (2005) The Serotonin Syndrome. New England Journal of Medicine. 352, 1112-1120.
~ Prevention, Diagnosis, and Management of Serotonin Syndrome http://www.aafp.org/afp/2010/0501/p1139.html
~ Bijl D. The serotonin syndrome. Nether J Med.2004;62:309-313.
~ Dr. Santhosh Kumar https://www.slideshare.net/SanthoshKumar291/serotonin-syndrome-75848602/2
~ Opioid Receptors: Distinct Roles in Mood Disorders https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3594542/