Sertraline-Induced Visual Hallucinations

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Psychopharmacology Reviews: June 2004

L. Ginsberg, MD

Primary Psychiatry. 2004;11(6):13-17

Sertraline-Induced Visual Hallucinations

While visual hallucinations have been reported in association with

selective serotonin reuptake inhibitors (SSRIs), most cases have

occurred in vulnerable populations1,2 or involved the use of

concomitant drugs that are potential causes of perceptual

disturbances.3-6 Now comes a report of sertraline-induced visual

hallucinations in the absence of neurodegenerative disease or

coadministered psychotropic medication.7

A 70-year-old woman presented in July 2001 complaining of memory

loss, attentional deficits, depression, and severe anxiety. There was

no evidence of hallucinations, delusions, or behavioral disturbances.

The patient's score on the Mini-Mental State Examination (MMSE) was

22 out of 30 and demonstrated mild temporal disorientation, impaired

memory retrieval, and sustained attention deficit. A magnetic

resonance imaging scan of the brain showed mild frontal atrophy

consistent with age. The rest of the neurological examination was

normal, as was routine laboratory testing. The patient's psychiatric

history was remarkable for recurrent depressive episodes. In 1967,

she was admitted to the psychiatric unit for depressed mood, feelings

of guilt, penance rituals, and a religious delusion concerning the

search for her children's salvation. At that time, she was treated

with neuroleptics and electroconvulsive therapy. She did not have any

history of hallucinations and, for the past several years preceding

her admission, she had been treated with amitriptyline 10 mg/day and

perphenazine 4 mg/day.

At the time of evaluation, she was free of medication. Pseudodementia

was considered a possibility, so sertraline 50 mg/day was initiated.

While her cognition improved resulting in an MMSE score of 26,

approximately 3 weeks later she began experiencing daily visual

hallucinations, lasting from seconds to minutes with the content

involving unknown individuals hiding her personal objects or, on one

occasion, a tiger seated in her daughter's car. While these

hallucinations initially frightened her, the patient would gain

insight into their false nature within a few seconds. There were no

associated auditory hallucinations or delusions.

Sertraline was discontinued. Within a few days, the visual

hallucinations disappeared; however, the depression recurred.

Citalopram was initiated. At the patient's 1-year follow-up visit,

improvement of the depression and impaired cognition were noted.

Subsequent to discontinuation of sertraline, there were no further

visual hallucinations.

While not definitively known, the pathophysiology of visual

hallucinations is believed to involve the association cortex and

three predominant neurotransmitters: serotonin, dopamine, and

acetylcholine.8 SSRIs may potentially induce psychotic symptoms by a

5-HT2– and 5-HT3–mediated dopamine release in ventral striate.9-11

Unusual about this case is the fact that sertraline was the only

medication taken by the patient at the time of her visual

hallucinations; given the resolution of visual hallucinations within

a few days of discontinuing sertraline, it is likely the medication

responsible for this adverse effect. Sertraline's high affinity for

dopamine receptors renders such an association even more plausible.

While the incidence of visual hallucinations due to sertraline would

appear to be quite low, given its highly prevalent use in clinical

practice, physicians who prescribe sertraline ought to be aware of

its potential for inducing hallucinations.

References

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