Considerable controversy exists regarding the relationship 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 . Moreover, a systematic review of randomised controlled trials supports the relationship between the use of SSRIs and the increased risk of suicidal behaviour. According to this review, such risk may be underestimated due to a number of methodological limitations of the published reports .
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 . In another matched case-control study, the risk of suicidal behaviour was reported to be similar among users of amitriptyline, fluoxetine and paroxetine . Also, a nationwide cohort study in Finland found that fluoxetine 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 associated with increased risk of attempted suicide by self-poisoning, but with a decreased risk of completed suicide and death. The latter could be attributed to the fewer cardiovascular and cerebrovascular side effects of SSRI medication . Finally, a meta-analysis of randomised control trials of SSRIs conducted by pharmaceutical 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 .
Akathisia or dysphoric extrapyramidal reactions may be a contributing factor to the emergence of suicidal ideation during treatment with fluoxetine . 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 abnormal 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.