Psychiatria Danubina, 2011; Vol. 23, No. 1, pp 120–122
© Medicinska naklada - Zagreb, Croatia
Conference case report
ALLERGIC REACTIONS - OUTCOME OF SERTRALINE
AND ESCITALOPRAM TREATMENTS
Elizabeta Dadić-Hero1,2, Klementina Ružić3, Tanja Grahovac3, Mirjana Graovac3,
Tija Žarković Palijan4 & Dubravka Šepić-Grahovac5
1Community Primary Health Centre, Primorsko-goranska county, Croatia
2Department of Social Medicine and Epidemiology, School of Medicine, Rijeka, Croatia
3University Psychiatric Clinic Rijeka, Clinical Hospital Centre Rijeka, Croatia
4Neuropsychiatric hospital Dr Ivan Barbot Popovača, Croatia
5Policlinic for Neurology and Psychiatry "Interneuron", Rijeka, Croatia
The treatment of dysthymia in itself poses a problem in the everyday psychiatric practice and it can be further hindered when
accompanied by pronounced personality traits (which are indicative of disorder). Due to its pathology and duration dysthymia
interferes with the patient's quality of life and the ability to function in some segments of everyday life. These interferences enticed
our patient to opt for psychiatric treatment.
During a three-year period, despite all the efforts made by psychiatrists in this comprehensive and challenging dysthymia
treatment (psychotherapy, group psychotherapy, psychopharmacotherapy), the expected outcomes of the treatment did not occur.
The patient's goals and expectations included lifestyle change, achieving life satisfaction and mood improvement. The patient was
refusing suggested psychopharmaca until confronted, in psychotherapy, with the fact that she is the one prolonging her own
helplessness and directing her passive agression at the members of the group.
In the end the patent agreed to take psychopharmaca. Therefore, sertraline was introduced in the treatment, but the patient
experienced a severe allergic reaction (Qiuncke's oedema). After four months the second attempt was made and escitaloptam was
introduced, which resulted in urticaria. Due to these allergic reactions to antidepressants, the patient decided not to pursue the
Key words: dysthymia- antidepressants- allergic reactions
* * * * *
Dysthymic disorder is a condition characterised by
chronic depressive mood that lasts for most of the day,
more days than not, for at least 2 years. People who
suffer from dysthymia describe their mood as sad or
dispirited (desponded) (American Psychiatric Associa-
tion 2000, World Health Organization 1999). Sufferers
can exhibit appetite disorder (increased or decreased),
low energy, low self-esteem, difficulties making deci-
sions, and feeling of hopelessness.
Dysthymia interferes with the person's ability to
function in everyday life, it reduces self-satisfaction and
significantly decreases the quality of life. Recovery
from dysthymia often takes a long time, and the
symptoms often return.
The literature clearly shows that medications that are
effective in treating major depressive disorder are also
effective in dysthymic disorder. A systematic review of
antidepressant treatment in dysthymia suggests that
SSRIs, tricyclic antidepressants and monoamine oxidase
inhibitors (MAOIs) are all equally effective, but SSRIs
may be slightly better tolerated (Kilts et al. 2009).
Sertraline and escitaloptam have comparable
antidepressant efficacy in the treatment of major
depressive disorder (Ventura et al. 2007).
Psychotherapy is also recommended alongside
medication treatment. The effectiveness of several types
of therapy, including psychodynamic, cognitive beha-
vioral, and interpersonal therapy, has been demonstrated
in controlled studies to be effective in the treatment of
depression and dysthymia. Supportive psychotherapy
and psychoeducation (teaching patients and their
families about this illness) significantly improve patient
compliance and family cooperation.
psychiatric treatment after the retirement. Prior to this
she sporadically sought psychiatric help but did not use
psychopharmaca. The psychiatric treatment was
initiated with the intent of claiming disability pension.
The patient stated that she is the elder child. She
described her father as being authoritative and mother as
emotionally unavailable (lacking emotional warmth).
She denied having any personal difficulties during her
school years and described herself as a sociable person
with a number of female friends (but no male ones). She
did not have emotional relationships prior to getting
married at the age of 36, following the short relationship
and a mutual decision to start a family. Both spouses
female patient started receiving
Elizabeta Dadić-Hero, Klementina Ružić, Tanja Grahovac, Mirjana Graovac, Tija Žarković Palijan & Dubravka Šepić-Grahovac: ALLERGIC
REACTIONS - OUTCOME OF SERTRALINE AND ESCITALOPRAM TREATMENTS Psychiatria Danubina, 2011; Vol. 23, No. 1, pp 120–122
were highly educated and employed, hence econo-
mically well situated. They did not have children.
At the first psychiatric appointment the patient
refused psychopharmacotherapy, and was insistent in
doing so for a lengthy period of time. However, she
readily accepted other forms of treatment such as group
and individual therapy which she attended regularly and
with sufficient motivation. Dominant disturbances were
related to her mood, which was predominantly depres-
sive but not on a daily basis, and they were accompa-
nied by poor concentration, neglect of physical
appearance, sexual intimacy avoidance (the patient did
not engage in sexual intercourse for more than 13
months, but she did often think about having children).
Over an extended period of time she suffered from low
self-esteem and was dissatisfied both her familial and
During the 36-month period after the patient started
receiving psychotherapy there was an increase in body
weight of approximately 20 kg, which the patient was
reluctant to talk about. She also exhibited sleep
The patient occasionally (once or twice a week) used
alprazolam at a dose that did not exceed 0.5 mg/day.
After 36 months of psychotherapy, which showed no
significant improvement, the patient was persuaded by
the group therapy members and the therapist to start
antidepressant treatment. Sertraline was introduced at
the initial dose of 25 mg due to the patient's reluctance
and sensitivity to psychopharmacotherapy.
After the administration of the first dose, that is 2 to
3 hours after taking 25 mg of sertraline the patient
experienced an allergic reaction and was forced to seek
medical help. Due to suffocation symptoms, tongue
oedema and facial flushing Qiuncke's syndrome was
diagnosed by the dermatologist. The allergic reaction
inevitably led to termination of the sertraline treatment.
After four months the second attempt at introducing
antidepressants was made and once again the members
of the group therapy and the therapist played an
important role in persuading the patient (which was not
an easy task). The patient reluctantly agreed to therapy
and escitaloptam was introduced, with extreme caution
due to the previous negative experience, at the initial
dose of 5 mg. After a couple of hours the patient
experienced rash and whole body flushing as well as
itching and diarrhoea. Consequently, she sought
immediate medical help. A dermatologist diagnosed
urticaria and prescribed a corresponding treatment. The
antidepressant treatment was promptly stopped.
Since the two attempts at treating dysthymia with
antidepressants resulted in severe allergic reactions, the
patient decided not to pursue the antidepressant
Currently the patient does not receive psychophar-
maca and the intensity of dysthymia symptoms is the
same as it was at the beginning of the psychiatric
treatment. The patient still receives psychotherapy.
Dysthymia is a disorder characterised by the chronic
depressive mood. It can occur during adolescence, but
can also develop later in life. When dysthymia occurs
after the age of 21 it is diagnosed as a late-onset
dysthymia, as was the case with the patient presented in
Duration of dysthymia is a diagnostic criterion that
differentiates dysthymia from other mood disorders.
Due to the nature of its symptoms, dysthymia interferes
with the person's ability to function in everyday life.
The person loses self-confidence and joie de vivre.
The treatment of dysthymia is similar to other mood
disorder treatments. The basis of the treatment are
antidepressants. In order for the treatment of dysthymia
to be successful the patient has to actively participate in
it. Avoiding psychopharmaca is unfavourable, and
psychotherapy as the only method of treatment turned
out to be ineffective in this particular case.
Sertraline is a selective serotonin reuptake inhibitor
(5-HT). In accordance with its selective inhibition of
reuptake of 5-HT, sertraline does not increase catechol-
aminergic activity nor it shows affinity towards
muscarinic (cholinergic), seratonergic, dopaminergic,
adrenergic, histaminergic, GABA or benzodiazepine
receptors (Ventura et al. 2007).
Even though, according to our estimate, the
antidepressant used in the treatment was safe, and there
was a clear indication for it, the administration of the
same resulted in Qiuncke's oedema. Prior to this, the
patient was neither allergic to food or other allergenic
When the next antidepressant which was indicated
for the treatment and which we successfully used in the
past, escitalopram, was introduced, the patient once
again experienced dermatological side-effects. As a
result we were forced to stop the escitalopram
The antidepressant action of escitalopram is
presumably linked to the potentiation of serotonergic
activity in the central nervous system resulting from its
inhibitory effect on the reuptake of 5-HT from the
synaptic cleft (Lalit et al. 2004). Escitalopram is a
highly selective serotonin reuptake inhibitor. Escitalo-
pram has no, or minimal effect on noradrenaline,
dopamine and gamma-amino butyric acid (GABA)
uptake (Llorca et al. 2005).
Despite the intensive psychotherapy, the patient
remained passive-agressive, which enabled her to
control the members of the group and to impose both
herself and her illness on the people around her. If she
had consented to the recommended medication
treatment earlier, she would have lost her position
within the group. Moreover, the improvement of her
psychological condition would inevitably lead to
acquiring a new status in the group.
Elizabeta Dadić-Hero, Klementina Ružić, Tanja Grahovac, Mirjana Graovac, Tija Žarković Palijan & Dubravka Šepić-Grahovac: ALLERGIC Download full-text
REACTIONS - OUTCOME OF SERTRALINE AND ESCITALOPRAM TREATMENTS Psychiatria Danubina, 2011; Vol. 23, No. 1, pp 120–122
The case clearly shows that the patient experienced
the same side effects when administered two different
antidepressants. Considering the patient's strong ambi-
valence toward psychopharmaca, we wonder whether
the side effects were not in fact defense mechanisms
created so that the patient could perpetuate her passive-
Each antidepressant, regardless of its administration
safety and the positive clinical experiences, can pose a
potential risk of side effects.
The administration of the antidepressants used in the
treatment of dysthymia resulted in severe side effects. If
we start with the premise that the allergic reactions are
psychosomatic, is it not plausible that the side effects
presented in this case are, in effect, patient's psycho-
somatic reaction to psychopharmacotherapy, which she
refused for years?
Even though it is our belief that the combined
methods of treatment (psychopharmacotheraphy and
psychotherapy) are more successful than individual
ones, we cannot but conclude that each treatment has to
be suited to patient's individual needs. In other words,
the course of treatment has to be individualised.
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Elizabeta Dadić- Hero, MD, PhD
Community Primary Health Centre,
Primorsko-goranska county, Rijeka, Croatia