Fluoxetine Induced Akathisia and Suicidally

Sir, Dr. S. Haque Nizamie & P.N. Suresh Kumar in their article 'fluoxetine induced extrapyramidal symptoms: Case reports' in Indian Journal of Psychiatry 1998, Vol. 1,No. 1, 87-89 have categorically remarked absence of suicidal ideation in both the cases who had developed pseudoparkinsonism and akathisia while being treated with fluoxetine alone and in combination with heloperidol & lithium. Akathisia had appeared in these cases on 5th day in easel and 6th & 14th day in case 2 respectively. The absence of suicidal ideation has been attributed to early detection and treatment of akathisia. The development of akathisia and emergence/ aggravation of suicidality is a complex issue. Suicidal ideation has been observed with anti depressant pharmacotherapy and has not been proved to be associated with any specific type of antidepressant. Whether certain anti depressants precipitate and or aggravate suicidal ideation in a subgroup of patients, responder as well as non responder to therapy is uncertain. It is unrelated to the dosage of fluoxetine (Mann & Kapur,1991). Suicidal ideation has been observed appearing suddenly, concurrent with neuroleptic induced akathisia and disappeared when akathisia was treated (Drake & Ehrlich, 1985). Fluoxetine induced akathisia is indistinguishable from that of neuroleptic induced akathisia (Lipinski et al., 1989). The proposed link between f'uoxetine induced akathisia and suicidality is explained on the basis of four neuron model of extrapyramidal motor system, in which increased serotonin activity by inhibiting the nigrostriatal dopamine tract, is capable of inducing a syndrome named Extra Pyramidal Dysphoric Reactions, one extreme form of manifestation of which is suicidal ideation (Hamilton & Opler,1992). I would like to raise a question and request for comments from the author on severity of akathisia and its relation to suicidality, which is lacking in the present case reports. Suicidality may be related to severity of THE EDITOR akathisia rather than its duration.