Bingham et al.
resumed taking 30 mg of paroxetine immediately
postoperatively (she did not miss a dose). At 2 days
after surgery, she started to experience irritability and
flulike symptoms. Her irritability was such that she
struck her husband during an argument. This behavior
was quite out of character for her and was disconcert-
ing to her and to her husband. When asked about her
symptoms systematically during a subsequent inter-
view, she also described experiencing dizziness, shock-
like sensations, nervousness, mood swings, agitation,
vivid dreams, insomnia, restless legs, unsteady gait,
and nausea. She recalled having similar (but less
severe) symptoms in the past after missing a dose of
paroxetine. She did not typically have any of these
symptoms at baseline.
On assessment, Ms. J scored 17 on 43 on the
Discontinuation-Emergent Signs and Symptoms
checklist, a clinician-rated scale that measures signs
and symptoms associated with antidepressant termi-
nation.7 Higher scores indicate more severe discontin-
uation symptoms. In clinical studies, patients are
typically defined as experiencing a discontinuation
syndrome if their Discontinuation-Emergent Signs
and Symptoms score increases by 4 points or more
from baseline7.
Ms. J's symptoms resolved within 10 days. How-
ever, approximately 4 weeks after surgery, she devel-
oped a recurrence of panic attacks. At 8 weeks after
surgery and after experiencing 4 panic attacks, she made
an appointment with her former psychiatrist, who
identified that the presentation was likely the result of
decreased paroxetine absorption following gastric
bypass surgery. Her psychiatrist increased the parox-
etine dose to 30 mg taken in the morning and 20 mg
before bedtime, with the view that increasing and
dividing the dosage would result in improved gastro-
intestinal absorption. Following this adjustment, the
panic attacks completely resolved and Ms. J returned to
her baseline.
She had a successful outcome 1 year after surgery,
with a weight loss of 45.4 kg for a new body mass
index of 25.1 kg/m2. Her medical co-morbidities and
quality of life had significantly improved.
This case illustrates the clinical effect of antide-
pressant pharmacokinetic changes following gastric
bypass surgery. In Ms. J's case, she experienced both
selective serotonin reuptake inhibitor (SSRI) discontin-
uation symptoms and a recurrence of the panic dis-
order, previously remitted for 10 years. Her symptoms
Psychosomatics 55:6, November/December 2014
affected her emotional and physical well-being and her
family relationships. Fortunately, once her condition
became more apparent, it was quickly stabilized, and
she experienced a very positive postsurgical outcome.
Pharmacokinetic Changes Following Gastric Bypass
Surgery
Small, observational pharmacokinetic studies have
demonstrated reduced bioavailability of sertraline,8,9
duloxetine,10 citalopram,8 and escitalopram8 in
patients after gastric bypass surgery. The small sample
sizes in these studies make it difficult to draw clinical
conclusions, but in a study of 12 patients taking stable
doses of antidepressant medication, with serum levels
drawn at sequential points before and after bariatric
surgery, Hamad et al. identified that in patients who
experienced relapse of depression after surgery, the
symptoms improved in conjunction with normal-
ization of antidepressant bioavailability.8 Bioavail-
ability tended to be lowest after 1 month and returned
to (or increased from) baseline by 6 months in this
study, although it remained lower than baseline for
1 patient at the 1-year point. The authors postulated
that the increase in bioavailability at 6 months was
because of the adaptive increase in the absorptive
component of the intestinal mucosa that occurs
postoperatively.8
Antidepressants, as with most oral medications,
are maximally absorbed in the small intestine, the
anatomy of which is significantly altered following
gastric bypass.5 The rate and amount of drug absorp-
tion may be affected by a variety of changes post-
operatively, including alterations in drug dissolution
and solubility because of differences in intestinal pH,
reduced intestinal surface area, and delayed gastric
emptying.5,8 In addition, antidepressants are lipophilic
and most are highly protein bound, qualities that make
them susceptible to the changes in the volume of
distribution and concentration of drug-binding pro-
teins that accompany obesity and rapid weight
loss.11,12
SSRI Discontinuation Syndrome
To our knowledge, there is no literature addressing
SSRI discontinuation syndrome after bariatric
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