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Serotonin syndrome is an iatrogenic disorder induced by serotonergic drug. It is characterised by a symptomatic polymorphism that may create confusion with other clinical conditions, delaying diagnosis and putting the vital prognosis at risk. In light of a case report and a literature review, we here report the clinical case of a patient presenting with confusion, psychomotor agitation, hyperreflexia and spontaneous myoclonus following simultaneous use of paroxetine and amitriptyline. The diagnosis of serotonin syndrome was made after ruling out other possible diagnoses. The patient was admitted to the intensive care unit. This clinical case highlights the importance of thoroughly understanding the clinical manifestations of serotonin syndrome to ensure early and appropriate therapeutic management., Competing Interests: Les auteurs ne déclarent aucun conflit d´intérêts., (Copyright: Kaouthar El Mir et al.)

A hundred and thirty patients have been treated with Amitriptylin in the "Clinique de Psychiatrie" in Marseille during the last eight years. The review of the hundred cases for which the information are the most detailed show that Amitriptylin remains one of the most powerful, manageable and well-tolerated anti-depressant drugs available at the present time. Its therapeutic indications are numerous, but the best ones are proceeding from depressed states with high anxious participation in subjects of less that 60 years of age.

The author has performed an open study of 27 patients with an acute depressive state, hospitalized and treated with slow intravenous perfusions of amitriptyline. Similar perfusions of chlorimipramine act certainly more rapidly on depression, but conversion to oral dose raises some problems regarding active dosis. Intravenous amitriptyline reduces latency, is more sedative and without major intolerance, such as hemodynamic. Conversion to oral diffused forms (Redomex diffucaps) consolidates the results obtained by parenteral administration, and the antianxiety component permits the use of this drug in monotherapy.

The study of the action of tricyclic antidepressant on epilepsy and E.E.G. leads to a separation between two groups of patients treated with these drugs : 1. The epileptic patients with personnal or family history of epilepsy have a higher risk of epileptic seizures during these treatments. However, a certain number of them get better as far as seizures and personnality disturbances are concerned. On these patients E.E.G. appears an activation of the pattern. We must precise that, with a proper anti-epileptic treatement, there are only rare seizures and, in any case, epilepsy is not a contra-indication to antidepressant treatments. E.E.G. gets even better in a few cases. 2. In patients without history of epilepsy, seizures are rare. If they appear, one finds several predisposing factors, alcoholism being the most frequent. High dosages are not a constant factor. Previous E.C.T. could increase the risk of seizures. On these patients E.E.G., the action of tricyclic antidepressant is not constant : we found important changes as well as no changes at all. The changes would be an aggravation with an epileptic pattern or slow rythms, as well as the pattern getting better. There is no correlation between clinical manifestations and E.E.G. patterns.

The cardiotoxicity of tricyclics is wellknown. The interpretations of such a mechanism are many: the tricyclic ring, the dimetilaminic group, the re-uptake NA mechanisms at myocardic level. A study was designed in order to answer the question. Four antidepressant drugs (a true quadricyclic: mianserin; a tricyclic with short later chain: amineptine; two tricyclic antidepressants with long chain: amitriptyline and chlorimipramine) were chosen in the double-blind cross-over study design in two different types of depression: anxious and retarded depression. A computerized cycloergometer test was performed at different times, together with ECG and depression evaluation. The patients with retarded depression were treated with amineptine (from 150 mg to 300 mg/day) and after a wash-out periods with chlorimipramine (150 mg/day). The patients with anxious depression were treated with mianserin (30-60 mg/day) for a fortnight and afterwards with amitriptyline (150 mg/day). The evaluation of the ergometric tests carried out at the fixed day have been carried out using the "Minnesota methodology". The results obtained show that the quadricyclic (mianserin) doesn't point out any cardiotoxicity. All tricyclics, especially amitriptyline, show cardiotoxicity signs.

Somatic disorders in depression can be separated into two main categories. The first comprises those which are true side effets of drug-therapy; the other includes somatic symptoms of the depression itself, which are subsequently considered as apparent side effects. Under the same treatment true side effects occur much more frequently in psychogenic depression, especially if the patient has a personality disorder. During the course of the treatment the disappearance of somatic complaints is noticed more easily by the physicians than the appearance of true side effects (schulterbrandt). The relative frequency of symptoms of depression as compared with all other symptoms seems to be higher in manic-depressive psychoses than in other varieties of depression (Watts). The other somatic disorders might either be symptoms of organic illness with secondary depression, the psycho-somatic equivalents of depression, or finaly the only symptoms of a masked depression.

Within the conditions of the double-blind trial, it appears that long-acting amitriptyline (Diffucaps), given at the dosage of 25 mg at the evening meal, is more active and better tolerated than a dosage of 40 mg of ordinary amitriptyline at bedtime in depressive sleep disorders.