Initiation of Selective Serotonin Reuptake Inhibitor After Intentional Acetaminophen Overdose: A Case Report

Although SSRIs are the first-line treatment for major depressive disorder, providers may be hesitant to initiate a trial of SSRI if the patient presented with drug induced liver injury as SSRIs (especially sertraline) have been linked with hepatotoxicity. We report on a case of a 20 year old female with unspecified depression and a prior suicide attempt presented with acute liver failure secondary to intentional overdose of Tylenol. APAP concentration was 43 mcg/mL 48-72 hours post ingestion, requiring N-acetylcysteine therapy, and liver failure was evidenced by ALT > 6,000 U/L, AST = 5,234 U/L, bilirubin = 4.8mg/dl, and ALP = 137 U/L. Multiple factors informed this patient’s high risk of suicide, including a prior attempt, multiple unresolved psychosocial stressors, and initial denial and refusal of psychiatric care. Due to this high risk, on day 13 of hospitalization, the patient agreed to start escitalopram 5 mg QAM with LFTs ALT =305 U/L, AST =46 U/L, bilirubin = 3.7mg/dl, and ALP = 137 U/L. Even at a low dose, the patient reported feeling more in control of her emotions and engaged with the psychiatric team. She was discharged with continual improvement of LFTs and the patient denied suicidal ideation, plan, or intent. This case highlights the importance of prompt evidence-based treatment of major depressive disorder with the safest drug in terms of hepatotoxicity if clinically indicated, as the risk of uncontrolled depression and repeat suicide attempts in a high-risk patient may outweigh the risk of SSRI-induced hepatotoxicity.