Intractable Yawning and Fluoxetine

Gursharan Lal Kashyap, Jitendra Kumar Nayar, Soosamma Varghese and Rizwana Jaffry

Background

SSRIs (Selective Serotonin Uptake Inhibitors) are very commonly used in Depression and Anxiety. Though considered as safest antidepressants, they have some common side effects which include gastrointestinal side effects, headache and at times sexual dysfunction. Yawning is one of the rare side effects of SSRIs. SSRIs were found to be the commonest cause of not so common drug induced yawning in a meta-analysis^1. Isolated cases of intractable yawning have been reported with citalopram² fluoxetine, citalopram and sertraline³ in the literature .Excessive yawning can cause injury to Temporo-Mandibular Joint (TMJ) ⁴. Paroxetine has also been shown to cause intractable yawning⁵. Yawning possibly helps in thermoregulation and is an unconscious effort by the body to cool the brain ^{6, 7}. It is known that yawning can be contagious. Reading, talking, seeing someone yawn or even thinking about yawning can induce yawning in the subjects⁸. Susceptibility to contagious yawning is different for different individuals depending upon their ability to process information about self⁹.

Case

A 60 year old postman presented with his first episode of depression. He attended the GP who started him on sertraline (an SSRI). He developed serious headaches and did not notice any therapeutic benefit. He was then referred to the psychiatric services for further management. He was assessed, Sertraline was stopped and Cipramil 20mg was introduced. He was reviewed after 2 months and the dose was increased to 40 mg to which he responded partially but relapsed within 4 months. There were no changes in his psycho- social circumstances. Cipramil was stopped and he was started on fluoxetine 20 mg. Once again the response was partial and was overshadowed by midnight insomnia and increased sleepiness in the daytime. Fluoxetine was increased to 40 mg and he was reviewed after 4 months when he reported clear and significant improvement in his depression but complained of “excessive yawning spells” causing him problems at his work place. The psychiatrist was surprised at the number of times he yawned at the Out Patient Clinic review. On further discussion it became clear that this side effect had become highly troublesome. He complained that his jaw was in severe pain. He was unable to do his delivery rounds and was having clear episodes of attention lapses leading to letters being put to wrong addresses. He was transferred to “sorting” the post at sorting counters and was taken off delivery rounds. Even here the intractable yawning continued and he was committing sorting errors. By now it was affecting his colleagues too and they also started yawning (it is known to be contagious).It was affecting his self-confidence and was extremely embarrassing in all social situations to an extent that he started avoiding social interactions. He was drowsy all the time. He was clearly suffering more due to excessive yawning than due to depression. He was unable to perform his employment duties and was signed off sick. At that point the dose of fluoxetine was reduced to 20 mg .After a couple of weeks his yawning reduced significantly but was still disruptive to his routines. He was advised to slowly taper off fluoxetine over next 4 weeks. Unfortunately his depression relapsed and his GP restarted him on Fluoxetine 20 mg. He was reviewed by the psychiatrist after a couple of weeks. Once again he reported return of intractable yawning.

Fluoxetine was stopped once again and he was started on Mirtazapine 15 mg. There was very little response. The dose was increased to 30 mg after around two weeks. This led to him to experience nausea and vomiting. Unfortunately Mirtazapine too had to be stopped.  He was then tried on amitriptyline 50 mg which improved his sleep and symptoms of Depression. He was reviewed in the outpatient clinic after a couple of months .He did not develop any side effects and responded quite well. He then started his job starting from part time to full time within 6 weeks. After 6 months on the same dose of amitriptyline, did not have any symptoms of depression and was finally discharged from the mental health services.

Discussion

SSRI is the first line antidepressants used in the treatment of depression and Anxiety disorders. They are known to have least side effects and safest when it comes to overdosing. Intractable Yawning is quite an unusual and uncommon side effect.  One has to be conscious of the fact that it may cause yawning that can be pathological and can cause severe disruption of patient’s life. It can contribute to poor compliance. It is quite easy to overlook and ignore this side effect as yawning usually seems to represent sleep problems which is also a significant feature of the associated depression itself.

Excessive yawning can cause Jaw/facial pain. It can even cause dislocation of temporo-mandibular-joint. It can cause severe problems with one’s work and self-esteem. The sufferer might be misunderstood for being inattentive, indolent and sluggish. It might affect relationships with spouse/friend/relatives and especially at place of work. It can be misunderstood by doctors and lead to unnecessary tests and investigations. One has to be aware when prescribing SSRIs in patients who are driving or are involved in handling heavy machinery, athletes, airline pilots, surgeons, life guards, air traffic controllers and many other professionals. Due to its contagious nature, it’s not only the patient who is affected but also others around him. Excessive yawning can adversely affect the level of arousal, the level of concentration and work efficiency leading to poor performances in tasks requiring undiverted attention.

Hence excessive or intractable yawning has to be kept in mind while prescribing the so called most safe anti-depressant class of medication, the SSRIs, in this case fluoxetine.

References

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