sertraline , a selective serotonin reuptake inhibitor ( ssri ) , is considered to be safe and relatively well - tolerated medication for anxiety and depression . extrapyramidal symptoms ( eps ) could be adverse effects of ssri , which include parkinsonism , dystonia , dyskinesia , and akathisia . , we describe a young female patient who developed both mandibular dystonia and bruxism with sertraline . a 29-year - old married woman who was suffering from sadness , anhedonia and feelings of worthlessness , decreased energy , disturbed sleep , reduced appetite , and impaired concentration visited our outpatient clinic . this patient was diagnosed with mild to moderate depressive episode , and a trial of sertraline was initiated with a morning dose of 50 mg / day . the patient did not have any or family history of movement disorder , substance abuse , or mental illness . after 15 days at this dosage without adverse effects , the dose was increased to 75 mg / day . during the next follow - up after 3 weeks , the patient showed marked improvement in her depressive symptoms , and she was pleased with this treatment . meanwhile , she started having  strange involuntary movements of the face  with  forced deviation of the jaw  to the lateral side which was extremely distressing in nature , lasting for few minutes . tablet sertraline was reduced to 50 mg / day , and the distressing symptoms resolved . however , after 2 months , again she started having distressing movements of the face , though with lesser intensity . along with it , she started having severe teeth clenching and associated loud grinding noises during sleep most of the days . the symptoms resolved immediately , and she is maintaining well on tablet agomelatine for the last 3 months . in this case , the patient developed mandibular dystonia and bruxism with sertraline , and there were no other medications with known effect on the dopaminergic system been consumed . the resolution of both the symptoms after discontinuation of sertraline and the naranjo score of 6 indicates a probable causal relationship . compared to tricyclic antidepressants , ssris have safer side effect profile and also widely used as first - line agents to treat conditions such as depression , social phobia , panic disorder , posttraumatic stress disorder , and obsessive - compulsive disorder , etc . , however , one important but least identified side effect due to the use of ssri is movement disorder such as eps . the mechanisms by which ssris cause bruxism and dystonia are unclear . however , recent findings indicate that central dopaminergic system may be involved in the pathophysiology of both . it has been hypothesized that ssris induce bruxism by excessive serotonergic action on the mesocortical neurons arising from the ventral tegmental area , causing a dopaminergic deficit , leading to bruxism . whereas ssris cause dystonia due to the inhibitory effect of serotonergic inputs on the dopaminergic pathways of the striatum . the role of basal ganglia and cerebellum has also been described in the etiology of ssri - induced dystonia . literature review shows few case reports of ssri - induced movement disorders such as bruxism and jaw dystonia . case reports of bruxism developing on venlafaxine , fluoxetine , paroxetine , citalopram , and sertraline are available . paroxetine - induced bruxism in an elderly japanese man with depression was successfully treated by 5-ht1a agonist tandospirone . a review noted sertraline to be the second most commonly implicated antidepressant next to duloxetine in causing eps ; tremors , dystonia , hypertonia , myoclonus , parkinsonism , and akathisia being the most common . cases are reported in a 25-year - old indian female and a 17-year - old turkish female with sertraline - induced acute mandibular dystonia . contrary to paroxetine - induced movement disorders , in the first case , the symptoms completely resolved after stopping the sertraline . similar findings were noted in our case report ; the sertraline - induced distressing jaw movements with spontaneous resolution after removing the offending agent . the second case received biperiden intramuscular injection for acute relief , which did not recur after stopping sertraline . as in our case , most of the cases have been with females who are known to be more vulnerable than males . although noted more often in extremes of age , even young and middle - aged person can also experience epss with sertraline . hence , caution is needed in every female patient prescribed sertraline . gabapentin , buspirone , and tandospirone are the agents reported to be effective in ssri - induced bruxism . however , they should be used when symptoms are severe and implicated medicine can not be removed for some reason . dose reduction and removal of the offending drug although there are reports of agomelatine induced akathisia , in the present case , agomelatine did not lead to the relapse of the adverse effect by controlling the psychopathology . agomelatine with more of melatonergic and less of serotoninergic activity in ameliorating the depression could be a safe and effective alternative in patients sensitive to serotoninergic induced eps . thus , the present case describes two rare but important side effects associated with the use of ssris co - occurring in a single young female patient . hence , it is necessary for the clinicians to be aware of this kind of alarming side effect with the use ssri drugs , which are considered to be safer .
specific serotonin reuptake inhibitors have been associated with the occurrence of drug - induced parkinsonism , dystonia , dyskinesia , and akathisia . here , we describe a young female patient with a diagnosis of the moderate depressive episode who developed mandibular dystonia and bruxism with sertraline in the absence of concurrent prescription of medications , which have potential action on the dopaminergic system .