The Lethal Triad: Sertraline, Mirtazapine and Methadone.

Serotonin syndrome is a potentially life-threatening complication of using serotonergic agents. Mirtazapine is a relatively safe antidepressant and has a comparatively low incidence of side effects but can induce serotonin syndrome in combination with other serotonergic agents such as methadone and sertraline. We described a 41-year-old man with a history of heroin misuse and depression. He developed symptoms indicative of serotonin syndrome during his ICU stay. The serotonin-related symptoms resolved soon after withdrawal of mirtazapine and sertraline combined with supportive measures. After receiving appropriate supportive treatment, his general condition recovered and he was discharged without any neurological sequelae. With the increasing use of serotonergic agents, awareness of serotonin syndrome is important. Early diagnosis and timely discontinuation of the offending agent(s) are imperative to prevent morbidity and mortality.