Nocebo-induced cardiopulmonary symptoms following sertraline initiation mimicking acute cardiac pathology: a case report

Abstract

Nocebo effects are increasingly recognized as important contributors to perceived adverse events during the early phases of selective serotonin reuptake inhibitor (SSRI) therapy. Expectation-driven symptoms may mimic pharmacological adverse effects or acute medical conditions, leading to diagnostic uncertainty, unnecessary investigations, and premature treatment discontinuation. However, clinically significant cardiopulmonary presentations remain rarely reported in routine psychiatric practice. A 32-year-old woman with moderate major depressive disorder (MDD) developed acute cardiopulmonary symptoms, including palpitations, dyspnea, dizziness, and chest tightness, within 48 h of initiating sertraline. Symptoms prompted medication discontinuation and emergency department (ED) evaluation. Clinical assessment demonstrated sinus tachycardia without ischemic electrocardiographic changes, serial cardiac biomarkers within normal limits, and transthoracic echocardiography showing borderline left ventricular systolic function (left ventricular ejection fraction 51%) with mild diffuse global hypokinesia. Brain magnetic resonance imaging (MRI) excluded acute intracranial pathology. Symptoms progressively resolved with reassurance and supportive care. Detailed psychiatric reassessment revealed significant pre-treatment exposure to online information regarding antidepressant adverse effects, with marked concordance between anticipated and experienced symptoms. Following structured psychoeducation and expectation-targeted counselling, sertraline was successfully reintroduced at a lower dose without recurrence of cardiopulmonary symptoms. Follow-up echocardiography performed five weeks later demonstrated normalization of left ventricular systolic function (LVEF 58%), accompanied by substantial improvement in depressive symptoms (Hamilton Depression Rating Scale-17: 21 to 10). This case describes a clinical presentation consistent with a probable expectation-mediated nocebo response manifesting as acute cardiopulmonary symptoms that mimicked cardiac pathology. Although causality cannot be established from a single case and early SSRI-related adverse effects cannot be completely excluded, the absence of symptom recurrence following psychoeducation-guided rechallenge supports a substantial contribution of expectation-driven mechanisms. Recognition of nocebo phenomena, careful patient counselling, and proactive expectation management may improve antidepressant adherence while reducing unnecessary investigations and inappropriate treatment discontinuation in psychiatric practice. Not applicable.