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This is the first of a two part series on drug induced psychiatric symptoms that is based on the July 8, 2002 issue of The Medical Letter on Drugs and Therapeutics. Regular readers of Worst Pills, Best Pills News will recognize The Medical Letter as a reference source written for physicians and pharmacists that we often use because of its reputation as an objective and independent source of drug information.
Many drugs can cause psychiatric symptoms. However, psychiatric symptoms may...
This is the first of a two part series on drug induced psychiatric symptoms that is based on the July 8, 2002 issue of The Medical Letter on Drugs and Therapeutics. Regular readers of Worst Pills, Best Pills News will recognize The Medical Letter as a reference source written for physicians and pharmacists that we often use because of its reputation as an objective and independent source of drug information.
Many drugs can cause psychiatric symptoms. However, psychiatric symptoms may also emerge during drug treatment due to an underlying illness, previously unrecognized mental illness, or psychosocial factors. The stopping or withdrawal of some drugs can also cause symptoms such as anxiety, psychosis, delirium, agitation or depression.
This month’s article lists psychiatric symptoms associated with some families or classes of drugs. Examples of some drugs in the family are given. The list of examples is not exhaustive. The type of psychiatric symptom is listed and then an explanatory note.
Alcohol, agents that cause hallucinations and other drugs not generally used for medical purposes are omitted. Withdrawal reactions in individuals addicted to narcotics are also omitted.
We will refer a number of times to anticholinergic drugs and anticholinergic adverse effects in the list below. An anticholinergic is a drug that blocks the effects of acetylcholine, a substance produced by the body which is responsible for certain nervous system activities (parasympathetic). Drugs with anticholinergic effects (including antidepressants, antihistamines, antipsychotics, drugs for intestinal problems, and anti-parkinsonians) inhibit the secretion of acid in the stomach, slow the passage of food through the digestive system, inhibit the production of saliva, sweat, and bronchial secretions, and increase the heart rate and blood pressure. Adverse effects of these drugs include dry mouth, constipation, difficulty urinating, confusion, worsening of glaucoma, blurred vision, and short term memory problems.
Next month’s issue of the newsletter will conclude the series with some specific drugs that can cause particular psychiatric symptoms.
What You Can Do
Keep in mind Rule 3 of our rules for safer drug use: Assume that any new symptom you develop upon starting a new drug may be caused by the drug. If you have a new symptom, psychiatric or otherwise, report it to your doctor.
| Family | Examples | Reactions | Notes |
|---|---|---|---|
|
Amphetamine-Like Drugs Herbal dietary supplements containing ephedra should also be considered as amphetamine-like drugs. |
This family includes the diet drugs such as sibutramine (MERIDIA) and phentermine (IONAMIN) | bizarre behavior, hallucinations, paranoia, agitation, anxiety, mania, nightmares | Usually with overdose or abuse; can occur with asthma inhaler abuse; depression on withdrawal |
|
Anabolic steroids (body-building steroids) |
oxymetholone (ANADROL); oxandrin (OXANDRIN); stanozolol (WINSTROL). There are many illegal sources of anabolic steroids. Anabolic steroids may also be contained in dietary or herbal supplements. | psychosis, mania, depression, anxiety, aggressiveness, paranoia | most reports are with abuse |
| Angiotensin-Converting Enzyme (ACE) Inhibitors | captopril (CAPOTEN); enalapril (VASOTEC); lisinopril (PRINIVIL, ZESTRIL) | mania, anxiety, hallucinations, depression, psychosis | many reports |
| Anticholinergics and Atropine | many drugs have anticholinergic properties including some antidepressants, antihistamines, antipsychotics, drugs for intestinal problems, and antiparkinsonian drugs | confusion, memory loss, disorientation, depersonalization, delirium, auditory and visual hallucinations, fear, paranoia, agitation, bizarre behavior | more frequent in the elderly and children with high doses; can occur with transdermal scopolamine (TRANSDERM SCOP); atropine eye drops, particularly when mistaken for nose drops can cause sudden incoherent speech, delirium with high fever, flushed dry skin, hallucinations, or amnesia |
| Antidepressants, Tricyclic | amitriptyline (ELAVIL); doxepin (SINEQUAN); imipramine (TOFRANIL) | mania or hypomania, delirium, hallucinations, paranoia, irritability, dysphoria | patients with bipolar disorder are at highest risk for mania; anticholinergic effects may cause delirium in elderly |
| Antiepileptics (drugs for seizure disorders) | phenytoin (DILANTIN) | agitation, confusion, delirium, depression, psychosis, aggression, mania, toxic encephalopathy (disease of the brain), nightmares | usually with high doses or high blood concentrations |
| Barbiturates | phenobarbital (SOLFOTON); aprobarbital (ALURATE); butabarbital (BUTISOL) | excitement, hyperactivity, visual hallucinations, depression, delirium-tremens - like syndrome (seen in alcohol withdrawal) | especially in children and the elderly, or on withdrawal |
| Benzodiazepines | diazepam (VALIUM); flurazepam (DALMANE); alprazolam (XANAX) | rage, hostility, paranoia, hallucinations, delirium, depression, nightmares, anterograde amnesia, mania, disinhibition | during treatment or on withdrawal; may be more common in the elderly |
| Beta - Blockers | atenolol (TENORMIN); metoprolol (LOPRESSOR, TOPROL); propranolol (INDERAL); levobunolol (BETAGAN); betaxolol (BETOPTIC); timolol (TIMOPTIC) | depression, psychosis, delirium, anxiety, nightmares, hallucinations | with oral or eye drop preparations, incidence of depression may be overestimated |
| Calcium Channel Blockers | amlodipine (NORVASC); diltiazem (CARDIZEM, DILACOR, TIAZAC); verapamil (CALAN, ISOPTIN, VERELAN) | depression, delirium, confusion, psychosis, mania | several reports |
| Cephalosporin Antibiotics | cefaclor (CECLOR); cefuroxime (CEFTIN); cephalexin (KEFLEX) | euphoria, delusions, depersonalization, illusions | kidney disease is a risk factor |
| Dopamine Agonists for Parkinson's Disease | bromocriptine (PARLODEL); pergolide (PERMAX); pramipexole (MIRAPEX) | hallucinations, paranoia, delusions, confusion, mania, hypersexuality, anxiety, depression, nightmares | during treatment or on withdrawal |
| Estrogens | conjugated estrongens (PREMARIN); estradiol (CLIMARA, ESTRACE) | panic attacks, depression | several reports |
| Fluoroquinolone Antibiotics | ciprofloxacin (CIPRO); levofloxacin (LEVAQUIN); sparfloxacin (ZAGAM) | psychosis, confusion, agitation, depression, hallucinations, paranoia, Tourette-like syndrome (a form of tic), mania | many reports |
| Histamine H-1 Blockers | chlorpheniramine (CHLOR-TRIMETON); diphenhydramine (BENADRYL); loratadine (CLARITIN); fexofenadine (ALLEGRA) | hallucinations | especially with over dosage of the older antihistamine drugs such as diphenhydramine |
| Histamine H-2 Blockers | cimetidine (TAGAMET); famotidine (PEPCID); nizatidine (AXID); ranitidine (ZANTAC) | delirium, confusion, psychosis, mania, aggression, depression, nightmares | especially in the elderly and seriously ill |
| Monoamine Oxidase (MAO) Inhibitor Antidepressants | isocarboxazid (MARPLAN); phenelzine (NARDIL); tranylcypromine (PARNATE) | mania or hypomania | |
| Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) | ibuprofen (MOTRIN); naproxen (NAPROSYN); meloxicam (MOBIC); rofecoxib (VIOXX) | depression, paranoia, psychosis, confusion, anxiety | probably more common with indomethacin (INDOCIN); one case of auditory hallucinations with celecoxib (CELEBREX) |
| Opioids | narcotic pain relievers such as morphine, codeine, and oxycodone (OXYCONTIN) | nightmares, anxiety, agitation, euphoria, dysphoria, depression, paranoia, psychosis, hallucinations, dementia | usually with high doses; also occurs with intrathecal (administration into the spine) morphine; especially in the elderly |
| Procaine Derivatives (procainamide, procaine penicillin G) | procainamide (PROCANBID); procaine penicillin G is an injectable form of penicillin given by a doctor | fear of imminent death, hallucinations, illusions, delusions, agitation, mania, depersonalization, psychosis | probably due to procaine |
| Salicylates | aspirin | agitation, confusion, hallucinations, paranoia, | with chronic intoxication |
| Selective Serotonin Reuptake Inhibitors (SSRIs) | escitalopram (LEXAPRO); citalopram (CELEXA); fluoxetine (PROZAC); paroxetine (PAXIL); sertraline (ZOLOFT) | mania, hypomania, hallucinations | anxiety, irritability, aggression or impulsivity on withdrawal |
| Statins | atorvastatin (LOPID); fluvastatin (LESCOL); pravastatin (PRAVACHOL); simvastatin (ZOCOR) | anxiety, depression, obsessions, delusions | several reports |
| Steroids, Inhaled | triamcinolone (AZMACORT); beclomethasone (VANCERIL) | hyperactivity, aggression, disinhibition | several reports |
| Steroids, Oral | prednisone (DELTASONE, METICORTEN); prednisolone (METRETON) | psychosis, delirium, mania, depression | 1% to 3% incidence, may be dose-related; can occur on withdrawal |
| Sulfonamides | sulfamethoxazole and trimethoprim (BACTRIM, SEPTRA, COTRIM) | confusion, disorientation, depression, euphoria, hallucinations | several reports |
| Thiazide Diuretics | hydrochlorothiazide (HYDRODIURIL); chlorthalidone (HYGROTON) | depression, suicidal ideation | after weeks to months of use |
