California Psychiatric Association Documents
Utilization of Psychiatry and Psychiatric Specialists in Managed Care Systems Appendix II

Psychosis or Side Effect

Volume II No. 2
December 1994

It has been recognized for many years that drugs not only cure medical disease but may also cause it. Medication reactions account for 3-5% of admissions to acute-care facilities, 0.3% of admissions to hospitals, and 7% of admission to intensive care units.(1) One seventh of hospital days are devoted to drug toxicity at an estimated cost of 3 billion dollars.(2 )As advances in medical science and technology increase, the risk of iatrogenic illnesses rises proportionately (iatrogenic illnesses are those caused by medical interventions themselves including procedures, medications, and even hospitalization). Unfortunately, medication induced side effects are frequently misdiagnosed as mental illness by health care providers and mental health practitioners.

The entire issue of the July 1993 Medical Letter on Drugs and Therapeutics 3 was devoted to a review of one hundred and sixty nine different medications that may cause psychiatric symptoms that could be mistaken for mental illness. These include such commonly prescribed drugs as Dilantin, Tagamet, Cardizem, Motrin, Mevacor, Reglan, Flagyl, Procardia, Darvon, Inderal, and most steroid preparations. The adverse effects range from hallucinations (seeing, hearing, smelling, or feeling things that are not real) and delusions (beliefs that have no basis in reality) to confusion, disorientation, agitation, apprehension, mania, panic attacks, depression and irritability.

These adverse effects may, in some cases, be dose related in that they occur only at higher doses and disappear if the dose is reduced. In other cases, some people experience what are called idiosyncratic side effects. In this case a person has an inherent sensitivity to a medication, regardless of dose, and the side effect may be one that would not ordinarily be expected in most situations. This may sometimes even cause the opposite effect from what was intended. These invariably disappear when the medication is discontinued. Finally, another set of psychiatric-like symptoms may occur when certain medications are precipitously discontinued or withdrawn too rapidly. This is most commonly seen with steroids, atropine-like drugs, narcotics and most minor tranquilizers. Patients, frequently the elderly, precipitously stop medications of this sort without physician consultation because they are too expensive, because they feel they may be having side effects, or because they fear becoming too dependent on the medication. The withdrawal effects can be eliminated with a medically supervised, gradual reduction of the dose.

To complicate things even further, many of the illnesses for which these 169 medications are prescribed may themselves cause psychiatric symptoms. Obvious examples include thyroid disease, autoimmune illnesses, seizure disorders, and adrenal gland dysfunction among others. To tease apart which psychiatric symptom is due to the illness itself and which is due to the medication prescribed for the illness is frequently a quite formidable challenge. In other situations, prescribed medication can precipitate attacks of underlying medical conditions such as porphyria. This is a metabolic condition which can be triggered by medications including barbiturates (or their derivatives), and which causes abdominal pain that may be accompanied by psychiatric symptoms.

An earlier edition of The Medical Letter 4 reviewed medically prescribed drugs that can also cause sexual dysfunction, a complaint for which consumers frequently seek the help of mental health professionals. One hundred and ten different medications fall into this category including such frequently prescribed drugs as Tenormin, Pepoid, Lopid, Indocin, Prilosec, Minipress, Zantac, and the thiazide diuretics among others. Sexual dysfunction is frequently cause for a patient stopping medication without telling their physician which then only complicates the medical condition for which the drug was prescribed in the first place. On the other hand, they may remain on the medication, not recognizing the drug is causing the sexual problem, and seek mental health treatment or sexual counseling.

Psychotherapy, counseling, behavior modification or the introduction of psychiatric medication will clearly not resolve problems that are precipitated by medications being used to treat medical conditions. This will only prolong, and many times significantly complicate, what appears to be a psychiatric condition. This, of course, only intensifies the person's suffering and very much increases the cost of treatment.

Discontinuing the medication, or switching to another that does not have the same side effects, costs literally nothing and can be accomplished in anywhere from a day to two or three weeks.

In this era of soaring health costs it is critical that consumers of health care be educated as to the potential adverse psychiatric effects of prescribed medications and that they are afforded a careful medical review of any drugs they may be taking for physical conditions they are diagnosed as having a mental illness or sexual dysfunction and before counseling, psychotherapy, behavior modification or before psychotropic medication is introduced.

(1) Karch, FE, Lasagna, L Adverse Drug Reactions; A Critical Review. JAMA 1975; 234 (12), 1236-1241.
(2) Melmon, KL Preventable Drug Reactions; Causes and Cures, NEJM 1971:284 (24); 1361-8
(3) The Medical Letter, Inc., Vol. 35 Issue 901, July 23, 1993, 1000 Main St. New Rochelle, New York, 10801.
(4) The Medical Letter, Inc., Vol. 34 Issue 876 August 7, 1992.

Utilization of Psychiatry and Psychiatric Specialists in Managed Care Systems
Appendix I, Appendix III, Appendix IV