Medication Psychosis

Mrs. Smith is diabetic and recently had a stroke. She also has issues with depression and needs psychiatric help.

“She’s going to be on insulin and probably another glucose-control drug, at least one drug to control her heart rate, at least one drug to thin her blood, and maybe baby aspirin, too,” says Timothy Moore, chief of inpatient psychiatry at Emory University Hospital at Wesley Woods.

“She’s already on five medications before she ever sees a psychiatrist, which makes things pretty complicated.”

While no two patients are the same, Moore’s example is typical of an elderly patient at risk for medication-induced psychosis.

“We’re in an era of polypharmacy,” Moore says. “There’s a pill for every symptom. Patients can wind up taking enormous amounts of medication and that can be a pretty dark road to follow. It’s a very expensive way to treat people as well.”

These drugs—along with alcohol, over-the-counter medications, and dietary and herbal supplements—can interact in unexpected ways and in some instances produce severe psychological problems, including hallucinations, aggressive behavior, delusions, memory loss, and catatonia. “The most common medication-induced psychosis we see is caused by amphetamines, followed by steroids, which are well-known for producing psychotic symptoms,” he says. “These patients are in pretty rough shape. They usually look profoundly confused. They don’t know where they are, and sometimes they hear voices.”

Elderly patients are particularly vulnerable to medication-induced psychosis for several reasons. These include:

• Older people don’t tolerate a large number of pills as well as younger people.
• Nevertheless, they usually take more prescribed medications because they get sick more frequently and may have chronic illnesses that require daily medications.
• They tend to see a number of specialists, each of whom writes prescriptions addressing their area of expertise.

Health care providers in the same system can prevent some adverse drug interactions by communicating through “medication reconciliations” at hospitals. Such reconciliations involve making a list of all medications a patient is taking—including drug name, dosage, frequency, and route—and comparing it with the physician’s admission, transfer, and discharge orders. Sometimes, however, medications are left off the list or not all negative drug interactions are known.

Wesley Woods, an adult and geriatric psychiatric facility on the Emory campus, provides inpatient and outpatient services through an interdisciplinary team of physicians, nurses, social workers, and counselors. Among the conditions they address is medication-induced psychosis.

Moore’s objective is to treat patients’ psychological problems with a minimum number of antipsychotic drugs and with consideration of other medications they may be taking. It’s a complicated dynamic that takes into account any underlying pre-existing mental illness, and if prescribed medication is being taken properly and in the correct dosage. Also, some drugs lose their effectiveness over time as the patient gets older.

“Very few psychological conditions call for more than three medications,” says Moore. Depending on the person’s situation, he may start them on a few different antipsychotic drugs and then adjust them one by one over three to six months until he finds the long-term treatment that provides the greatest benefit and the least side effects. Patients are assessed during this time through one of two intensive outpatient programs. In one, the patient sees a psychiatrist and therapist for four to six hours a day, three days a week.

Another program, intended primarily for the elderly, meets for about four hours, five mornings a week.

Wesley Woods provides inpatient services in situations where major changes are necessary. “Generally, people don’t like being in a hospital, so we try to minimize the amount of time they’re here—the hospital stays average between seven and 11 days,” Moore says.

Inpatient care gives doctors space to make changes and start to simplify treatment. “You can very quickly stop medications entirely as you look for the minimum effective treatment that you need,” Moore says. “You don’t have to worry about bad outcomes because patients are under close supervision in a safe, secure, controlled environment. You don’t have to worry about grandpa being off his medication and going out for a drive or giving the neighbor a piece of his mind. The worst that can happen is the nurses call you at night and say grandpa is getting out of hand.”

People have high expectations for medications, says Moore, but there is not a pill for everything. “For example, we have effective treatments for depression, but there’s not a lot we can do about dementia,” he says. “Even if you can’t completely eliminate every symptom, you hope to keep the patient’s overall mental health from getting worse by cautiously prescribing the minimum of necessary medications.”­­