Every year, nearly 90,000 adults go to emergency rooms for side effects of psychiatric medications. According to a recent study by the Centers for Disease Control, the majority of these visits can be attributed to ten commonly used medications. Today, Dr. Gray will tell us a little about these ten drugs that lead to ER visits.
Top 10 Drugs that lead to ER Visits
First, I will start by listing the top ten drugs, in decreasing frequency:
1. Ambien (zolpidem tartrate): a sedating medication
2. Seroquel (quetiapine fumarate): an antipsychotic medication
3. Xanax (alprazolam): an anti-anxiety medication
4. Ativan (lorazepam): an anti-anxiety or sedating medication
5. Haldol (haloperidol): an antipsychotic medication
6. Klonopin (clonazepam): an anti-anxiety and sedating medication
7. Trazodone (trazodone hydrochloride): a very old antidepressant used for sedation
8. Celexa (citalopram hydrobromide): an antidepressant
9. Lithium: a mood stabilizing medication
10. Risperdal (risperidone): an antipsychotic
Why is Ambien at the Top of the List?
Alone, Ambien is responsible for more than 1 in 5 ER visits among older adults. To be clear, Ambien is prescribed far more commonly than the other drugs on the list, so while it is at the top, it has actually caused significantly fewer ER visits than the others. In addition, Ambien has only been approved to treat insomnia by the Food and Drug Administration (FDA) and it is known to be addictive. It also has many concerning side effects such as sleep walking, sleep eating, sleep driving and even sleep- texting!
What Providers Can Do
Providers can help reduce the number of ER visits by first considering alternate treatments, such as sleep hygiene education; stimulus control, restriction of TV in bed; sleep regiments, such as going to bed and getting up at the same time each day; relaxation training such as deep breathing or meditation; and also cognitive behavioral therapy.
What is ‘On’ and ‘Off’ Label Prescribing?
Do understand why and how ER visits come about from using prescription medications, you must first understand the difference of ‘on’ and ‘off’ labeling.
On-Label Prescriptions: When a medication is approved for use by the FDA, it is typically approved for a particular use such as depression, anxiety or insomnia – these are on-label approved uses.
Off-Label Prescriptions: Medications most commonly used for indications other than those approved by the FDA are considered off-label and are typically antipsychotics.
For example: these are often used to treat insomnia, depression and anxiety, when they were approved to treat psychotic symptoms such as hallucinations, delusions and paranoia. In fact, over half of the off-label use of these medications is based on little or no evidence that the patient will benefit. Also, many of them have unwanted side effects such as weight gain and sedation.
Why Do ER Visits Occur?
Different classes of medications have different side effects and some of these side effects are more serious than others.
Anti-anxiety and sedation medications – delirium and sleepiness are the most common side effects. In fact, this class, and Ambien in particular, were implicated in almost 80% of ER visits for falls. These can result in head injuries, broken bones or worse.
Antidepressants – commonly cause dizziness, headaches, vertigo, and also hypersensitivity reactions such as rashes and hives.
Antipsychotics – the most common side effects are movement disorders such as joint stiffness, uncontrollable involuntary jerking, jaw clenching, tremor and painful joints.
Lithium salts – the most common side effects were abnormal drug levels. In order to be used effectively, the level of lithium in the blood needs to be within a certain range. There are many factors that can influence this range such as salt intake, fluid intake, kidney function and other medications that a person is taking.
Stimulants – the most common reasons for ER visits were heart abnormalities, such as palpitations, anxiety and panic. It is always recommended that a patient get an electrocardiogram or EKG before starting a stimulant, although is frequently not done. When it is done, it provides a baseline of how the heart is functioning with which to compare any other EKG that may be done in the future if a patient has any cardiac symptoms.
Do Patients Have to Be Admitted?
Overall, data from several sources shows that almost half of ER visits occurred in patients aged 19 to 44 years, and 20 % of these resulted in admission. For Lithium patients specifically, approximately 50% of patients presenting to the ER due to side effects need to be admitted due to dehydration and incorrect sodium levels. Patients may also need to be admitted if there is an alteration need in their medication regimen or they are having kidney problems. Overall, admission due to psychiatric medication side effects are more likely to happen with elderly patients. This is most likely because older patients tend to be on multiple medications.
So, is it Safe to Take These Medications?
Psychiatric medications, (antidepressants, antipsychotics, anti-anxiety and sedating medications, lithium and stimulants) play an important role in the management of mental illness. However, they can also cause severe and significant side effects. Given the wide range of treatments available for the many mental illnesses, providers must weigh the risks and benefits of them before prescribing. In addition, patients should make sure they understand why he or she is being prescribed a given medication and if it being used on or off-label and be confident in their knowledge about it to question decisions made by their provider.
I realize this is a study that can bring forth a lot of concern about the mentioned prescription medications. The reality is, two-thirds of antipsychotic medications are prescribed for off-label uses, contributing to the need for an ER visit. To decrease your chances of this happening to you, make sure your physician is being responsible and only prescribing you medications that have on-label uses. If you have any questions or concerns about your current medications, please do not to hesitate to call our Cognitive Psychiatry team at 919.636.5240.
Dr. Nicola Gray