KELLIE NEWSOME: Depression and cognitive impairment on benzos, tardive dyskinesia, anticholinergics, and neurotoxicity from high-dose stimulants. These are the side effects that patients aren’t likely to notice until it’s too late. Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003.

CHRIS AIKEN: I’m Chris Aiken, the editor-in-chief of the Carlat Report.

KELLIE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue. Last time on Psychopharm Secrets, we talked about times when your patient isn’t likely to appreciate the benefits of a med. If it has a slow build or purely preventative effects, they aren’t likely to notice, like lithium and lamotrigine. And when sleep meds are rewarding and causes amnesia – like benzos and Z-hypnotics – they may overestimate the benefits. But problems can also be hard to pick up on when they have a slow build or when they are obscured by rewarding effects. Today, we will cover three situations where patients are likely to miss the harm that’s happening – with anticholinergics, benzos, and stimulants.

CHRIS AIKEN: Like the proverbial frog in boiling water, your patient is not likely to tell you about side effects that gradually get worse over time.

KELLIE NEWSOME: Take anticholinergic side effects. These are subtle, but they get worse as you age, wearing down quality of life. Slowly, their memory gets worse, but they’re not going to think it's the med. A little dry mouth is not a big deal at first, but over time, it causes tooth decay and bad breath until it's hard to eat and no one wants to kiss you. Anticholinergics will dilate the pupils and impair papillary accommodation, which sounds benign, but it means car accidents, falls, and inability to read fine print. The lungs dry up, which you don’t feel at first, but eventually, that mucous thickens, clogging airways and worsening asthma. Anticholinergics make people sweat less, probably not a big deal until summer comes or until they get older and can’t regulate their body temperature as well. Then there’s constipation and urinary retention, again problems that are going to double up as you get older.

CHRIS AIKEN: Yes, these notorious anticholinergic side effects might not show up until the patient's older or until another anticholinergic gets added to their regimen, tipping the scale. I once saw a man who kept getting admitted to the hospital for psychotic episodes in his 60s. Like, when does psychotic episodes start in the 60s? That's rare. So, I asked him about all the over-the-counter medications that he was taking, and there was a long list of anticholinergics. After we stopped them, he didn't need the risperidone anymore, and he didn't keep going back to the hospital. The psychotic episodes were actually delirium on those anticholinergics. 

KELLIE NEWSOME: Here are drugs with strong anticholinergic effects. Tricyclics, older antipsychotics, but also a few newer ones like clozapine and olanzapine; the SSRI Paroxetine; hydroxyzine – which is often used for sleep and anxiety; and Benztropine – aka cogentin– which is a bit overused for extrapyramidal side effects on antipsychotics. Those are the big ones, but there are a lot of meds with anticholinergic effects, some of which might surprise you, like Xanax and carbamazepine, and they all add up. A good way to add them up is online at www.acbcalc.com or just google anticholinergic burden calculator. And now, for a preview of the CME quiz for this episode. Earn CME for each episode through the link in the show notes.   

1. Which population has a higher risk of tardive dyskinesia?  

A. Older adults  

B. Children and adolescents  

C. Men  

D. People with schizophrenia  

Another slow-burn side effect that surprises me is tardive dyskinesia. We’re taught that TD is a major source of distress for patients, but in my experience, most patients don’t even notice they are having it. After a few years on an antipsychotic, I’ll notice the start wiggling their feet, tapping their fingers, and twitching their eyes and lips. But patients are likely to dismiss this, as in I just tap my fingers like this when I’m anxious. They’ll be grimacing during the interview and not even aware of it.

CHRIS AIKEN: Yes, tardive dyskinesia is socially disabling, which means that others are likely to notice the eye blinking and tongue protrusion before the patient does. This is why a full AIMS exam is in order at least once a year while your patient is on an antipsychotic. Just Google it, the AIMS exam is free online. The chance of tardive dyskinesia is about 3-4 % per year with second-generation antipsychotics and 5-7% per year with the older ones, but after age 50, those differences disappear, and the risk of tardive dyskinesia is around 5-7% per year for both old and new antipsychotics. The older brain is just more fragile. Now, 4% a year is not a lot. That's the risk that the average patient would have of, say, taking quetiapine or aripiprazole of tardive dyskinesia. Just 4% a year, right? But think about that. Those odds pile up over time. I ran the numbers and estimate that after 10 years, that means the chance of having tardive dyskinesia is about 30%. Most of these cases are mild, below the patient's radar, but they do worsen over time, which is why your patient is not likely to tell you that they're having TD, at least not until it's too late. The bottom line, know which medications cause anticholinergic side effects, and pay particular attention to them when your patient is taking at least one, and they're over age 60 or more than one at any age, and don't be fooled by the old industry myth that newer antipsychotics don't cause tardive dyskinesia. They do. Maybe these cases are subtler, but they grow over time at a concerning rate of 3% per year. So, follow those AIMS exams, your patients aren't going to tell you about it unless you check yourself. Join us next time, where we're going to reveal psychopharm secrets about cognition getting worse on benzodiazepines, yes, and even on stimulants.

KELLIE NEWSOME: Got your own psychopharm secrets you’d like to share? Write to caiken@thecarlatreport.com. Check out our new issue on our website for articles on tapering psych meds, antipsychotics in depression, and updates on Vyvanse, lithium, treatment-resistant depression, and schizophrenia. Get $30 off your first year’s subscription with the promo code PODCAST.