April 18, 2025 • 28 mins
This episode of Psych News Special Report delves into the complexities of prescribing psychotropic medications for medically ill patients. Dr. Adrian Preda and Dr. Jim Levinson discuss the challenges faced by psychiatrists, including pharmacokinetics, drug interactions, and the importance of collaboration with other healthcare providers. They emphasize the need for careful medication management, especially in patients with complex medical histories, and highlight the risks of not addressing psychiatric symptoms in these individuals.
“PsychNews Special Report” is a production of Psychiatric News, a media platform dedicated to serving as the primary and most trusted source of information for APA members, other psychiatrists and physicians, health professionals, and the public about developments in the field of psychiatry and mental health that impact clinical care and professional practice. Learn more at psychiatryonline.org/journal/pn.”
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr. Adrian Preda (00:00):
Hello, and, uh, welcome to Psych News Special Report, a monthly podcast from Psychiatric News produced for the APA Medical Minds channel. I'm Dr. Adrian Preda, Editor in Chief of Psychiatric News and Professor of Clinical Psychiatry and Human Behavior at the University of California, Irvine School of Medicine.
Dr. Jim Levenson (00:01):
Thank you for having me.
Dr. Adrian Preda (00:01):
Let's start with the big picture. Why is prescribing psychotropic medication so complex when dealing with medically ill patients?
Dr. Jim Levenson (00:01):
Well, there are several reasons. One is that patients who are medically seriously ill are more sensitive to side effects. They may metabolize. Drugs differently, uh, impairment of kidney or liver function in particular, uh, makes it more difficult for the body to get rid of medications. Medical illnesses can generate symptoms that can be mistaken for psychiatric disorders as well.
Dr. Adrian Preda (00:02):
So it's about the psychiatrist taking more of a traditional medical role in this, uh, high stake situations.
Dr. Jim Levenson (00:02):
Well, let me clarify. It's more a matter of keeping up one's knowledge. It doesn't mean taking over management of those other medical conditions. Making sure one understands the ways in which other medical conditions may require us to choose our medications more carefully, choose our doses more cautiously.
Dr. Adrian Preda (00:03):
You made a point that in medically complicated patients, Part of the complications is that drugs are processed differently. So you talked in your article about pharmacokinetics. Would you explain for our listeners what pharmacokinetics means?
Dr. Jim Levenson (00:03):
Sure, pharmacokinetics refers to the sequence of the absorption of a drug, because until it gets into the body it, of course, can't have any benefits or side effects.
Dr. Adrian Preda (00:04):
In what way could physical illness change pharmacokinetics? Can you give us some examples?
Dr. Jim Levenson (00:04):
Sure. So, patients who have a decrease in their ability to absorb drugs, and examples would include Patients with chronic inflammatory bowel diseases, like Crohn's disease, or the increasingly large number of people who've had gastric bypass surgery for obesity in this country, they have less functioning absorptive surface on their small bowel.
Dr. Adrian Preda (00:05):
So this would be a situation where the same dose of medication would result in different levels in patients would have different levels of absorption. So in other words, in addition to considering the dosing, it's important to consider these other variables that could significantly influence the drug levels and thus its, uh, its effectiveness.
Dr. Jim Levenson (00:05):
Exactly. Another example would be. Patients with severe chronic liver disease, most often we would be talking about cirrhosis, will have more difficulty metabolizing some psychiatric drugs than other psychiatric drugs. For example, if one were to choose a benzodiazepine, three of the benzodiazepines require less metabolism by the liver than all the others.
Dr. Adrian Preda (00:06):
right? So these are examples of the effects of the drugs being changed because changes in the absorption or distribution or metabolism and you also mentioned changes in how the drugs could be eliminated.
Dr. Jim Levenson (00:06):
Yes, exactly.
Dr. Adrian Preda (00:06):
Now, the other part about medically complicated patients is that in addition to the medical conditions that could then affect the drug effects as we discussed, these patients tend to take a lot of other medications.
Dr. Jim Levenson (00:07):
Well, so this is another whole area that it's important for psychiatrists to keep up on to educate themselves because Our medications can have effects that we are otherwise not aware of on the effectiveness of non psychiatric medications. So I'll give you two examples.
Dr. Adrian Preda (00:08):
And also, uh, other drugs could, uh, in turn affect the metabolism of the psychotropic drugs.
Dr. Jim Levenson (00:09):
Yes. Yes. It goes in both directions.
Dr. Adrian Preda (00:09):
Any, like, you know, sort of, let's go, uh, maybe what are the first, you know, I would say the first three other drugs interacting with psychotropic things that psychiatrists should pay attention to?
Dr. Jim Levenson (00:09):
Um, well, some of these are very familiar to psychiatrists. to most psychiatrists, but I'll, I'll, I'll mention one here, which is that lithium levels can be influenced to be increased or decreased by diuretics, depending on which diuretic it is, and various other antihypertensives.
Dr. Adrian Preda (00:09):
What about grapefruit juice?
Dr. Jim Levenson (00:09):
I love grapefruit juice. But I think anybody who's taking multiple medications. An occasional glass of grapefruit juice won't harm anything. And if they always drank the same amount of grape juice every day, then doses can get adjusted around that. But if somebody is intermittently drinking large amounts of grape juice, that can throw off the blood levels of a variety of medications.
Dr. Adrian Preda (00:10):
That brings me to the next question because there are so many drug drug interactions that could go in either direction and there are drug food interactions. Grapefruit juice is an example. And then there are the drug, you know, nicotine smoking interactions. I mean, that's a lot. That's a lot to kind of remember and.
Dr. Jim Levenson (00:10):
Well, it continues to be a real challenge. Any prescribing health care provider who's listening to this podcast has had the experience if they work somewhere that has an electronic medical record of being warned about all kinds of combinations.
Dr. Adrian Preda (00:11):
SSRI.
Dr. Jim Levenson (00:12):
Yes, um, and as you know, about two thirds of the psychiatric drugs in the United States are prescribed by non psychiatrists. And they can tend to be overly cautious, both in dosing and in worry about drug drug interactions. If their patient also has a serious medical condition, they can become afraid to use the psychiatric drug at all, or maybe a psychiatrist has been prescribing the psychiatric drug, and the non psychiatric physician may, out of an excess of caution, tell the patient to stop taking the drug, which would usually be a mistake.
Dr. Adrian Preda (00:13):
Yeah, that's, that's worth emphasizing. Absolutely right. So, Jim, let's talk about the, um, some of the severe drug reactions. What are the biggest dangers that psychiatrists need to look out when prescribing psychotropics specifically in medically ill patients?
Dr. Jim Levenson (00:13):
Well, psychiatrists are well aware of neuroleptic malignant syndrome. If the psychiatrist is following a patient who's on some non psychiatric medicines. They should be aware that our colleagues outside of psychiatry are not very knowledgeable about neuroleptic malignant syndrome and don't realize that it can be caused by some non psychiatric drugs like, uh, promethazine and prochlorperazine.
Dr. Adrian Preda (00:15):
Uh, what about lithium toxicity? Are any of the more discreet medical ill patients at higher risk for that?
Dr. Jim Levenson (00:15):
Sure. So lithium There are difficulties with both toxicity and too low a blood level in a variety of medical conditions. So, in a patient with unstable heart failure, their kidney function is going to be variable.
Dr. Adrian Preda (00:17):
So you are emphasizing, uh, like at the level of principles.
Dr. Jim Levenson (00:18):
Yeah, so let me add another general principle. It's, it's not specific to our topic. I think it really applies throughout life, but, but it has particular relevance here. And that's that it doesn't make sense to ask the question. Is prescribing this drug risky? Without asking the question, well, what are the risks of not prescribing it?
Dr. Adrian Preda (00:19):
I think that's such a great point because, of course, we need to be aware of the risks but there are also benefits that in the bigger context, you know, considering the bigger context, you would want to be not risk adverse, but you would want to be appropriately assessing the risk benefit ratio as opposed to just deciding that the medication is not recommended.
Dr. Jim Levenson (00:20):
I'll give you another concrete example. The question arises, if someone. is on a psychiatric medication and they're going to have an elective surgical procedure should the medication be stopped. There's a publication consensus document that says, uh, lithium should be stopped three days Before the surgery.
Dr. Adrian Preda (00:21):
That makes sense. And with that, actually, let's shift to special cases.
Dr. Jim Levenson (00:21):
That's a complex subject because we don't have as much data as we would like. I think that there are some things we can say clearly. In a patient who has bipolar disorder, valproic acid is something that one would want to avoid if at all possible.
Dr. Adrian Preda (00:22):
You know, I have patients who want to breastfeed and they're at risk for postpartum depression. Any specific recommendations to consider when in that type of situation, breastfeeding recommendations for antidepressants, mood stabilizers?
Dr. Jim Levenson (00:22):
Sure. So one thing is that I wouldn't ever make a unilateral recommendation.
Dr. Adrian Preda (00:24):
Yeah. And I think it's so important you are emphasizing, and you said that a few times, time and again, that first. You know, uh, we should very carefully consider the overall picture and, uh, there is a lot of value in working collab collaboratively. The psychiatrists should consult with the surgeon. The surgeon should consult with the psychiatrist, with the pediatrician, with the OB, GYN in the case of a pregnant woman.
Dr. Jim Levenson (00:24):
For anyone who's in an academic medical center, it's likely that, uh, like I, I do here have expert pharmacists who specialize in psychiatric medications.
Dr. Adrian Preda (00:26):
Absolutely.
Dr. Jim Levenson (00:26):
A key message is. Don't be afraid to prescribe a psychiatric medication in someone with a complex medical picture. It can be done safely and effectively, but do it carefully. Consult with other providers. Go to the many online resources that are available to all of us these days that make it much easier to practice than when probably you and I started out.
Dr. Adrian Preda (00:27):
Jim, thank you for this fantastic discussion.
Hello, and, uh, welcome to Psych News Special Report, a monthly podcast from Psychiatric News produced for the APA Medical Minds channel. I'm Dr. Adrian Preda, Editor in Chief of Psychiatric News and Professor of Clinical Psychiatry and Human Behavior at the University of California, Irvine School of Medicine.
Dr. Jim Levenson (00:01):
Thank you for having me.
Dr. Adrian Preda (00:01):
Let's start with the big picture. Why is prescribing psychotropic medication so complex when dealing with medically ill patients?
Dr. Jim Levenson (00:01):
Well, there are several reasons. One is that patients who are medically seriously ill are more sensitive to side effects. They may metabolize. Drugs differently, uh, impairment of kidney or liver function in particular, uh, makes it more difficult for the body to get rid of medications. Medical illnesses can generate symptoms that can be mistaken for psychiatric disorders as well.
Dr. Adrian Preda (00:02):
So it's about the psychiatrist taking more of a traditional medical role in this, uh, high stake situations.
Dr. Jim Levenson (00:02):
Well, let me clarify. It's more a matter of keeping up one's knowledge. It doesn't mean taking over management of those other medical conditions. Making sure one understands the ways in which other medical conditions may require us to choose our medications more carefully, choose our doses more cautiously.
Dr. Adrian Preda (00:03):
You made a point that in medically complicated patients, Part of the complications is that drugs are processed differently. So you talked in your article about pharmacokinetics. Would you explain for our listeners what pharmacokinetics means?
Dr. Jim Levenson (00:03):
Sure, pharmacokinetics refers to the sequence of the absorption of a drug, because until it gets into the body it, of course, can't have any benefits or side effects.
Dr. Adrian Preda (00:04):
In what way could physical illness change pharmacokinetics? Can you give us some examples?
Dr. Jim Levenson (00:04):
Sure. So, patients who have a decrease in their ability to absorb drugs, and examples would include Patients with chronic inflammatory bowel diseases, like Crohn's disease, or the increasingly large number of people who've had gastric bypass surgery for obesity in this country, they have less functioning absorptive surface on their small bowel.
Dr. Adrian Preda (00:05):
So this would be a situation where the same dose of medication would result in different levels in patients would have different levels of absorption. So in other words, in addition to considering the dosing, it's important to consider these other variables that could significantly influence the drug levels and thus its, uh, its effectiveness.
Dr. Jim Levenson (00:05):
Exactly. Another example would be. Patients with severe chronic liver disease, most often we would be talking about cirrhosis, will have more difficulty metabolizing some psychiatric drugs than other psychiatric drugs. For example, if one were to choose a benzodiazepine, three of the benzodiazepines require less metabolism by the liver than all the others.
Dr. Adrian Preda (00:06):
right? So these are examples of the effects of the drugs being changed because changes in the absorption or distribution or metabolism and you also mentioned changes in how the drugs could be eliminated.
Dr. Jim Levenson (00:06):
Yes, exactly.
Dr. Adrian Preda (00:06):
Now, the other part about medically complicated patients is that in addition to the medical conditions that could then affect the drug effects as we discussed, these patients tend to take a lot of other medications.
Dr. Jim Levenson (00:07):
Well, so this is another whole area that it's important for psychiatrists to keep up on to educate themselves because Our medications can have effects that we are otherwise not aware of on the effectiveness of non psychiatric medications. So I'll give you two examples.
Dr. Adrian Preda (00:08):
And also, uh, other drugs could, uh, in turn affect the metabolism of the psychotropic drugs.
Dr. Jim Levenson (00:09):
Yes. Yes. It goes in both directions.
Dr. Adrian Preda (00:09):
Any, like, you know, sort of, let's go, uh, maybe what are the first, you know, I would say the first three other drugs interacting with psychotropic things that psychiatrists should pay attention to?
Dr. Jim Levenson (00:09):
Um, well, some of these are very familiar to psychiatrists. to most psychiatrists, but I'll, I'll, I'll mention one here, which is that lithium levels can be influenced to be increased or decreased by diuretics, depending on which diuretic it is, and various other antihypertensives.
Dr. Adrian Preda (00:09):
What about grapefruit juice?
Dr. Jim Levenson (00:09):
I love grapefruit juice. But I think anybody who's taking multiple medications. An occasional glass of grapefruit juice won't harm anything. And if they always drank the same amount of grape juice every day, then doses can get adjusted around that. But if somebody is intermittently drinking large amounts of grape juice, that can throw off the blood levels of a variety of medications.
Dr. Adrian Preda (00:10):
That brings me to the next question because there are so many drug drug interactions that could go in either direction and there are drug food interactions. Grapefruit juice is an example. And then there are the drug, you know, nicotine smoking interactions. I mean, that's a lot. That's a lot to kind of remember and.
Dr. Jim Levenson (00:10):
Well, it continues to be a real challenge. Any prescribing health care provider who's listening to this podcast has had the experience if they work somewhere that has an electronic medical record of being warned about all kinds of combinations.
Dr. Adrian Preda (00:11):
SSRI.
Dr. Jim Levenson (00:12):
Yes, um, and as you know, about two thirds of the psychiatric drugs in the United States are prescribed by non psychiatrists. And they can tend to be overly cautious, both in dosing and in worry about drug drug interactions. If their patient also has a serious medical condition, they can become afraid to use the psychiatric drug at all, or maybe a psychiatrist has been prescribing the psychiatric drug, and the non psychiatric physician may, out of an excess of caution, tell the patient to stop taking the drug, which would usually be a mistake.
Dr. Adrian Preda (00:13):
Yeah, that's, that's worth emphasizing. Absolutely right. So, Jim, let's talk about the, um, some of the severe drug reactions. What are the biggest dangers that psychiatrists need to look out when prescribing psychotropics specifically in medically ill patients?
Dr. Jim Levenson (00:13):
Well, psychiatrists are well aware of neuroleptic malignant syndrome. If the psychiatrist is following a patient who's on some non psychiatric medicines. They should be aware that our colleagues outside of psychiatry are not very knowledgeable about neuroleptic malignant syndrome and don't realize that it can be caused by some non psychiatric drugs like, uh, promethazine and prochlorperazine.
Dr. Adrian Preda (00:15):
Uh, what about lithium toxicity? Are any of the more discreet medical ill patients at higher risk for that?
Dr. Jim Levenson (00:15):
Sure. So lithium There are difficulties with both toxicity and too low a blood level in a variety of medical conditions. So, in a patient with unstable heart failure, their kidney function is going to be variable.
Dr. Adrian Preda (00:17):
So you are emphasizing, uh, like at the level of principles.
Dr. Jim Levenson (00:18):
Yeah, so let me add another general principle. It's, it's not specific to our topic. I think it really applies throughout life, but, but it has particular relevance here. And that's that it doesn't make sense to ask the question. Is prescribing this drug risky? Without asking the question, well, what are the risks of not prescribing it?
Dr. Adrian Preda (00:19):
I think that's such a great point because, of course, we need to be aware of the risks but there are also benefits that in the bigger context, you know, considering the bigger context, you would want to be not risk adverse, but you would want to be appropriately assessing the risk benefit ratio as opposed to just deciding that the medication is not recommended.
Dr. Jim Levenson (00:20):
I'll give you another concrete example. The question arises, if someone. is on a psychiatric medication and they're going to have an elective surgical procedure should the medication be stopped. There's a publication consensus document that says, uh, lithium should be stopped three days Before the surgery.
Dr. Adrian Preda (00:21):
That makes sense. And with that, actually, let's shift to special cases.
Dr. Jim Levenson (00:21):
That's a complex subject because we don't have as much data as we would like. I think that there are some things we can say clearly. In a patient who has bipolar disorder, valproic acid is something that one would want to avoid if at all possible.
Dr. Adrian Preda (00:22):
You know, I have patients who want to breastfeed and they're at risk for postpartum depression. Any specific recommendations to consider when in that type of situation, breastfeeding recommendations for antidepressants, mood stabilizers?
Dr. Jim Levenson (00:22):
Sure. So one thing is that I wouldn't ever make a unilateral recommendation.
Dr. Adrian Preda (00:24):
Yeah. And I think it's so important you are emphasizing, and you said that a few times, time and again, that first. You know, uh, we should very carefully consider the overall picture and, uh, there is a lot of value in working collab collaboratively. The psychiatrists should consult with the surgeon. The surgeon should consult with the psychiatrist, with the pediatrician, with the OB, GYN in the case of a pregnant woman.
Dr. Jim Levenson (00:24):
For anyone who's in an academic medical center, it's likely that, uh, like I, I do here have expert pharmacists who specialize in psychiatric medications.
Dr. Adrian Preda (00:26):
Absolutely.
Dr. Jim Levenson (00:26):
A key message is. Don't be afraid to prescribe a psychiatric medication in someone with a complex medical picture. It can be done safely and effectively, but do it carefully. Consult with other providers. Go to the many online resources that are available to all of us these days that make it much easier to practice than when probably you and I started out.
Dr. Adrian Preda (00:27):
Jim, thank you for this fantastic discussion.
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