TPC
Should it stay or should it go?
Psychiatric medications on the wards
Sarah Graff, MD · The Psychiatric Center
Before we start
Disclosures
Financial relationships
Myriad Genetics: speaker. This talk does not discuss pharmacogenomic testing.
Use of AI
Portions of this educational activity were developed or edited with the assistance of artificial intelligence (AI) tools. I have reviewed, verified, and accept full responsibility for all content presented.
Off-label use
These uses are not currently approved by the FDA: chlordiazepoxide to taper alprazolam, clozapine in bipolar I disorder, lamotrigine for depression, and haloperidol for agitation (an answer option only).
Patient privacy
All three cases are real patients: names are changed, and dates, places and other identifying details are removed. Kathy's setting and details are also changed.
TPC
Do not discontinue
The reflex: "hold home meds"
For psychiatric medications, stopping is an intervention too.
01
Withdrawal
Benzodiazepines, short half-life antidepressants
Case 01 · Kathy
02
A harder restart
Lithium after toxicity, clozapine
Case 02 · Dorothy
03
Relapse
Mood stabilizers, antipsychotics
Case 03 · Richard
Respect the medications patients walk in on.
Three patients · seven best-choice questions
TPC
Do not discontinue
Case 01 · Kathy · Emergency department
52, up all night with RUQ pain
How she got here
Right upper quadrant pain after a heavy dinner, then vomiting through the night.
In the ED
Murphy sign positive.
Ultrasound: stones, a thickened wall, pericholecystic fluid.
IV fluids, antibiotics, hydromorphone.
Admitted
To medicine, with surgery consulted.
NPO for surgery. Home medications held.
ED vitals
T
101.0°F
HR
108
BP
146/90
RR
18
SpO2
98% RA
Labs
WBC
14.2
Alk phos
168
Total bilirubin
1.6
Lipase
Normal
TPC
Do not discontinue
Case 01 · Kathy · History and hospital days 1–2
Surgery on day 2, diet that evening
History
Depression and anxiety, stable for years. Hypertension. Prior biliary colic and C‑section.
Home meds
Venlafaxine XR 225 mg daily · Lisinopril 10 mg daily
Order
Day 1
Day 2 evening
Surgery
Planned
Laparoscopic cholecystectomy
Diet
NPO
Advanced
Venlafaxine XR 225 mg
Held for NPO
Still held
The "hold for NPO" order on her home medications is never lifted.
TPC
Do not discontinue
Case 01 · Kathy · Hospital day 3, 2 a.m.
The night team gets paged
The night nurse reports
•
Not sleeping; on the call light all night
•
Irritable and tearful, snapping at staff
•
Nauseated and sweaty
At the bedside
•
Dizzy when she turns her head
•
Electric-shock "zaps" when she moves her eyes
•
Neuro exam nonfocal; incisions clean
•
On the MAR: venlafaxine held for about 48 hours
Vitals
T
99.1°F
HR
98
BP
138/84
RR
18
SpO2
98% RA
Labs
WBC
9.8
down from 14.2
Lactate
1.1
LFTs
Improving
TPC
Do not discontinue
Case 01 · Kathy · Question
What is the most likely cause of her symptoms?
A
Antidepressant discontinuation syndrome
B
Postoperative infection
C
Anxiety and insomnia after surgery
D
Side effects of her postoperative opioids
TPC
Do not discontinue
Case 01 · Kathy · Answer
A. Discontinuation syndrome
A
Antidepressant discontinuation syndrome
•
Last venlafaxine dose: about 48 hours ago
•
Zaps and dizziness with eye and head movement
•
Fever, WBC and LFTs are all improving
Restart the home dose: it's the treatment and the test.
Why not the others
B · Postoperative infection
Temperature, WBC and LFTs are all improving, and lactate is normal.
C · Anxiety and insomnia after surgery
Doesn't explain the zaps or the dizziness with head turns. A PRN quiets the page and misses the cause.
D · Opioid side effects
Can explain nausea and dizziness, but not electric-shock zaps.
TPC
Do not discontinue
Case 01 · Kathy · Teaching point
Discontinuation looks like FINISH
F
Flu-like
Fatigue, aches, sweating, chills
I
Insomnia
Trouble sleeping, vivid dreams
N
Nausea
Sometimes vomiting or diarrhea
I
Imbalance
Dizziness, vertigo, unsteadiness
S
Sensory
"Brain zaps," tingling
H
Hyperarousal
Anxiety, irritability, agitation
Onset 1–3 days after the last dose
Worst with venlafaxine and paroxetine
Restarting usually resolves it within a day
TPC
Do not discontinue
Case 01 · Kathy · Question
Which held medication can go straight back at the home dose?
Another patient on your list: NPO for two days around surgery, diet resumed tonight.
A
Clozapine 200 mg, held 3 days
B
Sertraline 100 mg, held 2 days
C
Lamotrigine 200 mg, held 6 days
D
Lithium 900 mg, held 2 days; creatinine 0.9 → 1.6
TPC
Do not discontinue
Case 01 · Kathy · Answer
B. Sertraline goes straight back
Resume the home dose
If the reason for the hold is gone
- SSRIs and SNRIs
- Bupropion, mirtazapine
- Most antipsychotics
- Benzodiazepines
Check first
Labs or an ECG before the next dose
- Lithium: level, creatinine, sodium
- Valproate: LFTs, ammonia, platelets
- Carbamazepine: sodium, CBC, LFTs
- TCAs and QT-risk antipsychotics: ECG
Retitrate or call psychiatry
Don't go back to the old dose
- Clozapine, off more than 48 hours
- Lamotrigine, off about 5 days
- MAOIs
- Any drug that caused the problem
NPO isn't no psych meds. Every hold needs a stop date.
TPC
Do not discontinue
Case 02 · Dorothy · Emergency department
Late 50s and medically complicated
How she got here
Altered mental status
Brought in by her husband: incoherent speech, hallucinations, unsteady gait.
Building for months, worse this past week. Recent med changes.
In the ED
Oriented to self only. NIHSS 13.
CT head, CTA chest and chest x-ray: negative.
Teleneurology: MRI and a toxic-metabolic workup.
Admitted
To medicine.
Most psychiatric medications held pending a psychiatry consult.
ED vitals
T
97.6°F
HR
80
BP
116/56
RR
23
up to 35
SpO2
92% RA
then 2 L
Labs
Creatinine
1.58
Na
135
Ca
10.9
QTc
585 ms
Lithium
Not drawn
TPC
Do not discontinue
Case 02 · Dorothy · History
Twelve medications, many moving parts
Medical history
- Bipolar I disorder
- Anxiety
- Hypothyroidism
- Lung nodule
- Lithium toxicity, years ago
Surgical history
- Thyroidectomy
- Parathyroidectomy
- Cholecystectomy
- Lymph node biopsy, benign
- Right salpingo-oophorectomy, D&C
Home medications
Psychiatric
- Lithium 750 mg nightly
- Clozapine 37.5 mg daily, new
- Ziprasidone 20 mg BID, tapering
- Diazepam 5 mg TID
- Bupropion 75 mg daily
- Hydroxyzine 10 mg BID
- Prazosin 2 mg nightly
- Trihexyphenidyl 2 mg TID
Medical
- Spironolactone 50 mg BID
- Levothyroxine 137 mcg daily
- Gabapentin 300 mg TID
- Bethanechol 10 mg TID
TPC
Do not discontinue
Case 02 · Dorothy · Hospital day 1
A facial droop drew the focus
Exam
Facial droop
Oriented to self only, slurred speech, tremor, unsteady. NIHSS 13. Worked up first as a stroke.
Admitted for
Acute encephalopathy
Lithium and clozapine held
Chemistry
Cr
1.58
eGFR 37
BUN
21
Na
135
K
3.9
Mg
2.1
Ca
10.9
Lithium
Not yet drawn
Labs
Glucose
94
Ammonia
<10
WBC
9.2
AST/ALT
22/23
TSH
0.006
Tests
ABG on 2 L
7.34/43/90
QTc
585 ms
Troponin
<3
BNP
7.3
UDS
Benzo only
Imaging
CT head
Negative
CTA chest
Negative
IV contrast
Chest x-ray
Negative
MRI
Declined
TPC
Do not discontinue
Case 02 · Dorothy · Question
What's the next test?
Admitted for acute encephalopathy, on lithium. Head CT, CTA chest and chest x-ray are negative.
A
MRI brain
B
EEG
C
Lumbar puncture
D
Lithium level
TPC
Do not discontinue
Case 02 · Dorothy · Answer
D. The lithium level
Lithium level
1.7
Drawn the next morning, about 10 hours after she arrived
0.4–0.8, then 1.0
her usual range for a decade; 1.0 two weeks before admission
Additional context
- Spironolactone, a diuretic that pushes lithium up
- Past month: exercise, weight loss, diarrhea
- Ibuprofen from urgent care for a cold
- Clozapine cross-taper started two weeks earlier
Confused on lithium? The level comes first.
TPC
Do not discontinue
Case 02 · Dorothy · Teaching point
A creatinine that crept up
Creatinine (mg/dL) by years before admission
1.6
1.4
1.2
1.0
0.8
11 yr
8 yr
5 yr
2 yr
Admit
Old baseline 0.8–1.0
Lab upper limit 1.11
1.31
1.06
1.08
1.31
results not on hand
1.58 on admission
0.8–1.0
for about six years
1.08 → 1.31
in the 3 months before admission (eGFR 59 → 47)
1.58
on admission
What changed in those 3 months?
TPC
Do not discontinue
Case 02 · Dorothy · Question
What happened?
Her lithium dose hadn't changed. Her level went from 1.0 to 1.7 in about two weeks.
A
Less kidney reserve, plus volume loss, an NSAID and a diuretic
B
Clozapine, started two weeks earlier, raised her lithium level
C
Her lithium dose was too high
D
IV contrast in the ED raised her lithium level
TPC
Do not discontinue
Case 02 · Dorothy · Answer
A. Her kidneys changed, not her dose
A
Less kidney reserve, plus volume loss, an NSAID and a diuretic
•
Creatinine 1.31 two weeks out, 1.58 on arrival
•
Volume loss: exercise, weight loss, diarrhea
•
Ibuprofen and spironolactone can raise the level
Same dose, less clearance: a higher level.
Why not the others
B · Clozapine raised the level
Clozapine doesn't raise lithium levels, though the pair can add neurotoxicity.
C · Her dose was too high
750 mg a day is a low dose. With healthy kidneys it usually keeps the level under 1.0; hers ran 0.4–0.8. Clearance fell, so the level rose.
D · IV contrast raised the level
Lithium was held from arrival, so the level could only fall before the draw.
TPC
Do not discontinue
Case 02 · Dorothy · Hospital day 2
PT note: the droop was a side effect
Physical therapy evaluation, the morning after admission
- Facial asymmetry: not new, from her meds, per her husband
- Awake, verbal, oriented. Strength normal in all four limbs; no new sensory or visual changes.
- Wobbly gait, needs a steadying hand; better with distance
- Husband: much better than yesterday, when she "could hardly take a step"
- Home with assistance, home health PT, rolling walker
The takeaway
Read the PT note.
Therapists watch patients move and talk with family. This note answered the question behind the stroke workup.
TPC
Do not discontinue
Case 02 · Dorothy · Teaching point
Read her chart through her med list
What the team saw
What explains it
Confusion, ataxia, tremor
Lithium toxicity
QTc 585, normal K and Mg
Lithium toxicity, plus ziprasidone and hydroxyzine
Calcium 10.9
Volume loss; high-normal on lithium: check a PTH
Creatinine 1.58
Years of lithium, plus spironolactone and ibuprofen
Facial asymmetry
An old medication side effect, per her husband
TSH 0.006
Not lithium: too much levothyroxine
Holding her psychiatric medications was right. They were the canary, not the cause.
TPC
Do not discontinue
Case 02 · Dorothy · Days 3–5 · Question
What's the most important addition to her discharge plan?
Day 3: lithium 0.9, creatinine 1.0. Restarted at 300 mg twice daily; her home dose was 750 mg nightly.
No level since the restart. Clozapine still held; diazepam resumed. Discharge creatinine 1.05.
A
Stop lithium for good because of her kidneys
B
Follow up with her PCP and psychiatrist within a week
C
Recheck lithium and creatinine in 5–7 days, and arrange nephrology follow-up
D
Restart clozapine at her home dose of 37.5 mg
TPC
Do not discontinue
Case 02 · Dorothy · Answer
C. Recheck in 5–7 days, and refer
C
Recheck lithium and creatinine in 5–7 days, and arrange nephrology follow-up
•
New dose, never checked at steady state
•
In 2 weeks: lithium 1.0 → 1.7, Cr 1.31 → 1.58
•
A shrinking kidney reserve belongs with nephrology
Schedule the checks before she leaves.
Why not the others
A · Stop lithium for good
A long-term decision for psychiatry and nephrology together, not a discharge order.
B · PCP and psychiatry within a week
What actually happened. Not wrong, but it doesn't say what to check.
D · Restart clozapine at 37.5 mg
Off more than 48 hours: retitrate from 12.5 mg, not the old dose.
TPC
Do not discontinue
Case 03 · Richard · Emergency department
Mid-60s, with a draining ICD pocket
How he got here
Four months of drainage from the pocket despite outpatient antibiotics.
His new cardiologist sent him in for device extraction.
In the ED
Shaking and yelling at the admitting physician and NP.
No history until his sister arrived.
Triage suicide screen: negative.
Admitted
To medicine for a device infection workup.
Cultures and a TEE planned.
ED vitals
T
98.2°F
HR
69
BP
164/93
RR
18
SpO2
100% RA
Labs
WBC
6.5
Lactate
0.6
Procalcitonin
<0.05
ECG
QTc 431 ms
TPC
Do not discontinue
Case 03 · Richard · History
Heart disease and a benzo taper
Medical and surgical history
- Coronary artery disease, s/p CABG
- Ischemic cardiomyopathy, EF 45–55%
- Dual-chamber ICD, about 7 years
- Paroxysmal atrial fibrillation
- Hypertension
- Chronic kidney disease, stage 3a
- Anxiety and depression
- Quit drinking about 7 years ago
Home medications
Psychiatric
- Alprazolam 1 mg TID
- Chlordiazepoxide 25 mg BID
- Paroxetine 30 mg
- Eszopiclone 2 mg nightly
- Lamotrigine 25 mg daily
- Atomoxetine 100 mg daily
Cardiac and other
- Amiodarone 200 mg daily
- Apixaban 5 mg BID
- Carvedilol 6.25 mg BID
- Sacubitril-valsartan 24/26 mg BID
- Atorvastatin 40 mg daily
- Tamsulosin 0.4 mg daily
- Tadalafil 20 mg daily
TPC
Do not discontinue
Case 03 · Richard · Hospital day 1
The admission med rec
Ischemic cardiomyopathy, EF 45–55%, with an ICD. Paroxysmal AF on amiodarone.
His psychiatrist is using chlordiazepoxide to taper him off alprazolam.
Still shaking and yelling. Staff say he's always difficult. By his own description, he is.
Home medication
Admission order
Alprazolam 1 mg TID
Continued
Chlordiazepoxide 25 mg BID
Bedtime only
Paroxetine 30 mg
Continued
Eszopiclone 2 mg at bedtime
Not ordered
Lamotrigine 25 mg
Not ordered
Atomoxetine 100 mg
Not ordered
TPC
Do not discontinue
Case 03 · Richard · Hospital day 2
Barely sedated, and worse overnight
TEE today with midazolam 9 mg, fentanyl 100 mcg and diphenhydramine 50 mg. He was still barely sedated.
His sister tells the team
He stopped two of his psychiatric medications cold turkey two weeks ago.
He was screaming at people at a family funeral last weekend.
This is worse than his baseline.
Overnight
Peak HR
119
Peak BP
159/105
Peak RR
27
TPC
Do not discontinue
Case 03 · Richard · Question
What's the best next step?
A
Give haloperidol for agitation
B
Restore his home chlordiazepoxide dose and call his outpatient psychiatrist
C
Reassure him: he's upset about his care and has always been difficult
D
Stop the alprazolam, since two benzodiazepines is a duplication
TPC
Do not discontinue
Case 03 · Richard · Answer
B. Restore the taper and call
B
Restore his home chlordiazepoxide dose and call his outpatient psychiatrist
•
Bedtime-only was a partial stop of his taper
•
HR 119, BP 159/105, RR 27 overnight
•
Barely sedated by 9 mg of midazolam
•
His psychiatrist knows the plan, and what he stopped
Then assess his safety.
Why not the others
A · Haloperidol
Treats the noise, not the cause, and adds QT risk on top of amiodarone.
C · Reassure him
A difficult patient getting worse is still a change.
D · Stop the alprazolam
Two benzodiazepines can be a taper. Stopping one would be a second cut.
TPC
Do not discontinue
Case 03 · Richard · Teaching point
What he stopped on his own
Lamotrigine 25 mg
Mood stabilizer
If stopped
Mood can destabilize. The label advises a taper over about 2 weeks.
To restart
Off about 5 days? Start over at 25 mg and retitrate. Rash risk, including SJS.
Atomoxetine 100 mg
ADHD, a norepinephrine reuptake inhibitor
If stopped
No true withdrawal, but irritability and impulsivity can return.
To restart
Decide with the prescriber. It raises heart rate and blood pressure.
Self-discontinuation counts. Ask what they've stopped, and why.
TPC
Do not discontinue
Case 03 · Richard · Question
Discharge day: what matters most?
He's going home alone on four weeks of IV antibiotics. His sister asked him to stay with her; he declined. His day 1 triage suicide screen was negative.
A
Re-screen suicide risk: family history, anniversaries, who's at home
B
Confirm home infusion and PICC teaching
C
Restart his atomoxetine before he leaves
D
Psychiatry follow-up within a month
TPC
Do not discontinue
Case 03 · Richard · Answer
A. Re-screen before he goes
Day 1 triage suicide screen: negative. What it missed:
- A family history of suicide, with an anniversary approaching
- Serious medical illness
- Living alone
- Psychiatric medications he stopped on his own
- Weeks of agitation
The takeaway
Ask the people he trusts.
He told his psychiatrist he didn't see a reason to keep living. Patients often tell the person they trust, not the admitting team.
TPC
Do not discontinue
Takeaways
Clean rules, admission to discharge
01
On admission
•
NPO isn't no psych meds.
•
Call the prescriber on day 1.
•
Ask what they've stopped.
•
Listen to family.
•
Confused on lithium? Level first.
02
During the stay
•
Diet resumes? Revisit held meds.
•
Two benzos may be a taper.
•
A dose cut is a partial stop.
•
Worse is still a change.
•
Check the MAR before the PRN.
•
Read the PT and med rec notes.
03
Before discharge
•
Lithium level and Cr in 5–7 days.
•
Shrinking kidneys? Nephrology.
•
On lithium? TSH and calcium too.
•
Re-screen suicide risk.
One more rule: ask what they'd like to be called, and put it in the chart.
You may not know what the other name carries.
TPC
Do not discontinue
TPC
Questions
Sarah Graff, MD · The Psychiatric Center
(478) 745-9206 · 2064 Vineville Avenue, Macon, GA 31204 · tpcmacon.com
Backup · If clozapine comes up
Clozapine in the hospital
01
Off more than 48 hours? Retitrate.
Restart at 12.5 mg and build back up. The old dose risks hypotension, syncope and seizures.
02
Fever? Check an ANC.
Early in treatment, think about myocarditis too.
03
Quitting smoking raises levels.
A hospital smoking ban counts. Nicotine replacement doesn't prevent the rise. Call psychiatry.
04
Ciprofloxacin raises levels.
Choose another antibiotic when you can, or call psychiatry to adjust.
Every held psychiatric medication needs a restart plan on the discharge list.
TPC
Backup slide
Backup · Discontinuation risk by drug
Which antidepressants cause it most?
Higher risk
Short half-lives; paroxetine is also anticholinergic
- Paroxetine
- Venlafaxine
- Desvenlafaxine
- Duloxetine
- Fluvoxamine
- TCAs and MAOIs
Moderate risk
Usually milder, but still common
- Sertraline
- Citalopram
- Escitalopram
- Mirtazapine
Lower risk
Long half-life, or a different mechanism
- Fluoxetine, which tapers itself
- Vortioxetine
- Bupropion
Risk goes up with a short half-life, a higher dose, longer use, an abrupt stop, and past discontinuation symptoms.
TPC
Do not discontinue
Case 02 · Dorothy · Hospital days 3–5
Ready for discharge
Lithium and clozapine held on admission; diazepam resumed. IV fluids.
By day 3: lithium 0.9, creatinine 1.0, QTc 452.
Day 3, after a call with her psychiatrist: lithium restarted at 300 mg twice daily. Her home dose was 750 mg nightly.
No lithium level since the restart. Clozapine is still held.
Vitals
HR
62
BP
144/79
SpO2
97% RA
Labs
Creatinine
1.05
Na
142
Mg
1.8
TPC
Do not discontinue
Case 01 · Kathy · History
Stable for years on venlafaxine
Medical and surgical history
- Major depressive disorder
- Generalized anxiety disorder
- Hypertension
- Two prior episodes of biliary colic
- Prior cesarean section
Home medications
Psychiatric
- Venlafaxine XR 225 mg daily
Medical
- Lisinopril 10 mg daily
TPC
Do not discontinue