Extreme heat can be dangerous for people taking psychiatric medication

June 29, 2018 8:36 AM

Here's a surprising extreme heat risk for 1 in 6 Americans Psychiatric medications can interfere with the body's ability to regulate temperature, and most patients don't know, experts say.

From the Psychiatric Times:

Anticholinergic medications can interfere with thermoregulation by inhibiting parasympathetic pathways. This results in an inhibition of sweating and leads to decreased ability to eliminate heat. The antidopaminergic activity of an antipsychotic can increase the set point of the body’s temperature regulation. Antipsychotics may also reduce behaviors that regulate temperature, such as increasing water intake or removing extra clothing.2

>Phenothiazines, such as chlorpromazine, thioridazine, fluphenazine, and perphenazine, have anticholinergic and central thermo-regulatory effects. Phenothiazines inhibit afferent neuronal input to the hypothalamus, which decreases the hypothalamus’s compensatory response of increasing cutaneous blood flow to assist in heat dissipation. Other commonly used psychiatric medications that have been shown to disturb thermoregulation include atypical antipsychotics, serotonergic agonists, and β-blockers.3 Some psychiatric medications may increase the risk of dehydration by reducing thirst. Such medications include SSRIs, clonidine, carbamazepine, and valproic acid.

posted by MrVisible (30 comments total)

The one time I did Pride, I almost passed out, and I knew a big part of this was how dehydrating my ADD meds have always been for me, and discovering that the beta blockers I take to regulate the heart palpitations I get from the ADD meds (and the crowds) probably made it worse is so unsurprising. And I've explained to my psychiatrist that like, how well I tolerate the Adderall is a lot down to stuff like "dry mouth" and "obnoxious sweating", but hadn't really realized the other part was temperature-related. Still 100% in favor of meds, but I really do appreciate having more info to better plan this stuff.
posted by Sequence at 8:42 AM on June 29, 2018 [6 favorites]

I am literally getting my PhD in extreme heat as a hazard and I had never seen actual conclusive knowledge on this. I am taking this to my colleagues. Thank you!
posted by WidgetAlley at 8:48 AM on June 29, 2018 [37 favorites]

I was constantly too warm on Cymbalta. I never had those types of extreme-heat reactions, even in 100-degree temps, but I could easily go out for short walks on snowy days in a t-shirt and light jacket and be fine. I hadn't realized how much it had really shifted my internal thermometer until I went off it and stopped my continual internal monologue about how overheated every single indoor space is.
posted by lazuli at 8:55 AM on June 29, 2018 [8 favorites]

Hats in the sun fellow medicine-takers. Hats hats hats.
posted by griphus at 8:56 AM on June 29, 2018 [18 favorites]

Oh, good to know. I'm on the generic version of Lexapro for anxiety and it's gonna be a scorcher up here in Eastern Ontario. I didn't know my meds could make me feel worse in the heat! Thanks!
posted by Kitteh at 8:57 AM on June 29, 2018 [4 favorites]

So yeah, I've always known how dehydrating some of the meds were - but I never put two and two together as far as temperature regulation goes... Much to the happiness of my wife, in anything over 50 degrees, I am basically a space heater, and I've been that way for some time. The bad side of this is that summer can be a miserable time for me - I had to move from KY because I literally had to spend the majority of summer indoors in A/C, the heat and humidity would make me sweat out to the point that i'd saturate my clothes, and I would literally get stupid from the heat. I didn't remember being this way as a kid, and I chalked it up to the fact that I was severely underweight back then, and that the summers had actually become tangibly worse over time.

The thing I could never figure out is that winter was equally miserable for me.... My normally warm body would get cold and just stay cold to the point that I accepted that I basically would have numb feet for three months out of the year. This didn't make sense to me, since I felt like I generally "ran warm" - but if the bodies temperature regulation is just "off" then this starts to make more sense.

This has been going on long enough that I thought it was just what my bodies baseline had become. While the cold is annoying, the heat is actively disruptive to the point that I cannot think or talk straight in it. I had never once considered it could be the meds.

I'm not going to stop taking them, as my life has been drastically improved since I've been on them and the periods of time I've tried off of them have not gone well at all, but it's really interesting to know that this could be what's behind a lot of my inability to be comfortable in anything outside of mild temperatures.
posted by MysticMCJ at 9:01 AM on June 29, 2018 [6 favorites]

I have a condition that, among other things, makes it difficult for me to regulate temperature, and I take a medication for that condition that also makes it difficult for me to regulate temperature, and tells me to avoid direct sun exposure. I don't think anyone ever told me this, I just happened to read the medication packet closely enough to figure this out. I accepted a long time ago that I'm basically a vampire. Luckily my partner is also literally allergic to the sun (they get severe sun rashes) so at least our lifestyles don't crash in regards to spending the entire summer holed up indoors.

Another thing about anticholinergic medications: they can make it difficult to focus your vision. So, if you ever up your dosage of an anticholinergic medication (or add another anticholinergic medication) and start getting double vision, that might be why. Ask me how I know and how much money I spent to be told that...
posted by brook horse at 9:12 AM on June 29, 2018 [5 favorites]

Huh. Thanks. I know someone on a significant amount of psychotropic medication who is almost never happy with the temperature. She'll be interested to read these links, I'm sure.

(She actually was warned about latuda specifically for this, but not earlier ones.)
posted by mordax at 9:14 AM on June 29, 2018 [1 favorite]

One of the things that makes me think a stranger is mentally ill besides overt things like screaming at hallucinations is the wearing of much more clothing than the temperature requires. Heavy coats in 85 degree weather.

It would be nice if it were as exciting to develop ways of helping people with mental illness as it seems to be figuring out how to kill people remotely with drones and such.
posted by Pembquist at 10:15 AM on June 29, 2018 [1 favorite]

I'm overweight and on SSRIs and have always had problems in the heat. Last year, I lost a bunch of weight through calorie restriction. I thought I'd be cold in the winter and normal in the summer with the weight loss, but it turns out that losing weight let my body regulate my temperature much, much better, and I was more comfortable all the time.
posted by infinitewindow at 10:44 AM on June 29, 2018 [2 favorites]

Hopefully someone who understands the science better can clarify this for me, but it seems like the Psychiatric Times article is saying it's mainly antipsychotics that can increase the effects of extreme heat? And then the NBC News article jumps from "antipsychotics are a risk" to "psych meds in general are a risk" to "1 in 6 Americans may be at risk!"

(At the same time, lots of people get prescribed antipsychotics off-label when they're not actually psychotic, so it may still be more people than one would expect).

I'm on meds and my city's on track to get a massive heat wave this weekend (with no air conditioning!) so it's good to know, but I think I worked myself up unnecessarily with worries after just reading the NBC News article.
posted by Jeanne at 10:44 AM on June 29, 2018 [3 favorites]

I'm really curious about the link between mental health and thermoregulation. Is it only schizophrenia that can lead to problems with thermoregulation? From the article it sounds like the exact link is unclear.

What other factors can contribute? I'm curious in part because I get unbearably hot very quickly (I went to the gym once in Michigan and got so hot I stripped down to my T shirt to walk home, at night in -7 degree weather), and I start feeling ill if the temperature rises above like 75 F. For all I know there's a whole host of factors that can contribute to issues with thermoregulation, so I don't mean to start a major derail. I'm just curious because I've never heard of a link between mental illness and body temperature, so I'm fascinated to learn more about how the body regulates heat.
posted by shapes that haunt the dusk at 11:19 AM on June 29, 2018 [1 favorite]

I wonder how much of this is related to the photosensitivity that can be a side-effect of psych meds. Heat itself doesn't bother me too much, but being in the sun for more than a minute or two kills me, especially now that I no longer live at sea level - the sun is evil at higher elevations.
posted by elsietheeel at 11:31 AM on June 29, 2018 [2 favorites]

One of the things that makes me think a stranger is mentally ill besides overt things like screaming at hallucinations is the wearing of much more clothing than the temperature requires. Heavy coats in 85 degree weather.

Sometimes that can be due to paranoia, too, not just thermo-regulation issues. Or general homelessness requiring creative ways of carrying one's entire wardrobe.
posted by lazuli at 11:33 AM on June 29, 2018 [2 favorites]

Wow, this would explain a WHOLE lot about my life. Everyone I know makes fun of my weird temperature regulation problems, which get worse after I get a ketamine infusion for reasons nobody can explain. It is not fun to have a fever once every two to three weeks, anecdotally.
posted by colorblock sock at 11:40 AM on June 29, 2018 [6 favorites]

tl:dr I think that antipsychotics are a red herring. Psych meds are a red herring. Thermoregulation is a problem for a lot of meds that are more widely prescribed. The NBC piece is bad journalism, even if it means well. Most important info is buried in the last paragraph of it.

The Psych Times article is a targeted piece for professionals from 4 years ago. Not that it isn't interesting or relevent, but it isn't meant for a wider audience. I read it as "Here, look at these interesting numbers and cases, people who have science and experience enough not to panic."

The NBC piece is badly framed and presented. It is good to warn people, but they are doing it wrong. Psych meds are not the only anticholinergics, nor are they the only meds that cause problems in heat regulation. I mean, they just tack on a small bit at the end that maybe it is not only crazy people who need to be aware that medications can cause heat problems. Antipsychotics, original-style or atypical, are so much less commonly used than SSRIs, antihistamines, beta-blockers, and pretty much any other class of medication that might be a problem.

As one of the mentally ill, I resent the hell out of this shitty sensationalistic journalism. By all means, single out the poor sad crazies but don't mention the brave but normal Cardiac-Americans or Allergy Afflicted.

Hell, the med that has given me the worst heat issues is the one I take for lowering blood pressure. Now I feel cold right up until the moment that I overheat.
posted by monopas at 11:43 AM on June 29, 2018 [5 favorites]

I’ve dealt with this before on certain meds, and just generally ‘run hot.’ When I found this, I had written it off as vaporware, but Embr labs developed a wrist mounted cooling unit that looks real dumb but I’ve tried it and it actually works and they released it a little while ago. I’m not quite at the point where I’d need one, but there were work environments iced had in the past, and might in the future that would necessitate one of these. They’re really interesting.
posted by furnace.heart at 11:46 AM on June 29, 2018

I’m on meds for a couple of chronic illnesses that do this, in addition to having SLE, which has nasty flares triggered by sunlight. I live in Florida. I get lots of speculative looks when I go out fully covered in 98 degree heat plus humidity. The gloves really push it over the edge (thanks, Shingles!). I had no idea so many people faced this challenge.
posted by Nancy_LockIsLit_Palmer at 12:25 PM on June 29, 2018 [2 favorites]

I definitely didn't get the "poor sad crazies" vibe out of this, more like "hey look lots of people are on these and you probably haven't heard about it" and they were right, I hadn't. A bit overblown, but I'm pretty sure they were in fact making a point of things like SSRIs being a problem. The very first person mentioned is on Cymbalta, not an antipsychotic. They also mention beta blockers and amphetamines, and even the antihistamines. The NBC article doesn't even mention antipsychotics or anticholinergics, which I think is probably kind of underreporting the issue, particularly if it really does turn out that antipsychotics represent a unique danger, even if it's just because the people on them are more likely to be unable to recognize or act on the need to do something about overheating.

My actual worst daily problem with all of this is that the Adderall makes me too warm but it makes my circulation worse so that the rest of me is too hot but my hands and feet are freezing.
posted by Sequence at 12:37 PM on June 29, 2018 [3 favorites]

In the NBC article, I find it spectacularly offensive that the Sympathetic Human is someone who is taking an SNRI for fibromyalgia and implies that it is only because of taking the psychiatric medication for her physical illness that the Sympathetic Human has heat problems that turn her into a tragic outcast that must stay locked away. FFS. Middle-age, overweight, and fibromylagia, but the real and only culprit is the medication. Right.

From the article:

Studies have shown that those with mental illness are at higher risk during heat waves. A study of the 2012 Wisconsin heat wave that killed 27 people found that more than half of those deaths had mental illness, and half of those were taking psychiatric medication

The line more than half of those deaths had mental illness is painful to read, whether one is offended by dehumanization or bad phrasing.

Misleading statistics BS too. Use of the word "Studies" to imply a vast amount of available information when only one is mentioned or cited. If you don't go look at the cited abstract, you might think that the study showed anything out of the ordinary. It doesn't. 70% of the 27 people were over 65, 75% had cardiovascular disease, and only 7 were taking what is described as a psychiatric drug. None of them were in air conditioned spaces.

This is the kind of Totally Scientitious! misinformation article that causes people to draw stupid conclusions and share them on social media. I would not be surprised to see panic about it on other websites in the near future.
posted by monopas at 12:59 PM on June 29, 2018

Here's some more information.

This thoughtful blog post sums up the issue pretty well, and references a number of studies.

Here's the list of medications which, according to American Family Physician, can contribute to heat-related illness:

Alcohol
Alpha-adrenergic agonists
Amphetamines·
Anticholinergics
Antihistamines
Benzodiazepines
Beta blockers
Calcium channel blockers
Cocaine
Diuretics
Ephedra-containing supplements
Laxatives
Neuroleptics
Phenothiazines
Stimulants
Thyroid receptor agonists
Tricyclic antidepressants

Here's the Mayo Clinic on medications that make people more prone to heat stroke:

Certain medications. Some medications affect your body's ability to stay hydrated and respond to heat. Be especially careful in hot weather if you take medications that narrow your blood vessels (vasoconstrictors), regulate your blood pressure by blocking adrenaline (beta blockers), rid your body of sodium and water (diuretics), or reduce psychiatric symptoms (antidepressants or antipsychotics).

Wikipedia:

Many psychotropic medications, such as selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), and tricyclic antidepressants, can cause hyperthermia.[8] Serotonin syndrome is a rare adverse reaction to overdose of these medications or the use of several simultaneously. Similarly, neuroleptic malignant syndrome is an uncommon reaction to neuroleptic agents.[11] These syndromes are differentiated by other associated symptoms, such as tremor in serotonin syndrome and "lead-pipe" muscle rigidity in neuroleptic malignant syndrome.[8]

...

The use of anticholinergics, more specifically muscarinic antagonists are thought to cause mild hyperthermic episodes due to its parasympatholytic effects. The sympathetic nervous system a.k.a. the "Fight or Flight Response" dominates by raising catecholamine levels by the blocked action of the Rest and Digest System.[14]

From Consumer Reports:

Meds That Might Increase Sun Sensitivity

Acne and aging skin treatments: Products containing salicylic acid (Clearasil Pore Cleansing Pads) and tretinoin (Retin-A, Renova)

Antibiotics: Fluoroquinolone antibiotics such as ciprofloxacin (Cipro); sulfa antibiotics such as sulfadiazine; tetracycline antibiotics such as doxycycline (Doryx)

Antidepressants: Tricyclic antidepressants such as amitriptyline (Elavil) doxepin (Sinequan), and nortriptyline (Pamelor)

High blood pressure drugs: ACE inhibitors such as benazepril (Lotensin) and captopril (Capoten); angiotensin II receptor antagonists such as valsartan (Diovan) and thiazide diuretics such as chlorothiazide (Diuril) and hydrochlorothiazide (HydroDiuril)

Pain medications: Ibuprofen (Advil, Motrin) and naproxen (Aleve, Naprosyn); topical pain relievers such as diclofenac (Voltaren gel, Pennsaid)

Meds That Might Increase Heat Sensitivity

Antidepressants: Tricyclic antidepressants such as amitriptyline (Elavil) doxepin (Sinequan), and nortriptyline (Pamelor)

Antihistamines: Diphenhydramine (Benadryl Allergy)

Antipsychotic drugs: Atypical antipsychotics such as olanzapine (Zyprexa) and risperidone (Risperdal), and conventional antipsychotics such as thioridazine

High-blood-pressure drugs: Thiazide diuretics such as chlorothiazide (Diuril) and hydrochlorothiazide (HydroDiuril)

Overactive-bladder treatments: Anticholinergics such as oxybutynin (Oxytrol) and solifenacin (Vesicare)

And the CDC:

"...taking certain medications (e.g., anti-psychotics, tranquilizers, antidepressants, and over-the-counter sleeping pills) that impair the body’s ability to regulate its temperature or that inhibit perspiration."

The CDC again:

Other risk factors are alcohol consumption, which may cause dehydration, previous heatstroke, physical exertion in exceptionally hot environments, the use of medications that interfere with the body's heat regulatory system, such as neuroleptics (e.g., antipsychotics and major tranquilizers), and medications with anticholinergic effects (e.g., tricyclic antidepressants, antihistamines, some antiparkinsonian agents, and some over-the-counter sleep medication [2--4]).

posted by MrVisible at 1:46 PM on June 29, 2018 [8 favorites]

Sequence, you have a good point. Lots of good points. I am choosing to read and respond to the NBC article in a particularly bombastic tone because I find it dreadful (including definitions 1a, 2, and 3). I am angry about the targeting of psych meds and under-mentioning of other meds. I'm afraid that people might make bad choices because of it. Also, I was writing my previous comment as you were writing yours, I did not mean it as some kind of passive-aggressive response to you.

My writing process these days is not as linear as I would like, and the part about antipsychotics at the end of the paragraph on the NBC article should be in a different place. It was meant more as a response to the post as a whole. Though NBC should have mentioned anticholinergic, as it is the context of the warning they are seemingly trying to give.

I might just be overly touchy on the subject of medication, especially psych meds, and mental vs. physical illness treatment and depiction. Just a bit. Tiny bit.
posted by monopas at 1:53 PM on June 29, 2018 [2 favorites]

I concur about cymbalta. It's a miracle drug for me in nearly every way, but I never used to noticeably sweat unless it was above 90 degrees outside, now sweat pours from me at like 72. It makes my rosacea worse and my photo-sensitivity worse too. Sunscreen helps, water helps, a hat helps, but nothing helps like just staying cool.
posted by I'm Not Even Supposed To Be Here Today! at 2:02 PM on June 29, 2018 [2 favorites]

Psych meds are not the only anticholinergics

You're definitely right about this part - not even close to the only ones (and also this isn't the only side effect of anticholinergics one should be alert to). There may be some legitimacy to giving antipsychotics special mention, though, because they can affect more than one pathway related to thermoregulation, and because of neuroleptic malignant syndrome.
posted by atoxyl at 3:28 PM on June 29, 2018 [1 favorite]

I understand the concerns of stigma and singling out, but I have told multiple people about my extreme heat reaction to SNRIs and many have been like "oh crap, I didn't even consider, I just thought something was wrong with me." Some doctors tell too few side effects because they want to get people treatment, but that sometimes leaves patients in the dark.
posted by I'm Not Even Supposed To Be Here Today! at 5:20 PM on June 29, 2018 [4 favorites]

I concur about cymbalta. It's a miracle drug for me in nearly every way, but I never used to noticeably sweat unless it was above 90 degrees outside, now sweat pours from me at like 72.

I stopped taking Sertraline for this reason. I'm lucky I mostly don't need it right now because it absolutely sucked. Today I visited a greenhouse where I used to work and remarked that it didn't seem nearly as hot and humid. "Nope, all the set points are the same as they used to be!" said my former colleague when I mentioned it. Every so often I wonder if I should go back on it, but the pouring sweat at 70 degrees is a huge deterrent.
posted by oneirodynia at 6:43 PM on June 29, 2018 [1 favorite]

Looking at the top of that list...

The only two times I've been blackout drunk were when it was really hot. In neither case, well, maybe once, had I drunk an unusually large amount. Very interesting. I'm not on psych meds, but I do have temperature regulation issues.
posted by Windopaene at 7:53 PM on June 29, 2018 [1 favorite]

Well.

This fucking explains a lot.
posted by nogoodverybad at 9:44 PM on June 29, 2018 [3 favorites]

I'm going to be posting this on Facebook and forwarding it to some people. No, I can't go to the farmer's market with you. No, I can't sit on your patio. No, I can't go to lunch. Even if you pick me up in your car. I cannot go outside when the dew point is over 70.

I have one small window air conditioner, which lives in my bedroom. Yesterday the heat index outside was 105. Inside my bedroom it was 80 with 50% humidity (tolerable) but in the living room it was 89 degrees and I could not breathe. Save brief trips to the kitchen and bathroom, I've been in the bedroom for 48 hours. I don't know what I'm going to do this summer if it continues like this. I don't work so I have no refuge.
posted by AFABulous at 7:17 AM on July 1, 2018 [3 favorites]

There are also a number of illnesses such as MS, where heat is debilitating. There are cooling vests that help with this. I just googled "cooling vest" and the first result was a list of vest recommended for MS sufferers.

There are also less expensive cooling vests sold for motorcyclists. I have one that you soak in ice water for 15 minutes, wring gently and then put on. It feels slightly damp but doesn't drip very much, and it provides evaporative cooling for a couple of hours - it actually works pretty well! I have also been known to put ice in my pockets.

Just mentioning this as a possible remedy that will help people function while taking a necessary med.
posted by elizilla at 10:34 AM on July 2, 2018 [1 favorite]