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 M POCKET GUIDE to
ost psychotropic medications, when pre-
scribed appropriately, are reasonably safe.
Although some side effects are common

POCKET GUIDE to Emergent and Serious Adverse Events in PSYCHOPHARMACOLOGY

and even expected, occasional serious—and even
life-threatening—adverse events may arise. Emergent and Serious
This pocket guide addresses these serious condi-
tions. Designed to be easily referenced, it features
Adverse Events in
alphabetically arranged chapters that summarize
current knowledge of adverse events from acute
dystonia and cardiac emergencies to hepatotoxicity
PSYCHOPHARMACOLOGY
and ocular side effects.

Readers will come away with a better understanding

of the recognition and detection of adverse events in
psychopharmacology, culprit medications, assess-
ment, management, and follow-up treatment—and
be better positioned to communicate with patients
and improve patient care.

About the Editors

Richard Balon, M.D., is Professor of Psychiatry and
Anesthesiology; Associate Chair for Education and Fac-
ulty Affairs; and Program Director in the Department of
Psychiatry and Behavioral Neurosciences at Wayne State
University School of Medicine in Detroit, Michigan.
Mary K. Morreale, M.D., is Professor in the Department
of Psychiatry and Behavioral Neurosciences at Wayne
State University School of Medicine in Detroit, Michigan,
and affliated with Karmanos Cancer Center.
Balon | Morreale

Edited by
Richard Balon, M.D.
WWW.APPI.ORG
Mary K. Morreale, M.D.
Cover design: Rick A. Prather
Cover image: © Drazen Zigic
Used under license from Shutterstock

Balon_coverFinal.indd 1 2/1/2023 3:38:23 PM

 POCKET GUIDE TO
EMERGENT AND SERIOUS
ADVERSE EVENTS IN
PSYCHOPHARMACOLOGY
 POCKET GUIDE TO
EMERGENT AND SERIOUS
ADVERSE EVENTS IN
PSYCHOPHARMACOLOGY

Edited by

Richard Balon, M.D.

Mary K. Morreale, M.D.
Note: The authors have worked to ensure that all information
in this book is accurate at the time of publication and consistent
with general psychiatric and medical standards and that
information concerning drug dosages, schedules, and routes
of administration is accurate at the time of publication and
consistent with standards set by the U.S. Food and Drug
Administration and the general medical community. As
medical research and practice continue to advance, however,
therapeutic standards may change. Moreover, specific
situations may require a specific therapeutic response not
included in this book. For these reasons and because human
and mechanical errors sometimes occur, we recommend that
readers follow the advice of physicians directly involved in
their care or the care of a member of their family.
Books published by American Psychiatric Association
Publishing represent the findings, conclusions, and views of
the individual authors and do not necessarily represent the
policies and opinions of American Psychiatric Association
Publishing or the American Psychiatric Association.
If you wish to buy 50 or more copies of the same title, please
go to www.appi.org/specialdiscounts for more information.
Copyright © 2023 American Psychiatric Association Publishing
ALL RIGHTS RESERVED
First Edition
Manufactured in the United States of America on acid-free
paper
27 26 25 24 23 5 4 3 2 1
ISBN 978-1-61537-453-3 (paperback), 978-1-61537-454-0
(ebook)
American Psychiatric Association Publishing
800 Maine Avenue SW, Suite 900
Washington, DC 20024-2812
www.appi.org
Library of Congress Cataloging-in-Publication Data
A CIP record is available from the Library of Congress.
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
 Contents

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . ix
Introduction . . . . . . . . . . . . . . . . . . . . . . . . xv

1 Acute Dystonia . . . . . . . . . . . . . . . . . . . . . 1
Bhargav Patel, M.D.
Urja Shah, M.A.
Nagy A. Youssef, M.D., Ph.D.

2 Agitation . . . . . . . . . . . . . . . . . . . . . . . . . 11
Jeffrey J. Rakofsky, M.D.

3 Agranulocytosis With Clozapine and

Other Psychotropic Medications . . . . . . 21
Obiora Onwuameze, M.D., Ph.D.
Eric Black, M.D.

4 Benzodiazepines in Combination With

Opioids: Therapeutic Benefit Versus
Fatal Overdose . . . . . . . . . . . . . . . . . . . . 29
Edward Silberman, M.D.

5 Cardiac Emergencies Such as

Arrhythmias, QTc Prolongation, and
Cardiomyopathy . . . . . . . . . . . . . . . . . . . 39
Margo C. Funk, M.D., M.A.
Junyang Lou, M.D., Ph.D.

6 Discontinuation of
Psychotropic Medications . . . . . . . . . . . 51
Vladan Starcevic, M.D., Ph.D., FRANZCP
7 Hepatotoxicity of
Psychotropic Medications . . . . . . . . . . . 63
Ashika Bains, M.D.

8 Hypertensive Crisis Associated With

Monoamine Oxidase Inhibitors . . . . . . . . 75
Mary K. Morreale, M.D.

9 Hyponatremia, Especially in
Older Adults . . . . . . . . . . . . . . . . . . . . . . 81
Art Walaszek, M.D.

10 Neuroleptic Malignant Syndrome . . . . . . 91

Michael Maksimowski, M.D.

11 Ocular Side Effects of

Psychotropic Medications . . . . . . . . . . . 99
Haoxing Chen, M.D.
Richard Balon, M.D.

12 Overdoses of Psychotropic Medications

ANTIDEPRESSANTS, LITHIUM, AND
ANTIPSYCHOTICS . . . . . . . . . . . . . . . . . . . . 111
Spencer Greene, M.D., M.S., FACEP, FACMT,
FAACT, FAAEM

13 Polypharmacy and
Acute Side Effects . . . . . . . . . . . . . . . . 125
Sweta Bhoopatiraju, B.S.
Marissa Hirsch, M.D.
Harjinderpal Singh, B.S., B.Ed.
George Grossberg, M.D.
14 Pregnancy and Use of
Psychotropic Medication . . . . . . . . . . . 135
Katherine Taljan, M.D.
Adele C. Viguera, M.D., M.P.H.

15 Seizure Risk Management . . . . . . . . . . 147

Nicholas A. Mischel, M.D., Ph.D.

16 Serotonin Syndrome . . . . . . . . . . . . . . . 157

Memphis Diaz Garcia, M.D.
Rashi Aggarwal, M.D.

17 Substances With Addictive Potential

and Psychotropic Medications . . . . . . . 167
Peter J. Na, M.D., M.P.H.
Sanya Virani, M.D., M.P.H.
Oluwole Jegede, M.D., M.P.H.
Adrienne Hicks, M.D., Ph.D.
Sivabalaji Kaliamurthy, M.D.
Aaron Wolfgang, M.D.
Ellen L. Edens, M.D.

18 Tardive Dyskinesia . . . . . . . . . . . . . . . . 181

Michael D. Jibson, M.D., Ph.D.

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
 Contributors

Rashi Aggarwal, M.D.

Vice-Chair and Residency Program Director; and Professor,
Department of Psychiatry, Rutgers New Jersey Medical
School, Newark, New Jersey

Ashika Bains, M.D.

Physician, Department of Psychiatry, Massachusetts General
Hospital; and Instructor, Department of Psychiatry, Harvard
Medical School, Boston, Massachusetts

Richard Balon, M.D.

Professor of Psychiatry and Anesthesiology; Associate Chair
for Education and Faculty Affairs; and Program Director, De-
partment of Psychiatry and Behavioral Neurosciences, Wayne
State University School of Medicine, Detroit, Michigan

Sweta Bhoopatiraju, B.S.

Student, Department of Psychiatry and Behavioral Neurosci-
ence, Saint Louis University School of Medicine, St. Louis,
Missouri

Eric Black, M.D.

Assistant Professor, Department of Psychiatry, Southern Illi-
nois University School of Medicine, Springfield, Illinois

Haoxing Chen, M.D.

Glaucoma Fellow, Kresge Eye Institute and Department of
Ophthalmology, Visual and Anatomical Sciences, Wayne
State University, Detroit, Michigan

Ellen L. Edens, M.D.

Associate Professor of Psychiatry, Yale School of Medicine,
New Haven, Connecticut; and Substance Use Disorder Lead,
National Telemental Health Center, VA Connecticut Health-
care System, West Haven, Connecticut

Margo C. Funk, M.D., M.A.

Vice Chair for Education, Director of Residency Education,
and Director of Cardiovascular Psychiatry, Department of

ix
Psychiatry, Brigham and Women’s Hospital; Assistant Pro-
fessor of Psychiatry, Department of Psychiatry, Harvard
Medical School, Boston, Massachusetts

Memphis Diaz Garcia, M.D.

Resident, Department of Psychiatry, Rutgers New Jersey
Medical School, Newark, New Jersey

Spencer Greene, M.D., M.S., FACEP, FACMT, FAACT,

FAAEM
Director of Toxicology, Department of Emergency Medicine,
HCA Houston Healthcare Kingwood; and Clinical Professor,
University of Houston College of Medicine, Houston, Texas

George Grossberg, M.D.

Samuel W. Fordyce Professor, Department of Psychiatry and
Behavioral Neuroscience, Saint Louis University School of
Medicine, St. Louis, Missouri

Adrienne Hicks, M.D., Ph.D.

Assistant Professor of Clinical Psychiatry, Yale School of
Medicine, New Haven, Connecticut; and Addiction Psychia-
trist, VA Connecticut Healthcare System, West Haven, Con-
necticut

Marissa Hirsch, M.D.

Resident Psychiatrist, Department of Psychiatry and Behav-
ioral Neuroscience, Saint Louis University School of Medi-
cine, St. Louis, Missouri

Oluwole Jegede, M.D., M.P.H.

Assistant Professor of Psychiatry, Yale School of Medicine,
New Haven, Connecticut; and Addiction Psychiatrist, Con-
necticut Mental Health Center, New Haven, Connecticut

Michael D. Jibson, M.D., Ph.D.

Professor of Psychiatry, University of Michigan, Ann Arbor,
Michigan

Sivabalaji Kaliamurthy, M.D.

Attending Physician, Division of Psychiatry and Behavioral
Sciences, Children’s National Hospital, Washington, D.C.;
Assistant Professor of Psychiatry, Howard University Col-

x Pocket Guide to Adverse Events in Psychopharmacology

lege of Medicine, Washington, D.C.; and Instructor of Psychi-
atry, Yale School of Medicine, New Haven, Connecticut

Junyang Lou, M.D., Ph.D.

Interventional Cardiologist, Division of Cardiovascular
Medicine, Brigham and Women’s Hospital; Instructor of
Medicine, Department of Medicine, Harvard Medical School,
Boston, Massachusetts

Michael Maksimowski, M.D.

Assistant Clinical Professor, Department of Psychiatry,
Wayne State University; and Staff Psychiatrist, John D. Ding-
ell Veterans Affairs Medical Center, Detroit, Michigan

Nicholas A. Mischel, M.D., Ph.D.

Assistant Professor, Department of Psychiatry and Behavior-
al Neurosciences, Wayne State University School of Medi-
cine, Detroit, Michigan

Mary K. Morreale, M.D.

Professor, Department of Psychiatry, Wayne State University,
Detroit, Michigan

Peter J. Na, M.D., M.P.H.

Assistant Professor of Psychiatry, Yale School of Medicine,
New Haven, Connecticut; and Addiction Psychiatrist, VA
Connecticut Healthcare System, West Haven, Connecticut

Obiora Onwuameze, M.D., Ph.D.

Associate Professor and Director Clerkship, Department of
Psychiatry, Southern Illinois University School of Medicine,
Springfield, Illinois

Bhargav Patel, M.D.

Resident Physician, Department of Psychiatry and Health
Behavior, Medical College of Georgia, Augusta, Georgia

Jeffrey J. Rakofsky, M.D.

Associate Professor and Director of Medical Student Educa-
tion, Department of Psychiatry and Behavioral Sciences, Em-
ory University School of Medicine, Atlanta, Georgia

Urja Shah, M.A.

D.O. Candidate, Campbell University School of Osteopathic
Medicine, Buies Creek, North Carolina

Contributors xi
Edward Silberman, M.D.
Professor of Psychiatry, Tufts Medical Center/Tufts Universi-
ty School of Medicine, Boston, Massachusetts

Harjinderpal Singh, B.S., B.Ed.

Student, Department of Psychiatry and Behavioral Neurosci-
ence, Saint Louis University School of Medicine, St. Louis,
Missouri
Vladan Starcevic, M.D., Ph.D., FRANZCP
Professor, Nepean Clinical School, Sydney Medical School,
Faculty of Medicine and Health, University of Sydney, Syd-
ney, Australia

Katherine Taljan, M.D.

Associate Staff, Psychiatry, Cleveland Clinic, Cleveland, Ohio

Adele C. Viguera, M.D., M.P.H.

Clerkship Director of Psychiatry and Staff Psychiatrist, Con-
sultation Liaison Service, Cleveland Clinic, Cleveland, Ohio

Sanya Virani, M.D., M.P.H.

Director, Addiction Services, Worcester Recovery Center and
Hospital, Worcester, Massachusetts; and Assistant Professor
and Associate Program Director, Addiction Psychiatry Fel-
lowship, University of Massachusetts Chan Medical School,
Worcester, Massachusetts

Art Walaszek, M.D.

Professor of Psychiatry and Medicine, University of Wisconsin
School of Medicine and Public Health, Madison, Wisconsin

Aaron Wolfgang, M.D.

Assistant Professor, Uniformed Services University, Bethes-
da, Maryland; and Adjunct Assistant Professor of Psychiatry,
Yale School of Medicine, New Haven, Connecticut

Nagy A. Youssef, M.D., Ph.D.

Director of Clinical Research, Director of ECT Program, and
Professor of Psychiatry, The Ohio State University College of
Medicine, Wexner Medical Center, Department of Psychiatry
& Behavioral Health, Harding Hospital, Columbus, Ohio

xii Pocket Guide to Adverse Events in Psychopharmacology

Disclosures
The following contributor to this book has indicated a finan-
cial interest in or other affiliation with a commercial sup-
porter, a manufacturer of a commercial product, a provider of
a commercial service, a nongovernmental organization, and/
or a government agency, as listed below:
Margo C. Funk, M.D., M.A., has received a speaking
honorarium of less than $1,000 from Acadia Pharmaceuticals
for a 4-hour Education Session for Scientific Team on QTc
Prolongation (July 2021).

Contributors xiii
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