Drug Induced Psychiatric Symptoms

Worst Pills, Best Pills News article October, 2002

This is the first of a two part series on drug induced psychiatric symptoms that is based on the July 8, 2002 issue of The Medical Letter on Drugs and Therapeutics. Regular readers of Worst Pills, Best Pills News will recognize The Medical Letter as a reference source written for physicians and pharmacists that we often use because of its reputation as an objective and independent source of drug information.

Many drugs can cause psychiatric symptoms. However, psychiatric symptoms may also emerge during drug treatment due to an underlying illness, previously unrecognized mental illness, or psychosocial factors. The stopping or withdrawal of some drugs can also cause symptoms such as anxiety, psychosis, delirium, agitation or depression.

This month’s article lists psychiatric symptoms associated with some families or classes of drugs. Examples of some drugs in the family are given. The list of examples is not exhaustive. The type of psychiatric symptom is listed and then an explanatory note.

Alcohol, agents that cause hallucinations and other drugs not generally used for medical purposes are omitted. Withdrawal reactions in individuals addicted to narcotics are also omitted.

We will refer a number of times to anticholinergic drugs and anticholinergic adverse effects in the list below. An anticholinergic is a drug that blocks the effects of acetylcholine, a substance produced by the body which is responsible for certain nervous system activities (parasympathetic). Drugs with anticholinergic effects (including antidepressants, antihistamines, antipsychotics, drugs for intestinal problems, and anti-parkinsonians) inhibit the secretion of acid in the stomach, slow the passage of food through the digestive system, inhibit the production of saliva, sweat, and bronchial secretions, and increase the heart rate and blood pressure. Adverse effects of these drugs include dry mouth, constipation, difficulty urinating, confusion, worsening of glaucoma, blurred vision, and short term memory problems.

Next month’s issue of the newsletter will conclude the series with some specific drugs that can cause particular psychiatric symptoms.

What You Can Do

Keep in mind Rule 3 of our rules for safer drug use: Assume that any new symptom you develop upon starting a new drug may be caused by the drug. If you have a new symptom, psychiatric or otherwise, report it to your doctor.





Amphetamine-Like Drugs
Herbal dietary supplements containing ephedra should also be considered as  amphetamine-like drugs.

This family includes the diet drugs such as sibutramine (MERIDIA) and phentermine (IONAMIN)

bizarre behavior, hallucinations, paranoia, agitation, anxiety, mania, nightmares

Usually with overdose or abuse; can occur with asthma inhaler abuse; depression on withdrawal

Anabolic steroids
(body-building steroids)

oxymetholone (ANADROL); oxandrin (OXANDRIN); stanozolol (WINSTROL). There are many illegal sources of anabolic steroids.  Anabolic steroids may also be contained in dietary or herbal supplements.

psychosis, mania, depression, anxiety, aggressiveness, paranoia

most reports are with abuse

Angiotensin-Converting Enzyme (ACE) Inhibitors

captopril (CAPOTEN); enalapril (VASOTEC); lisinopril (PRINIVIL, ZESTRIL)

mania, anxiety, hallucinations, depression, psychosis

many reports

Anticholinergics and Atropine

many drugs have anticholinergic properties including some antidepressants, antihistamines, antipsychotics, drugs for intestinal problems, and antiparkinsonian drugs

confusion, memory loss, disorientation, depersonalization, delirium, auditory and visual hallucinations, fear, paranoia, agitation, bizarre behavior

more frequent in the elderly and children with high doses; can occur with transdermal scopolamine (TRANSDERM SCOP); atropine eye drops, particularly when mistaken for nose drops can cause sudden incoherent speech, delirium with high fever, flushed dry skin, hallucinations, or amnesia

Antidepressants, Tricyclic

amitriptyline (ELAVIL); doxepin (SINEQUAN); imipramine (TOFRANIL)

mania or hypomania, delirium, hallucinations, paranoia, irritability, dysphoria

patients with bipolar disorder are at highest risk for mania; anticholinergic effects may cause delirium in elderly

Antiepileptics (drugs for seizure disorders)

phenytoin (DILANTIN)

agitation, confusion, delirium, depression, psychosis, aggression, mania, toxic encephalopathy (disease of the brain), nightmares

usually with high doses or high blood concentrations


phenobarbital (SOLFOTON); aprobarbital (ALURATE); butabarbital (BUTISOL)

excitement, hyperactivity, visual hallucinations, depression, delirium-tremens - like syndrome (seen in alcohol withdrawal)

especially in children and the elderly, or on withdrawal


diazepam (VALIUM); flurazepam (DALMANE); alprazolam (XANAX)

rage, hostility, paranoia, hallucinations, delirium, depression, nightmares, anterograde amnesia, mania, disinhibition

during treatment or on withdrawal; may be more common in the elderly

Beta - Blockers

atenolol (TENORMIN); metoprolol (LOPRESSOR, TOPROL); propranolol (INDERAL); levobunolol (BETAGAN); betaxolol (BETOPTIC); timolol (TIMOPTIC)

depression, psychosis, delirium, anxiety, nightmares, hallucinations

with oral or eye drop preparations, incidence of depression may be overestimated

Calcium Channel Blockers

amlodipine (NORVASC); diltiazem (CARDIZEM, DILACOR, TIAZAC); verapamil (CALAN, ISOPTIN, VERELAN)

depression, delirium, confusion, psychosis, mania

several reports

Cephalosporin Antibiotics

cefaclor (CECLOR); cefuroxime (CEFTIN); cephalexin (KEFLEX)

euphoria, delusions, depersonalization, illusions

kidney disease is a risk factor

Dopamine Agonists for Parkinson's Disease

bromocriptine (PARLODEL); pergolide (PERMAX); pramipexole (MIRAPEX)

hallucinations, paranoia, delusions, confusion, mania, hypersexuality, anxiety, depression, nightmares

during treatment or on withdrawal


conjugated estrongens (PREMARIN); estradiol (CLIMARA, ESTRACE)

panic attacks, depression

several reports

Fluoroquinolone Antibiotics

ciprofloxacin (CIPRO); levofloxacin (LEVAQUIN); sparfloxacin (ZAGAM)

psychosis, confusion, agitation, depression, hallucinations, paranoia, Tourette-like syndrome (a form of tic), mania

many reports

Histamine H-1 Blockers

chlorpheniramine (CHLOR-TRIMETON); diphenhydramine (BENADRYL); loratadine (CLARITIN); fexofenadine (ALLEGRA)


especially with over dosage of the older antihistamine drugs such as diphenhydramine

Histamine H-2 Blockers

cimetidine (TAGAMET); famotidine (PEPCID); nizatidine (AXID); ranitidine (ZANTAC)

delirium, confusion, psychosis, mania, aggression, depression, nightmares

especially in the elderly and seriously ill

Monoamine Oxidase (MAO) Inhibitor Antidepressants

isocarboxazid (MARPLAN); phenelzine (NARDIL); tranylcypromine (PARNATE)

mania or hypomania


Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

ibuprofen (MOTRIN); naproxen (NAPROSYN); meloxicam (MOBIC); rofecoxib (VIOXX)

depression, paranoia, psychosis, confusion, anxiety

probably more common with indomethacin (INDOCIN); one case of auditory hallucinations with celecoxib (CELEBREX)


narcotic pain relievers such as morphine, codeine, and oxycodone (OXYCONTIN)

nightmares, anxiety, agitation, euphoria, dysphoria, depression, paranoia, psychosis, hallucinations, dementia

usually with high doses; also occurs with intrathecal (administration into the spine) morphine; especially in the elderly

Procaine Derivatives (procainamide, procaine penicillin G)

procainamide (PROCANBID); procaine penicillin G is an injectable form of penicillin given by a doctor

fear of imminent death, hallucinations, illusions, delusions, agitation, mania, depersonalization, psychosis

probably due to procaine



agitation, confusion, hallucinations, paranoia,

with chronic intoxication

Selective Serotonin Reuptake Inhibitors (SSRIs)

escitalopram (LEXAPRO); citalopram (CELEXA); fluoxetine (PROZAC); paroxetine (PAXIL); sertraline (ZOLOFT)

mania, hypomania, hallucinations

anxiety, irritability, aggression or impulsivity on withdrawal


atorvastatin (LOPID); fluvastatin (LESCOL); pravastatin (PRAVACHOL); simvastatin (ZOCOR)

anxiety, depression, obsessions, delusions

several reports

Steroids, Inhaled

triamcinolone (AZMACORT); beclomethasone (VANCERIL)

hyperactivity, aggression, disinhibition

several reports

Steroids, Oral

prednisone (DELTASONE, METICORTEN); prednisolone (METRETON)

psychosis, delirium, mania, depression

1% to 3% incidence, may be dose-related; can occur on withdrawal


sulfamethoxazole and trimethoprim (BACTRIM, SEPTRA, COTRIM)

confusion, disorientation, depression, euphoria, hallucinations

several reports

Thiazide Diuretics

hydrochlorothiazide (HYDRODIURIL); chlorthalidone (HYGROTON)

depression, suicidal ideation

after weeks to months of use


Last Updated 6/25/04