Psychopharmacology and Psychiatry Updates QT Prolongation and Psychiatric Medication: A Cardiac Safety Update
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Dec 7, 2025 Scott Beach, a psychiatrist and expert commentator, shares insights from a crucial case-control study on QT prolongation linked to psychiatric medications. He discusses the rarity and unpredictability of torsades de pointes, revealing that single antidepressant or antipsychotic use shows no significant risk, while polypharmacy does. Beach emphasizes the importance of careful monitoring of QTc values and addressing reversible factors, urging clinicians to avoid knee-jerk reactions in medication management for psychiatric patients.
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ICU Consultation Dilemma
- A cardiology consult is called for a 52-year-old woman on sertraline plus mirtazapine after an acute MI with concerns about QT.
- She and the team fear stopping antidepressants could trigger recurrent suicidal depression, creating a clinical dilemma.
Monotherapy Not Linked To Torsade
- Monotherapy with antidepressants or antipsychotics was not associated with increased TORSAD in the case-control study.
- Risk factors that were associated included female sex, LV dysfunction, acute MI, hypokalemia, other QT drugs, and two or more antidepressants.
Small QT Changes Rarely Predict Events
- Even drugs that prolong QT by ~10–20 ms (eg, citalopram, ziprasidone) rarely show increased torsade or sudden death in large studies.
- QT prolongation magnitude often doesn't translate to meaningful clinical outcomes because TORSAD is very rare.