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Research Letter
October 6, 2021

Long-term Arrhythmia Detection Using an Implantable Loop Recorder in Patients Receiving Psychotropic Medication

Author Affiliations
  • 1Mental Health Center Amager, Copenhagen, Denmark
  • 2Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Denmark
JAMA Psychiatry. Published online October 6, 2021. doi:10.1001/jamapsychiatry.2021.2809

Patients with mental disorders have increased risk of premature death compared with the background population.1 One suspected cause is arrhythmia associated with treatment with psychotropic drugs. Many of these drugs affect the heart's conduction system and can, in the worst case, lead to life-threatening ventricular arrhythmias.2 Recently, cardiologists have performed long-term (2-3 years) monitoring of electrocardiographic findings using an implantable loop recorder (ILR).3 To our knowledge, no ILR study has examined the incidence of arrhythmia in patients with mental disorder or in a background population. In a cohort of 103 patients suspected to have epilepsy (mean age, 46 years) who were monitored for a mean of 2.3 years, the incidence of arrhythmia was 21%.4 Pooled data from 9 studies of ILRs that examined unexplained syncope showed a median diagnostic yield of 35% (range, 26%-51%).5 In comparison, a study from the UK found a prevalence of arrhythmia of 2.35% in community-dwelling adults (mean age, 58 years), and the prevalence increased with increasing age.6 The purpose of the present study was to assess the feasibility of arrhythmia monitoring using an ILR and the incidence of arrhythmia in a population of psychiatric outpatients receiving psychotropic medication.

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    1 Comment for this article
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    Psychiatric risks of implantable devices
    Wenqi Lyu, MS | Department of psychiatry, West China Hospital, Chengdu, China
    In our knowledge, Dr. Julie Nordgaard’s research [1] is the first long-term arrhythmia detection in patients receiving psychotropic medication by using the implantable loop recorder (ILR). Psychotropic medications have been widely reported the risk of arrhythmias [2]. Detection of arrhythmias caused by psychotropic medications is important to prevent this severe adverse effect. However, the use of implanted devices in patients also carries the risk of causing some mental disorders including delusions of persecutory, delusion of reference, agitation, chronic stress, or vegetative nervous disorder. As an invasive device, the patients will certainty know the whole implant process clearly. Even if they have been informed of the purpose of the implant, they may still feel anxious about the device harming their body, severe cases may also have somatic symptoms caused by vegetative nervous disorders. Patients with psychiatric symptoms may firmly believe the device implanted in their body is being used by someone to spy or track them that they must remove the device, serious cases may become agitated and act in ways that harm themselves or caregivers. There has been a previous report of appearance of delusion and agitation caused by using cochlear implants in a man with schizophrenia who was in stable condition [3].
    However, there was no detailed description in Dr. Julie Nordgaard 's study of evaluation in participants' psychotic symptoms. The schizophrenic patient in case 1 developed anxiety for unknown reasons. In the interest of patient safety, we believe it is necessary to use relevant scales and conduct regular face-to-face interviews with professional psychiatrists to remain vigilant and determine whether the patient is experiencing exacerbation or recurrence of psychotic symptoms caused by the implanted device.
    In conclusion, ILR has great advantages in detecting arrhythmias but also carries a risk of exacerbation. To avoid adverse events, clinicians and researchers must evaluate the condition carefully. It would be even better if the device be used in patients with good care settings. More caution should be exercised in susceptible groups, including schizophrenic patients with positive symptoms, anxiety, and paranoid personality [4]. The adverse events can be monitored by opening a telephone hotline or regular on-site follow-up. Measures such as remote telephone intervention, drug dose adjustment, and removal of implanted devices should be made in time.



    References:
    [1] Nordgaard J, Melchior T. Long-term Arrhythmia Detection Using an Implantable Loop Recorder in Patients Receiving Psychotropic Medication. JAMA Psychiatry. Published online October 06, 2021. doi:10.1001/jamapsychiatry.2021.2809
    [2] Tisdale JE, Chung MK, Campbell KB, et al. Drug-Induced Arrhythmias: A Scientific Statement From the American Heart Association. Circulation. 2020;142(15):e214-e233. doi:10.1161/CIR.0000000000000905
    [3] Siegal JT, Robiner W, Smith S, et al. Cochlear implantation in severe traumatic brain-injury and paranoid schizophren
    [4] Triebwasser J, Chemerinski E, Roussos P, Siever LJ. Paranoid personality disorder. J Pers Disord. 2013;27(6):795-805. doi:10.1521/pedi_2012_26_055

    Authors: Wenqi Lü, Weihong Kuang
    Department of Psychiatry, West China Hospital, Sichuan University, Chengdu, China

    *Correspondence to:
    Prof. Weihong Kuang MD
    Department of Psychiatry, West China Hospital, Sichuan University, Chengdu, China
    Add: No. 37, Guo Xue Alley, Chengdu 610041, China
    Tel: +86-28-85422917
    Email: kwhhlj@scu.edu.cn
    CONFLICT OF INTEREST: None Reported
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