Review 2002 © Ashley Publications Ltd ISSN 1465-6566 479 Ashley Publications w w w.ashley-pub.com 1. Introduction 2. Antipsychotics 3. Antidepressants 4. Mood stabilisers, others 5. Expert opinion Monthly Focus: Cardiovascular, Renal, Endocrine & Metabolic Psychotropic drugs and the ECG: focus on the QTc interval Paul J Goodnick † , Jason Jerry & Francisco Parra † Department of Psychiatry and Behavioral Sciences, University of Miami School of Medicine, Florida, USA The QT interval measuring depolarisation and repolarisation has, when lengthened, been implicated as a risk factor for the development of torsades de pointes and sudden death, particularly in patients predisposed to these complications due to cardiovascular impairment. Since some of the medica- tions used in psychiatry have been implicated, an extensive review of availa- ble literature was made of the major classes, including antipsychotics, antidepressants, lithium, anticonvulsants and benzodiazepines. Further, where no publications were found on a particular medication, the pharma- ceutical firms responsible for these items were contacted concerning possibly unpublished data. Results of the survey indicate that there may be difficulty in one of three situations: immediate (in the first minutes to hours after oral or parenteral administration), short-term use of 4 – 12 weeks or long-term use of ≥ 6 months. Based on this approach, the greatest concern is directed at the immediate application of haloperidol, droperidol, pimozide and trazo- done, the short-term use of thioridazine, pimozide, sertindole, nortriptyline, clomipramine, doxepin and the long-term use of clozapine, olanzapine and carbamazepine. It is of interest that a reduction in QTc is reported with arip- iprazole. Among the antidepressants, the tertiary tricyclic antidepressants (imipramine, amitriptyline and doxepin) appear to have a more general impact, while the secondary tricyclic antidepressants (nortriptyline, desipramine) may impact more on children and the elderly. Among other antidepressants, the only reports of torsades de pointes appeared to occur with mirtazapine. It was also of interest to find data showing no effect or reductions in QTc produced by sertraline, citalopram, paroxetine and bupro- pion in multiple studies. Effects of medications on other heart parameters are also briefly reviewed. In particular, the safety of sertraline in post-MI patients and of bupropion in heart disease patients is highlighted. Little information was available on other classes of medications used in psychiatric disorders. What is available concerning lithium, the anticonvulsants and the benzodi- azepines indicates little effect on the QTc, although there may be effects on other cardiovascular parameters. Keywords: anticonvulsant, antidepressant, antipsychotic, benzodiazepine, ECG, lithium, psychotropic effects, QT c Expert Opin. Pharmacother. (2002) 3(5):479-498 1. Introduction Since chlorpromazine was first used to treat psychosis, many different classes of med- ications have been introduced for the therapy of psychiatric disorders. In the past 50 years, the classes introduced include antipsychotics, antidepressants, antianxiety medications (mostly benzodiazepines) and mood stabilisers (mostly anticonvul- sants). T he side effects of these medications have become known in greater detail since their introduction, including possible fatal effects. Among possible warning