Heatstroke and Psychiatric Patients

Table 1

Table 2

Jerome Murdough was a 56-year-old former Marine who was receiving antipsychotic and antiseizure medication. He was found dead in his Rikers Island jail cell. When his lifeless body was discovered, his cell was found to be at least 100°F. The initial autopsy performed on Mr Murdough was inconclusive, but evidence strongly suggested that his death was likely due to severe dehydration and heatstroke. Mr Murdough had not been convicted of a crime-rather, he had been arrested on a misdemeanor trespassing charge (for sleeping in a stairwell of a public housing building).

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Heatstroke is a severe, life-threatening illness that occurs with regularity during the summer months, particularly among psychiatric patients. Psychiatric patients in jails and prisons face a difficult challenge in that they may not have the freedom to change their environment to avoid heatstroke.

Thermoregulation and heatstroke

Body temperature is regulated by balancing heat production and heat loss. Heat production is a principal by-product of metabolism. The rate of heat loss is determined by how rapidly heat can be conducted from the body core to the skin, and how rapidly heat from the skin can be transferred to the surroundings.

When body temperature rises to 105°F, heatstroke becomes likely. Heatstroke is characterized by a core temperature of more than 104°F and CNS abnormalities (delirium, seizures, coma), which lead to multiorgan dysfunction, sepsis, and tissue destruction. Symptoms heralding the onset of heatstroke include dizziness and abdominal distress that may be followed by vomiting, confusion, and loss of consciousness. Even a few minutes with a high body temperature can be fatal because of damage to body tissues and end-organs, especially the brain (Table 1).

Heatstroke is either “classic” or “exertional.” When it results from exposure to high environmental heat, it is passive, or classic. Heatstroke primarily from strenuous work is exertional. Preexisting conditions, such as mental illness, alcoholism, and drug use (especially anticholinergics), may interfere with the physiological ability to adjust to heat stress, thus increasing the risk of passive heatstroke.

Thermoregulation and medications

Anticholinergic medications can interfere with thermoregulation by inhibiting parasympathetic pathways. This results in an inhibition of sweating and leads to decreased ability to eliminate heat. The antidopaminergic activity of an antipsychotic can increase the set point of the body’s temperature regulation. Antipsychotics may also reduce behaviors that regulate temperature, such as increasing water intake or removing extra clothing.²

Phenothiazines, such as chlorpromazine, thioridazine, fluphenazine, and perphenazine, have anticholinergic and central thermo-regulatory effects. Phenothiazines inhibit afferent neuronal input to the hypothalamus, which decreases the hypothalamus’s compensatory response of increasing cutaneous blood flow to assist in heat dissipation. Other commonly used psychiatric medications that have been shown to disturb thermoregulation include atypical antipsychotics, serotonergic agonists, and β-blockers.³ Some psychiatric medications may increase the risk of dehydration by reducing thirst. Such medications include SSRIs, clonidine, carbamazepine, and valproic acid.

Abnormal thermoregulation in schizophrenia

Evidence suggests that individuals with schizophrenia may have abnormal thermoregulation; however, the respective roles of CNS pathology and medication are unclear. The biochemical and physiological explanations found in the literature are inconclusive, but peripheral and central abnormalities may be responsible.⁴ The theory of a peripheral abnormality is related to impaired heat loss through peripheral vasodilation via abnormalities in niacin and prostaglandin-E₁. The theory of a central abnormality is related to a disruption of the mesolimbic dopamine system that is believed to be responsible for temperature regulation and psychosis.

Shiloh and colleagues⁵ compared drug-free outpatients who had schizophrenia with healthy controls. They all participated in a standardized exercise-heat tolerance test of walking on a treadmill. The persons with schizophrenia showed significantly higher baseline and exertion-related temperatures.

Heat waves and psychiatric patient deaths

A heat wave is usually defined as 3 or more consecutive days of temperatures above 89.96°F. Heat waves have been found to be strongly associated with psychiatric presentations to emergency departments.⁶ In a study of deaths resulting from a 2003 heat wave in France, it was concluded that physiologic adaptation to heat was impaired because of the adverse effects of medications, in particular, psychiatric medications.³

A meta-analysis of observational studies on risk and protective factors in heat wave–related deaths showed that having a preexisting psychiatric illness can more than triple the risk of death during a heat wave.⁷ This study also showed that taking psychotropic medication can nearly double one’s risk of death during a heat wave.

An Australian study looked at the hospitalization rates during heat waves over a 13-year period. Findings from the study indicate that heat-related deaths among persons with schizophrenia and schizotypal and delusional disorders increased more than 2-fold.⁸

Another study compared the deaths among patients in state psychiatric hospitals in the New York City area with those among the general New York City population from 1950 to 1984. The risk of death in hospitalized psychiatric patients was twice that in the general population during a heat wave. The risk of death was highest in the 1970s, and it was noted that this was when higher doses of antipsychotics were often used. Moreover, the increased risk of death in psychiatric patients before the use of antipsychotics suggests that mental illness alone may be a significant risk factor for death during a heat wave.⁹

new¹⁰ found that mental illness placed individuals at a higher risk for death during a 1999 heat wave in Cincinnati. Data from this case-control study of 18 heat-related deaths show that of the 8 patients who had a mental illness, 4 had schizophrenia and 4 had prescriptions for psychotropic medication, which included amitriptyline, clozapine, or olanzapine. While prescribed psychotropic and anticholinergic drugs were positively associated with heat-related death, quantitative drug screening suggested that medication adherence was low.

Heatstroke and legal liability

The risk of heatstroke and death in psychiatric patients has resulted in numerous lawsuits, usually involving residential facilities or state hospitals. For example, in Kotler v Alma Lodge, the California court of appeals affirmed a wrongful death action-the owner and administrator of the residential facility for mentally ill adults were found liable.¹¹ Two patients with schizophrenia died during a heat wave-the temperature rose to near or above 100°F for 5 consecutive days-in the Los Angeles area. The coroner testified that both patients died of hyperthermia due to environmental heat. A jury found that Alma Lodge had been negligent, and awarded $600,000 in damages to the patients’ families.

The case of Trisdale v Ohio Department of Mental Health involved physical exertion outdoors during warm weather.12 Ms Trisdale’s son, 30-year-old Dawayne Colyer, died on June 22, 1993. Mr Colyer had schizophrenia and was being treated with 2000 mg/d of chlorpromazine, 30 mg/d of fluphenazine, and 2 mg/d of benztropine. Although there was some disagreement about the precise temperature on the day of Mr Colyer’s death, the National Weather Service reported a temperature of 84°F with 46% relative humidity.

Mr Colyer was playing basketball with staff and other patients when he became confused and disoriented; he collapsed and lost consciousness. He was transported to the local hospital, where he was pronounced dead a few hours later. At the time he arrived at the hospital, his rectal temperature was 108°F. Judgment was rendered in favor of the plaintiff-the court found Mr Colyer’s physician negligent, specifically citing the doctor’s failure to annotate physical exercise and heat exposure limitations in his patient’s medical record.

Heat-related death during incarceration

Determinations of liability in inmate heat-related deaths are complicated by the fact that mental health professionals may face 2 general forms of legal liability: allegations of civil rights violations (claims of deliberate indifference violating 42 USC 1983), and allegations of professional negligence (malpractice). Deliberate indifference claims often involve allegations of an intentional denial or delay of access to care or necessary treatment, and failure to use reasonable professional judgment. Because inmates are wholly dependent on correctional administrators for their serious medical needs, the failure to provide for these needs may amount to cruel and unusual punishment (an Eighth Amendment violation) in the eyes of the courts.

Deliberate indifference claims can be raised alone or in tandem with claims of medical negligence. The challenge with deliberate indifference claims lies in the fact that to prevail, the plaintiff must show that the correctional administrator had knowledge of the risk, yet disregarded it and took no action. It has been argued that this sets too high a bar for plaintiffs, because it requires “action or inaction taken in conscious disregard of a substantial risk of serious harm.”¹³ Thus, cases often hinge on whether a particular correctional official had personal knowledge of the risk or whether any effort was made to mitigate the risk. The result is that inadequate medical treatment in prison may not violate the Eighth Amendment, particularly when the correctional official made at least some effort (even if inadequate) to address the risk.

In Willis v Barksdale, Ms Willis sought damages for the death of her 26-year-old brother, Michael Lott.¹⁴ He had been charged with a misdemeanor for carrying a pistol. The County Medical Examiner found the cause of death to be heatstroke. The temperature inside of the jail cell when Mr Lott was found was 96°F. The high temperature for the day was 105°F.

Mr Lott was on a cell block reserved for inmates with medical or mental health problems, and two fans were in the area. Ice and water were available to inmates, and jail staff were provided with instructions for managing exhaustion and heatstroke.

Mr Lott had had numerous psychiatric admissions; at the time of his death, he was being treated with 60 mg of haloperidol at bedtime and 2 mg of benztropine twice daily. While the court acknowledged the effects of these medications on thermoregulation, judgment was entered for the defendants. The court held that the chief jail administrator did not have a duty to address the unique medical needs of an individual inmate because it was the medical personnel who had this responsibility (effectively separating a deliberate indifference from medical negligence claim). It was further held that the chief jail administrator did not display deliberate indifference to Mr Lott’s serious medical needs.

The case of Scarver v Litscher from 2006 is interesting for a number of reasons, including the fact that Mr Scarver is known as the killer of serial murderer Jeffrey Dahmer. Mr Scarver alleged that he was subjected to cruel and unusual punishment when he was transferred to a facility where he was confined to a small, windowless cell with no air-conditioning.¹⁵ He argued that during the summer, his antipsychotic medications interacted with the high heat in his cell.

He was not allowed access to a radio or another source of sound, which he stated would have helped control the voices in his head. As a result of the conditions, he became suicidal and overdosed on medications twice in attempts to kill himself. In addition, he banged his head against the cell wall for extended periods, cut his head with a razor, and cut his wrists. Worried that the heat in his cell would interact with his medication, he stopped taking his antipsychotic medication, which resulted in a worsening of his psychotic symptoms.

The court agreed that Mr Scarver was subjected to conditions that aggravated his symptoms and led to severe physical and mental suffering; nevertheless, the court ruled in favor of the defendants. The court’s reasoning followed the tradition of deferring to the authority of prison officials in the name of institutional security: “Prison authorities must be given considerable latitude in the design of measures for controlling homicidal maniacs . . .”

The court concluded that “the treatment of a mentally ill prisoner who happens also to have murdered 2 other inmates is much more complicated than the treatment of a harmless lunatic.” The rest of the court’s reasoning gives a good example of deference to prison officials, “the heat . . . may have been an indirect result of trying to prevent prisoners from fashioning weapons from fixtures, perhaps including air-conditioning vents and control. . . . In any event, . . . Scarver has failed to cite evidence to overcome the defendants’ denials that they knew these conditions were making his mental illness worse.”

Prevention and treatment of heatstroke

Heatstroke is described in the medical literature as “a preventable illness.” Prevention, however, requires awareness of risk factors and attention to cautionary measures. Psychiatric patients should be educated about and prepared for heat waves. Preparation involves limited exposure, increased fluid intake, and vigilance to the signs and symptoms of dehydration and heatstroke. Special attention should be given to patients with serious mental illness, especially those taking antipsychotic and anticholinergic medications. Other helpful measures include monitoring body temperature several times a day, dressing lightly, and allowing for additional showers with cool water (Table 2). Once symptoms suggest the onset of heatstroke (eg, vomiting, confusion, elevated body temperature), immediate transport to emergency medical services is indicated.

Disclosures:

Dr Charder is a Forensic Psychiatry Fellow at SUNY Upstate Medical University, Syracuse, NY. Dr Knoll is Professor of Psychiatry and Forensic Psychiatry Fellowship Director at SUNY Upstate Medical University. They report no conflicts of interest concerning the subject matter of this article.

References:

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3. Stöllberger C, Lutz W, Finsterer J. Heat-related side-effects of neurological and non-neurological medication may increase heatwave fatalities. Eur J Neurol. 2009;16:879-882.

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5. Shiloh R, Weizman A, Epstein Y, et al. Abnormal thermoregulation in drug-free male schizophrenia patients. Eur Neuropsychopharmacol. 2001;11:285-288.

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10. Kaiser R, Rubin CH, Henderson AK, et al. Heat-related death and mental illness during the 1999 Cincinnati heat wave. Am J Forensic Med Pathol. 2001;22:303-307.

11.Kotler v Alma Lodge, 63 Cal App 4th 1381 (1998).

12.Trisdale v Ohio Department of Mental Health, 103 Ohio Misc.2d 5 (1999).

13. Thompson JH. Today’s deliberate indifference: providing attention without providing treatment to prisoners with serious medical needs. Harv CR-CLL Rev. 2010;45:635-654.

14.Willis v Barksdale, 625 F Supp 411 (WD Tenn 1985).

15.Scarver v Litscher, 434 F3d 972 (7th cir 2006); 2006 US App Lexis 1135.