Psychosomatics 44:261-262, June 2003
© 2003 The Academy of Psychosomatic Medicine
Sauna and Hot Tub Warnings
Sirpa A. Tavakoli, M.D., and
William R. Yates, M.D., Tulsa, Okla.
TO THE EDITOR: Many people are looking for ways to cope with everyday stressors in our contemporary complex and fast-paced Western lifestyle. Saunas and hot tubs seem to alleviate both physical and mental stress and are increasing in popularity. Individuals with health problems and taking certain medications may be at a higher risk for potential ill effects of hyperthermia when using these facilities.
Thermoregulation is controlled by the hypothalamus.1 Normally, thermoregulation is highly efficient, keeping the internal temperature within a narrow range of ±0.5–0.9°C.1 In response to an elevated external temperature, heat is lost by increases in blood flow in the skin, vasodilatation, and sweating. Chronic diseases, certain medications, and poor physical conditioning may impair the body's thermoregulation, leading to a dangerous increase in core temperature. This letter examines the scientific evidence for common warnings posted in saunas and hot tubs for users of psychotropic medications, alcohol, and illicit drugs. We searched PUBMED using the terms "hot tub," "sauna," "adverse effects," "death," "neuroleptic malignant syndrome," "heat stroke," "antidepressant," "antipsychotic," "lithium," "anxiolytic," "benzodiazepine," "anticholinergic," "cocaine," "alcohol," "amphetamines," and "drugs."
Our findings suggest that the risks involved in bathing in saunas and hot tubs are controversial, and fatal outcome is rare but does happen. One study of 54 such deaths2 showed that children are especially vulnerable to accidental drowning; hyperthermia caused the most deaths of individuals of an older age with heart disease or seizure disorder and/or use of alcohol or cocaine. There are numerous cases in the literature of summer heat waves causing strokes and deaths.3 To our knowledge, there are no reported cases of sauna- or hot-tub-related deaths of patients taking antidepressants, neuroleptics, benzodiazepines, or lithium.
Neuroleptic medications, both typical and atypical, are associated with dysfunction of thermoregulation and reduced sweating.4 Impaired heat tolerance may lead to hyperthermia syndromes, such as heat cramps, heat stroke, and neuroleptic malignant syndrome. Neuroleptic malignant syndrome is an uncommon, potentially fatal complication of neuroleptic treatment that is characterized by hyperthermia, muscular rigidity, and autonomic dysregulation.4 The causes of neuroleptic malignant syndrome are being studied, but ambient heat and dehydration seem to be likely triggers. Schizophrenia patients taking antipsychotic medications may be at a greater risk of hyperthermia syndromes in hot weather, when exercising, or when using a sauna or a hot tub.
Finns have used saunas for centuries, and in Finland, psychiatric inpatients are provided with an opportunity for at least one sauna bath per week.5 A study involving 16 patients in a mental hospital in eastern Finland5 showed that moderate sauna bathing is safe for somatically healthy patients taking neuroleptics. These patients had most likely been exposed to regular sauna baths since early an age.
Physicians prescribing neuroleptics and other medications that may impair thermoregulation should warn their patients of the potential dangers of exposure to high heat. There is not enough scientific evidence to recommend that physically healthy patients taking psychotropics stay out of saunas and hot tubs, but patients should be encouraged to limit their time in sauna baths and hastily replace lost fluid and salt. Abusers of alcohol and cocaine are at a higher risk for sudden death when bathing in saunas and hot tubs.2 The risks involved when taking other illicit drugs are unclear.
Further studies are needed to evaluate the effect of hot tub exposure and sauna baths on individuals taking psychotropic medications and/or illicit drugs, especially on individuals unaccustomed to saunas.
REFERENCES
- Lomax P: The effects of drugs on thermoregulation during exposure to hot environments. Prog Brain Res 1998; 115:193-204[Medline]
- Press E: The health hazards of saunas and spas and how to minimize them. Am J Public Health 1991; 81:1034-1037[Abstract/Free Full Text]
- Martinez M, Devenport L, Saussy J, Martinez J: Drug-associated heat stroke. South Med J 2002; 95:799-802[Medline]
- Physicians' Desk Reference, 56th ed. Montvale, NJ, Medical Economics, 2002, pp 1528, 1656, 1799, 1975
- Tache U, Venalainen E: Heat stress and neuroleptic drugs. J Neurol Neurosurg Psychiatry 1987; 50:937-938
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