When Psychiatric Symptoms Are Not Necessarily Psychiatric in Origin
Thursday, September 16, 2010
Psychiatrists, especially in hospital and nursing home settings, are frequently requested to consult on patients that exhibit common psychiatric symptoms.
In most cases, a psychiatric diagnosis is evident and psychiatric medication(s) are ordered. However, in some cases, especially in the elderly, a careful review of medical diagnoses and possible change in medications can lead to significant improvement.
Tiredness, bland affect, poor motivation to work in physical therapy: these are common reasons for psychiatric consult requests in the medical/surgical setting. At first glance, a patient with such symptoms would be considered to have “Clinical Depression” and would either be started on an anti-depressant or switched to a different one if already on one.
Before pursuing this course, one should review lab results for signs of anemia, infection, electrolyte disturbance, abnormal glucose, elevated TSH, signs of dehydration, renal insufficiency, or liver pathology. If any medications have blood levels, make sure they have been checked recently such as lithium, valproate, phenytoin, digoxin, theophylline. One should make sure that none of these medications are above the therapeutic range.
Blood pressure is often ignored as a guide to understanding lethargy and bland affect. The usual focus is on preventing elevated BP readings, but at the other end of the spectrum low BP readings can possibly explain why a patient does not want to get out of chair or bed and work in therapy. Supine or sitting BP readings may not tell the whole story so orthostatic BP readings should be checked. A reduction in an anti-hypertensive and/or diuretic might be considered.
Some psychoactive medications such as quetiapine can cause a decrease in BP and/or heart rate. Both the patient’s routine and prn medication lists should be reviewed for anything possibly sedating, such as diphenhydramine for itching. Analgesics are notorious for contributing to tiredness, yet severe pain must be addressed since pain alone can prevent clinical progress. Clinicians should be aware that prn analgesics are generally underutilized. One approach to consider is extra-strength acetaminophen 1 Gram bid routinely in addition to the prn opiate.
One should not forget to check for stiffness in the otherwise depressed-looking patient with very bland affect since undiagnosed Parkinson’s Disease can present in such fashion. Even a small dose of levo-dopa in such a case can produce a significant improvement in facial expression, self-care, and conversational ability. It is tempting to attribute stiffness in a patient with previously diagnosed dementia as being due solely to that condition, but a trial of low dose levo-dopa (half-tab 25/100 q a.m. and q 1 p.m.) can lead to addressing a new untreated condition by producing a noticeable degree of clinical improvement. Generally psychotic side effects will not develop on low doses of dopaminergic medications.
Just as lethargy can be due to medications and medical conditions, so can agitation and excitability. One should check for any medications that might contain stimulating properties such as theophyllines, dopaminergic agents, the more stimulating anti-depressants such as buproprion and fluoxetine, and even the atypical antipsychotic agent aripiprazole. It is easy to forget the role of caffeine in cases of mood lability and excitability. Encourage decaf coffee and tea and caffeine-free soda especially if the patient is on medications that have stimulating properties.
Delirium can be the underlying etiology of both hypoactive and hyperactive mood states. A careful review of vital signs, CBC, chemistry profile, blood gases, urinalysis, and drug levels should be reviewed and updated if needed.
A common symptom that can contribute to agitation but often undertreated is pain. The same principles apply here as in lethargic states described above: prn analgesics more often than not are not given. One should consider a routine regimen of analgesic agent with prn backup of something stronger perhaps and remember to check frequently for effectiveness—ask the patient, the family, and the nursing staff.
In conclusion, psychiatric symptoms, if indicative of a psychiatric diagnosis, will likely improve with psychiatric treatment which usually includes medication and perhaps some psychotherapy. However, one must consider medical etiologies, especially in the elderly, and concurrently consider changes in medical treatment either before or at least in conjunction with psychotropic medication utilization.
Dr. Louis Klein is a geriatric psychiatrist and Medical Director of the Geriatric Behavioral Health Unit at Southwest General Health Center.
MD News September/October 2010