Doctors, psychiatrists mistreat medical conditions as psychiatric

[Altostrata]

A new book by a psychiatrist suggests mental health counselors, of all people, look out for medical illnesses that are misidentified as psychiatric problems. Because they're "too busy," primary care doctors and psychiatrists are overlooking the medical diagnoses.

 

Have you ever known a psychiatrist to pay any attention to a medical history or order blood tests before medicating? This article claims they do.

 

Confusing Medical Ailments With Mental Illness

 

By MELINDA BECK The Wall Street Journal AUGUST 9, 2011

 

....

More than 100 medical disorders can masquerade as psychological conditions, according to Harvard psychiatrist Barbara Schildkrout, who cited these examples among others in "Unmasking Psychological Symptoms," a book aimed at helping therapists broaden their diagnostic skills.

 

Studies have suggested that medical conditions may cause mental-health issues in as many as 25% of psychiatric patients and contribute to them in more than 75%.

 

Untangling cause and effect can challenge even seasoned clinicians, and the potential for missed diagnoses is growing these days, said Dr. Schildkrout, who has more than 25 years of clinical practice in the Boston area. Most mental-health counselors rely on primary-care doctors to spot medical issues, but those physicians are increasingly time-pressed and may not know their patients well. Neither do the psychiatrists who mainly write prescriptions and see patients only briefly, she said in an interview.

 

Common culprits include under- or over-active thyroid glands, which can cause depression and anxiety, respectively. Deficiencies of vitamins D, B-12 and folate, as well as hormonal changes and sleep disorders have also been linked to depression.

 

Diabetes, lupus and Lyme disease can have a variety of psychiatric symptoms, as can mercury and lead poisoning and sexually transmitted diseases. Many medications also list mood changes among their side effects, and substance abuse is notorious for causing psychiatric problems.

 

Some underlying conditions are readily treatable. Others, such as Alzheimer's and Parkinson's disease and some brain tumors, are not. But a correct diagnosis can save months or years of frustration and ineffective treatment.

 

In some cases, a psychological problem is just the first sign of a serious medical issue. "Depression predicts heart disease and heart disease predicts depression," said Gary Kennedy, director of the geriatric psychiatry at Montefiore Medical Center in Bronx, N.Y.

 

About one-third of people who have their first episode of depression after age 55 have changes in brain circuits that are associated with hypertension, diabetes and heart attacks. Such patients are usually apathetic, have difficulty with executive planning and don't respond well to antidepressants. Making sure their blood pressure and blood-sugar levels are on target is crucial, though medical and psychotherapy may be needed as well, Dr. Kennedy said.

 

Recognizing an underlying medical condition can be particularly difficult when there is also a psychological explanation for a patient's dark moods. For example, victims of domestic violence are often anxious, depressed and withdrawn—but mild brain injury could be causing such symptoms, too.

 

Warning Signs

 

When to suspect a mental problem may be medical:

 

• Sudden change in mood or personality

 

• History of head trauma

 

• Depression that occurs for the first time after age 55

 

• Recent travel or exposure to infections

 

• Any rash, swelling, drooping eyelid; facial tic

 

• Standard medication or therapy isn't effective

 

Similarly, a former college athlete who becomes angry and irritable in his 40s could be suffering a midlife crisis—or delayed reaction to head injuries sustained decades earlier. "We now know that multiple concussions can have a sleeper effect for years. Then one day, out of the blue, you start acting explosive and depressed," due to a brain swelling known as chronic trauma encephalopathy, said Jerrold Pollak, a neuropsychologist at Seacoast Mental Health Center in Portsmouth, N.H., and lead author of an article on distinguishing mental from medical disorders in the Journal of Clinical Psychology Practice this spring.

 

If the head-injury diagnosis is missed, Dr. Pollak added, the patient could be in psychotherapy for months, "thinking that he has trouble with his father or feels like a failure for not becoming a pro athlete."

 

....experts say mental-health counselors should ask patients about their medical histories as well as emotional issues, and make sure they've had a recent physical exam.

 

Tell-tale signs of underlying medical problems include significant changes in energy, weight, appetite or sleep, which could be due to an endocrine disorder. Sudden changes in mood or personality, visual hallucinations and alternations in smell, taste or tactile senses could signal a brain tumor or other abnormality.

 

Sometimes a single physical sign can broaden a clinician's diagnostic thinking. Manhattan psychiatrist Drew Ramsey recalled that early in his career, he examined a patient with daily panic attacks and noticed a swelling on her shins, a classic sign of Graves' disease, a form of overactive thyroid that can cause severe anxiety.

 

Like other psychiatrists, Dr. Ramsey said he always takes a medical history and orders blood tests for patients. He found that one was anemic and improved markedly when meat was added to her diet. Another who was depressed and drinking heavily was low on vitamins D and B-12.

 

Similarly, Dr. Schildkrout once treated a 50-year-old woman for mood swings and noticed a slight slurring to her speech. While it could have been dismissed as ill-fitting dentures, it turned out to be the first sign of amyotrophic lateral sclerosis, which also causes severe fatigue and odd jags of laughing and crying in its early stages.

 

Some patients may benefit from both psychological counseling and medical help. Therapists need not turn patients away while medical issues are being explored, experts say. "Clinicians can say, 'While we work on these issues, let's also discuss any possible medical conditions that could be contributing, so we can at least rule them out,"' Dr. Pollak said.

 

Finally clarifying a diagnosis can be a relief to clinicians and patients—particularly when therapy hasn't been working or patients have spent years blaming themselves. "When you find the right diagnosis, not only is there appropriate treatment, but it can make a dramatic improvement in terms of healing their self esteem," Dr. Schildkrout said.

 

—Email HealthJournal@wsj.com

 

Different Diagnoses

 

More than 100 medical disorders can masquerade as psychological conditions or contribute to them, complicating treatment decisions.

WHAT

SEEMS LIKE ... MAY ACTUALLY BE ...

• Depression Underactive thyroid; low vitamin D or B-12 or folate; diabetes; hormonal changes; heart disease; Lyme disease; lupus; head trauma, sleep disorders; some cancers and cancer drugs
• Anxiety Overactive thyroid; respiratory problems; very low blood pressure; concussion; anaphylactic shock
• Irritability Brain injury; temporal lobe epilepsy; Alzheimer's disease and early stage dementia; parasitic infection; hormonal changes
• Hallucinations Epilepsy; brain tumor; fever; narcolepsy; substance abuse
• Cognitive changes Brain injury or infection; Alzheimer's; Parkinson's; liver failure; mercury or lead poisoning
• Psychosis Venereal disease; brain tumors and cysts; stroke; epilepsy; steroids; substance abuse

 

http://online.wsj.com/article/SB10001424053111904480904576496271983911668.html

[cinephile]

Have you ever known a psychiatrist to pay any attention to a medical history or order blood tests before medicating? This article claims they do.

BINGO. This is why I have a hard time believing psychiatrists when they defend their MDs, saying it's an absolute necessity. Now, I'm willing to accept that it may be useful in a hospital/inpatient setting, but I have never heard of anyone (myself included) having a private practice psychiatrist even think of pre-existing medical conditions (thyroid, sleep apnea, vitamin deficiencies, low testosterone, etc) to test for before prescribing. Never.

 

On a related note: I had a doctor recently admit to me that in all of his medical training, he didn't have any training in or even exposure to psychiatry! And yet primary care docs are giving out this stuff like candy! This doctor's admission confirmed what I'd suspected all along: the average family doctor knows as much as (and, in some cases, LESS THAN) the average patient about psych meds. Now THAT is scary!

[compsports]

I don't remember the exact details but I do recall my former internist trying to hijack my psych care from my psychiatrist. I am not sure what led to it. Perhaps I expressed concern about the meds I was on helping or something like that.

 

So he prescribes Effexor XR, which if he had bothered to check was one of my worst experiences on meds.

 

I never took it and after that, I think I saw this guy one more time before I realized I didn't trust him due to this experience. Not that the meds my psychiatrist were prescribing were helping but I felt I was dealing with someone who was trying to out poison the other guy.

 

Regarding medical tests, the first therapist I had several years ago strongly insisted that I see a doctor for a checkup before going on antidepressants. When I procrastinated, she got on me big time which she deserves alot of credit for.

 

This was before the era of checking vitamin levels and fish oil, so nothing was found wrong.

 

CS

[compsports]

""This is why I have a hard time believing psychiatrists when they defend their MDs, saying it's an absolute necessity. Now, I'm willing to accept that it may be useful in a hospital/inpatient setting, but I have never heard of anyone (myself included) having a private practice psychiatrist even think of pre-existing medical conditions (thyroid, sleep apnea, vitamin deficiencies, low testosterone, etc) to test for before prescribing. Never.""

 

I saw 8 psychiatrists in the 90s and not one ever suggested any tests. They all suggested the same crappy drug, Serzone, which didn't work. Actually, it was a blessing it didn't because it ended up causing liver damage.

 

So much for them being medical doctors. I could done just as well with the dart board method.

 

""On a related note: I had a doctor recently admit to me that in all of his medical training, he didn't have any training in or even exposure to psychiatry! And yet primary care docs are giving out this stuff like candy! This doctor's admission confirmed what I'd suspected all along: the average family doctor knows as much as (and, in some cases, LESS THAN) the average patient about psych meds. Now THAT is scary!""

 

As I have previously mentioned on this board, a PMC I was considering seeing essentially said in response to my statements that I was tapering off of meds, "Why, most people on ADs need to be on them for life" Needless to say, I didn't chose him.

 

And according to what you're saying, he probably made that statement knowing less than me. And here he was going to condemn people to a life of meds. Wow.

 

CS

[Eliotsmum]

Interesting......

 

Common culprits include under- or over-active thyroid glands, which can cause depression and anxiety, respectively. Deficiencies of vitamins D, B-12 and folate, as well as hormonal changes and sleep disorders have also been linked to depression.

 

 

My Naturopath asked me to get my b12 and iron tested........she said I was low on both. I am now taking iron, and getting b12 shots for the next 5 weeks. I am also post menopausal (1 1/2 yrs) so my hormones are all over the place. Now I'm convinced that it was not the best time to stop the ADS. I am now on BHRT and 5 mg of Citalopram. I am feeling a bit better....but not 100%. I plan to get myself back into better health, including regular exercise, ( I want to stay at the 5mg of Citalopram) and then start tapering again at a VERY slow rate. I'm going to ask her about my thyroid next time I go in.......

[Altostrata]

It's always a good idea to make sure your body is strong and healthy before trying to withdraw, but how would anyone know that?

[Nadia]

Never, ever has a psychiatrist called for tests. Rather, I've had the opposite experience... a regular doctor refers me to a psychiatrist because they can't find anything wrong. Or in this case, what is wrong, my cortisol level, appears not to be significant.

 

In the end, though... the brain and nervous system are just another organ. Psychiatry is still in diapers compared to other medical specialties, however (not that those are too advanced either). The whole "it's all in your head" take... does it make it any less real??

 

Thoughts DO have an effect on how we feel, and how we feel and what we think has an effect on our overall health, but it also goes the other way. And often it is a complex interplay of brain/nervous system issues with endocrine issues with other systemic issues that is the culprit.

 

For example, I feel like so much of what is happening to me is first a physical thing and then a psychological thing. The doctors all seem to think that I'm stressed and worried THEREFORE I have anxiety and insomnia. And it's true to some extent... real life events and thoughts can spark the anxiety. BUT I feel, right now, that it's going more in the other direction... my nervous system is on the fritz, and that creates some crazy thoughts. But once you're labeled as "anxious" then anything you feel is suspect. For example, the doctor thought my reaction to the amoeaba medication she gave me was "just in my head"... but I'm pretty sure that is not the case (at least not in the conventional way we think of "just in your head", which is an abstraction and separation from the material substrate of our consciousness... it could very well be primarily a BRAIN issue).

 

If I mention the terror feeling when falling asleep, pffft... the clear answer for the doctor is, this person needs to go to therapy and talk these fears out, and maybe get prescribed some Xanax. But for me it is pretty clear that it is not anxiety about my life that is creating that terror, but rather a physical condition... the high cortisol and surrounding out-of-whack mechanisms. Clearly there are issues with how I think and feel about what is going on in my life, and those need to be addressed, but if I were to approach this only from a psychological perspective, I think I would fail miserably.

 

It would be wonderful if psychiatrists called for tests always as a first step. At least they would catch the clear issues of menopause, thyroid problems, etc. But it would also be nice if they did some more subtle checking. There are so many things no one checks for in a regular checkup... and even if they are checked, maybe you fall within a "normal" range, but not normal for you. It would be nice if they did some more fine-tuning... a holistic approach that took everything into account.

[Barbarannamated]

Again, I return to the question "if the disorders that psychiatrists (and other MDs) treat are due to 'chemical imbalances in the brain' (ahem!) and the drugs supposedly (magically) 'correct' those theoretical imbalances, is this not a MEDICAL condition of the brain, similar to epilepsy, Alzheimers, Parkinsons, etc.??? Dealing with same neurotransmitters, correct? Why are these other disorders classified as Neurological MEDICAL conditions, but psych/mental health is a separate entity even though it's in the same head/brain and BODY?!

When did Psychiatry split from Neurology? Used to be same Board, I believe.

I wonder what neurologists think of psychiatry....

RE: testing. It might put psychiatry out of business. Oh dear.

I believe Endocrinologists are, for the most part, aware of dangers of psych drugs, esp AAPs. Are there no protocols for endocrine screening in place anywhere?

ADs used for PMDD... estrogen/progesterone used for mood... Who has the final call on diagnosis being medical or 'psych'?

Cymbalta is labeled for various pain conditions. When used for pain, is it a psych drug or neuro/medical?

My husband does Utilization Review for Work Comp. He's always talking about the treating docs not documenting 'Functional Improvement' with opiates and the abuse/overuse of pain meds, millions of dollars that can be saved, blah blah blah. ADs are frequently used in WC pain patients. I asked him how Functional Improvement is measured w ADs which are far more expensive. He's still scratching his head (trying to get thru that Effexor fog).

Apparently, I'm still in anger stage!

 

Barbarannamated

-DC'd Pristiq slow taper over past year, having protracted WD symptoms

-on SS/NRIs since '93

-DC'd opiates 2008 (prescribed for chronic pain/neck injury)

-still on trazodone 75mg qhs and Klonopin 1mg qhs (initiated in '95 for bruxism, now know caused by SSRIs)

Vyvanse 70mg qam (I say it's for depression; doc documents as ADD)

I have a long way to go....

[Barbarannamated]

I must add....endocrine testing seems to be a mystery in itself. Even Endocrinologists don't all do same testing. Thyroid testing is all over the place: TSH, T3 or 4, free, total, uptake? Did I read REVERSE T3 somewhere? I'm not familiar w that.

My point is that if endocrines don't have set protocol, do we want PCPs and Psychs to attempt?

As Nadia says... PFFFFT!!!

I don't know the answer.

Barbarannamated

[Altostrata]

Here's the answer: All of pharmapsychiatry is bullsh*t. It's the second biggest fraud ever perpetrated, after the collateralized mortgage fraud.

 

With your participation in the pharmaceutical industry, Bar, this may give you pause. It's all snake oil being thrown at people, some of whom are injured by it. The doctors are the marketing and distribution arm of the process.

 

The enormity of this is hard to assimilate, but a growing number of people (such as Dr. Marcia Angell) are becoming aware of it.

[Barbarannamated]

Just saw this message.

I have been officially paused. Many other negative feelings I'm dealing with (GUILT).

[Altostrata]

Well, a lot of people were fooled, don't blame yourself.

 

You've also been a guinea pig for the drugs and a victim, too.

[alexjuice]

I've had doctors order tests. For instance, after putting me on depakote he checked my liver enzymes after some months to make certain his treatment wasn't causing organ failure. In another instance, he ordered a cranial MRI. It came back normal which has good evidence in favor of use of antipsychotics (no brain tumor!).

 

In the beginning, God created... no that's not what I want to say.

 

In the beginning, Doc prescribed...

 

Yes, it's a bit like the old joke Japanese businessman levied at their American corporate counterparts in the 80s. It went like this: How does an American corporation execute a strategy? Always in the same three-step sequence: "ready... FIRE... aim."

 

alex.i

[Barbarannamated]

Bumping. Good article.

 

ETA: my GAWD, I was so hypomanic and obnoxious in earlier withdrawal. My apologies.

[mattinsmom]

I've had a psychiatrist suggest that there may be an underlying medical condition but this was "in addition to" a psychiatric illness. I've never had a pdoc suggest "in lieu of". Pretty much my experience has been that once diagnosed always diagnosed.  Unfortunately, with the new DSM5, everything is a mental illness.