So you’re conducting an interview with a patient in your clinic or office setting and you’re up against the clock when it comes to doing a thorough, systematic mental health evaluation. The allotted time for the session is ticking away and you’re wondering whether the patient you’re seeing has a medical disorder that is influencing or responsible for at least some of the psychiatric symptoms you’re observing. Well, there are specific red flags indicating that you’re definitely dealing with something medical.
I have long been an advocate of “think medical first,” so signs of overt confusion manifesting in an inability to fill out your intake form, failure to accommodate and assimilate your assessment questions, lack of insight, psychotic features or obvious physical irregularities such as a shuffling gait are all reliable from a medical perspective. But many of your patients may not have such symptomatic presentations, so you’re then left with thinking beyond the DSM to keep the possibility of a lurking medical disorder top of mind, at first.
Let’s begin with depression — which is a disorder we commonly see in our practices. Start with considering age of onset. Are you working with a 25-30 year old, or someone say 70 or older? What about family history of mental illness, specifically depression? Although there are always exceptions, if I’m working with a 25-30 year old reporting a first episode depression accompanied by physical symptoms such as sleep irregularity, weight fluctuation or GI symptoms, I’d be inclined to conclude that these symptoms are associated with biological changes that often accompany true clinical depression. On the other hand, if my patient is age 70 or older, without a family history and it’s a first episode, I’d be thinking and asking about specific sleep disorders, (sleep apnea, restless legs), underlying malignancies, arthritis or endocrine disorders such as diabetes or hypothyroidism. In either age group, carefully inquire about the severity of symptoms.
As for the thyroid disorders, regardless of age, I’d ask about any changes in feeling especially hot or cold, weight gain or loss, constipation, drying or coarsening of skin or hair, nail cracking and fatigue. Hypothyroidism classically is linked to depression, but in older subjects especially, hyperthyroidism can also be indicative of depression.
As for anxiety symptoms or disorders, pheochromocytoma – a rare type of tumor of the adrenal glands that can release high levels of epinephrine or norepinephrine – may mimic panic-type symptoms or accelerated feelings of anxiety. More commonly, though, anxiety episodes can be associated with partial seizure disorders, so always inquire about seizure history.
And then there’s continuity of care. It’s always important — when working with a patient where possible medical conditions may be an issue — to emphasize that the individual should discuss these matters with a primary care physician or other specialist.
But there will be times when you feel the complexity or severity of the concerns may not be something the patient can adequately convey. So although time is short all around, picking up the phone and having a one-on-one conversation with the PCP to ensure that he or she is aware of what may be going on is always best.
Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.
To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.