The Endocrinologist's Role on the Psych Floor

Richard M. Plotzker, MD

Our psychiatrists tell me that our hospital now has Philadelphia's largest inpatient psychiatric unit, usually fully occupied. Of the available medical specialties, endocrinology has been by far the most frequently consulted to address problems that arise as the psychiatrists manage the patients' primary illnesses.

For the most part, the endocrine disorders of patients on the psychiatry unit overlap a good deal with what occurs in the office or elsewhere in the hospital, but the unique environment and frequent barriers to routine office care pose special challenges. For instance, there are no IVs for conducting convenient saline suppression tests on hypokalemic hypertensive patients. The antibiotic hand gel is kept behind the nursing counter, for fear that someone might ingest it. And I have pretty much been banned from consulting other specialists after I asked for some assistance from a nephrologist who ordered an extensive lab and radiologic assessment—a routine strategy on the hospital's medical floors but an approach that would exhaust the global per diem fee on the psychiatric unit.

The endocrine population of the psychiatric unit takes a number of forms. Some patients have rare diseases with psychiatric presentations. Some who are transferred from another floor to the psychiatric unit turn out to have steroid psychosis from treatment of chronic obstructive pulmonary disease (COPD).

Then there are the problems generated by drugs commonly dispensed on the psychiatric unit that have endocrine effects. One young person with difficult-to-manage Graves disease developed hypothyroidism when lithium was added to methimazole. Hyperprolactinemia with amenorrhea more commonly is diagnosed in the office but occasionally becomes part of the consultant's review of systems on the psychiatry unit. And because these people are usually quite disabled from their psychiatric condition, they often are taking modern antipsychotic agents that affect diabetes management.

For all the uniqueness of what is encountered medically on our psychiatric units, however, most of the consult requests are for assessment of the "bread and butter" conditions of hyperglycemia, thyroid-stimulating hormone (TSH) abnormalities, and sometimes hyperparathyroidism, the same things that bring the endocrinologist aboard elsewhere in the hospital. What is somewhat surprising is that other specialists are not brought into the patient care loop nearly as much. Of course, psychiatric patients also have angina, COPD, heart murmurs, urinary hesitancy, bowel complaints, insomnia, and arthritis, just like everywhere else in the hospital. But somatic complaints do not generate lab numbers that stare at the providers, demanding action the way an elevated glucose or an abnormal TSH does. Thus, it is the lab work or a history that includes use of anti-hyperglycemic agents that selects out the endocrinologist as the non-psychiatrist responsible for periodic rounds and the need to address some of those unrelated review-of-systems symptoms, because this endocrinologist is often the only consultant.

Although the medical problems seem similar, the needs of these patients often diverge in a way that challenges the best intentions. For a fair number of these patients, whose ongoing behavior makes them unreliable at seeking office care and sometimes eager for their providers to move them along quickly, their days on the psychiatric unit may be the best time to think about their diabetes, not only for calibrating their medicines based on fingerstick glucose levels but also to assess more fundamental needs such as eye and foot care, pedal paresthesias, heart risks, and the like.

There are some restraints on care as well. Psychiatric nurses have familiarity with extrapyramidal effects of common psychiatric medications, but they may not have quite the same ease when dealing with insulin-related hypoglycemia or recognize the achiness from the statins started the week before. Many of these patients depend on other people for their care and often function at the fringes of insurance coverage or even homelessness, which makes expensive or cumbersome interventions unrealistic, even if medically preferable for their condition.

The thyroid needs are also considered differently. TSH values overtly in the hypothyroid range pose little divided opinion on how to proceed. But a less clear-cut value of 7 uIU/mL, which would be repeated before treating in the outpatient setting, becomes a source of discussion in the psychiatric unit. Is it a contributor to depression? Is it a distraction that the various doctors point to as the cause of the behavioral phenotype that prevents more effective therapy? Might it be transient? In a psychiatric unit, you generally do not care. Thyroxine is a whole lot safer and more economical than the stuff being prescribed for the psychiatric disorder, and there is some evidence that depressed patients benefit from thyroid replacement with no downside. Thus, I err on the side of treatment even when I do not expect much benefit to accrue, particularly in the short time of a week or two that that person stays on the unit.

The lesson I have learned from my time on the psychiatric units—a lesson we often forget as we provide care to people in our offices and on our medical floors—is that everyone has a different set of circumstances that forces the type of individualized decision-making that has atrophied over the past years in favor of numerical targets and the standardized protocols that we use to hit these targets. You just cannot put someone on a complex treatment program that carries risk when that person has no reliable ongoing medical care or perhaps even delusions. You cannot obtain MRI for every complaint. You even have to make a special effort to disinfect your hands between patients, because that requires going out of your way to get to the disinfectant.

Perhaps we really should be thinking more about individual circumstances than we do.