Many medical issues can cause or exacerbate psychiatric issues and can interfere with potentially effective treatments. For example, as we saw in the above cases, neurological and endocrine issues can interfere with psychiatric treatment or can causes psychiatric symptoms.
When I see a patient for depression or anxiety, I am always thinking about whether there could be an underlying medical issue either causing or exacerbating the psychiatric presentation. My differential is influenced by the patient’s overall symptoms as well as medical history.
Here are some tips to always consider when seeing someone with anxiety or depression.
1. ALWAYS THINK MEDS!!!- Here is a partial list of the medications that can cause depression: antihypertensives, Parkinson meds, antibiotics (even the common ones like cipro), H2 blockers, SSRIs (can often cause dysphoria, especially in patients with ADHD or who are elderly), steroids, muscle relaxants, narcotics, sulfonamides, interferon, and sustiva.
2. Hypogonadism- Suspect this in the male patient who is complaining of new onset depression which came on gradually and when there was no past history of family history of depression. Checking a total testosterone is helpful but only part of the story. A total testosterone can often be normal even when the free testosterone is abnormal. Always check a free testosterone. Suspect hypogonadism if the patient is cold even in the spring and summer, if there is a decrease in overall sense of well being, and if there is a decrease in sex drive from the baseline. Low testosterone is not normal, even in an older patient and treating this can make you a hero in the eyes of your patient.
3. Hypothyroid, hyperthyroidism. Abnormal thyroid levels are very common and screening for this is essential. Treatment is extremely effective but the patient must realize that it can take months to “kick in”. I had one patient on the inpatient unit who became suicidal when her Synthroid didn’t help her mood. No one told her that it could take months for the treatment to be effective. Also, I like to be a pretty aggressive when replacing the thyroid. People use different TSH levels but one of my former mentors at Mass General Hospital, Dr. Jonathon Alpert, recommends to treat anything TSH that is above 6.1 rather than the typical 20 used in most labs as abnormal. I have had excellent results when I headed his advice.
4. Always think OVARIAN CANCER with women. Ovarian cancer is awful and kills patients. Often, one of the first symptoms of ovarian cancer is depression and it can precede the diagnosis of ovarian cancer for many months or even years before the cancer is discovered and when treatment for the cancer is too late.
5. Restless Leg Syndrome, Periodic Leg Movement and Sleep Apnea-Often patients who have restless leg syndrome, period leg movement, or sleep apnea don’t think to discuss this with their internist. However, these illnesses can disturb sleep and with the sleep deprivation, depression and anxiety can occur. In addition, RLS can be precipitated or exacerbated by the SSRIs, atypicals antipsychotics, antidopamine medications such as Reglan, and by the MAOIs. Thus, ask you patients if they have a creeping sensation in their legs or if they kick their bed partners. Many doctors treat RLS with Requip, and an additional and very effective treatment is Klonopin or a small dose of an opiate. This is off label of course. Always ask the patient if they feel tired during the day and if the bed partners ever complain about kicking or snoring. Have a low threshold of referring the patient to neurology, ENT or a sleep study. I have several high quality specialists who I trust, so if you need a referral, feel free to send me an email.
This is a short list of items to consider when a patient presents with depression or anxiety. If you ever have any questions about whether medications or an illness may be causing or exacerbating a psychiatric issue, please reach out and call or email me.