Monday, February 2, 2009

Psychiatrist vs Endocrinologist: Who is Responsible?

Problems within the endocrine system (i.e. with hormone levels) can cause psychiatric problems. Psychiatric medications can cause problems within the endocrine system.[1] So wherein lies the responsibility to test and treat the endocrine problems of children (or adults) with "mental disorders?"

This is not a trivial question, nor an attempt to start an esoteric philosophical debate. The question is being raised out of urgent need, with profound consequences for the well-being of our children.

Often when a child presents with severe psychiatric symptoms, the focus is on quickly alleviating those symptoms with psychotropic medications. Those medications often get added to, changed, more added to... and more symptoms crop up, sometimes as side-effects masquerading as "progression of the illness".

At some point, someone realizes that extensive endocrinological testing needs to be done. Truth be told, even if not to diagnose other ailments, the tests should have been done to at least get baseline values before the psychotropics were ever started.

So who orders the tests? The psychiatrist often does NOT order the tests. After all, they are not endocrinologists. But they ARE M.D.s and since the endocrine system is so often intertwined with psychiatric symptoms, AND the medications affect the endocrine system, should they not order the proper TESTS? Are psychiatrists in the United States not being adequately trained to address these issues as a MEDICAL doctor should? In the United States (not every country is this way), the psychiatrists are not even supposed to touch the patient -- give an exam, to feel if their thyroid has goiter, check reflexes, look at their skin and fingernails for signs of ill-health, and look for other possible neurological and endocrinologic complications.

Perhaps they have spent too many years focused on just the psychiatric symptoms themselves, immersed in treating with the psychotropics and paying no attention to the rest of the body and the endocrine impact. They CAN order tests, at least, but they defer that to other specialists. The psychiatrist assumes that since the endocrine system is involved, an endocrinologist should monitor what is going on in the endocrine system. An endocrinologist is presumed to be the appropriate specialist to run the appropriate tests.

Let's say the child IS sent to an endocrinologist. The endocrinologist is likely to say that since the child is on psychiatric medication, and the psychiatric medications affect the balance of neurotransmitters such as serotonin, dopamine and norepinephrine as well as hormones such as testosterone, prolactin, ACTH, cortisol, thyroid stimulating hormone, thyroxine (T4), and triiodothyronin (T3) among others including hormones affecting hunger, satiety, and even glucose regulation (even "just" antidepressants have some of these effects),  it is therefore the responsibility of the psychiatrist to order endocrine testing as part of monitoring for the side-effects of the given medications.

So the net result, unless the parent is lucky enough to encounter an actual practicing Psychoendocronologist or, better yet, a neuropschoendocrinologist, the child gets left in limbo with insufficient endocrinological testing.

The lucky person gets the thorough endocrine testing prior to the introduction of psychotropics, but here is the catch. Many endocrine problems develop slowly over time and fluctuate. Even getting a partial snapshot of the system at a given time, (like only TSH) -- which is what tends to happen -- can miss what is really going on.

And then once the person is on the psychiatric medications - all bets are off.

IF the parents have enough money to doctor search, travel, or order their own tests, the child may get adequate testing, monitoring, and care. If not... the child, family, and all of society suffers in the long-run economically as tax-payers, as well as emotionally and socially.

So whose responsibility is it?
Ask a psychiatrist and the answer is likely to be "the endocrinologist."
Ask the endocrinologist. The answer is likely to be "the psychiatrist."

That's a problem.

And that was our experience.

But being fore-warned is being fore-armed. KNOWING at least that routine testing is NEEDED while on psychotropic medications such as antidepressant and neuroleptics (antipsychotics) can give us the confidence to INSIST that someone run the tests. If all else fails, find a pediatrician, General Practitioner, Family Doctor, or even an M.D. specializing in Integrative Medicine, to order the tests.

Who knows, it may be the side-effects of the medications themselves contributing to the continuation of symptoms.

Update: It's Not Mental - finding innovative support and medical treatment for a child diagnosed with a severe mental illness
includes information (and an entire appendix) about endocrine testing gathered from Dr. Thomas Geracioti M.D., Dr. Robert Fredericks M.D., Dr. David Marwil M.D. and a few others.

Further Reading:

[1] Side effects blunt antidepressants gains Oklahoma Feb 2, 2009

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29 June 2011


Anonymous said...

The biggest problem is that even if not to diagnose an endocrine problem before starting these antidepressants, mood stabilizers and antipsychotics, psychiatrist in my opinion has a RESPONSIBILITY to get baseline values for everything that these drugs can alter.

That include Fasting Plasma Glucose, CBC, prolactin, thyroid, cortisol and more. They don't tend to do that.

The next problem is that they then do not monitor.

NO WONDER they are not taken seriously as MEDICAL doctors. No wonder insurance companies do not want to pay for them the same as medical doctors!

They need to ACT like real doctors! Their patients are depending on that even if most parents and adult patients don't even realize the shoddy care that is being given.

jejns1 said...

I am going through that exact problem right now with my daughter. She has had pre-mature adrenarche since 2 1/2, sleep problems, insulin ressistance and maybe Dyslexia.
We were sent in the "Bi-polar Disorder" direction. The psychiatrists all ignored the other issues and said her behavior and rage problems were due to a mood disorder. She has never had any degree of stability.
I have had to become a medical researcher myself and we are now weaning her off the psych meds to start from square one the proper way.
Parents are left floundering out there by the "experts".
Fortunately our pediatrician is helping us do this. The system is very messed up

jejns1 said...

My daughter was diagnosed today as having Hashimoto's Thyroiditis. It is an auto-immune disorder which causes the thyroid gland to underfunction and eventually fail. This was found after I had the new Endocrinologist we saw last week test for T4 free, TSH AND Thyroid anti-bodies. Her t4 free level has been at the lowest number (.6-.7) for at least two years. It was only after I re-read all her copies of previous blood tests that it jumped out at me that she seemed to have a thyroid problem.

She was diagnosed with Bi-polar/mood disorder over 2 years ago and now I am wondering how long the thyroid problem has been going on and possibly causing so many mood, sleep and attention problems.

Even if the doctor tells you the numbers are "Not that Bad", which is the phrase I am sick of hearing from doctors, check out the information on your own!

Anonymous said...

The DSM diff dx says 'rule out underlying medical condition' but to a psychiatrist, every behavior outside the proverbial 'norm' is diagnosed and medicated.
I've been treated for depression and chronic pain for 15yrs--w/no relief from depression until Vyvanse (dopaminergic/ADD med). Serotonin made me worse. Lost ALOT of weight over 8 yrs. Psychs and AN ENDOCRINOLOGIST attributed to depression and repeatedly suggested (accused) that I had an eating disorder. 'Eat more '. I eat and eat and eat bad high fat foods to try to maintain wt. At what cost to my heart/arteries, etc.?? Bloodwork will tell.
Went to new brilliant endocrinologist last week. Dx: PANHYPOPITUITARISM- - muliple endocrine failure. Plus a few autoimmune disorders. Will need steroids and multiple hormones replaced for rest of life. Likely began many years ago, possibly genetic component. And I was just getting holistic.
The irony is that I used to be a pharma rep, specializing in psychiatry. Advocated for MH treatment.
I was first relieved to learn of the medical/biological cause that can be measured by labs rather than some vague unmeasurable chemical imbalance treated w drugs whose mechanism 'remains uncertain' and no normal neurotransmitter levels have been identified. Any other class of drug would never pass thru FDA with that paltry data.
The anger is overwhelming that 20+ docs (incl my husband) totally missed this. SCARY. A 5'2" women in 40s doesn't lose 40lbs w/o trying FOR NO REASON. My friends are envious b/c they are gaining wt at this age. HA! I do not recommend my wt loss plan.

Sorry, I digress. The system is a disaster and needs to implode. With all of the technology today, online med records, etc., it seems there is a greater disconnect among physicians.
To surgeons, every disc protrusion means surgery.
Psychiatrists...take a med.
PCPs are so busy that it would take a miracle to catch most endocrine probs.
Who is in charge? It is ultimately the patient who suffers and needs to be educated and empowered. ESPECIALLY the elderly! They often have 'white coat syndrome', intimidated by docs and would not dream of questioning the GodDoc. I've done a bit of PatientAdvocacy work beginning w my parents.

Sorry, off track again. Damn ADD! Or is it the fog created by my whacked out endo system?

Change must happen. My final answer is that psychiatrists MUST screen for endo and other medical issues that cause BEHAVIORAL SYMPTOMS prior to giving ANY med. The psychotropics can alter brain chemistry WITH JUST ONE DOSE. I've experienced it in a profound way. SS/NRIs cause permanent changes. Google 'SSRI DETOX'. I found more info than I could wrap my head around. 'Just' JOKE. They are the most insidious offenders b/c they are perceived as safe and are handed out like candy.

How many docs inform their pts that by taking ADs even for short time will send them directly to high risk insurance category? IF they can get insurance at all. Life Insurance>> excluded if you've been diagnosed with or treated for depression. OR put into very high risk pool.

Anonymous said...

@jejns1. Great that you caught that! There is quite a bit of med lit on thyroid/mood as you've likely discovered. Peter Whybrow, MD, psychiatrist at UCLA does alot of work in this area. He is a wonderful man. Several books published for lay persons.
I find it interesting that the out of box physicians are NOT US born and educated. Australian, E. European, Far East (that one is obvious!). Is the US that behind in medical care? Statistics DO show that schizophrenia and other DSM diagnoses are rapidly increasing with more treatments available in 'advanced countries' as opposed to 3rd world countries w less treatment.
Peter Breggin, MD, has written extensively on topic. Also check out Icarus Project, MindFreedom, Safe Harbor, Robert Whitaker (altho I disagree w his approach).

Best to you w your son. KUDOS to you!

Anonymous said...

Just one last thought....

DSM-5 is in the works. I recently tried to find the reason that a separate diagnostic system and codes are used for 'Mental Illness' when the ICD (INTERNATIONAL) coding system ALREADY includes the psych diagnoses?
** WHY, if these are treated as chemical imbalances, are they not called 'Neurochemical Disorders' or similar? 'Mental illness' is a horrible term and should be banned.

I learned that the DSM is a fabrication of the American Psychiatric Association and used in US only (I believe). To have a guide to aid in DIAGNOSING is reasonable. However, the DSM codes are used for billing, immediately flagging psych patients in insurance systems (I surmise). ALSO, most insurers use 3rd party vendors to administer behavioral health benefits. WHY??

Just food for thought. I don't know the answers.

Anonymous said...

Psychratic and endocrine disorder symptoms are co related..I had anxiety ocd bdd.. my psychratist never told me all this and given medication which caused several side effects.. then he also said to consult endocrinologist and as curious I did consult and unnecessarily took hormone injections.. though the problem was not in my endocrine. . Then after going in loop I changed my Psychratist and confrimed that all problems are due to anxiety..butbi wasted lots of money in the loop and hormone injections.there are lots of psychratist who dont know how to evaluate their paitents. .

Anonymous said...

My sister was misdiagnosed as bi-polar with panic disorder when she actually had Grave's Disease. Once they destroyed her thyroid gland and put her on synthroid, she was able to get her life back together. She hasn't had a panic attack or severe depression since. When she was finally diagnosed, the doctor told her she could have had a heart attack if they hadn't eventually realized it was hyperthyroidism. She still has to take beta blockers.