Prior to the last decade, the interface between medical and psychiatric disorders was largely discussed as medical conditions that are risk factors for behavioral problems. More recently, however, we are focusing on the ways in which psychiatric conditions are risk factors for medical (physical) disorders.
It still bears reminding ourselves of common medical conditions – and common medical treatments – that can produce a clinical picture that mimics a psychiatric disorder. For example, hyperthyroidism – an overactive thyroid gland – will often cause an individual to complain of feeling anxious, jittery, having trouble sleeping, and losing weight, which may look like an anxiety disorder, if the underlying medical condition is not recognized.
An underactive thyroid gland – hypothyroidism – will present a clinical picture of feeling tired, sluggish, confused, and gaining weight, which might be mistaken for depression. In each instance, it would be a mistake to treat the behavioral phenomena, when the underlying thyroid disorder should more properly be addressed.
Similarly, fluctuating blood sugar levels – seen in diabetes mellitus and hypoglycemia – can produce periods of confusion, anxiety, personality changes, and mood swings. Older treatments for hypertension, such as alpha-methyldopa, were notorious for causing depressive symptoms. Steroids, used to treat a variety of disorders, are associated with mood swings and psychosis.
More recently, Retin-A, a powerful acne medicine, has been associated with cases of clinical depression. Pancreatic cancer, which is often undetected until it is advanced, is associated with symptoms of depression, which may be the first signs of the cancer. Disorders that involve brain structures, such as HIV infections, strokes, brain tumors, head injuries, and seizure disorders, commonly produce changes in mood, personality, cognitive functioning, perceptions and behavior.
From these examples, we see how important it is to consider the patient’s medical status when assessing a suspected psychiatric condition. Ideally, all possible medical conditions – such as those mentioned above – would be tested for or ruled out before any psychiatric treatment would be considered. It is not unusual for a thorough psychiatric evaluation to reveal a medical problem that has been unrecognized by primary care practitioners. In practice, however, it is often difficult to maintain this standard, and psychiatrists generally limit a medical work-up to the most likely problems that must be assessed.
The Medical Side of Psychiatric Illness
Of growing importance, in more recent years, are the medical aspects of psychiatric illness. Since the introduction of modern psychiatric medications in the 1950’s, we have recognized various medical complications that could result from their use. We referred to these consequences as “side effects” or “adverse events,” such as sedation, muscle stiffness, tremors, dry mouth, dizziness, constipation, and others.
These side effects can generally be well managed by adjusting the dose of medications, changing medications, or adding another medication that reduces the side effect. Some psychiatric medications require periodic blood tests to monitor possible toxic effects on liver functioning, kidneys, thyroid, blood cell production, and other normal physiology, that might go unnoticed without these special tests.
Presently, and for the foreseeable future, we are turning our attention to a set of medical problems that we underappreciated for many years. It is common for individuals with a psychiatric condition, taking psychiatric medication, to gain a significant amount of weight. In the past, we attributed this to an improvement in appetite as psychiatric symptoms resolved. Now we can more closely associate weight gain with particular medications, notably antipsychotic medications, although others can produce some increase, as well.
More thorough investigation has revealed that these medications can also cause elevations of blood sugar – which can progress to diabetes mellitus – elevated blood pressure, and elevated triglycerides and cholesterol. These issues contribute to an overall increase in risk factors for cardiovascular disease, which can result in heart attacks, strokes, and death. This constellation of risk factors has become known as the “metabolic syndrome,” and is of concern throughout the general population, for all ages, beyond the psychiatric community.
While it now seems clear that some psychiatric medications increase the risk of certain medical problems, we have also recognized that individuals with a chronic psychiatric condition are at risk for medical complications, independent of treatment.
On average, individuals with chronic schizophrenia have a twenty percent shorter lifespan than people without psychiatric illness. Individuals with chronic psychiatric illness – including schizophrenia and bipolar disorder – are at greater risk of developing many serious medical conditions, such as cardiovascular disease, diabetes, pulmonary conditions, and cancer. We do not yet understand if this is a consequence of poor self-care, neglect, exposure to other risk factors, or some physiologic or genetic connection between physical and mental illness.
Additionally, the above factors, involving the interface of medical and psychiatric disorders, occur in children as well as adults. This raises questions about potential effects on development and long-term consequences.
A Response to Health Risks
At the Jewish Board of Family and Children’s Services, a high priority project is developing programs to assist clients in managing both medical and psychiatric issues. Solutions will address a broad range of services for clients of all ages with diverse needs and support systems. New programs will reach our residential and community-based services as well as our day treatment programs and clinics.
Two new initiatives have already started in our residential programs. In cooperation with the Institute for Community Living (ICL), JBFCS is participating in a grant funded by the New York State Health Foundation to advance best practices in diabetes management.
A new curriculum was developed to assist adults with chronic mental illness in identifying and dealing with issues of obesity, elevated blood sugar, and both type I and type II diabetes.
In our children’s residential programs, an intensive education initiative focuses on obese clients with pre-diabetes, type I and type II diabetes. Exercise and weight loss programs and reward systems are in progress and they are proving effective. In a short period of time, children have achieved significant weight loss, and we are planning new modules to help our clients continue their progress.
Our adult continuing day treatment programs are incorporating components of established “wellness” programs to promote healthy living, in general, and minimize the risky medical effects of illness and medication, specifically. We are considering ways to make the monitoring of weight, blood pressure, blood sugar control, and cholesterol status part of our routine care, even in clinic patients.
Increasingly, the care of individuals with mental health problems also requires a consideration of physical health issues, and demands new efforts to intervene in effective ways. JBFCS will continue to respond to this interplay of needs.