Labs in Psychiatry

A few bits you should know

When I went to school I found that there wasn’t a big emphasis on lab values and because of that they weren’t really a focus of my study and learning. What is interesting is that when it comes to passing a class, you will be alright focusing on what is “high yield” aka what is sure to be covered on the test. Nobody was ever that mad about missing 2-3 questions on a tough test, but still finishing with an A.

Unfortunately in the real world, we aren’t taking tests we are working with real people’s lives which means that consistently missing 2-3 questions equates to patient mismanagement. This is especially true if questions are missed due to lack of focus on subject matter due to focusing on what is “high yield.”

This is all to say: we don’t get to focus on just what is high yield, we need to be competent and working towards mastery in every aspect of the field. We should also be looking to have a better understanding of peripherally relevant fields of medicine.

With that said, let’s talk about labs.

TSH: What is TSH… it is thyroid stimulating hormone. It is released by the pituitary gland and triggers release of thyroid hormones. When TSH is elevated that means that thyroid hormones are down. When TSH is down, that means that the thyroid hormones are up and this could be labeled as hyperthyroidism… So why do PMHNPs monitor TSH?

Because alterations in thyroid hormones can induce psychiatric symptoms such as depression, fatigue, decrease in mood and energy levels. Alternatively they may also cause increased energy, rapid speech and restlessness. In this way alterations in thyroid hormones can mimic depressive or manic episodes.

Sodium:

it is important to monitor for hyponatremia because it is a side effect that can occur with some psychiatric medications, particularly antipsychotics and antidepressants.

Hyponatremia is a condition where the sodium levels in the blood become abnormally low (<135). This can lead to a number of symptoms such as headache, nausea, confusion, seizures, and in severe cases, coma. Monitoring for hyponatremia is important in order to identify and treat this condition early, as it can be life-threatening if left untreated. I have personally seen pts admitted to a level 1 psych facility under the guise of “psychosis” when in fact the patient was experiencing severe hyponatremia. Imagine missing that & treating said patient with something like Zyprexa… YIKES

Ammonia:

This one is particularly important in the context of etoh detox. WHY?

Hyperammonemia is a condition in which there is an elevated level of ammonia in the blood. Ammonia is a waste product that is normally removed from the body by the liver. Heavy alcohol use can keep the liver preoccupied with metabolizing said alcohol rather than ammonia leading to hyperammonemia. This can affect the functioning of the brain and lead to changes in mental status.

Hyperammonemia can cause a wide range of neurological symptoms, including confusion, disorientation, memory problems, and changes in consciousness, such as lethargy or coma. It can also lead to behavioral changes, such as irritability, agitation, and delirium. In severe cases, hyperammonemia can cause serious brain damage and even death. An insufficient understanding of hyperammonemia and it’s presentation in the context of alcohol w/d could lead to mismanagement and assumption of DT’s and incorrect treatment.

There are also medications which may affect ammonia levels, such as Depakote. Monitoring for this condition is important to ensure prompt treatment and to prevent serious consequences for the patient's health and well-being.

Lipids, hba1c and weight:

Psychiatric medications can affect lipid levels, HbA1c, and weight in different ways, depending on the type of medication and the individual's response to it.

Regarding lipid levels, some psychotropics, such as antipsychotics and mood stabilizers, have been associated with an increased risk of elevated cholesterol and triglycerides. These medications may interfere with the metabolism of lipids, leading to their accumulation in the bloodstream.

HbA1c is a measure of long-term blood sugar control and can be influenced by the use of some psychotropics, such as antipsychotics and antidepressants. These medications may alter insulin sensitivity and glucose metabolism, leading to an increase in HbA1c levels.

Regarding weight, many psychiatric medications have been associated with weight gain. Antipsychotics, mood stabilizers, and some antidepressants are particularly known for their potential to cause weight gain. This can be due to a variety of factors, including changes in appetite and metabolism, as well as the sedative effects of some medications.

It's important to note that not all individuals who take psychotropics will experience these changes, and the extent to which they occur can vary widely from person to person. However, monitoring of lipid levels, HbA1c, and weight is crucial for individuals who are taking psychotropics, as it can help identify potential problems early and allow for appropriate intervention.

There’s more… but it is late & I will write an update another time. Sorry for the double posts in one night. But it had been too long since the last few posts. Also expect a part 5 for the “Managing Depression” series.

DISCLAIMER

This is not Medical Advice and while the writer believes what he has shared, substack dot com does not equate to strong evidence. Please do not treat patients based on what is read in this post, these are opinions of an internet stranger. Instead use these posts as a starting point for furthering your own study & education.