Outpatient Tests and Labs in Psych

Psych Management
Psych Team

To continue with the topic of labs in psych, part II goes over some implications of abnormal labs in the manifestations in psych. Yes, more work that no one has time for. Overall, many people don’t do what they’re supposed to do. That’s patients and medical providers so we can’t lose sleep over it. However, having to weed out the red flags can be tiresome but this is why I believe this post is important (so yes it includes ranting). I’ll start with 2 case studies: 

The Preschooler Mysteries

AB is 4 y/o and I decided to get a psychological test done because of increased difficulty in behaviors and family hx. The testing came back positive for ADHD but the physician did some additional testing and found some brain dysfunction suggesting epilepsy. The testing also included a sleep study and AB was diagnosed with sleep apnea but otherwise, healthy. The parent was upset because she felt like if we haven’t done the testing, they wouldn’t have found more problems. I expressed to the family that problems are best treated in early childhood and suggested getting a second opinion from a neurologist. AB never had a seizure and brain structures don’t determine a seizure disorder. I still was able to start ADHD medications and use clonidine and guanfacine as well and now AB is thriving in class and at home. 

Key Points: 

  • If a test, sleep study, or any test finds an anomaly, get a SECOND opinion. The doctor put epilepsy in the ADHD testing results but that requires treatment and/or a follow-up. Sometimes patients don’t know or realize that it’s in their right to get a second opinion and more specifically have a specialist involved. So it was frustrating to let this parent know that this super thorough evaluation is somewhat incomplete to diagnose a seizure disorder but good enough to start treating the learning issues… 
  • All tests are not created equal. Some of the psychological tests are very detailed like the one AB had and others are vague. The parent was actually angry about a past substance hx and thought it was related, not wanting to let the child know at this time…I reassured the family that I don’t think that was the issue and encouraged them to ask the doctor to refer them to a specialist. The point here is to NOT lose focus on treating ADHD, or the main mental symptom/condition.  
  • Furthermore, document these interactions, your recommendations/compliance, etc. Whether the family followed your plans or not, documentation shows at least abnormal things (especially for a test I ordered) were addressed. Plus it’s hard to remember these random outliers. 

The Wrong Recommendation

JD is a 28y/o with multiple neurological/autoimmune symptoms hx of depression. He was diagnosed with Sjogren’s syndrome, in which a prestigious facility recommended literally prescribing an “anti-depressant” cyclobenzaprine (Flexeril) or amitriptyline (Elavil) for his migraines. Yes, they actually put that in discharge papers. I was shocked and just irritated. I don’t prescribe cyclobenzaprine or the hospital should’ve done it since they think the “antidepressant” would’ve helped. Plus, I explained to JD that a TCA will make his Sjogren’s syndrome worse. He was already on an antidepressant but wasn’t having depressive symptoms. The facility just didn’t want the responsibility…

Key Points 

  • Again, stick to what you’re treating. Psych providers don’t treat migraines, autoimmune disorders..etc. but we don’t want to make anything worse. JD wasn’t depressed but just frustrated with her MEDICAL care. It’s not a big deal for me to do refills, but with scheduled medications i.e. cyclobenzaprine, pain meds, or muscle relaxers, I wouldn’t start them or do refills. This is not a pain clinic or get ready to be on a slippery slope. Overall, it’s simply not our scope, and pain, autoimmune, neurological patients, etc. NEED specialized care. 
  • Stick to the Zebras (i.e. SSRIs). I did genetic testing with JD and he had multiple interactions as I already suspected. If you don’t want to do genetic testing just know to be careful with people who have autoimmune issues. They may already have kidney or liver issues or be on MANY medications, that could limit what you can prescribe so try to avoid the unicorn meds. You don’t want to cause another hyperimmune response or risk metabolic complications, so consider the risks vs. benefits. About poor response to medications and adverse reactions.  
  • Lastly, my collaborative physician is aware of my many crazy situations. Not that I needed an orientation but the number of social issues in community mental health can be overwhelming. Many things aren’t covered anymore, specialists aren’t readily available or MIA, and everyone passes the buck and just wants YOU or anyone with a pulse to fix everything. You DESERVE to vent to someone.

Lab Testing

I hope that technology continues to help with brain injuries like CTE but with psych disorders, there’s no radiographic diagnostic testing. However, abnormal blood levels can manifest psych symptoms and should be addressed.  So think of labs as a way to possibly diagnosed and treat certain moods/symptoms. This does not mean ordering every lab under the sun nor does everyone needs lab testing. Here are a few factors that I usually don’t consider testing:

  • If someone has been stable on the medications with no major issues 
  • If I’m weaning the medication or it’s been so short-term, it shouldn’t cause big changes 
  • For people who regularly go to the doctor or get health checks, I simply ask was anything found abnormal…etc.   
  • Other considerations with labs   

Sorry for all the ramblings, I gave the following 2 case studies above to express how we have to look beyond the psych disorder or as usual, the WHOLE clinical picture. So here are some important considerations about lab levels: 

Vitamin B12 <500 should be treated: functional insufficiency can cause a lack of neurotransmitters. Folate and a B12 level don’t reflect the problem, the body has to convert it instead of floating around or there will be an increased risk of nerve-related disorders. Homocysteine levels help point out chronic B12 functional problems. B9 (methylmalonic acid) and B12 assess chronic deficiencies that determine if you have to replace them with functionally active vitamins like IM shots versus natural or nutritional replacements.  B12 is difficult to measure adequately, as 50% of people with deficiencies have normal or high B12 serum levels:

  • High Homocysteine (>15 mcmol/L): can contribute to arterial damage & blood clots. Indicates deficiency in B-12 or folate deficiencies correlates with nerve health i.e. neural tube defects.
  • High Methylmalonic Acid (>.40 umol/L): chronic biological folate deficiency. May have symptoms such as (brain fog) cognitive impairment, confusion, irritability, MDD, anxiety, peripheral neuropathy, swelling, and yellowing of the skin or eyes.
  • Low B12 (<250 pg/mL): caused by inadequate intake, intestinal malabsorption, low gastric acid levels (antacid use), lack of intrinsic factor, and others.
  • High serum B12 (>900 pg/mL): suggests a functional deficiency from defects in tissue uptake & action of B-12 at the cellular level. High serum B-12 levels can be caused by solid cancers, hematologic malignancies, liver & kidney disease (& excessive supplementation).

–NIH

Vitamin D (25-hydroxy) consider treating if <60-70: Vit. D is a nerve hormone and is related to other hormone levels such as the thyroid. Kids/adolescents need a higher amount due to growing. Older/Elderly need lower amounts of Vitamin D because of kidney stone risks.

Iron Levels: total iron-binding count (TIBC) with  % saturation, which is the most sensitive for anemias, ferritin level (stored iron) –if low, your body is not storing it properly but if high, it can mean chronic inflammatory issues. Anemia has been associated with mood symptoms.

RBC Magnesium and Zinc level (RBC intracellular mineral is the best indicator): low Mg+ levels are commonly associated with migraines, pain disorders, insomnia, anxiety, and irritability. Regular levels (outside the RBC) can be inaccurate from the body constantly shifting it around.

Extra Considerations: here are some additional considerations to check out with labs or if you have abnormal psych symptoms:

  • Heavy Metals: r/o possible cognition, dementia/memory problems.
  • Highly sensitive C-reactive protein (hsCRP): measures inflammation in blood vessels which correlates to mood disorders such as depression and anxiety.
  • Full Thyroid Panel: hypothyroidism signals the brain to produce more TSH. Most labs define “normal” as 0.5–4.0, but patients can have clinical symptoms of hypothyroidism with a TSH level <4. Free T3 is the most important measure of thyroid function r/t measuring the free and active thyroid hormone. Low free T3 levels are usually the most common causes of low thyroid or hypothyroidism. Also, check the thyroid panel for antibodies r/t Hashimoto’s. 
  • Testosterone: males; low-levels r/t cannabis use, opioid pain medications, obesity (will make more estrogen vs testosterone). For females with high levels of testosterone or ruling out PCOS, the patient should be referred to an endocrine specialist. A PCOS diagnosis is mainly based on a variety of symptoms (the transvaginal US is no longer diagnostic because cysts on the ovaries can come/go) and managed via specialist/OB/Primary.
  • Iodine: low serum levels of iodine affect more than the thyroid function, it can cause symptoms such as weight gain & learning difficulties, and preventable brain damage. If T3 is higher in relation to the normal range and the T4 is lower than its normal range, then it may indicate an iodine deficiency due to the T3 stealing the T4 to make an active hormone while the TSH is >2.5, thus look at the thyroid levels with the iodine lab results.

In Conclusion 

Yup psych is a lot of work. Many clinics and providers are not this super thorough because most of the time, we are getting slammed. How can we get around most of this?? Truly promoting preventative care. With most adults and especially kids recommend vitamins, healthy living, avoiding junk food/sugars, etc. For example, if my patient is pale or with heavy cycles, I ask the person to NOT keep neglecting meat or take certain vitamins and f/u with the PCP. The above implications mainly showcased how certain labs can cause psych symptoms and be treatable. Not to dig around and find the problems. Also, be mindful that these lab tests or treatments can easily lead to spending hundreds and thousands of dollars that the patient usually can’t afford. My next post is about supplements, I usually try to promote complementary health however anything extra and major, continue to encourage the patient to f/u with the doctor.

Additional References and Resources  

functional lab work

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