from the Experts at the Norman Parathyroid Center
Interesting stories of hyperparathyroidism we see every day. Parathyroid blog published bi-weekly.
A guest Parathyroid Blog by a leading psychiatrist that regularly finds people sent to her office with symptoms due to high calcium and hyperparathyroidism that was overlooked by the referring doctors. It is extremely important for your mental health doctor to make sure you don’t have high blood calcium or some other medical problem that is the cause of the mental health symptoms. This guest blog is by Sarah Keiser, M.D. a Board Certified Psychiatrist.
For most people, seeing a mental health provider is more distressing than seeing any other doctor. As a psychiatrist, most of my patients are referred by other physicians. Often, I am the last stop for people who are in mental distress and have already “failed” treatments given by their primary care doctors. If you are reading this, you could be one of these patients. For physicians, a psychiatry referral can be the “last resort” for their patients complaining of things like, depression, anxiety, irritability, fatigue, pain, or difficulty sleeping. These physicians throw up their hands saying, “I can’t figure out what is going on, it must all be in your head.” Psychiatry and mental health are legitimate areas of evidence-based medicine which have serious impacts to your physical well-being. It is a gross injustice to label something as a mental illness when in actuality it is a medical illness harming you. It is the psychiatrist’s job to catch the medical illness, such as hyperparathyroidism, when previous doctors have overlooked it.
If you have been referred to a psychiatrist, it is important that you go to the appointment well informed and have specific goals you want met. In order to do that, I want to draw back the curtain and invite you to see how a good psychiatrist should approach your referral. Make sure you identify all the “red flags” in this article – these are things that cue me to look for a medical disease (such as hyperparathyroidism) rather than a true psychiatric diagnosis. If you have many of these “red flags,” you may have been misdiagnosed and may have a medical illness causing your symptoms. The good news is that many medical illnesses, such as hyperparathyroidism can be treated or cured, typically leading to curing of your mental health symptoms.
1) Why did your doctor refer you to the psychiatrist? What are you and your doctor concerned about?
It’s amazing how many patients and their physicians can’t answer that question! People know that they don’t feel well, and their doctors know that their patients don’t feel well, but the doctors haven’t been able to find a cause. Patients usually are previously diagnosed with “anxiety disorder” or “depression.” They often haven’t responded to multiple medications and, in frustration, have been sent to me–the psyciatrist. If your doctor is sending you out of his office with a referral to see a psychiatrist, take the time to ask why you are being referred. Your doctor needs a specific consult question to be answered (as do you)! A bad example of a referral is a doctor sending a “40 year old male with anxiety and depression who has failed SSRI treatment.” A good example would be a “40 year old male, well known to me, who was previously functioning well and had no history of mental illness, who, 4 years ago developed insidious fatigue, muscle pain, and hypertension who has not responded to two 6 week trials of both Celexa and Zoloft. Please evaluate patient for depression and provide treatment recommendations.” The doctor would then proceed to inform me of all diagnostic work-up thus far. You and your doctor need to be on the same page as to what symptoms you have (is it fatigue, or is it depression, or is it a combination), when they symptoms started, all of the tests that have been done, and the results of those studies. Ideally, you would have a copy of your records that you have reviewed, and a referral letter.
Sometimes, the patient provides a different history (and more accurate) than their doctor. This can be harmful! If your doctor reports misinformation in your chart, future bad doctors will not take the time to find out the truth and go by what is reported in the chart (we term this “chart lore”). So, for example, if you have had 8 months of elevated calcium labs, and the doctor reports in his chart it was a “one time elevation,” the endocrinologist might decide (wrongly) that it was a “lab error.” Unbelievably, some doctors don’t listen to their patients and take all their history from the chart. Or, when they document the visit, they don’t remember specifics and look to the previous chart for (wrong) information. It is highly recommended that all patients get a copy of their lab tests. Things like high blood calcium are overlooked all the time!
2) Make sure you have all your previous medical, social, psychiatric history – and that of your family too!
A detailed history should be obtained by any physician; this is rule number one and one of the first things taught in medical school. If a patient reports a strong family history of anxiety, then chances of them also having anxiety is high because of genetics. It is a “red flag” if a patient reports no family history of mental illness. This does not mean that Generalized Anxiety Disorder (GAD) can be ruled out, however, the chances that something else medically could be causing their symptoms are higher. Also, medications that work for one family member usually work for others, so another “red flag” is if the patient has tried the same medications as their brother with no relief of symptoms. Psychiatric medication is very effective when utilized correctly, and is one of the most effective drugs in a physician’s armamentarium – often more effective than other medications used to treat other illnesses, such as antibiotics!! If you have not responded to multiple trials of psychopharmacologic medications, this is a “red flag!”
Most psychiatric illnesses are apparent by young adulthood. It is a “red flag” if the patient is 50 years old or older and they have never had psychiatric treatment before. Also, I always assess a patient’s coping mechanisms, which can be another “red flag.” If a patient has previously coped well with adversity, they likely will in the future. For example, if a patient suffered the death of her daughter ten years ago without experiencing depression, then the chances that she will develop “out of the blue” depression at age 60 is very unlikely. However, if you are medically ill, your previous effective coping mechanisms cannot overcome the illness. (They can help you, but they will not stop fatigue, for example.) This is a VERY common presentation for primary hyperparathyroidism. Often the patients will state: “I’ve been fatigued and/or depressed before–this is different. I’m not depressed–something else is going on!”
3) What is the concluding mental health assessment and/or diagnosis?
If your psychiatrist concludes that you have General Anxiety Disorder (GAD) or Major Depressive Disorder (MDD) on the first visit, without ruling out medical causes – they are wrong!! Even worse, if they give you a more complex diagnosis, such as fibromyalgia, or chronic fatigue, or a personality disorder, then they are even more wrong (these are nuanced diagnoses that take time to establish – i.e. more than one visit). I cannot emphasize that enough. Almost all psychiatric diagnoses are diagnoses of exclusion! This means that all medical causes must be ruled out before a psychiatric diagnosis can be given (and if your primary care doctor diagnosed a mental illness, they should follow the same rules). This means that the psychiatrist should get vitals (such as blood pressure, pulse, respiratory count, weight) and should be ordering blood work. Common labs psychiatrists draw are blood counts, chemistries, thyroid hormone levels, and possibly other labs to investigate inflammatory conditions or illnesses. For example, there are many other causes of fatigue other than depression, such as low red blood cells, high blood calcium, poor ventilation, viral illness, etc. Number two rule taught in medical school is to have a reason and plan for whatever test ordered; if I am ordering a Vitamin D, I want to know why I am ordering it, what I will do if it is low, what I will do if it is normal, what I will do if it is high, and the rationale for all of these results. Doctors too often make the mistake of ordering a test, and then treating the test result without ever figuring out the reason for the abnormal result (we call this “chasing a lab value”)! For example, hypercalcemia is not a diagnosis, it is a lab value. Therefore, it cannot be a diagnosis in and of itself. You have done enough reading at parathyroid.com to know what this lab abnormality means in almost every case!
Number three rule taught in medical school is to find a unifying diagnosis for all the symptoms. So, if you have 5 symptoms, you should not be given 5 diagnoses. If your unifying diagnosis is decided to be Major Depressive Disorder (MDD), make sure it can explain all your symptoms! (For example, the pain of depression is different than the bone ache type of pain of hyperparathyroidism.) Once a medical condition has been ruled out or treated, then the psychiatrist can provide a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders (DSM). Specific criteria must be met. You can see the criteria for GAD on Wikipedia here, and here for MDD (Note: the newest DSM version is DSM-5, however most people are still using the last version, DSM-IV. The main criteria for these two disorders have not changed in either version.)
I feel I must repeat the previous paragraph because it is so important. Read it again, and then come back here. We all worry, we all get down. This is not a mental illness. It must be impairing your functioning in life to be a mental illness. General Anxiety Disorder (GAD) must have worries that are pervasive and interfere with most of your day. You cannot escape them. Major Depressive Disorder (MDD) must have persistent low mood AND loss of pleasure or interest for at least two weeks! Why is this important? Most people with hyperparathyroidism feel tired, fatigue and depressed, but it usually does not cause them to completely give up on life. Instead, in people with high blood calcium and hyperparathyroidism I hear things like, “I love going to my grandkid’s soccer games, but I’m just too tired.” Or, “I used to love working in the garden, or working crossword puzzles, but now I just don’t feel like doing any of the things that I used to love to do”. That means there is fatigue, and some loss of interest, but not usually a complete loss of interest in everything. “I worry that my health is declining so rapidly, what am I going to be like in 10 years?” This can be a rational worry stemming from your body telling you something is wrong, which is an adaptive anxiety not to be ignored.
Can people have both an anxiety disorder and hyperparathyroidism at the same time? Can people have both major depression and hyperparathyroidism at the same time? Yes. However, if GAD or MDD showed up after your physical health started declining, and you have no prior history of mental illness, more than likely your GAD and MDD will go away after parathyroid surgery. If you continue to have symptoms or new symptoms after the surgery, you can be re-evaluated. Psychiatric medications are not able to cure the symptoms of hyperparathyroidism. Similarly, if you were on effective medication for depression and anxiety before you became ill with hyperparathyroidism, those medications will no longer be effective. We are our worst selves when sick. In fact, the process of being sick and being misdiagnosed can be so devastating, you actually CAN develop a psychiatric diagnosis of Post-Traumatic Stress Disorder, which I see frequently in patients who had adverse medical journeys. The process can be stressful, and this is where a psychiatrist can be useful. You do not need a psychiatric illness or be on psychiatric medication to get the care of a psychiatrist! (Amen sister! — editorial comment).
4) What is the treatment plan? Treat a disease, not a symptom!
Number four rule taught in medical school is to treat a disease, not a symptom. Doctors commonly chase symptoms, just like they chase lab values, and this is wrong. The most common mistake we see for hyperparathyroidism is that the doctor treats the low vitamin D level instead of figuring out why the vitamin D is low (over 95% of patients with hyperparathyroidism have low blood vitamin D). There are times when treatment might begin before a solid diagnosis can be decided upon; however, a treatment goal should be established and at some point a diagnosis must be given (a unifying one for all your symptoms: see medical school rule #3!). This means you and your doctor should know what “being well” (i.e. cured, in remission, etc.) will look like before you start treatment; all physicians should be practicing with an aim for remission. This also gives metrics for tracking your progress. I use different tools to do this, sometimes I use self-report scales, sometimes I use other methods, but the most reliable and accurate method is asking the patient. I often say this phrase: “On a scale of 0-100, when you were at your worst, what number was it, and where are we now?” Most patients can tell if they are 25% better, 60% better, etc., and sometimes I’m surprised by their answer!
Make sure your psychiatrist has answered all of your questions, and you both have arrived at a common goal. More often than not, the plan should involve getting labs or other studies, obtaining releases to talk to other people that might aid in diagnosis, and setting a follow up appointment. Sometimes a medication will be prescribed, even if there is something medical causing your illness, and this is by and large acceptable. Just make sure that you know the reasoning behind it being prescribed – a good doctor should always consent you on the risks and benefits and alternatives of the treatment plan. A good doctor should also be willing to hear your thoughts and be open to their assessment and treatment plan being challenged. A good doctor will welcome second opinions, especially if those opinions follow standards of care and evidence-based treatment. Ideally, a good doctor will apologize when they make mistakes. Finally, a good doctor should be open to feedback and want to learn and grow with their patients. Your relationship with your doctor should be a dialogue. A doctor-patient relationship is intimate and it is important that you feel comfortable, and most patients know by the end of their first appointment if they like a doctor. Not all doctors fit all patients, and patients should not be afraid to change doctors and find a doctor they trust.
Dr Sarah Keiser can be found online at the Riverview Family Psychiatry Clinic where she practices in Wisconsin Rapids, Wisconsin.
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Sarah Keiser, M.D. is a Board Certified Psychiatrist. She completed her medical training and residency at Georgetown Medical School and George Washington University in Washington D.C. She now lives in a rural area in Wisconsin Rapids, Wisconsin where she established the Riverview Family Clinic Psychiatry outpatient clinic. As a physician, Dr. Keiser is a trained diagnostician and works with her patients to uncover the biological, psychological, and social factors influencing their symptoms. She treats the whole patient utilizing her skills in psychopharmacology and psychotherapy. She listens to her patients’ goals, and they arrive together at a cohesive treatment plan. She is eager to collaborate with other providers to enhance patients’ health. She promotes mental health understanding and education, both within the physician community and for the public.