"Not in my wheelhouse" specialization problem

[birchswing]

If this is asking for medical advice, shut it down.

I am a bit frustrated with how balkanized my medical care is. I have a PCP, psychiatrist, cardiologist, and psychologist. Because of the amount of time the psychologist has to see me each week I feel like he's the only one who knows what's going on with me.

When I see my psychiatrist, we have fifteen minute appointments and she takes personal phone calls (I know people will say I should find another psychiatrist, but she's the best I can do). It seems like we only have time for refills and only a minute or two at most for strategy on how to make the next cut in my benzos. But as one frustrating issue, for example, I have secondary hypogonadism (and I just sunk to a new low of 82). I don't know why. I've asked her before whether it could be from my medications and she tells me that it's not in her wheelhouse. I am researching all these things and I found some evidence that SSRIs over the long-term (I've taken then since 15 and I'm now 32) can damage the hypothalamus. I find a little bit of evidence for each drug I take that shows it could affect the HPA axis. I do all this research but at the end I get frustrated and feel like I might as well go to medical school to find out what's wrong with me. I'm debating the long-term safety of Clomid vs. exogenous testosterone—not to mention that my PCP didn't even know Clomid treated low testosterone. And I'm also wondering whether it's better just to wait it out and go down on my meds and hope my testosterone returns naturally, but I don't know if the meds are the cause or not. My PCP who is addressing the testosterone issue doesn't know about the effect of the psych meds either. There's also the issue of my dysautonomia, which my psychiatrist is uninterested in. I've even shown her in session how just standing up my pulse goes to the 160s and she is nonplussed. It just feels like my care is very non-comprehensive. I've heard the expression "not in my wheelhouse" more than once.

I know you all can't give advice, but more generally what should a patient be able to expect in terms of one doctor sort of taking ownership of a variety of issues across different body systems? I would just like really simple information like whether my psychotropic drugs could possibly or likely be the cause of having "in the toilet" testosterone (as my PCP calls it) along with really low LH and FSH. It would help me make a decision about whether to treat the low testosterone or be even more motivated to get off more of my meds. But the psychiatrist says testosterone isn't in her wheelhouse, and the PCP says the psych meds aren't in his wheelhouse. I think a less involved patient would just take the exogenous testosterone, but I'm a once bitten twice shy type of person now. I want to know the cause of a problem and I want to make informed choices. So, I guess I am wondering what is reasonable to expect in terms of advice across disciplines?

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[Bartelby]

A very good PCP might be the closest you would get to a one-stop-shop. Your psychiatrist should be able to offer an opinion about whether a given medical effect is likely a side effect of your psych meds, although they may refer for more testing or even a consult (such as endocrine) before saying anything with certainty. Unfortunately to dabble in dysautonomic disorders or endocrine disruption as a psychiatrist is pretty high risk and low reward--- if the psychiatrist is right in a given workup she has taken ownership of a non-billable problem that will be quite difficult for her to manage (given unfamiliarity). If she is wrong, she opens herself up to liability for practicing outside of her scope. Overall it's kind of a lose-lose, hence the frustrating piecemeal care in our current highly specialized system.

 

[doctorpilgrim]

SSRI effect/association on hypothalamus pituitary axis is well studied, its clinical relevance is not well established IMHO. Bartleby has made an astute observation. An endocrinologist will be the one best suited for your question.

 

[birchswing]

A very good PCP might be the closest you would get to a one-stop-shop. Your psychiatrist should be able to offer an opinion about whether a given medical effect is likely a side effect of your psych meds, although they may refer for more testing or even a consult (such as endocrine) before saying anything with certainty. Unfortunately to dabble in dysautonomic disorders or endocrine disruption as a psychiatrist is pretty high risk and low reward--- if the psychiatrist is right in a given workup she has taken ownership of a non-billable problem that will be quite difficult for her to manage (given unfamiliarity). If she is wrong, she opens herself up to liability for practicing outside of her scope. Overall it's kind of a lose-lose, hence the frustrating piecemeal care in our current highly specialized system.

Yeah, my PCP is pretty good. He's very humble when it comes to the psych meds and likes to defer to the psychiatrist, though, when it comes to such specific questions about could this med be doing this.

SSRI effect/association on hypothalamus pituitary axis is well studied, its clinical relevance is not well established IMHO. Bartleby has made an astute observation. An endocrinologist will be the one best suited for your question.

Yup, I'm on a waiting list for an endocrinologist. I do see things online about the SSRIs and also benzos and the HPA axis but I really don't understand it.

 

[heyjack70]

Endocrinologist all the way. The difficult thing is they are few and far between. It could be that despite an extra 2 year fellowship (3 years maybe?) they make the same on average as a general internist.

 

[hamstergang]

This is related to why I'm against the concept of psychologist prescribers. I'm sure they can be taught how to appropriately manage medications in many cases (in which field of medicine can't this be done with reasonably intelligent and hard working people?), but they really will be specialized. At least from going through medical school, we psychiatrists have learned about these other systems and been exposed to them. Starting the basic work-up here, knowing when to make the referral, and reading/understanding papers written about our meds interacting with other systems are all things we should be able to do thanks to our broader education.

 

[birchswing]

This is related to why I'm against the concept of psychologist prescribers. I'm sure they can be taught how to appropriately manage medications in many cases (in which field of medicine can't this be done with reasonably intelligent and hard working people?), but they really will be specialized. At least from going through medical school, we psychiatrists have learned about these other systems and been exposed to them. Starting the basic work-up here, knowing when to make the referral, and reading/understanding papers written about our meds interacting with other systems are all things we should be able to do thanks to our broader education.

It doesn't seem to me, at least in my experience, that psychiatrists schedule appointments long enough to take on a multi-displinary approach. And in my experience they haven't been terribly interested in anything except the problems that are psychiatric (I consider myself lucky if they are interested in that)--my psychiatrist didn't even want to write that I have Tourette's on a form I had to have filled out. It didn't really matter, but she said something to the effect of that being a neurologist's purview (which it might be to some extent, but I think when you have psychiatric disorders and Tourette's they don't need to be separated). I've also found I have had to be the one to ask for blood tests related to medications I take. I'm sure psychiatrists would always order blood tests for lithium, for example, but I was once called a "spaz" for wanting a blood sugar test due to being on Seroquel and having had weight gain. I can see your point, though, that a psychiatrist has a broader medical education. I have developed a greater fondness for the idea and potential of psychiatry as a field, but to reach some of its aims would require doctors having more time with patients.

The thing about my psychologist is that an hour of time once a week feels very significant. I feel very much like he knows me; he's attentive. We actually spend a good deal of time talking about my medical issues and prioritizing things and even coming up with ways to be more effective during appointments with my psychiatrist, which is a bit of an art-form. I have to suppress quite a bit to make it as productive as possible in the time-frame I have. I don't want my psychologist to prescribe, but I would be very happy if he were able to communicate with my psychiatrist, which he has tried to over the years. I feel like he might have a short-hand way of describing how he sees me and they might be able to be more constructive teaming up together. He has told me, however, that she just doesn't return calls. He said that isn't unusual, for her or for most psychiatrists he's tried consulting with. He is beneficial in how much he has pushed me on the benzo issue reminding me that it has been a goal of mine since I met him. And that is helpful because when I see my psychiatrist, she would be content to just have me check in and check out with a refill if I weren't the one wanting to make changes. So in a way my psychologist does help with the medication.

 

[heyjack70]

It doesn't seem to me, at least in my experience, that psychiatrists schedule appointments long enough to take on a multi-displinary approach. And in my experience they haven't been terribly interested in anything except the problems that are psychiatric (I consider myself lucky if they are interested in that)--my psychiatrist didn't even want to write that I have Tourette's on a form I had to have filled out. It didn't really matter, but she said something to the effect of that being a neurologist's purview (which it might be to some extent, but I think when you have psychiatric disorders and Tourette's they don't need to be separated). I've also found I have had to be the one to ask for blood tests related to medications I take. I'm sure psychiatrists would always order blood tests for lithium, for example, but I was once called a "spaz" for wanting a blood sugar test due to being on Seroquel and having had weight gain. I can see your point, though, that a psychiatrist has a broader medical education. I have developed a greater fondness for the idea and potential of psychiatry as a field, but to reach some of its aims would require doctors having more time with patients.

The thing about my psychologist is that an hour of time once a week feels very significant. I feel very much like he knows me; he's attentive. We actually spend a good deal of time talking about my medical issues and prioritizing things and even coming up with ways to be more effective during appointments with my psychiatrist, which is a bit of an art-form. I have to suppress quite a bit to make it as productive as possible in the time-frame I have. I don't want my psychologist to prescribe, but I would be very happy if he were able to communicate with my psychiatrist, which he has tried to over the years. I feel like he might have a short-hand way of describing how he sees me and they might be able to be more constructive teaming up together. He has told me, however, that she just doesn't return calls. He said that isn't unusual, for her or for most psychiatrists he's tried consulting with. He is beneficial in how much he has pushed me on the benzo issue reminding me that it has been a goal of mine since I met him. And that is helpful because when I see my psychiatrist, she would be content to just have me check in and check out with a refill if I weren't the one wanting to make changes. So in a way my psychologist does help with the medication.

This is therapy. Or what sort of sounds like therapy. Though not really therapy. It sounds like your psychologist is advocating for you and that's great. You are probably one of 25 therapy patients the psychologist sees each week. So he/she is able to spend lots of time with you. And could you imagine what would happen if every psychiatrist cut their practice down to 25 total patients whom they met with each week? There would be no access. Not to say your psychiatrist is doing a great job or anything, but you are seeing extremes of mental health treatment, with a full hour of weekly 'therapy' on one hand and a focused medication visit on the other. I would prefer to have 30 minute appointments as a psychiatrist, but that may not keep the lights on.

In regards to a patient needing endocrine or neurology referral, it may not make sense for the psychiatrist to be the hub for sending out referrals because that's more the PCPs domain. But, I think a psychiatrist should be coordinating with a PCP and at the very least making the PCP aware of non-psychiatric medical concerns and suggesting referral to these other specialists.

 

[birchswing]

This is therapy. Or what sort of sounds like therapy. Though not really therapy. It sounds like your psychologist is advocating for you and that's great. You are probably one of 25 therapy patients the psychologist sees each week. So he/she is able to spend lots of time with you. And could you imagine what would happen if every psychiatrist cut their practice down to 25 total patients whom they met with each week? There would be no access. Not to say your psychiatrist is doing a great job or anything, but you are seeing extremes of mental health treatment, with a full hour of weekly 'therapy' on one hand and a focused medication visit on the other. I would prefer to have 30 minute appointments as a psychiatrist, but that may not keep the lights on.

In regards to a patient needing endocrine or neurology referral, it may not make sense for the psychiatrist to be the hub for sending out referrals because that's more the PCPs domain. But, I think a psychiatrist should be coordinating with a PCP and at the very least making the PCP aware of non-psychiatric medical concerns and suggesting referral to these other specialists.

I see your point. Drives home the importance of initial psychiatric care being high quality and thorough (stitch in time saves nine). I think that in a number of cases the frustration of short med checks is a result of a path dependency that originated with initially poor care. Fitting in a lot of patients and setting them on the wrong path just results in a need to continue to fit in a lot of patients to fix mistakes of the past, and if the appointments don't result in much change, it seems like a lot of busyness without a lot of effectiveness. That's obviously not the case with the psychiatrists on this forum who seem very conscientious, and I know initial consults are usually longer (in my case my very first initial consult was not). I don't want to jaywalk down memory lane, but my own experiences are such that I feel I was set on a bad path, and I find that even when trying to get on a better path now, there is a frustration when there isn't enough time, or my psychiatrist isn't terribly interested in things I believe to be relevant like like hormones.

More generally, I guess you could ask, why do psychiatric patients need to see their psychiatrists so often? It does seem like the visits for most patients are fairly frequent compared to other specialties.

 

[PikminOC]

I see your point. Drives home the importance of initial psychiatric care being high quality and thorough (stitch in time saves nine). I think that in a number of cases the frustration of short med checks is a result of a path dependency that originated with initially poor care. Fitting in a lot of patients and setting them on the wrong path just results in a need to continue to fit in a lot of patients to fix mistakes of the past, and if the appointments don't result in much change, it seems like a lot of busyness without a lot of effectiveness. That's obviously not the case with the psychiatrists on this forum who seem very conscientious, and I know initial consults are usually longer (in my case my very first initial consult was not). I don't want to jaywalk down memory lane, but my own experiences are such that I feel I was set on a bad path, and I find that even when trying to get on a better path now, there is a frustration when there isn't enough time, or my psychiatrist isn't terribly interested in things I believe to be relevant like like hormones.

More generally, I guess you could ask, why do psychiatric patients need to see their psychiatrists so often? It does seem like the visits for most patients are fairly frequent compared to other specialties.

Hi risk patients. Lots of med changes to get them optimized. Not every med works the first time. You meet psychologist weekly and psychiatry needs to get your meds right too.

 

[PikminOC]

It doesn't seem to me, at least in my experience, that psychiatrists schedule appointments long enough to take on a multi-displinary approach. And in my experience they haven't been terribly interested in anything except the problems that are psychiatric (I consider myself lucky if they are interested in that)--my psychiatrist didn't even want to write that I have Tourette's on a form I had to have filled out. It didn't really matter, but she said something to the effect of that being a neurologist's purview (which it might be to some extent, but I think when you have psychiatric disorders and Tourette's they don't need to be separated). I've also found I have had to be the one to ask for blood tests related to medications I take. I'm sure psychiatrists would always order blood tests for lithium, for example, but I was once called a "spaz" for wanting a blood sugar test due to being on Seroquel and having had weight gain. I can see your point, though, that a psychiatrist has a broader medical education. I have developed a greater fondness for the idea and potential of psychiatry as a field, but to reach some of its aims would require doctors having more time with patients.

The thing about my psychologist is that an hour of time once a week feels very significant. I feel very much like he knows me; he's attentive. We actually spend a good deal of time talking about my medical issues and prioritizing things and even coming up with ways to be more effective during appointments with my psychiatrist, which is a bit of an art-form. I have to suppress quite a bit to make it as productive as possible in the time-frame I have. I don't want my psychologist to prescribe, but I would be very happy if he were able to communicate with my psychiatrist, which he has tried to over the years. I feel like he might have a short-hand way of describing how he sees me and they might be able to be more constructive teaming up together. He has told me, however, that she just doesn't return calls. He said that isn't unusual, for her or for most psychiatrists he's tried consulting with. He is beneficial in how much he has pushed me on the benzo issue reminding me that it has been a goal of mine since I met him. And that is helpful because when I see my psychiatrist, she would be content to just have me check in and check out with a refill if I weren't the one wanting to make changes. So in a way my psychologist does help with the medication.

Would you be willing to pay for more time?

 

[Ceke2002]

I do understand your frustration, I have a few physical health issues, on top of the mental health stuff, and until I got all the proper diagnosis in place, and a treatment plan worked out it felt like I was spending two thirds of my life running back and forth between Doctor's appointments. The thing is though if you want all the proper diagnosis and treatments in place then you actually want the Doctor who'll say 'Not in my wheelhouse', and refer where necessary, not the Doctor who'll just sit there and hand wave 'Oh yeah, that sounds like *insert whatever condition'. I know I'm lucky as well in that my Psychiatrist does therapy so I don't have to see a separate therapist, but at the same time he's not my one stop treatment shop, and that goes for my GP as well. My GP can monitor/take notes on my mental health status, and liaise with my Psychiatrist, but it's not his area of treatment; my Psychiatrist can monitor/take notes on physical health status, and liaise with my GP, but that's not his area of treatment. For example I have mild-moderate Gastroparesis (delayed gastric emptying) and in order for that to be properly diagnosed and treated I had to see someone for whom 'Gastroparesis' was in their 'wheelhouse' - once the diagnosis was made, and a treatment plan set in place, then my GP could take over and administer said treatment plan, but before that the symptoms I was experiencing could have matched any number of conditions that needed specialist diagnosis so 'not in my wheelhouse' was absolutely the correct response for my GP to give. Just recently, starting from around November last year, I had a major Gastroparesis flare up - almost constant nausea, struggled to keep much of anything down, dropped around 12 kilos (26 pounds) in 4 months, etc - which culminated in me almost passing out as I was leaving my Psychiatrist's office after a session ('Thanks Dr __, I'll see you next...hey look a door frame, let me just grab onto this'). Now of course he took care of me in that moment, I mean it's not like he waited until I'd actually passed out and then just rolled me out the way, but at the same time he didn't suddenly turn into a GP or a Gastroenterologist - he was aware of what was going on, he kept note per session of how things were progressing, he knew what sort of monitoring/tests my GP had ordered, and when I had the presyncope episode he ran through a quick check list of other tests he thought might need consideration, but at no time did he take over any of my treatment in this area because he would have been giving me a half-ar5ed deal if he did, considering the letters after his name stand for "Fellow of The Royal Australian and New Zealand College of Psychiatrists", not "Fellow of the Royal Australian and New Zealand College of Things I'm not Actually Properly Qualified to Treat'. So as frustrating as it is to hear, plain old incompetence or laziness aside, those Doctors that are telling you 'Not in my wheelhouse' are probably the ones who are trying to do right by you.

I hope things get better. Hang in there, okay.

 

[birchswing]

Would you be willing to pay for more time?

Yes. I've offered to pay for e-mail and phone support between sessions (my psychiatrist doesn't communicate between appointments). Also, when I was looking for another psychiatrist I did reach out to a psychiatrist who had a self-pay practice, which I was more than happy to do. Unfortunately he closed up shop and started working for a hospital. I can try asking my psychiatrist about setting up longer appointments. It's hard to be fit in as it is, but I can see what she says.

 

[birchswing]

I do understand your frustration, I have a few physical health issues, on top of the mental health stuff, and until I got all the proper diagnosis in place, and a treatment plan worked out it felt like I was spending two thirds of my life running back and forth between Doctor's appointments. The thing is though if you want all the proper diagnosis and treatments in place then you actually want the Doctor who'll say 'Not in my wheelhouse', and refer where necessary, not the Doctor who'll just sit there and hand wave 'Oh yeah, that sounds like *insert whatever condition'. I know I'm lucky as well in that my Psychiatrist does therapy so I don't have to see a separate therapist, but at the same time he's not my one stop treatment shop, and that goes for my GP as well. My GP can monitor/take notes on my mental health status, and liaise with my Psychiatrist, but it's not his area of treatment; my Psychiatrist can monitor/take notes on physical health status, and liaise with my GP, but that's not his area of treatment. For example I have mild-moderate Gastroparesis (delayed gastric emptying) and in order for that to be properly diagnosed and treated I had to see someone for whom 'Gastroparesis' was in their 'wheelhouse' - once the diagnosis was made, and a treatment plan set in place, then my GP could take over and administer said treatment plan, but before that the symptoms I was experiencing could have matched any number of conditions that needed specialist diagnosis so 'not in my wheelhouse' was absolutely the correct response for my GP to give. Just recently, starting from around November last year, I had a major Gastroparesis flare up - almost constant nausea, struggled to keep much of anything down, dropped around 12 kilos (26 pounds) in 4 months, etc - which culminated in me almost passing out as I was leaving my Psychiatrist's office after a session ('Thanks Dr __, I'll see you next...hey look a door frame, let me just grab onto this'). Now of course he took care of me in that moment, I mean it's not like he waited until I'd actually passed out and then just rolled me out the way, but at the same time he didn't suddenly turn into a GP or a Gastroenterologist - he was aware of what was going on, he kept note per session of how things were progressing, he knew what sort of monitoring/tests my GP had ordered, and when I had the presyncope episode he ran through a quick check list of other tests he thought might need consideration, but at no time did he take over any of my treatment in this area because he would have been giving me a half-ar5ed deal if he did, considering the letters after his name stand for "Fellow of The Royal Australian and New Zealand College of Psychiatrists", not "Fellow of the Royal Australian and New Zealand College of Things I'm not Actually Properly Qualified to Treat'. So as frustrating as it is to hear, plain old incompetence or laziness aside, those Doctors that are telling you 'Not in my wheelhouse' are probably the ones who are trying to do right by you.

I hope things get better. Hang in there, okay.

Yeah, that's a good perspective. It's better to have someone tell you that they don't feel comfortable enough to give an expert opinion rather than to make one up. Very true.

 

[PikminOC]

Yes. I've offered to pay for e-mail and phone support between sessions (my psychiatrist doesn't communicate between appointments). Also, when I was looking for another psychiatrist I did reach out to a psychiatrist who had a self-pay practice, which I was more than happy to do. Unfortunately he closed up shop and started working for a hospital. I can try asking my psychiatrist about setting up longer appointments. It's hard to be fit in as it is, but I can see what she says.

there's liability in that communication

 

[birchswing]

there's liability in that communication

Where I live there are these large healthcare groups that have hospitals and outpatient practices; I'm not sure what you call them. In my area the big ones are Sentara and Riverside. My PCP and cardiologist each work for one of those, and they have web portals where I can send e-mail and see my test results, etc. They usually respond within 12-24 hours. My psychologist is in private practice but he gives out his e-mail and cell phone. He is big into the frame, so he will acknowledge receiving an e-mail, but anything I write is saved for session. My psychiatrist works for a small group practice, but it's not part of a larger group. For some reason those larger outfits like Sentara and Riverside don't have outpatient psychiatric services (although they do have inpatient beds). Anyhow, it seems like the trend is for these larger organizations to automatically provide e-mail access to patients but it's more variable with private practitioners. The self-pay one I was trying to see had a price list that included phone calls and e-mails. The psychiatrist I currently see does no communication at all between appointments. It's either 911 or an appointment.

 

[splik]

Where I live there are these large healthcare groups that have hospitals and outpatient practices; I'm not sure what you call them. In my area the big ones are Sentara and Riverside. My PCP and cardiologist each work for one of those, and they have web portals where I can send e-mail and see my test results, etc. They usually respond within 12-24 hours. My psychologist is in private practice but he gives out his e-mail and cell phone. He is big into the frame, so he will acknowledge receiving an e-mail, but anything I write is saved for session. My psychiatrist works for a small group practice, but it's not part of a larger group. For some reason those larger outfits like Sentara and Riverside don't have outpatient psychiatric services (although they do have inpatient beds). Anyhow, it seems like the trend is for these larger organizations to automatically provide e-mail access to patients but it's more variable with private practitioners. The self-pay one I was trying to see had a price list that included phone calls and e-mails. The psychiatrist I currently see does no communication at all between appointments. It's either 911 or an appointment.

larger hospitals usually have HIPAA compliant systems specifically for electronic communication which people in smaller group or solo private practices dont have. there can be HIPAA or other confidentiality issues around the use of email, and the information regarding psychiatric consultations can be more sensitive that for other medical stuff. also these portals, the messages often aren't directly sent to the provider, they are read by the front desk staff and then routed to us. The other issue is what happens if you get a patient sending you an email saying they are going to kill themselves at 2am and you just happen to be checking your email at that time?

I have had patients ask if they could send me suicide notes through ecare "because I would want you to know" (!)

I actually do allow some patients to contact me through email, but only if I know they can be responsible, and they sign a disclosure noting this isn't confidential and they won't use email for any emergent issues (such as suicidal ideation) and will not expect a response outside of 8am-5pm M-F. But I only do this with a minority of patients and where I think this is the most effective way of facilitating communication.

 

[birchswing]

Would it be beyond the bounds of this site's framework to ask if there is recent research on which psychiatric drugs can affect testosterone production? I again asked my psychiatrist and got an "I don't know" regarding whether any of my meds (Seroquel--low dose, Paxil, Ativan, Valium--low dose, as a step down from Ativan) could be responsible for my low testosterone (which is a change from her previous stance that they couldn't affect testosterone). I keep finding people mentioning that psychotropic drugs lower testosterone (for example, this shows up when you do a Google search on urologists' websites), but it doesn't specify which psychotropics are implicated. I found one source that explicitly linked SSRIs, but the conclusion of that study was that it "raised more questions than answers." My PCP wants to go ahead and treat with testosterone exogenously, so I probably will do that. He told me today he has never seen anyone in the male species with a total testosterone as low as mine (82). I am just frustrated at not knowing the cause, and if a psych med could make me that ill, I would prefer to taper it, rather than just treat the disease-state it's causing. Starting hormone replacement therapy at 32 and facing it for life seems unappealing, although at the moment it seems necessary as well to protect my bone health, etc. I am still waiting to hear back from an endocrinologist's office about being seen, but I can't imagine that the endocrinologist will know more about the effects of psychiatric meds than a psychiatrist would. I started Ativan and Paxil back in 1998. I don't know if they have followed people like me who have been on these drugs this long to see what happens--especially the Paxil. I found this study from 1999:

http://www.mental-health-today.com/rx/testos.htm

I noted that they didn't find any other unifying factors in the people they tested. It sounds like there weren't other abnormalities, which is the same for me. I have never had an abnormal CBC or CMP, never had thyroid issues (which have been checked every single way possible). I just have this one, really huge outlier. And the low testosterone does match many of my symptoms, but many of those symptoms are the same for long-term benzo use, as well (and maybe for long-term Paxil and Seroquel use—I'm less aware of what those symptoms would be if any—having been on all of them contemporaneously I can't tell which symptoms come from which, but long-term benzo use has been very well studied compared to Paxil and Seroquel, and the symptoms of long-term benzo use match mine).

However, it was a really small study and is quite old. I couldn't find any follow up studies for the same issue. But I don't have access to any university databases at the moment. Does anyone know of any more recent research on psychiatric drugs and testosterone? It would help a lot to know specifically which one(s) are implicated. I also wonder if it could be the benzos. I haven't seen anything explicitly linking them, but I regularly see that long-term benzo use leads to generally poor health (not indicating in which way). Testosterone is low in people with chronic illness (diabetes, cancers, etc.). Maybe long-term benzo use, to the extent that it causes generally poor health, is a chronic illness that the body responds to in the same way with regard to testosterone. The frustration is that I'm conjecturing and not knowing. The risk of starting TRT is that it does shut down the body's endogenous testosterone production and reduces fertility. I've read cases of men having difficulty even regaining their original low-testosterone levels after discontinuing TRT and becoming infertile. It seems like people take TRT rather lightly, and I do know the risks of not treating it, but it would be so much more ideal to find and then eliminate the cause of low testosterone.

EDIT: I found a citation in an article that suggest the citation includes information on SSRIs and hormonal changes:
Gitlin MJ. Psychotropic medications and their effects on sexual function: diagnosis, biology, and treatment approaches. J Clin Psychiatry. 1994;55:406-413.

 

[smalltownpsych]

I almost wish that the doctors here could answer this question, but I am thinking it is asking for medical advice. Unfortunately, the biochemical-neurological-behavioral-psychological-pharmaceutical-environmental interconnectedness and complexity leads me to believe that if they were to answer truthfully it would be to say, "we don't know". Although usually MDs say that in a highly technical way and focus on what they do know and state it very confidently.

 

[michaelrack]

Antipsychotics (D2 blockers) can raise prolactin, which can lower testosterone. High dose SSRI's can sometimes cause dopamine blockade

 

[birchswing]

I almost wish that the doctors here could answer this question, but I am thinking it is asking for medical advice. Unfortunately, the biochemical-neurological-behavioral-psychological-pharmaceutical-environmental interconnectedness and complexity leads me to believe that if they were to answer truthfully it would be to say, "we don't know". Although usually MDs say that in a highly technical way and focus on what they do know and state it very confidently.

I used to do tech support for Apple. The same was true there, as well. You are measured on how fast you can handle the call, whether you can upsell (AppleCare), and on customer satisfaction. The first two work against the third. And often you can't help the customer at all. The motto in our training was, "Fix the customer, then the problem." Implicit in that is that we sometimes couldn't do the second. There were people much better at it than me. Sometimes people can enjoy being bull****ted too, and there were some people who were very good at that. There is also the aspect of having a lot of procedures you have to follow on a call (documenting things, following SOPs, making sure you're not giving away service that should be paid) while making it seem to the customer like you're having a casual, friendly conversation. I guess that's the same in medicine, as well.

Antipsychotics (D2 blockers) can raise prolactin, which can lower testosterone. High dose SSRI's can sometimes cause dopamine blockade

Thanks. I just went back through my records and my prolactin was tested and was normal. But that is interesting to know about antipsychotics and SSRIs.

 

[michaelrack]

birchswing, here are 2 articles that may be of interest: http://www.ncbi.nlm.nih.gov/pubmed/24399720
http://www.ncbi.nlm.nih.gov/pubmed/24286389

 

[birchswing]

birchswing, here are 2 articles that may be of interest: http://www.ncbi.nlm.nih.gov/pubmed/24399720
http://www.ncbi.nlm.nih.gov/pubmed/24286389

Thank you very much for these. The second article is interesting in that it demonstrates lower testosterone associated with depression in women and increasing after antidepressant treatment. I am curious how that would apply to men, in whom testosterone is the primary sex hormone. Would also be interesting to know their estrogen levels before and after treatment. My lay inductive understanding is that testosterone works in men similarly to how estrogen works in women (my understanding of such is based on the lack of each causing similar problems).

The first article is a bit more difficult for me to understand. All I could gather is that the metabolization of antidepressants in the liver is somehow measurable through or related to testosterone, or that testosterone helps with the metabolization? It's a bit outside my wheelhouse.

EDIT:
I found this:
http://www.researchgate.net/publica...zodiazepine_receptors_in_the_female_rat_brain

It seems to say that testosterone treatment in rats decreases the number of benzodiazepine receptor sites.

This is really spitballing here, but what if it were such that in order to compensate for benzodiazepine tolerance, there are adaptations the body makes to increase the number of benzodiazepine receptor sites or at least to preserve them--and that those adaptations include a change in testosterone levels.

I have seen some men say that going on TRT just to get to normal levels causes anxiety. Again, just spitballing.

 

[michaelrack]

I just briefly looked at the abstract of the first article, it seemed to suggest that some antidepressants affect the metabolism- blood level- of testosterone, although this was not the point of the article.

 

[smalltownpsych]

Connection to anxiety is interesting. After all fear and aggression are closely related both psychologically and neurologically in the amygdala and aggression is linked to testosterone levels. Another factor is some patients are afraid of aggression because of their history and something that would make them angry causes fear instead. Others are conditioned to replace fear with anger they have the opposite effect. Females tend to have the former and males the latter. Research points to biological and cultural and family factors.

 

[birchswing]

I got a very nice e-mail from the endocrinologist I'm scheduled to see. Since I can't get in for a couple months more, I asked if I could e-mail and I actually already had access to e-mail her through the portal system. She wrote back a very detailed e-mail. She said she sees a lot of patients on Paxil and has not noticed an associated decrease in testosterone. She said older antipsychotics were more likely to cause increased prolactin and thus decreased testosterone, but given that my prolactin was normal it's likely not the cause unless it's an idiosyncratic reaction to it. She mentioned that untreated anxiety itself decreases testosterone. She had a lot of good info. I didn't realize they would be so familiar with psychiatric meds.

 

[birchswing]

I came across this if anyone is curious:

http://www.ncbi.nlm.nih.gov/pubmed/9373701

Apparently it's well known that alcohol abuse lowers testosterone. This study looked at hormonal improvement during and after detoxification. May be relevant to benzodiazepine use, as well, since they function somewhat similarly.