Few questions as an psychiatry intern

[phantasmagoric]

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Hello all,

I am currently a PGY1 at a psychiatry program. Over the last few months, I have accumulated a few questions particularly when it comes to inpatient/CL psychiatry.
I have brought up these topics in some capacity with my attendings, but would still appreciate further/alternative insights from this forum.

Thank you very much in advance!

1) In the inpatient/CL settings, how might we conceptualize when we might want to order labs for Vitamin B12, Vitamin D, HIV, Syphilis etc.? Can we generalize it as when the patient has a mental status change and/or encephalopathic presentation, in addition to having risk factors (e.g.vitamins when they may be mal-nourished)?

2a) How do you approach the decision to stop or continue medications inpatient/CL setting if a patient presents with an overdose? If we believe that the medication would be at a supra-therapeutic level based on the HPI, do we stop the offending medication or also other hepatically metabolized medications in order to give it "hepatic washout/vacation"? Would this apply if the patient overdosed on something that is not a psychotropic e.g. Tylenol? Do you refer to LFTs at all to inform this decision at all?

2b) In terms of restarting, I've learned that if we want to continue the medication that the patient ODed on, we would give it 2-3 half-lives of the overdosed medication before restarting it and other psychiatric medications. If we didn't want to continue the medication, we would restart the other psychiatric medications after waiting for 5 half-lives of the overdose med. Is this consistent with your practice and do you check LFTs to see downtrend before restarting psych meds?

 

[Bartelby]

For the #1 labs if they haven't been checked recently and the person is delirious without a clear cause, I think it's worth ordering. They are low yield but important to catch if they are playing a role.

For #2 I would wait for 2-3 half lives. I would also make sure there is no clinical evidence of an ongoing toxidrome: EKG is fine, labs are fine, mental status is normal, no clear complications / side effects from the overdose persist. Beyond that, there will likely be an IM or toxicology team following and I would make sure they are comfortable with resuming. As an aside, poison control is also an amazing free resource that will give excellent advice about overdose, what to watch for, etc.

 

[lobstar]

1) Typically based on presentation which is hard and why you're in residency. There's no 100% rule really. Random 40 yo delirious guy rolls in off the street with no reliable history -- would probably do all the things, even CSF and heavy metals would make sense here potentially. 85yo had hip surgery 2 days ago baseline living independent and getting own groceries without issue, now confused you can skip the HIV, syphilis and things. Malnourished- yeah get the vitamins and HIV and things. Some people do vitamin D for depression but I'd argue no one is admitted to a psych ward or general medicine because their vitamin D is low. Can help optimize malnourished people but won't fix the actual problem. I think getting an altered mental status lab and imaging bomb on everyone is overkill.

2) if they won't be on CL long I defer to the inpatient team that will be getting them. Like you said mainly for washout and so inpatient that will see them for weeks can have control of it. However, it depends on the patient. If BPD, I often hold nearly everything. If someone had an attempt from actual MDD with psychosis or something I'll start SSRI and antipsychotic whenever toxicology or medicine or whoever thinks it's safe. It's often a risk benefit weighing. I'd be hard pressed to restart a TCA or bupropion after serious overdose without tremendous collateral saying it's the only thing that helped and even then it's dicey and might not do it. If it's a personality problem and they took 5 days worth of sertraline or whatever and barely need medical observation even, I'd probably do some rough half life calculations to wait for normal levels to restart--assuming the med is even indicated. If it's not indicated, like 3 antipsychotics in BPD I use the OD as the opportunity to not restart.

2a) yeah gotta do the math, make sure toxicology, hepatology, whoever think it's safe too if a serious overdose. I don't think 2-3 half lives is a rule to follow. If someone takes #30 of sertraline 200 mg that's 6000 mg. Then is 3000, then 1500, then 750 mg left at 3 half lives. I don’t know why we would start then rather then waiting for blood levels similar to treatment levels for actual diagnoses which in this example would be like 5 half lives. Sure check LFTs and things if you want I suppose but any serious overdose will have appropriate medical teams doing that and I defer to them. Even the taking 800 mg sertraline OD the ED team will probably have rough guidance for someone coming straight to psych.

I don't know why we'd have to wait 5 half lives of sertraline after OD to restart Haldol, naltrexone, a benzo, etc. I don't follow that rule either.

Overall I think these are tough clinical scenarios for an R1 since there aren't many 100% rules. Sure you could do the no thinking policies of all OD must admit to psych for 48 hours, stop all meds every time, wait 5 half life every time but I think most docs are skilled enough to do a better job than that.

 

[comp1]

These are excellent questions for a PGY1. Unfortunately as others have said, these are not algorithmic decisions or if they are, they aren't simple algorithms. What labs you recommend are indeed going to be based on the clinical history, but...not by much and ideally the medical team is already on top of basic causes of delirium. The labs you described are a microscopic fraction of the cost of one day in an inpatient unit or even ED visit. As such, even extremely low yield in the vast majority of cases, they're probably getting ordered. Essentially if you think about those, you order them. You may not think about them in every case.
I do like what some others have said above that if the person is going to an inpatient psych unit any time soon, it might be best to wait to restart meds after an overdose and let them figure it out. This is particularly the case if the primary (or most appropriate) diagnosis is borderline personality disorder and perhaps there should be a general med diuresis. Beyond that, sure five half lives is great, but it's really all so medication dependent. Some meds are literally non-toxic in overdose and others you have a seizure if you withdraw suddenly. The great thing is that you're just starting out in training and you're going to get to see this a lot and determine what works best through your own observations.

 

[Stagg737]

Agree with the above, some good answers here and great questions for an intern. Hopefully your attendings are answering these too, but some additional thoughts to some points above.

Unfortunately as others have said, these are not algorithmic decisions or if they are, they aren't simple algorithms.

Can't emphasize this enough and it's part of the reason I love psych. There's not a one-size-fits-all answer and things will vary significantly based on the situation (also gives us good job security as actual experts). You could have 2 nearly identical situations but a small detail or different social situation may completely change the treatment plan. Best way to learn is just getting the reps in with different situations.

Random 40 yo delirious guy rolls in off the street with no reliable history -- would probably do all the things, even CSF and heavy metals would make sense here potentially.

Potentially sure, but this is something we wouldn't even be thinking about until 4-5 days of treating other underlying possibilities without any improvement. Remember, LPs have some significant risks and we've patients who had pretty serious complications from their LP (one possibly developed meningitis last month). That said, I did see this a couple of months ago with a 50 yo lady who turned out to be anti-NMDAr encephalitis. They waited about a week to poke her for CSF because neuro initially felt strongly it was a seizure disorder (it wasn't).

I don't know why we'd have to wait 5 half lives of sertraline after OD to restart Haldol, naltrexone, a benzo, etc. I don't follow that rule either.

Overall I think these are tough clinical scenarios for an R1 since there aren't many 100% rules. Sure you could do the no thinking policies of all OD must admit to psych for 48 hours, stop all meds every time, wait 5 half life every time but I think most docs are skilled enough to do a better job than that.

Imo it depends less on the interactions and more on the extent of damage from sertraline. If a patient has suffered significant liver injury from the sertraline, I sure don't want to restart naltrexone until hepatology is confident their liver is healing appropriately. Especially if this patient is going to be admitted/inpt psych for a while where they aren't going to be at risk of relapse. Imo the blanket policies like what you're mentioning should be reserved for places that don't have experts available to weigh in on these decisions. Agree that these have no place at academic centers or places with psych residencies other than administrators sticking their noses where they don't belong.

Would this apply if the patient overdosed on something that is not a psychotropic e.g. Tylenol? Do you refer to LFTs at all to inform this decision at all?

Depends on the substance and the extent of end organ damage. LFTs are used to inform the decision to some extent, but there typically aren't hard and fast rules as stated above. Ie, if it's day 5 and LFTs aren't trending down hepatology better be involved (if available). I agree that I'm less worried about a set number of half-lives (depending on WHAT they actually OD'd on). As you mentioned, downtrending LFTs should be expected if significantly elevated, if not that's definitely a point of concern.

ETA: toxicology and poison control are fantastic resources. The former may not be available everywhere, but poison control is freely available to the public and all medical professionals. If you or your someone on your team isn't utilizing them I would make yourself familiar with them if you plan to continue working on an inpatient medical or C/L setting.

 

[phantasmagoric]

Thank you all for your responses. Really helpful and edifying. I definitely took some notes!

Seems like there is no simple rule of thumb on how many days/half-lives after the overdose we consider restarting the other psychotropic meds if they were stopped - and that it would be a clinical decision based on multiple factors.

I had one more question that I forgot to pose:

"I have some difficulty in approaching maintenance therapy for bipolar. As I understand, we generally can continue the medications that we've started during acute mania/acute bipolar depression, perhaps at a lower dose (and also possibly simplifying the regiment if multiple meds were started), as long as they have mood stabilizing effects. Are there any other considerations to keep in mind as we shift from acute mania/depression to maintenance therapy?"

Thank you again!

 

[lobstar]

- substance use is often misdiagnosed as bipolar
- personality disorders are often misdiagnosed as bipolar
- probably wouldn't start decreasing helpful antipsychotics for 6 months or more unless bad side effects
- continue to do standard side effect and lab monitoring
- lithium has the largest and most unbiased evidence base for maintenance treatment
- just because they have another mood episode doesn't mean the med doesn't work and needs to be discontinued and replaced, particularly if lithium

 

[comp1]

Definitely second that you should be darn sure you're dealing with bipolar disorder. It's a relatively rare condition compared to substance abuse and (most importantly) personality disorders, even in inpatient settings. This is particularly true for lithium as people more on the Cluster B spectrum do love to chug their whole bottle in front of the ED right after discharge.

 

[Stagg737]

"I have some difficulty in approaching maintenance therapy for bipolar. As I understand, we generally can continue the medications that we've started during acute mania/acute bipolar depression, perhaps at a lower dose (and also possibly simplifying the regiment if multiple meds were started), as long as they have mood stabilizing effects. Are there any other considerations to keep in mind as we shift from acute mania/depression to maintenance therapy?"

@lobstar gave a pretty concise but thorough list of important considerations. The one thing I'd add to the bolded is that if they've got an extended period of stability (at least 1 year) and have not had recurrent episodes, it's worth trying to transition to a more benign long-term option like lamotrigine. Fantastic for prevention of further episodes for some (truly bipolar) patients without nearly as many major long-term side effects like with SGAs or lithium.

I'm also a fan of using minimal meds while they're stable and having a low threshold to start short-term course of olanzapine or even ambien if they're noticing sleep disturbances BEFORE it transitions to full blown mania. I've had several patients who did just fine with lamotrigine (or even no mood stabilizers) who would start a 2-4 week course of olanzapine 10mg when noticing early signs who were able to come off after 1-2 months and have 12+ month periods of stability without being on anything. Of course this is not going to be a viable option for patients who are rapid cycling or have really rapid onset and severe episodes, but worth it to minimize side effects in the right patients. This is also dependent on the patient being insightful and wanting to start meds to prevent those periods. So definitely something you'll need more experience before being confident about.

 

[FlowRate]

@lobstar gave a pretty concise but thorough list of important considerations. The one thing I'd add to the bolded is that if they've got an extended period of stability (at least 1 year) and have not had recurrent episodes, it's worth trying to transition to a more benign long-term option like lamotrigine. Fantastic for prevention of further episodes for some (truly bipolar) patients without nearly as many major long-term side effects like with SGAs or lithium.

I'm also a fan of using minimal meds while they're stable and having a low threshold to start short-term course of olanzapine or even ambien if they're noticing sleep disturbances BEFORE it transitions to full blown mania. I've had several patients who did just fine with lamotrigine (or even no mood stabilizers) who would start a 2-4 week course of olanzapine 10mg when noticing early signs who were able to come off after 1-2 months and have 12+ month periods of stability without being on anything. Of course this is not going to be a viable option for patients who are rapid cycling or have really rapid onset and severe episodes, but worth it to minimize side effects in the right patients. This is also dependent on the patient being insightful and wanting to start meds to prevent those periods. So definitely something you'll need more experience before being confident about.

This is roughly my practice, although I don't usually attempt LTG monotherapy as often as aripiprazole monotherapy. But if someone had a not-life-destroying mania, especially if they were able to be maintained outpatient, then I try to get them off of olanzapine relatively quickly after they're fully back to a normal mental status. And if they were put on Depakote inpatient, that's a great place to start with simplification after resolution.