Psych Patient on the Medical Unit? Focus on This

This transcript has been edited for clarity. 

Monee Amin, MD: Welcome back to The Curbsiders hospitalist edition. I’m Dr Monee Amin with my great friend and effervescent cohost, Dr Meredith Trubitt. We’re going to discuss our recent podcast, Psychiatry Primer for the Hospitalist, with Dr Aaron Gluth, a medicine-psychiatry physician at Emory University. 

Meredith Trubitt, MD: Yes, we got lots of great tidbits and pearls from Dr Gluth. There is a wide range of comfort levels for managing patients with comorbid psychiatric conditions, and Dr Gluth did a great job of explaining why this should be important to hospitalists, answering the most common questions that arise on the wards.

Amin: By far, the biggest takeaway was the concept of the mortality gap, which is a 10-20-year lower life expectancy for patients with psychiatric comorbidities. The most important thing about this, though, is that the deaths are more frequently from nonpsychiatric conditions, and common things being common, it’s conditions like heart disease and diabetes. It’s easy to get bogged down with the patient’s psychiatric illness, but as internists, we need to reframe it as, hey, the medical conditions —the things we handle all the time — are actually going to be the cause of their death. 

There’s probably a misconception out there that these patients only die from complications of their psychiatric illness when that could not be further from the truth. 

Trubitt: The main takeaway from that, when you’re thinking about their workup, is that all these things are largely risk factors of their medical conditions and the medications they have to be on. So, we really should be checking A1c and lipid panels on all of these patients. This is why it should be important to hospitalists. It’s definitely within our wheelhouse. 

The other pain point is where should the patient go? Where can they be best served? 

Amin: If you’re a hospitalist with any percentage of patients with psychiatric comorbidities at your facility, this is a conversation that happens a lot between medicine and psychiatry. The underlying theme is, what is the safest thing for the patient? Psychiatry floors are not just medical floors with nonmedical patients; they’re considered milieu units, which are places where patients are supposed to live and participate in group and exercise therapy and other things that are immersive. If they have an acute medical illness, they’re not really able to do that. If they have an IV or they need oxygen, those things tie them to their room and are also potential safety hazards for them and other patients. 

Framing it that way helps. You tamp down some of your anxieties about it and just focus on what’s right for the patient. 

Trubitt: Yes, and by acknowledging where those limitations exist, you may find that the patient is going to be best served on a medicine floor. This is a time to have a conversation with your multidisciplinary team about taking care of this patient and how you may be able to continue their psychiatric care and improve their medical conditions to get them to that right milieu unit that they will need eventually. It may take longer than it might for a patient without a comorbid psychiatric condition, but it’s important to be thinking about that. 

The other big aspect that we talked about that’s in the wheelhouse for the hospitalist is the famed reversible workup — and where our money should be on that workup.

Amin: They’re here with you now. They’re on the medical floor. What now? The things we need to work up are the things that are easily reversible or treatable — syphilis, HIV — it’s very important to catch those. He was a big proponent of saying you can check a thiamine level, or even just give it. He also felt strongly about folate and vitamin D, which he said was kind of a chicken or egg problem. Is the patient’s psychiatric illness preventing them from getting what they need for better vitamin D levels or vice versa? 

Dr Gluth also said that it seems that every patient who comes in with altered mental status gets a CT of the head, but it’s not always necessary. The two most important situations requiring a head CT are patients on any kind of anticoagulation and those in the geriatric population because they tend to be at a higher fall risk. 

Trubitt: I’ll add that he mentioned that antiepileptic medications used as mood stabilizers can, by themselves, cause metabolic syndromes so we need to think about the A1c and lipid panel. These drugs can cause a low vitamin D level, which we can replete.

Amin: Reframing it in medical terms makes it so much easier and takes the pressure off from feeling like you are dealing with a patient with psychiatric illness. You don’t call a nephrologist for a creatinine of 1.4 if that’s the patient’s baseline creatinine, right? It’s the same thing here.

We went into a lot more detail about this on the podcast, so click here if you want to hear our full conversation with Dr Gluth.