Romantic Love and SSRIs

 

A paper came out this week that examined the relationship between selective serotonin reuptake inhibitors) SSRIs and romantic love. The lead author is a PhD candidate in anthropology with an interest in romantic love.  At first glance, the paper seems to run counter to a lot of sensational papers on the sexual side effects and possible persistent sexual side effects of SSRIs, because it found no differences between romantic love as assessed by a standardized scale and SSRI use. 

That is contrary to well-known sexual sides effects of these medications and the more recent controversy that SSRIs may cause persistent sexual dysfunction as either PSSD (Post SSRI Sexual Dysfunction) or PGAD (Persistent Genital Arousal Disorder). I have written about this controversy in the past and have not seen any useful advance in that literature.  Since that writing my information has been posted somewhere and I continue to get emails from people requesting my assistance in either assessing or treating PSSD.  I am no longer treating patients and therefore must decline. I am interested in researching this topic but do not have the resources on my own and my suggestions to various research entities have not produced any results.

This study looked at an N of 810 adults (48% women) from an original study of 1,556 adults from 33 countries who were defined as being in romantic love (Romantic Love Survey (RLS)).  The Passionate Love Scale (PLS-30) was used to identify romantic love.  The PLS-30 is a 30-point scale of descriptors of romantic love. Each item is rated on a scale of 1 (not true) to 9 (definitely true).  The scale is available at the above link.  This is an example of a typical item:

3. sometimes my body trembles with excitement at the sight of ____________

               not at all true 1 2 3 4 5 6 7 8 9 definitely true

 

By my inspection the 30 items of this scale are all cognitive and emotional features of love.  There are no items specific to sex or sexual fantasy.  The maximum scale score is 270 and participants in the RLS had to score a 130 or above and be in love for 23 months or less.  The authors of the scale suggest that a score of 106 -135 on the shortened version (15 items and a max score of 135) means – “Wildly, even recklessly, in love.”

The authors cite previous data suggesting the 2-year timeframe is necessary for romantic love and they removed 2 cases of high scorers because they were at the 4-year mark.  They deemed that 4 years of romantic love was improbable.

In their analysis the independent variable was SSRI use and they examined biological sex, mental health problems, intensity of romantic love, obsessive thinking, commitment, and frequency of sex as the dependent variables.  No specific details were given about the antidepressants – it was an SSRI or not binary.  At the time of the study only 9% of the sample (76 subjects out of 810) were taking SSRIs. Obsessive thinking was measured by a single question using a Likert rating.  Commitment was measured by adopting an item from another scale and changing the rating from 5 points to 9 points.  Frequency of sex was open to interpretation.  The question was “How often do you have sex on a weekly basis?” and a 50-point scale was used.  The mapping of responses to that scale is unclear from the description in this paper.  Mental health problems were measured with the Assessment of Quality of Life 4D (AQOL-4D) and distilled down to 1 question that looked at a anxiety, depression, or a combination ( “I do/do not feel anxious, worried or depressed). Any endorsement of these symptoms was considered a positive score of 1.

Binary logistic regression was done to see if any of the variables of interest predicted SSRI use and none was noted.  The authors confirm that none of their hypotheses about SSRI use correlating with less intense romantic love, less obsessive thinking, less commitment, and less frequency of sex were confirmed.  They conclude: “The results from this study demonstrate SSRIs use is not significantly associated with features of romantic love in our sample of young adults experiencing romantic love.”

I note that there was some reaction to this paper on social media.  Some were surprised by the results and some saw the result as a call for celebration. There are some people who claim that SSRIs have damaged their capacity for sex irreparably and the sexual side effects of the medication are well known.

The authors are more measured in their assessment of results. They comment on the discrepancy between their results and the literature on sexual side effects and consider several explanations.  The first has to do with selection bias.  Some people on SSRIs may have met exclusion criteria due to sexual side effects and for that reason would have been excluded from study.  Their demographic of young college age students may have been limiting. Is it possible that youthful vigor can counter known SSRI side effects? Specific drug, dosing and duration were also not specified.   

Any observational study like this one can be confounded by many factors.  As the authors mentioned selection bias can be primary. The original selection criteria may have selected out any persons with sexual dysfunction on or off SSRIs.  Interestingly the same phenomenon may occur in psychiatric practice.  Any psychiatrist who has been in practice for more than a few years has patients being seen on a long-term basis who are probably satisfied with treatment. Any medication being used may be well tolerated with few side effects.  Psychiatrists in that setting who routinely inquire about sexual side effects and relationship problems are not likely to hear about any.  The opposite selection bias occurs in some studies of these problems where subjects are recruited based on side effects.  In either scenario the true prevalence is likely to be over or underestimated.  

The authors advance several neurobiological explanations about brain substrates and serotonin that are highly speculative. Emotional blunting by antidepressants is discussed as a possible factor along with the potential brain substrates, but significant evidence against this occurring is not mentioned (3).   Several discuss the importance of the serotonin system and its up-regulation in romantic love.  Serotonin is a very important neurotransmitter in the human brain. Unfortunately, measuring it in vivo over time is very difficult.  Methods for accurate measurement in pre-clinical setting have only recently become available (5). One of the interesting findings is that serotonin can be increased in the extracellular space by several medications, therfore any serotonin-based mechanisms are not specific to SSRIs. I tried to capture the basic findings from this paper in the graphic at the top of this post.  The striking finding from Hashemi Lab is that antidepressants that purportedly have different up front mechanisms all increase extracellular serotonin. The discussion of serotonin is clouded by a lack of precision.  Terms like up regulated, down regulated, increase, and decrease are all meaningless unless it is relative to a specific location or structure and mechanism.   This finding needs to be incorporated into any discussion of how brain strictures are involved.  Any interested reader can find the referenced studies to see if that is happening.  In my experience it is not. 

In terms of the study design, metrics for anxiety, depression, and sexual side effects would provide additional comparisons.  Many psychopharmacological investigations use the Arizona Sexual Experience Scale (ASEX) to measure the sexual side effects of medications in a more detailed way.  The ASEX is a 5-item list that assesses sex drive, sexual arousal, erections/vaginal lubrication, orgasm ease and orgasm intensity using a 6-point scale.  It would also allow for the study of dissociations of romantic love from sexual behavior – as an example asexual adolescent crushes on one end of the spectrum and sexual behavior in the absence of romantic love on the other.  

In the end this study is reassuring that at least some people can take SSRI medications and it does not affect their love-life. But large questions linger at this point. The authors call for additional research. but it would also benefit from consultation with psychopharmacology researchers for additional design elements.  One interesting consideration is whether there is any dissociation of adverse effects between romantic love and sex and whether romantic love may be protective.  Like all complex human behavior precise mechanisms require more precise phenotypes and methodologies. 

Romantic love is no different.

 

George Dawson, MD, DFAPA

 

References:

1:  Bode A, Kowal M, Aghedu FC, Kavanagh PS. SSRI is not associated with the intensity of romantic love, obsessive thinking about a loved one, commitment, or sexual frequency in a sample of young adults experiencing romantic love. J Affect Disord. 2025 Jan 21:S0165-0327(25)00100-4. doi: 10.1016/j.jad.2025.01.103. Epub ahead of print. PMID: 39848471.

2:  Bode A, Kavanagh PS. Romantic Love and Behavioral Activation System Sensitivity to a Loved One. Behav Sci (Basel). 2023 Nov 10;13(11):921. doi: 10.3390/bs13110921. PMID: 37998668; PMCID: PMC10669312.

3:  Dawson G, Pies RW.  Antidepressants do not work by numbing emotions.  Psychiatric Times.  September 26, 2022.  https://www.psychiatrictimes.com/view/antidepressants-do-not-work-by-numbing-emotions

4:  McGahuey CA, Gelenberg AJ, Laukes CA, Moreno FA, Delgado PL, McKnight KM, Manber R. The Arizona Sexual Experience Scale (ASEX): reliability and validity. J Sex Marital Ther. 2000 Jan-Mar;26(1):25-40. doi: 10.1080/009262300278623. PMID: 10693114.

5:  Witt CE, Mena S, Holmes J, Hersey M, Buchanan AM, Parke B, Saylor R, Honan LE, Berger SN, Lumbreras S, Nijhout FH, Reed MC, Best J, Fadel J, Schloss P, Lau T, Hashemi P.  Serotonin is a common thread linking different classes of antidepressants. Cell Chem Biol. 2023 Dec 21;30(12):1557-1570.e6. doi: 10.1016/j.chembiol.2023.10.009. Epub 2023 Nov 21. PMID: 37992715.5:  (Open Access)

Levels of Physician Accountability

 

I thought I would start the new year out with a post that looks at the factual basis of physician accountability and satisfaction with care provided by psychiatrists.  Apart from the usual irrational and conflict of interest derived criticism of psychiatry – there appears to be a significant number of people promulgating the myth that there are many people with complaints about psychiatrists.  One of them suggested that the numbers were in the millions.  That number sounds large, but if there are roughly 40,000 psychiatrists treating 1,000 patients a year that is 40M people.  I did ask for that reference but there apparently was none.

I have written about this issue many times on this blog.  My position could not be clearer, but to restate it – I have no doubt that problems arise during clinical care in medicine that result in suboptimal care, dissatisfied patients, and in the extreme angry, offended, concerned, or injured patients.  I do not think that happens more often in psychiatry than any other specialty and have recorded a few examples of my experience with specialty care that was clearly suboptimal.  I do not think that complaining about these incidents in social media, suggesting that all psychiatrists learn from isolated incidents that they were not involved in, or criticizing the entire field based on these anecdotes is either productive or useful. What is useful is presenting these problems as soon as they occur to the various entities charged with monitoring physician professional standards, behavior, and qualifications.

My opinion on this matter goes beyond my personal clinical experience.  I was a physician reviewer for all Medicare hospitalizations in the states of Minnesota and Wisconsin for about 15 years.  My job was to perform top level reviews on both quality and utilization issues that were flagged by standardized criteria.  As an example, one of the many quality markers was any death that occurred on a psychiatric unit. My job was to review all the available documentation and give an opinion on whether the care was substandard.  Reimbursement for the work was trivial and that was intentional so that no reviewer could make a living doing the reviews.  Another requirement for the position was that reviewers had to be employed full time as practicing clinicians in the states where the reviews were occurring. The program was eventually shut down because not enough problems in inpatient care were identified to justify the cost of the program.  That alone is a statement about the general quality of care provided based on standardized criteria.

At about the same time, a billing and coding system was introduced.  It did not take long for the federal government to decide that it could be used for fraud investigations based on documentation and coding mismatches.  In other words, if there was not enough documentation or specific bullet points were missed the physician or clinic could be fined or worse.  They could be barred from billing government insurers (Medicaid or Medicare).  In the worst-case scenario, they could be charged with mail fraud (since the billing was mailed) or RICO (Racketeer Influenced and Corrupt Organizations Act) violations.  I was in an employer seminar where it was suggested that physicians could end up in federal prison if the documentation did not match the billing code! The FBI conducted many of these investigations and large fines were levied against clinics and in some cases teaching hospitals. Some of those rulings had to do with attending physicians countersigning resident notes rather than writing separate notes.  The resulted in a period when attending physicians had to write notes that were redundant with the resident documentation.  That had a significant effect on morale and teaching.  

Eventually both the policing of the billing and coding and the quality reviews were turned over to health care organizations.  That led to a different kind of accountability. The review process was no longer conducted by independent reviewers carefully screened for conflict of interest or law enforcement.  Now the reviewers were employees of health care companies who could profit from their decisions.  That has resulted in a rationed but semi standardized approach to health care. It is harder to see a physician or see them for any length of time, but since most physicians are employees it is easier to report them up the administrative ladder.  

These days the opportunity for filing these reports generally starts early in the process.  You attend a clinic and as part of the paperwork you are given a patient bill of rights. It explains how you should expect to be treated in health care settings and what the complaint process looks like if that fails. Specific contact numbers are usually given for filing complaints. I have noticed that this process can be selective.  For example, in my experience with emergency departments, some departments of surgery, and some departments of cardiology there was no explicit complaint or feedback process. I worked in 4 different psychiatry departments and that was not the case. Patient feedback was always part of the annual review.  My speculation is that high revenue producing centers may be less likely to solicit feedback or complaints.  Either way the process is not foolproof, but there are avenues for filing complaints outside of the medical institution where the incident occurred.

The diagram at the top of this post shows all the feedback loops available for reporting or critiquing physicians. The complaints can be spontaneous or solicited.  Several levels also report to other levels independent of any patient complaint. For example – several of the entities (State Licensing, DEA, Privileging, Law Enforcement) report to the National Practitioner Database.  The rationale for that database was to prevent any state disciplinary action from being hidden by relicensing in another state.

Apart from the mechanics in the diagram there are additional approaches to the problem of accountability.  Ikkos, et al (1) discuss both the physician patient relationship and the formulation as being central to the work of psychiatry. Professionalism is described as the contract of the profession with society.  That includes the fact that complaint procedures are necessary to maintain professionalism.  Some complaints are accurate and others are not.  The authors in this case look at the psychodynamic and systemic factors that may affect complaints and their accuracy.  Although this paper is form the UK, very similar mechanisms in the US through the medical practice boards of each state.  Those boards are political rather than medical agencies and they enforce state medical practice statutes including relicensing.

Another indirect indicator of physician complaints is malpractice cases.  Ideally malpractice in the US is a marker of negligence but the reality is that it is a much more complicated dimension. In any year a significant number of physicians face a malpractice action but only about ¼ result in a payment.  One study (3) documented that  7.4% of physicians across 25 specialties had a malpractice action in one year and 78% did not result in a financial award.  The rate of malpractice actions varied significantly across specialties with surgical specialties at the top and primary care specialties having the lowest risk.  Psychiatry ranked 25^th out of the 25 specialties in terms of malpractice risk.  Specialties were also analyzed by the 5 highest and lowest risk (includes psychiatry) for cumulative risk of a malpractice action by age 65 and those numbers were 71% and 19% respectively. Additionally, psychiatry used to have a two-tiered malpractice premium system in the US that was modified to one premium because of the low incidence of malpractice cases among the psychiatrists doing electroconvulsive therapy.          

What do I hope people have learned from this post?  First – the first line of approach can a direct discussion of the problem with your physician. Misunderstandings, disagreements, systems problems, and bad days are common and they do not have to be catastrophic. Psychiatrists should be more attentive to the relationship aspects of encounters making that discussion easier.   Second - if you have a complaint against a psychiatrist or any other physician there is an option to take it to one of the many channels in place to hear and act on those complaints.  Posting on social media and attempting to create the impression that your problem is widespread will not address it.  If you are really interested in a solution follow the designated channels. This suggestion does not diminish the problem you are experiencing at all – it is focused on an effective solution. Third – do not expect that all psychiatrists or physicians that you complain to will accept your suggestion that the problem is common or that they need to change based on your problem.  Most physicians practicing get constant feedback from all these accountability measures and none of their work is flagged.  Further – in some cases these same mechanisms are used by administrators to get physicians to do what they want.  There are also cases where complaints are made to harass physicians using these same mechanisms.  Fourth – in acute care psychiatric settings it is common to encounter patients who resent, complain about, or threaten psychiatrists on sight.  In other words – even if they are meeting a psychiatrist for the very first time, they exhibit aggressive behavior. It is the nature of some forms of severe psychopathology and in some cases, it can persist and form the basis of a complaint about that physician. Fifth -   much of the unfounded criticism from both outside and inside the field is based on the assumptions that there is massive wrongdoing, error-making, ignorance, malfeasance, etc on the part of psychiatrists.  There is absolutely nothing to back that position up. Many of those critics seem to be making a career out of criticizing the psychiatrists who are doing the work and have limited to no knowledge of how those psychiatrists work or the stressors they are under.  Sixth – there are no guarantees that any dispute will be resolved to your satisfaction. The number of malpractice cases resulting in a financial payment may be the best indication because it is a rigorous contested dispute where the plaintiffs’ interests are represented and over ¾ do not result in a financial settlement.  Most complaints and disputes do not require that degree of contentiousness.

If you have finally seen a psychiatrist, and there is a problem with the interaction or treatment – use your judgment and try one of the many ways to address that problem. Don’t hesitate to get a second opinion. 

George Dawson, MD, DFAPA

References:

1:  Ikkos G, McQueen D, St. John-Smith P.  Psychiatry’s contract with society: what is expected?  Acta Psychiatr Scand 2011: 124: 1–3

2:  Ikkos G, Barbenel D. Complaints against psychiatrists: Potential abuses, Psychoanalytic Psychotherapy 2000, 14:1, 49-62, DOI: 10.1080/02668730000700051

3:  Jena AB, Seabury S, Lakdawalla D, Chandra A. Malpractice risk according to physician specialty. N Engl J Med. 2011 Aug 18;365(7):629-36. doi: 10.1056/NEJMsa1012370. PMID: 21848463; PMCID: PMC3204310.

Graphic:

Done by me using Microsoft Visio.  Click directly on the graphic to enlarge and see a clearer graphic. 

Dry January? Why Not the Rest of the Year?

 

Every January one of the frequent pledges is to not use alcohol for the month.  In my capacity as a psychiatrist – I have had patients tell me that if they could do it was a sign that they were not an alcoholic because it shows that they can control their drinking.  Never mind the excessive drinking and adverse consequences the rest of the year.  I saw an exchange between a sober bartender and a stress drinker portrayed in a new TV series just today.  It went something like this:

Patron: “I stopped drinking whisky because I am an alcoholic – so I just stick with beer.”

Bartender: “Well you know there is alcohol in beer.”

Patron: (motioning to his light beer) “There is more alcohol in orange juice than there is in this”

Bartender: “I’m just saying…”

Patron: “I’ll tell you what – let me drink 6 of these beers and 6 whiskeys and you tell me which one has more alcohol.”

And so, it goes. If you have a problem with alcohol or any other substance (or behavior) that reinforces its own use – there are endless rationalizations to keep using it and never enough deterrents.  Studies have shown that it often takes a life-threatening problem or major life event to quit - but even that may not be enough.  I am witness to many people who kept drinking despite end stage liver disease in some cases fully supported by their family: “It’s his choice – if he wants to drink, he is free to drink.”   It seems that the only advocates for sober living are in Alcoholics Anonymous or other 12 step recovery groups.  I did post on the Curious Sober movement in the younger generation but that has either not caught on or it is not being adequately covered if it has.

The history of using intoxicants is long and detailed. The two dominant evolutionary theories are that the substances are used because of a mismatch of currently abundant intoxicants on a reward and endogenous opioid system originally there for other reasons or as a form of self-medication that can be observed in other primates. The latter idea is that primates learn that there are certain plants that contain compounds that can treat ailments.  Both of those theories leave out the cultural elements that include social settings, celebrations, religious ceremonies, traditions, and local customs that use intoxicants as part of the event. There are cultural portrayals in movies and television showing alcohol and other intoxicants as necessary to alleviate daily stress.  In more modern times, some of these substances are imbued with magical qualities like being vehicles for mind expansion or even cures for mental illnesses.

The reality of substance use for practically all of the people I have talked with who do not have a substance use problem comes down to using alcohol of drugs to get an enjoyable “buzz”, to get a heightened sense of social competence from the initial relaxation, or just going along with the crowd.  In many crowds there is intense peer pressure to not be the one who is not drinking or smoking cannabis. That is a major source of binge use in the late teens and early 20s. Even in those social situations it is common for people to experience excessive use, intoxication with impaired judgment, and bad outcomes.  I have talked with too many people who sustained severe legal consequences from a single night of excessive drinking. I have also talked with too many people to remember who were admitted to my acute care psychiatric unit based on something that happened when they were acutely intoxicated.

I have covered this issue in the past and will link that post here without having to repeat it.  The basic issue for me is why use intoxicants at all?  Considering just alcohol - it is a neurotoxin, a carcinogen, and a direct toxin to the pancreas, the heart, and the liver. For years it was promoted as a “heart healthy” drink despite methodological problems with studies that put subjects with significant alcohol exposure in the control group.    

There are both informal and professional advocates for getting high. One of the most well-known advocates estimates that 70-90% of people can use intoxicants and they do not become problematic.  He describes his own use of heroin as useful because it results in a “happy and stress-free feeling”, helps him “maintain work-life balance”, and should be legal for everybody.  He also describes the pain of heroin withdrawal but apparently does not see that as a deterrent.  A key question is whether it is possible to get to that “happy and stress-free feeling” without using heroin?  How many people are operating under this premise today as they use various intoxicants some of which are excessively hyped as being good for your mental health? American culture is promoting the idea that you can fine tune your brain by using intoxicants even though there is no evidence this works.  To promote that idea, we have been exposed to 20 years of intoxicants advertised as medical treatments beginning with cannabis.  As the dust settles this idea has little to substantiate it, adverse effects have been minimized, and commercial conflicts of interest have not been disclosed.

The basic consideration comes down to the values you have established for yourself and whether those values can be affected by intoxicants.  There are many approaches to values that apply to intoxicant use. There are several religions, philosophical approaches, and recovery movements that value not using alcohol or other intoxicants as well.  You may value your short term and long-term health and consider not using intoxicants on that basis.  You may have had a close call while intoxicated and decided that you did not want to take that chance again. You might even survey the damage done to your family by intoxicants and decide they are too risky to sample.  On the other hand, you can walk into any small-town bar in the Midwest and people will be joking about the effects of alcohol and in some cases about who has developed cirrhosis or died as a result. They may also be joking about the associated behaviors of excessive intoxication.  Gallows humor is an easily observed adaptation.  There are subcultures that value alcohol use – no matter what.  I would argue that extreme position is a direct result of the reinforcing effects of alcohol rather than any de novo philosophical position. 

In the final analysis this is not about whether intoxicant use is a disease or whether you can control the use or even gain something from it.  Most of the popular discussion comes down to political arguments. In other words – I have a particular belief system about intoxicants and I will marshal every possible bit of evidence to support my position. I will be the first to acknowledge that as an acute care and addiction psychiatrist – selection bias was certainly in effect. I would see the worst possible scenarios.  But I have also seen people in real life who were clearly not doing well at all varying from an intoxicated man I tried to help at 7AM in northern Wisconsin to a young woman my wife and I tried to help in Boston.  You can argue that those folks still had a substance use disorder and most people using intoxicants do not.

In that case – I would offer the personalized evidence.  If you are having a Sober January and things are unchanged, going well or even better than usual – why change that?  

Keep it going.

 

George Dawson, MD, DFAPA

 

 

Graphics Credit - click photo for all details:

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The most important thing you can do as a psychiatrist...

 

I won’t build the suspense.  The most important thing you can do as a psychiatrist is to be the medical doctor that you were trained to be.  The second-best thing is to be a good if not great psychiatrist.

I had those thoughts today after reading about a case of misdiagnosed panic disorder (1).  The patient was an athletic 30 yr old women who reported episodic panic attacks, palpitations, light headedness, and shortness of breath.  A Cardiology evaluation was negative.  That was not too surprising since she was asymptomatic during the testing, but given the final diagnosis I would have expected a subtle baseline ECG change.  She was treated with a selective serotonin reuptake inhibitor for presumed panic attacks by her primary care physician.  She is seen in the Emergency Department and an ECG shows an irregular, rapid, wide QRS complex, tachycardia and her usual symptoms. A shortened PR interval with a delta (preexcitation) wave is noted. The entire case description with the associated diagnostic reasoning can be located at this link (1). I am not sure that readers can access it without an account.

The case is an excellent example of the real task of being a psychiatrist. The usual dialogue about what psychiatrists do is typically restricted to criteria in the Diagnostic and Statistical Manual (DSM).  There is a lot of confusion about the importance of the DSM and what it means for psychiatric practice. For example, the popular stereotype is that psychiatrists just sit around and estimate whether people “meet criteria” for a DSM diagnosis and then prescribe an indicated medication.  Life as a psychiatrist is not that simple.  The unique problems of the person in front of you cannot be captured by a crude system of classification.

Using this case as a backdrop, I need to know as much medical detail about this young woman as possible.  More details about the onset of symptoms and associated symptoms. More details about her baseline physical health, associated symptoms, and any cardiology consultation and testing that has occurred.  If I am on the same electronic health record system, I am pulling all of that up including her vital signs over time, lab testing, and cardiac testing.  I am looking at each ECG tracing.  I need to know her detailed family history for cardiac disease, arrhythmias, and sudden cardiac death. How much alcohol, tobacco, and caffeine does she typically use?  Is she using any stimulants?  Does she have an intercurrent illness that could affect her heart rate?

In the next few minutes, I need to be checking her vital signs especially her heart rate and rhythm, respiratory rate, and doing a rapid cardiopulmonary exam. My first decision point is whether she is in a medical emergency or not. This is not always as clear cut as this case where the discussant points out that the patient is treated using the American Heart Association (AHA) Advanced Cardiac Life Support ( ACLS) algorithm and needs electrical or medical cardioversion.

That is where things get tough for a psychiatrist.  Setting is a significant issue.  If I am working in an acute care setting in a hospital – I typically have plenty of back up.  Hospitalists services generally run codes or even have a team for acute care that does not involve codes and I could get them there in a few minutes.  At the other end of the spectrum -  I have worked in a community mental health center with absolutely no access to ECGs and no equipment for cardioversion.  In that case – 911 needs to be called and all medical staff in the facility should be able to perform basic cardiopulmonary resuscitation. 

The main work in this situation is recognizing the medical emergency and getting the patient to the correct setting where she can be stabilized. It is not always black and white.  This patient was eventually diagnosed with atrial fibrillation and Wolf-Parkinson White (WPW) syndrome.  Atrial fibrillation was probably the most frequent cardiac diagnosis that I made as a psychiatrist.  Most people who had it were not aware of it. I happened to pick it up because I noticed an irregularly irregular pulse when checking their vital signs and a pulse deficit on physical exam. It was almost always in a range where the heart rate was not a big problem.  In some cases, it was partially treated by a rate controlling medication like a beta-blocker or calcium channel blocker.  I could typically call the patient’s primary care physician and get them in for a comprehensive evaluation of the problem.  I would have to send some patients to the emergency department or urgent care.     

The issue of cardiac related anxiety is a very interesting issue. Cardiac symptoms can be an associated symptom of anxiety, panic, and other affects like anger.  The symptoms can arise as a sensory phenomenon due to an awareness that the heart is “pounding” or “beating out of my chest”.  Both of those descriptions are very common in people with panic attacks. The sequence of events and what is causing the cardiac phenomenon are wide ranging from an intrinsic cardiac problem to an imbalance in the sympathetic and parasympathetic innervation of the heart. Some electrophysiological experts think that at least some atrial fibrillation is due to overactivity of both autonomic systems.  Even in the absence of a sustained arrhythmias – the autonomic effects can result in premature atrial contractions, premature ventricular contractions, and sustained sinus tachycardia.

There are many other cardiac emergencies that occur in psychiatric settings. I was asked to see an acutely manic woman who was 85 years old.  She was extremely agitated and shouting that her chest hurt.  I was able to get a stat ECG that showed she was having a myocardial infarction and got her transferred to the coronary care unit.  In another case – I was told that a 70-year-old woman was “delusional” about her abdomen.  She clearly had a belief that there were supernatural forces causing her abdominal discomfort.  At the same time, she had a pulsatile mass in her lower abdomen and an abdominal aortic aneurysm on ultrasound.  Both patients survived with timely intervention.

I was a quality reviewer for many years and that job involved reviewing potential quality problems associated with inpatient hospitalizations.  One of those reviews was a patient who was hyperventilating.  He was diagnosed with panic attacks and treated with behavior therapy that did not seem to be effective.  As his condition worsened, he was eventually diagnosed with an acute pulmonary embolism. Since that review, I have seen many ambulatory patients who were short of breath for days due to pulmonary emboli and are not seen in a setting where they can be diagnosed and treated.

There are many more medical problems that crop up in psychiatric outpatients and inpatients that cannot be missed.  They can present as a possible psychiatric disorder and the potentially fatal nature of many mean they cannot be missed.  Many settings are set up to give the appearance that an emergency room physician, hospitalist, primary care physician, or physician extender is medically clearing these patients and that is not the case.  Most frequently that is because the time course of the condition is erratic or communication with a psychiatrist at a more detailed level is necessary.  The only assurance that these patients have no acute problems is if they are acutely symptomatic when they are screened or seeing a psychiatrist who can communicate with them, has no biases against them, and who knows the difference between a medical and a psychiatric problem.

To be very clear, I am not suggesting that psychiatrists initiate care for life threatening medical problems.  They do need to know if there are undiagnosed acute or chronic medical problems and how fast they need to be addressed. They need to be able to recognize the medical causes of signs and symptoms that can be misinterpreted as psychiatric.  They also need to recognize and manage the associated systems problems that in my experience are primarily countertransference driven.  Let me provide a clear example of what I mean.  I was working in an acute care setting and came across a patient leaning against a pool table. He was acutely short of breath, somnolent, and had a history of valvular heart disease. On exam, he was in congestive heart failure. I placed a call to the medical consultant and was told that I should start an IV line and manage the patient myself on an acute care psychiatric unit.  When I suggested that he needed transfer to medicine – I was met with the comment: “Well you know how to start an IV don’t you?”

I most certainly have started hundreds of IVs, but that is not the issue.  My patient had an acute medical problem that needed both medical and nursing expertise to manage in a more medical acute care setting than a psychiatric unit.  I eventually contacted the Chief of Medicine and got the patient transferred where he was subsequently in an ICU setting.  Ideally acute care psychiatrists today can develop good relationships with hospitalists for these kinds of transitions.  The best way to do that is by letting them know you have made a medical assessment and have a good indication for transfer.

Being a good if not great psychiatrist is hard work. My most significant worry was missing a major medical problem and not getting adequate intervention.  That is just the first step. The next steps are a psychiatric formulation, diagnosis, and treatment plan that incorporates state of the art communication and relationship building with the patient.  Hopefully that is followed by a long period of seeing the patient, helping them meet their goals, and providing medical diagnosis and follow up as needed.  In today’s world that is often occurring in a rationed suboptimal environment, overburdened by businesses rationing of both care and medication for profit.

My hat is off to the psychiatrists who are doing this work and probably working way too hard in 2025.

Happy New Year!

 

George Dawson, MD, DFAPA

Supplementary 1:  There is no doubt that I have practiced in settings where there was a high level of concurrent medical and in some cases surgical illness.  There is also no doubt that it was a conscious decision on my part to practice in those settings.  That undoubtedly sharpened my focus on making sure that I had the skills necessary to provide adequate care to those populations. It may be possible to cleanly partition psychiatric work from the rest of medicine but I have not seen that happen for some of the reasons cited in the above essay.  The training of psychiatrists in the past has had a variable relationship with medicine - at one point going to the extreme that much of the medical internship was eliminated.  The best advice I got in medical school was not to use elective time for additional psychiatry rotations because I would be doing psychiatry the rest of my life. I took neurology, neurosurgery, nephrology, endocrinology, cardiology, allergy and immunology, and infectious disease rotations instead. That initial training worked well over my years of practice and I don't regret it.

Some may question the emphasis in this post on the importance of not missing concurrent medical diagnoses and I would offer these additional observations.  Many patients seeing psychiatrists consider them to be their primary care physicians. That should not deter a psychiatrist from clarifying their role, but the fact that psychiatrist is probably seeing the patient much more often than the primary care physician is often a useful reality.  I have called primary care physicians to report what I consider to be an exacerbation of the patient's underlying medical problem.  That collaboration can get more timely care for acute or chronic medical problems.  I have also had the experience hearing from a person that a psychiatrist diagnosed their medical problem when nobody else did.  Many of these scenarios degenerate into who is the better physician.  The focus needs to be on what the patient needs rather than what the physician needs.  Not ignoring or missing a patient's underlying medical problems is a large part of that personalized care. 

 

Reference:

 1:  Hemingway TJ.  An athletic patient who thinks she has panic attacks.  Medscape December 17, 2024 (accessed on December 31, 2024):  https://reference.medscape.com/viewarticle/858516_6