How Endocrinologists Can Better Support Patients' Mental Health

Many endocrine disorders physiologically affect mental health clinicians need to assess for both.

With Patricia Celan MD and Rocio Salas-Whalen MD

Endocrine disorders are often initially misdiagnosed as mental health problems.

The study of psychoneuroendocrinology examines the connection between hormone and human behavior. It reveals the importance of examining a patient’s symptoms through a mix of lenses: endocrinology as well as psychology, neurology, biochemistry, and psychiatry.

This is because patients living with an endocrine disorder face challenging physical and psychiatric symptoms and issues. For example, a patient might believe that their debilitating fatigue and the depression that comes with it must be a sign of clinical depression, while in reality their depression may be due to a hormonal balance.

With so many co-occurring and masquerading symptoms, it’s common for patients to feel confused, overwhelmed, and helpless when it comes to their mental and physical health. Managing a thyroid disorder on top of coping with severe mood changes can be particularly challenging, especially while waiting for hormone levels to balance out.

This is why it’s so important for medical health practitioners to assure their patients that they are invested in the patient’s overall wellness, including their mental health.

Often, the hypothalamic-pituitary-adrenal (HPA) axis is at the center of many health and wellness issues. “Endocrine disorders cause mental health issues as hormones work on different pathways in the body and in the brain,” says psychiatrist Patricia Celan MD, “which can feed back to emotional systems. For example, the hypothalamic-pituitary-adrenal (HPA) axis is sensitive to excessive cortisol as can be seen in Cushing's disease." Understanding and keeping abreast of research to do with the HPA axis, then, is crucial.

With the busy nature of modern life, healthcare providers have to understand how a patient’s life may be affecting their health. According to an abstract from the Journal of the Royal College of Physicians of Edinburgh, some patients with an endocrine disorder were chronically stressed before being diagnosed, with the stress itself acting as a trigger.

The abstract states, “Before disease onset, stressful life events may play a pathogenetic role and, together with chronic stress, may contribute to a cumulative burden also called allostatic load; psychological and psychiatric symptoms are common both in the prodromal and in the active phase of illness; after cure or remission, there could be residual symptoms and impaired quality of life that deserve attention.”

According to Isaac Gardner, M.D., a leading endocrine/psychiatric specialist, stress and abnormal hormone levels can be troubling. In fact, he says, “Endocrine disorders are a cause of psychiatric illness, as subtle endocrine alterations can lead to subtle to profound psychiatric symptoms.”

For this reason, it’s key to have a candid conversation with your patient, and to identify ways of self-care and coping, including a potential referral to a therapist if they don’t have one.

Mental health issues are common comorbidities with endocrine disorders

Dr. Rocio Salas-Whalen of New York Endocrinology, a triple-board-certified physician and clinical instructor at NYU Langone Hospital, explains: Patients with hypothyroidism or menopause may experience serious depression. Hyperthyroidism, on the other hand, can cause anxiety or psychosis. In Polycystic Ovary Syndrome (PCOS), patients might experience anxiety from a high testosterone level, while serious mood shifts can occur in cases of premenstrual dysphoric disorder (PMDD).

When healthcare providers look at a patient’s health from all angles, outcomes are better. The Indian Journal of Endocrinology and Metabolism, for example, found that diabetes patients are best served when their healthcare providers also consider psychosocial aspects of diabetes when it comes to treatment interventions.”

This consideration can help the patient “overcome the psychological barriers associated with adherence and self-care for diabetes.” For example, unmanaged stress and a lack of self-care can lead to poor glycemic control when patients eat for comfort.

The study offered a few key suggestions. First, you’ll want to identify and support patients early on in the diagnosis process. The goal?

“To help to promote psychosocial well-being and improve their ability to adjust or take adequate responsibility in diabetes self-management.” This can help to fight against the mortality and morbidity associated with diabetes.

The study also suggests that healthcare providers address psychological needs and utilize psychological screening in diabetes management. Lastly, it advises that healthcare professionals are sensitized to diabetics’ needs, and that they also sensitize family members and patients to the importance of diabetes management.

Additionally, the study proposes possible therapeutic interventions including cognitive behavioral therapy, or coping skills training which can help the patient take control of their health by adopting healthy coping mechanisms and behaviors. 

Working with endocrine patients with mental health symptoms

Some patients who might have suspected an endocrine disorder may have already seen a psychiatrist, believing that their feelings were purely psychological and hoping to alleviate symptoms of anxiety or depression. After speaking with an endocrinologist, though, it is sometimes found that their issues are rooted in hormonal imbalances or disorders.

For this reason, it’s always critical to have an open and honest conversation with your patient: “Discuss what is bothering them, ask them about their moods, if they have a support system, and if they see a therapist or if they want to be referred to a therapist, especially if the issue is beyond our scope of knowledge,” Dr. Salas-Whalen says.

Unless a patient has a pre-existing psychiatric issue, medication should theoretically correct the mental health issues. If not, however, she urges patients to speak with a psychiatrist or therapist about possibly having depression or anxiety, for example, on top of an endocrine disorder. In this case, an endocrinologist and psychiatrist should talk about a true diagnosis together, Salas-Whalen recommends. And if you make any changes to the patient’s medication, it’s important to notify their psychiatrist or therapist promptly.

If the patient is already on psychiatric medication to treat an issue that may be related to an endocrine disorder, though, Dr. Salas-Whalen stresses the importance of working with the patient’s mental health care provider to decide on a new treatment plan, which may include changing or stopping their medication.

In the end, each patient comes to the table with a unique makeup. A person’s developmental history, sex, and any environmental stressors they deal with will all change the way they respond to stress, their health issues, and to treatment. Taking a personalized approach is the best route.

Dr. Salas-Whalen offers sound advice for endocrinologists hoping to better understand their patients: “Always talk to the patient. The patient has the answer. The more information we gather will help us get to the right diagnosis. Don’t just depend on imaging studies and labs. Take the time to ask your patients questions. Really talk to them.”

Continue Reading:
Cushing's Disease Stresses Your Heart and Your Mental Health
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