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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_208_библиотеки_им_акад_М_И_Перельмана
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Infectious mononucleosis (IM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .455
Insomnia disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .456
Klinefelter’s syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .458
Lead poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .460
Limbic encephalitis (LE). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .462
Lyme disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .464
Major depressive disorder (MDD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .467
Manganese poisoning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .469
Manic episode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .471
Marchiafava-Bignami disease (MBD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .473
Meningitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .475
Mercury poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .478
Metabolic syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .480
Metachromatic leukodystrophy (MLD). . . . . . . . . . . . . . . . . . . . . . . . . . . . . .481
Methanol poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .483
Mild neurocognitive disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .485
Multiple sclerosis (MS). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .487
Myocardial infarction (MI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .489
Narcolepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .491
Neuroleptic malignant syndrome (NMS) . . . . . . . . . . . . . . . . . . . . . . . . . . . .493
Neuromyelitis optica spectrum disorder (NMOSD) . . . . . . . . . . . . . . . . . . .495
Obsessive-compulsive disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .497
Obstructive sleep apnea (OSA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .499
Organophosphate poisoning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .502
Osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .505
Pancreatitis, acute . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .506
Pancreatitis, chronic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .508
Panic attack and panic disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .510
Parkinson’s disease (PD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .512
Pellagra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .514
Peripheral neuropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .516
Pheochromocytoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .519
Pica . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .521
Porphyria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .522
Prader-Willi syndrome (PWS). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .524
Progressive multifocal leukoencephalopathy (PML). . . . . . . . . . . . . . . . . . .526
Psychogenic polydipsia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .528
Psychotic disorder due to another medical condition. . . . . . . . . . . . . . . . . .530
Pyridoxine deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .532
Restless legs syndrome (RLS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .534
Sarcoidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .536
Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .538
Seizures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .541
Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .544
Subdural hematoma (SDH)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .547
Syndrome of inappropriate antidiuresis (SIAD) . . . . . . . . . . . . . . . . . . . . . .549
Syphilis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .551
Systemic lupus erythematosus (SLE). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .554
Thiamine deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .556
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Thrombocytopenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 558
Thrombocytosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559
Thyrotoxicosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 560
Tuberculosis (TB). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 562
Uremic syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564
Urinary tract infection (UTI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566
Vitamin B
12
deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 568
Wernicke’s encephalopathy (WE) and
Wernicke-Korsakoff syndrome
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 570
Wilson’s disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 572
Chapter 3. Psychotropic Medications:
Laboratory Screening and Monitoring. . . . . . . . . . . . . . . . . . . . . . . . . . .575
Acamprosate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 576
Amphetamines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 576
Antipsychotics, first generation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577
Aripiprazole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 578
Asenapine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 578
Atomoxetine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 579
Benzodiazepines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 579
Bremelanotide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 580
Brexpiprazole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 580
Buprenorphine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 580
Bupropion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 581
Buspirone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 581
Carbamazepine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 582
Cariprazine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 582
Citalopram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583
Clozapine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 584
Desvenlafaxine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585
Donepezil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585
Duloxetine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 586
Escitalopram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 586
Fluoxetine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 587
Fluvoxamine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 588
Gabapentin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 588
Galantamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 589
Guanfacine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 589
Iloperidone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 590
Ketamine and esketamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 590
Lamotrigine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 591
Lemborexant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 591
Levetiracetam. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 592
Levomilnacipran . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 592
Lithium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 593
Lofexidine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 594
Lumateperone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
594
Lurasidone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595
Memantine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595
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Methylphenidate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .596
Milnacipran . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .596
Mirtazapine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .597
Monoamine oxidase inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .598
Naltrexone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .599
Nefazodone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .600
Nonbenzodiazepine hypnotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .600
Olanzapine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .601
Olanzapine-samidorphan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .602
Opioids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .603
Oxcarbazepine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .604
Paliperidone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .605
Paroxetine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .606
Pimavanserin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .606
Pitolisant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .607
Quetiapine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .608
Ramelteon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .609
Risperidone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .609
Rivastigmine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .610
Serdexmethylphenidate/Dexmethylphenidate . . . . . . . . . . . . . . . . . . . . . . .610
Sertraline. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .611
Sildenafil. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .611
Suvorexant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .612
Tasimelteon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .612
Topiramate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .613
Tramadol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .613
Trazodone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .614
Tricyclic antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .615
Valproate/Divalproex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .616
Vardenafil. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .617
Varenicline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .617
Venlafaxine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .618
Vilazodone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .618
Vortioxetine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .619
Ziprasidone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .619
Appendix A. Therapeutic and Toxic Drug Levels at a Glance . . . . . . . .621
Appendix B. Additional Information on Neuroimaging . . . . . . . . . . . . . .625
Neuroimaging signal appearance: MRI and CT. . . . . . . . . . . . . . . . . . . . . . .626
Approach to reading a head CT scan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .627
Appendix C. Additional Cardiac-Related Information . . . . . . . . . . . . . .629
Ten rules for a normal electrocardiogram. . . . . . . . . . . . . . . . . . . . . . . . . . . .630
Cardiovascular risk assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .631
Medical evaluation for electroconvulsive therapy (ECT) . . . . . . . . . . . . . . .632
Appendix D. The Bilirubin Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .635
Appendix E. The Syndrome of Inappropriate Antidiuresis
. . . . . . . . . . . 637
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .641
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 697
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About the Author
Sandra A. Jacobson, M.D., received her medical degree from the John
A. Burns School of Medicine in her home state of Hawaii. After completing an intern-
ship in internal medicine at the University of Hawaii Integrated Medical Residency
Program in Honolulu, she underwent psychiatry residency training and fellowship
training in neurophysiology at UCLA Neuropsychiatric Institute. She has held faculty
positions at UCLA, Tufts University School of Medicine, the Warren Alpert School of
Medicine at Brown University, and the University of Arizona College of Medicine–
Phoenix. Her work in consultation/liaison psychiatry, inpatient and outpatient psy-
chiatry, geriatric psychiatry, nursing home consultation, and clinical neurophysiology
(electroencephalography) informs the format, choice of tests and diseases, and com
-
ments on psychiatric relevance for the material included in Laboratory Medicine in Psy-
chiatry and Behavioral Science, Second Edition.
xiii
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Introduction
This second edition of Laboratory Medicine in Psychiatry and Behavioral Sci-
ence is substantially revised from the first edition published in 2012. In the intervening
decade, an explosion of research and publication related to laboratory science and
psychiatry has left virtually no subject area untouched. As with the first edition, this
manual is designed to assist psychiatrists and other behavioral health clinicians in the
care of adult psychiatric patients across a wide range of settings. To facilitate its use
as a reference manual, the book is divided into three main sections, each marked with
a black tab at the edge of its title page:
• Laboratory Tests
• Diseases and Conditions
• Psychotropic Medications: Laboratory Screening and Monitoring
Among the thousands of laboratory tests available, tests that were selected for in-
clusion met one or more of the following criteria: a core or basic laboratory test for any
patient; a test that is particularly pertinent to psychiatry or behavioral health; or a test
that is new to medicine and potentially of interest in the field of behavioral health, in-
cluding geriatrics. Diseases and conditions selected for inclusion were those for which
laboratory tests are primary or important in diagnosis or differential diagnosis; those
that are core or common conditions among psychiatric or geriatric patients; and those
that have important psychiatric, cognitive, or behavioral consequences. The appendi-
ces contain several algorithms, tables, and figures that may be useful in understanding
and interpreting various laboratory tests and their underlying biology.
Years of clinical practice and research in neuropsychiatry inform not only the choice
of tests but also the rationale for their use. For this edition, the primary source of medical
information was the published literature accessed through PubMed from the National
Library of Medicine. A wide range of other resources were also consulted, including
Drug Information, published annually by the American Society of Health-System Phar-
macists, and the online laboratory references at ARUP Laboratories (www.aruplab.com)
and the American Association for Clinical Chemistry (www.testing.com). A complete
listing of references appears in the back matter of the book.
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xvi Laboratory Medicine in Psychiatry and Behavioral Science
General Guidelines for Laboratory Testing
Judicious use of the laboratory improves patient care in psychiatry and behavioral
science just as it does in internal medicine and other specialties. Laboratory testing is
only one component of the complete psychiatric evaluation, which also includes a his
-
tory, review of systems, functional assessment, and physical and mental status exam-
inations. When lab results are reviewed in the context of the patient’s family history,
personal history, lifestyle, and particular exam findings, there is less likelihood of
overreacting to a result that may turn out to be inconsequential or even spurious. For
example, with an isolated elevation in one test such as alanine transaminase and in the
absence of any clinical evidence of disease, the test should simply be repeated and fur-
ther workup performed only if a twofold or greater elevation persists. When labora-
tory findings are unclear or present questions, clinical laboratory staff can be an
excellent resource for clinicians in the interpretation of test data and in planning fur
-
ther diagnostics. The reference ranges cited in this manual are only general guides, as
few reference ranges apply across laboratories and testing methods. Reference inter
-
vals supplied by the local laboratory always supersede the intervals suggested here.
Laboratory Testing in Psychiatry
What constitutes standard laboratory screening for psychiatric patients in general is
not well established. There does appear to be general agreement that a screening lab
-
oratory evaluation is indicated for the following patients: those presenting for the first
time with major psychiatric syndromes (e.g., psychosis or major mood disorders), el
-
derly patients admitted to the hospital, patients who are undernourished or signifi-
cantly dehydrated, those with alcohol or drug dependence, and those with delirium
or initial presentation of dementia.
Patients admitted to inpatient psychiatry services may undergo the following lab-
oratory evaluation upon admission:
• Complete blood count
• Comprehensive metabolic panel
•Urinalysis
• Urine drug screen with alcohol
• HIV testing (from which patients may “opt out”)
For patients who are at risk of the metabolic syndrome, or those who are to be
started on an atypical antipsychotic or other drug associated with this syndrome, the
following may be added:
•Lipidpanel
•Hemoglobin A1C
Thyroid-stimulating hormone may be checked for patients presenting with mood
disorders or significant anxiety, and for all females age 50 years and older unless test
-
ing was done within the past year. Urine or serum pregnancy testing may be per-
formed if there is any question of pregnancy. More extensive laboratory testing may
be indicated for patients presenting with syndromes such as acute psychosis, as dis-
cussed in the Diseases and Conditions chapter.
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Introduction xvii
Cardiac-Related Tests
Inpatient psychiatrists and those working in research settings may be required to ob-
tain and provide preliminary interpretation of electrocardiogram (ECG) tracings. The
ECG is therefore covered in some depth in the Laboratory Tests chapter (including
indications, critical and abnormal findings, and typical ECG findings associated with
psychotropic medications) and in Appendix C (which includes a table listing 10 rules
for a normal ECG, a figure depicting ECG waves and intervals, a figure depicting dif
-
ferent degrees of heart block, and a gateway to the evaluation of 10-year cardiac risk
using a tool developed by the American College of Cardiology). Other cardiac-related
entries appear in the Diseases and Conditions chapter.
Chemistries
The largest component of the Laboratory Tests chapter involves blood chemistries.
These are the laboratory tests most often found to be abnormal in patients seen in psy
-
chiatric consultation in the general hospital. Abnormalities of blood chemistry often
contribute to delirium, anxiety, depression, and other common psychiatric presenta
-
tions. Chemistry tests that are not yet clinically available are not included.
Cerebrospinal Fluid Testing
Cerebrospinal fluid (CSF) tests include amyloid-β
1-42
, CSF analysis, cell count and dif-
ferential, cytology, glucose, lactate, protein, and tau protein. These tests may be useful
in the diagnosis of Alzheimer’s disease, encephalitis, meningitis, and other neuropsy
-
chiatric disorders. For those who may be interested, several excellent video presenta-
tions showing in detail how the lumbar puncture is performed are available online
(e.g., on YouTube).
Genetic Testing
The number of genetic tests currently available is very large, but most test for rela-
tively rare conditions and thus are not included here. Genetic tests that are covered
include apolipoprotein E (ApoE) genotyping, cytochrome P450 (CYP450) genotyping,
fragile X (FMR1) mutation analysis, HTT mutation analysis for Huntington’s disease,
and 5-HTTLPR polymorphism in the serotonin transporter gene SLC6A4. For most
clinicians, genetic tests are laboratory send-outs. It is important to inquire directly with
the receiving laboratory about costs before sending samples, because these tests may
not be covered by insurance and can be prohibitively expensive.
Hematology
Basic hematology is relevant to psychiatric practice not only because hematological
abnormalities may underlie symptoms such as fatigue, inattention, and restless legs
but also because psychotropic medications may significantly affect hematological val-
ues. In addition to clozapine, many other psychotropic drugs can cause hematological
abnormalities. DRESS (drug reaction with eosinophilia and systemic symptoms) is
one example that is increasingly recognized with psychotropics such as valproate and
lamotrigine.
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xviii Laboratory Medicine in Psychiatry and Behavioral Science
Imaging
Structural imaging is a core component of the diagnostic workup for a variety of con-
ditions, particularly those at the interface of psychiatry and neurology. Structural im-
aging is indicated when signs and symptoms of a major psychiatric disorder first
become manifest, for atypical presentations, for atypical age at onset, or for psychiat
-
ric symptoms associated with a focal neurological examination.
Because behavioral health clinicians often work in tandem with neurologists, neu-
rosurgeons, and internists, they may find themselves in a position to order or suggest
a variety of imaging studies, to assist patients in understanding study results, and to
facilitate tests and procedures. Thus, the information related to imaging in this man
-
ual covers an array of services—not only neuroimaging but also basic studies such as
a chest X-ray and bone mineral density (DEXA) scan. Other imaging tests covered in
this manual include angiography, carotid ultrasound, CT, CT angiography, functional
MRI, mammography, magnetic resonance angiography, magnetic resonance spectros-
copy, MRI, PET, and SPECT. Appendix B includes a table listing signal appearances
for various tissues on CT and MRI T1 and T2 scans, along with a description of the
steps involved in reading a head CT scan.
Infectious Disease Testing
Specific infectious diseases encountered in neuropsychiatric practice that are covered in
the Diseases and Conditions chapter of this manual include brain abscess, Creutzfeldt-
Jakob disease, encephalitis (including arbovirus encephalitis and herpes simplex en-
cephalitis), hepatitis, HIV/AIDS, Lyme disease, meningitis, infectious mononucleosis,
progressive multifocal leukoencephalopathy, syphilis and neurosyphilis, tuberculosis,
and urinary tract infection. Related entries in the Laboratory Tests chapter include hep
-
atitis panel, HIV testing, Lyme antibodies, syphilis testing, and tuberculosis testing.
Screening and Monitoring of
Psychotropic Medications
The Laboratory Tests chapter of this manual includes information about drug level test-
ing for a selected group of medications, including benzodiazepines, clozapine, and
mood stabilizers. The Psychotropic Medications: Laboratory Screening and Monitor-
ing chapter covers what have come to be called “safety labs” for monitoring adverse ef-
fects of psychotropic medications, as well as screening lab tests used to obtain baseline
values and to ensure that medications can safely be started. Appendix A presents a table
of therapeutic and toxic drug levels for commonly used psychotropic medications.
In general, drug levels can be obtained for any drug to confirm toxicity or document
noncompliance (with very low levels). Therapeutic ranges are included in this manual
for many drugs. Free drug levels may be used in place of total drug levels when the
patient has hypoalbuminemia, which can affect the interpretation of total drug levels.
Stool Tests
Tests for blood in stool are included because certain psychotropic medications cause
occult gastrointestinal bleeding, an underdiagnosed problem in psychiatry. In addi-
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xix Introduction
tion to the fecal occult blood test, a newer test for occult blood—the fecal immu-
nochemical test—is described.
Urine Tests
Routine urinalysis provides a great deal of information about general health and gen-
itourinary function. Individual components of the urinalysis are discussed separately
to deal with the many implications of individual urine test abnormalities. These com
-
ponents include urine appearance, bilirubin, blood or hemoglobin, casts, color, crys-
tals, epithelial cells and casts, glucose, ketones, leukocyte esterase, microalbumin,
nitrite, pH, protein, red blood cell counts and casts, specific gravity, white blood cell
counts and casts, and urobilinogen.
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CHAPTER 1
Laboratory Tests
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