Laboratory Tests in PsychiatryPsychiatrists depend more on the clinical examination and the patient's signs and symptoms to make a diag-nosis than do other medical specialists. No laboratory tests in psychiatry can confirm or rule out diagnoses such as schizophrenia, bipolar I disorder, and major depressive disorder. With the continuing advances in bi-ological psychiatry and neuropsychiatry, however, laboratory tests have become increasingly valuable, both to the clinical psychiatrist and to the biological researcher.In clinical psychiatry, laboratory tests can help rule out potential underlying organic causes of psychi-atric symptoms for example, impaired copper metabolism in Wilson's disease and a positive result on an antinuclear antibody (ANA) test in systematic lupus erythematosus (SLE). Laboratory work is then used to monitor treatment, such as measuring the blood levels of antidepres-sant medications and assessing the effects of lithium on electrolytes, thyroid metabolism, and renal function. Laboratory data, however, can serve only as an underlying support for the essential skill of clinical assessment.Basic Screening TestsBefore initiating psychiatric treatment, a clinician should undertake a routine medical evaluation for the purposes of screening for concurrent disease, ruling out organicity, and establishing baseline values of functions to be monitored. Such an evaluation includes a medical history and routine medical laboratory tests, such as a complete blood count (CBC); hematocrit and hemoglobin; renal, liver, and thyroid function; electrolytes; and blood sugar.

Thyroid disease and other endocrinopathies can present as a mood disorder or a psychotic disorder; cancer or infectious disease can present as depression;

infection and connective tissue diseases can present as short-term changes in mental status. In addi-tion, a range of medical and neurological conditions may present initially to the psychiatrist.

Those conditions include multiple sclerosis, Parkinson's disease, dementia of the Alzheimer's type, Huntington's disease, dementia caused by human immunodeficiency virus (HIV) disease, and tempo-ral lobe epilepsy.

Any suspected medical or neurological condition should be thoroughly evaluated with appropriate laboratory tests and consultation (Table 7.4-1).

Neuroendocrine TestsThyroid Function TestsSeveral thyroid function tests are available, including tests for thyroxine (T4) by competitive protein binding (T4D) and by radioimmunoassay (T4RIA) involving a specific antigen-antibody reaction.

More than 90 percent of T 4 is bound to serum protein and is responsible for thyroid-stimulating hor-mone (TSH) secretion and cellular metabolism. Other thyroid measures include the free T4 index (FT4I), triiodothyronine uptake, and total serum triiodothyronine measured by radioimmunoassay (T3RIA). These tests are used to rule out hypothyroidism, which can appear with symptoms of depression. In some studies, up to 10 percent of patients complaining of depression and associated fatigue had incipient hypothyroid disease.

Other associated signs and symptoms common to both depression and hypothyroidism include weakness, stiffness, poor appetite, constipation, menstrual irregularities, slowed speech, apathy, im-paired memory, and even hallucinations and delusions.

Lithium can cause hypothyroidism and, more rarely, hyperthyroidism. Table 7.4-2 outlines the sug-gested monitoring of thyroid function for patients taking lithium.

Neonatal hypothyroidism results in mental retardation and is preventable if the diagnosis is made at birth.

Table 7.4-3 lists the thyroid function test changes associated with hypothyroidism.Table 7.4-1 Some Medical Conditions That May Manifest with Neuropsychiatric Symptoms

Neurological   Cerebrovascular disorders (hemorrhage, infarction)   Head trauma (concussion, posttraumatic hematoma)   Epilepsy (especially complex partial seizures)   Narcolepsy

   Brain neoplasms (primary or metastatic)   Normal-pressure hydrocephalus   Parkinson's disease   Multiple sclerosis   Huntington's disease   Dementia of the Alzheimer's type   Metachromatic leukodystrophy   MigraineEndocrine   Hypothyroidism   Hyperthyroidism   Hypoadrenalism   Hyperadrenalism   Hypoparathyroidism   Hyperparathyroidism   Hypoglycemia   Hyperglycemia   Diabetes mellitus   Panhypopituitarism   Pheochromocytoma   Gonadotropic hormonal disturbances   PregnancyMetabolic and systemic   Fluid and electrolyte disturbances (e.g., syndrome of inappropriate antidiuretic hormone secretion [SIADH])   Hepatic encephalopathy   Uremia   Porphyria   Hepatolenticular degeneration (Wilson's disease)   Hypoxemia (chronic pulmonary disease)   Hypotension   Hypertensive encephalopathyToxic   Intoxication or withdrawal associated with drug or alcohol abuse   Adverse effects of prescribed and over-the-counter medications   Environmental toxins (volatile hydrocarbons, heavy metals, carbon monoxide, organophosphates)Nutritional   Vitamin B12 deficiency (pernicious anemia)   Nicotinic acid deficiency (pellagra)   Folate deficiency (megaloblastic anemia)   Thiamine deficiency (Wernicke-Korsakoff syndrome)   Trace metal deficiency (zinc, magnesium)   Nonspecific malnutrition and dehydrationInfectious   Acquired immunodeficiency syndrome (AIDS)   Neurosyphilis   Viral meningitides and encephalitides (e.g., herpes simplex)   Brain abscess   Viral hepatitis   Infectious mononucleosis   Tuberculosis   Systemic bacterial infections (especially pneumonia) and viremia   Streptococcal infections   Pediatric infection-triggered, autoimmune neuropsychiatric disordersAutoimmune

   Systemic lupus erythematosusNeoplastic   Central nervous system (CNS) primary and metastatic tumors   Endocrine tumors   Pancreatic carcinoma   Paraneoplastic syndromes(Table adapted from Darrell G. Kirch, M.D.)The thyrotropin-releasing hormone (TRH) stimulation test is indicated for patients whose marginally ab-normal thyroid test results suggest subclinical hypothyroidism, which can account for clinical depression. The test is also used for patients with possible lithium-induced hypothyroidism. The procedure entails an in-travenous (IV) injection of 500 mg of TRH, which produces a sharp rise in serum TSH when measured at 15, 30, 60, and 90 minutes. An increase in serum TSH from 5 to 25 international units per milliliter (IU/mL) above baseline is normal. An increase of less than 7 IU/mL is considered a blunted response, which may correlate with a diagnosis of a depressive disorder. Eight percent of all patients with depressive disorders have some thyroid illness.Dexamethasone-Suppression TestThe dexamethasone suppression test (DST) is used to help confirm a diagnostic impression of major de-pressive disorder.The patient is given 1 mg of dexamethasone (a long-acting synthetic glucocorticoid) by mouth at 11 PM, and the plasma cortisol level is measured at 8 AM, 4 PM, and 11 PM. Plasma cortisol concentrations above 5 mg/dL (known as nonsuppression) are considered abnormal (i.e., a positive result). Suppression of cortisol indicates that the hypothalamic-adrenal-pituitary axis is functioning properly. Since the 1930s, dysfunction of this axis has been known to be associated with stress.The problems associated with the DST include varying reports of sensitivity and specificity. False-positive and false-negative results are common and many medical conditions and pharmacological agents can inter-fere with results. Some evidence indicates that patients with a positive DST result (especially, 10 mg/dL) will have a good response to somatic treatment, such as electroconvulsive therapy (ECT) or cyclic antide-pressant therapy.Other Endocrine TestsMany other hormones affect behavior. Exogenous hormonal administration has been shown to affect be-havior, and known endocrine diseases have associated mental disorders. In addition to thyroid hormones, these hormones include the anterior pituitary hormone prolactin, growth hormone, somatostatin, go-nadotrophin-releasing hormone (GnRH), the sex steroids, luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone, and estrogen. Melatonin from the pineal gland has been implicated in sea-sonal affective disorder. Symptoms of anxiety or depression in some patients may be explained on the ba-sis of unspecified changes in endocrine function or homeostasis.

Table 7.4-2 Thyroid Monitoring for Patients Taking LithiumEvaluation Before

TreatmentRepeat at 6

MonthsRepeat Yearly

Medical1. Careful medical and family history to detect family his-tory of thyroid disease

×    

2. Review of symptoms of hyperthyroidism and hypothy-roidism

× × ×

3. Physical examination, including palpation of thyroid ×   ×LaboratoryT3RU (triiodothyronine resin uptake) ×   ×T4RIA (triiodothyronine measured by radioimmunoassay) ×   ×T2I (free thyroxine index) ×   ×TSH (thyroid-stimulating hormone) × × ×Antithyroid antibodies ×   ×(Reprinted from MacKinnon RA, Yudofsky SC. Principles of the Psychiatric Evaluation. Philadelphia: JB Lippincott; 1991:104, with permission.)Prolactin

Prolactin levels can become elevated in response to the administration of antipsychotic agents. Elevations in serum prolactin result from blockade of dopamine receptors in the pituitary. This blockade produces an increase in prolactin synthesis and release.Elevated prolactin levels are associated with galactorrhea, menstrual abnormalities, and alterations in libido and bone calcium concentrations.Prolactin can briefly rise after a seizure. For this reason, prompt measurement of a prolactin level after pos-sible seizure activity may assist in differentiating a seizure from a pseudoseizure.CatecholaminesThe level of serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) is elevated in the urine of patients with carcinoid tumors. Elevated levels are noted at times in patients who take phenothiazine medication and in those who eat foods high in serotonin (e.g., walnuts, bananas, and avocados). The concentration of 5-HIAA in cerebrospinal fluid is low in some persons who are in a suicidal depression and in postmortem studies of those who have committed suicide in particularly violent ways. Low 5-HIAA levels in cere-brospinal fluid are associated with violence in general. Norepinephrine and its metabolic products metanephrine, normetanephrine, and vanillylmandelic acid (VMA) can be measured in urine, blood, and plasma. Plasma catecholamine levels are markedly elevated in pheochromocytoma, which is associated with anxiety, agitation, and hypertension. Some patients with chronic anxiety may exhibit elevated blood norepinephrine and epinephrine levels. Some depressed patients have a low urinary norepinephrine-to-epi-nephrine ratio (NE:E).

Table 7.4-3 Thyroid Function Test Changes in Patients with Hypothyroidism1. Serum T4 concentration is decreased. 2. Serum-free thyroxine is decreased. 3. Serum T3 concentration is decreased. 4. Serum T3 uptake is decreased. 5. Serum protein-bound iodine (PBI) is decreased. 6. Serum thyroxine-binding globulin is normal. 7. Serum T3-to-T4 ratio is increased. 8. Serum TSH is increased.

(Reprinted from MacKinnon RA, Yudofsky SC. Principles of the Psychiatric Evaluation. Philadelphia: JB Lippincott; 1991:97, with permission.)High levels of urinary norepinephrine and epinephrine have been found in some patients with post-traumatic stress disorder. The norepinephrine metabolite 3-methoxy-4-hydroxyphenylglycol (MHPG) concentration is decreased in patients with severe depressive disorders, especially those patients who attempt suicide.Kidney Function TestsCreatinine clearance detects early kidney damage and can be serially monitored to follow the course of renal disease. Blood urea nitrogen (BUN) is also elevated in renal disease and is excreted via the kidneys; serum BUN and creatinine levels are monitored in patients taking lithium. If the serum BUN or creatinine level is abnor-mal, the patient's 2-hour creatinine clearance and ultimately the 24-hour creatinine clearance are tested.Table 7.4-4 outlines a suggested protocol for monitoring renal function in patients taking lithium.Table 7.4-5 summarizes other laboratory testing for patients taking lithium.

Table 7.4-4 Renal Monitoring for Patients Taking Lithium

EvaluationBefore

TreatmentRepeat at 6

MonthsRepeat Yearly

Medical1. Careful medical and family history to detect presence of familial kidney disease or predisposition to kidney disease (diabetes, hyper-tension)

×    

2. Specific comprehensive review of genitourinary system symptoms × × ×3. Physical examination ×   ×LaboratoryBUN (blood, urea, nitrogen) ×   ×Creatinine × × ×

Creatinine clearance (24-hour urine) urinalysis ×   ×24-hour urine volume ×   ×12-hour fluid deprivation test ×    (Reprinted from MacKinnon RA, Yudofsky SC. Principles of the Psychiatric Evaluation. Philadelphia: JB Lippincott; 1991:103, with permission.)

Table 7.4-5 Other Laboratory Testing for Patients Taking LithiumTest Frequency1. Complete blood count Before treatment and yearly2. Serum electrolytes Before treatment and yearly3. Fasting blood glucose Before treatment and yearly4. Electrocardiogram Before treatment and yearly5. Pregnancy testing for women of childbearing agea Before treatmentaTest more frequently when compliance with treatment plan is uncertain.(Reprinted from MacKinnon RA, Yudofsky SC. Principles of the Psychiatric Evaluation. Philadelphia: JB Lippincott; 1991:106, with permission.)P.258

Liver Function TestsTotal bilirubin and direct bilirubin values are elevated in hepatocellular injury and intrahepatic bile stasis, which can occur

with phenothiazine or tricyclic medication and with alcohol and other substance abuse. Certain drugs (e.g., phenobarbital [Luminal]) can lower the serum bilirubin concentration.

Liver damage or disease, which is reflected by abnormal findings in liver function tests (LFTs), can manifest with signs and symptoms of a cognitive disorder, including disorientation and delirium. Impaired hepatic function can increase the elimination half-lives of certain drugs, includ-ing some benzodiazepines, so that the drug may stay in a patient's system longer than it would under normal circumstances.

LFTs must be monitored routinely when using certain drugs, such as carbamazepine (Tegre-tol) and valproate (Depakene).

Lipids, Fasting Blood Sugar and Glycosylated HemoglobinSome atypical antipsychotic agents have been associated with abnormalities in lipid and serum glucose levels, including the development of diabetes mellitus. Patients who take atypical antipsychotic agents should be monitored for the development of hyper-glycemia by obtaining fasting blood glucose levels and glycosylated hemoglobin levels on a quarterly or semiannual basis. In addition, extremes in serum glucose concentrations have been associated with delirium. Hypoglycemia has also been associated with agitation and anxiety. Evaluation for diabetes or other abnormalities in glucose metabolism is usually best done by specialists.Blood Test for Sexually Transmitted DiseasesThe Venereal Disease Research Laboratory (VDRL) is a screening test for syphilis. If positive, the result is confirmed by using the specific fluorescent treponemal antibody-absorption (FTA-ABS) test, in which the spirochete Treponema pallidum is used as the antigen. A central nervous system (CNS) VDRL test is per-formed in patients with suspected neurosyphilis. A positive HIV test result indicates that a person has been exposed to infection with the virus that causes acquired immune deficiency syndrome (AIDS).Tests Related to Psychotropic DrugsIn caring for patients receiving psychotropic medication, the trend is to measure regularly the concentration of the prescribed drug in plasma. For some drugs, such as lithium, the monitoring is essential; for other drugs, such as antipsychotics, it is mainly of academic or research interest. A clinician need not practice de-fensive medicine by insisting that all patients receiving psychotropic drugs have blood levels determined for medicolegal purposes. The current status of psychopharmacological treatment is such that a psychiatrist's clinical judgment and experience, except in rare instances, are better indications of a drug's therapeutic effi-cacy than determining its level in plasma. The reliance on plasma levels cannot replace clinical skills.The major classes of drugs and the suggested guidelines for their use are outlined below.

Benzodiazepines

No special tests are needed for patients taking benzodiazepines. Among the benzodiazepines metabolized in the liver by oxidation, impaired hepatic function increases the half-life. Baseline LFTs are indicated for patients with suspected liver damage. Urine is tested routinely for benzodiazepines in patients being treated for substance abuse.AntipsychoticsNo special tests are needed for patients taking antipsychotics, although it is a good idea to obtain baseline values for liver function and a complete blood cell count. Antipsychotics are metabolized primarily in the liver, with metabolites excreted primarily in urine. Many metabolites are active. Peak plasma concentration usually is reached 2 to 3 hours after an oral dose. Elimination half-life is 12 to 30 hours, but can be much longer. Steady state requires at least 1 week at a constant dose (months at a constant dose of depot antipsy-chotics). With the exception of clozapine (Clozaril), all antipsychotics cause a short-term elevation in serum prolactin concentration (secondary to tuberoinfundibular activity). A normal prolactin level of-ten indicates either noncompliance or nonabsorption. Adverse effects include leukocytosis, leukopenia, impaired platelet function, mild anemia (both aplas-tic and hemolytic), and agranulocytosis. Bone marrow and blood element adverse effects can occur abruptly, even when the dosage has re-mained constant. Low-potency antipsychotics are most likely to cause agranulocytosis, which is the most common bone marrow adverse effect. These agents can cause hepatocellular injury and intrahepatic biliary stasis (in-dicated by elevated total and direct bilirubin and elevated transaminases). They also can cause electrocardiographic changes (not as frequently as with tricyclic antidepressants), including a prolonged QT interval; flattened, inverted, or bifid T waves; and U waves. The relation of dose to plasma concentration differs widely among patients.ClozapineClozapine levels are determined in the morning before administration of the morning dose of medica-tion. Weekly CBCs are required during the first 6 months of treatment with clozapine because of the risk of agranulocytosis.After the first 6 months of treatment, CBCs are checked every 2 weeks. Results must be sent to a pharmacy for the patient to receive his or her medication. Clozapine should be held for a WBC of less than 3,000 per mm3 or a neutrophil count of less than 1,500 per mm3.

Table 7.4-6 Clinical Management of Reduced White Blood Cell Count (WBC), Leukopenia, and Agranulocytosis

Problem Phase WBC Findings Clinical Findings Treatment PlanReduced WBC count

WBC count reveals a significant drop (even if WBC count is still in normal range). “Significant drop†� is (1) drop of more than 3,000 cells from prior test or (2) three or more consecutive drops in WBC counts

No symptoms of infection

1. Monitor patient closely 2. Institute twice-weekly

CBC tests with differen-tials if deemed appro-priate by attending physician

3. Clozapine therapy may continue

Mild leukopenia WBC = 3,000 to 3,500 Patient may or may not show clinical symptoms, such as lethargy, fever, sore throat, weakness

1. Monitor patient closely 2. Institute a minimum of

twice-weekly complete blood count (CBC) tests with differentials

3. Clozapine therapy may continue

Leukopenia or granulocytopenia

WBC = 2,000 to 3,000 or granulo-cytes = 1,000 to 1,500

Patient may or may not show clinical symptoms, such as fever, sore throat,

1. Interrupt clozapine at once

2. Institute daily CBC tests with differentials

lethargy, weakness 3. Increase surveillance, consider hospitalization

4. Clozapine therapy may be reinstituted after nor-malization of WBC

Agranulocytosis (uncomplicated)

WBC count less than 2,000 or granulocytes less than 1,000

The patient may or may not show clinical symptoms, such as fever, sore throat, lethargy, weakness

1. Discontinue clozapine at once

2. Place patient in protec-tive isolation in a medi-cal unit with modern fa-cilities

3. Consider a bone mar-row specimen to deter-mine if progenitor cells are being suppressed

4. Monitor patient every 2 days until WBC and differential counts re-turn to normal (about 2 weeks)

5. Avoid use of concomi-tant medications with bone marrow-suppress-ing potential

Agranulocytosis (with complications)

WBC count less than 2,000 or granulocytes less than 1,000

Definite evidence of infection, such as fever, sore throat, lethargy, weakness, malaise, skin ulcera-tions, and so on.

1. Consult with hematolo-gist or other specialist to determine appropri-ate antibiotic regimen

2. Start appropriate ther-apy; monitor closely

Recovery WBC count more than 4,000 and granulocytes more than 2,000

No symptoms of infection

1. Once-weekly CBC with differential counts for four consecutive normal values

2. Clozapine must not be restarted

(Reprinted from Sandoz Pharmaceuticals Corporation and MacKinnon RA, Yudofsky SC. Principles of the Psychiatric Evaluation. Philadelphia: JB Lippincott; 1991:118, with permission.)A therapeutic range for clozapine has not been established; however, a level of 100 nanograms per milliliter (ng/mL) is widely considered to be a minimal therapeutic threshold. Although concentrations between 200 and 700 ng/mL correlate more with response, nonresponse does occur within this range. At least 350 ng/mL of clozapine is considered to be necessary to achieve a therapeutic response in pa-tients with refractory schizophrenia. The likelihood of seizures and other side effects increases with clozapine levels greater than 1,200 ng/mL or dosages greater than 600 mg per day, or both.Physicians and pharmacists who provide clozapine must be registered through the Clozaril National Registry (1-800-448-5938). Table 7.4-6 summarizes the clinical management of reduced WBC, leukopenia, and agranulocytosis in patients treated with clozapine.Tricyclic and Tetracyclic DrugsAn electrocardiogram (ECG) can be taken before starting a regimen of cyclic drugs to assess for conduc-tion delays, which may lead to heart block at therapeutic levels. Some clinicians believe that all patients re-

ceiving prolonged cyclic drug therapy should have an annual ECG. At therapeutic levels, the drugs suppress arrhythmias through a quinidine-like effect.Blood levels should be determined routinely when using imipramine (Tofranil), desipramine (Nor-pramin), or nortriptyline (Pamelor) in the treatment of depressive disorders. Blood level determina-tions can also be useful for patients with a poor response at normal dosage ranges and with high-risk patients for whom there is an urgent need to know whether a therapeutic or toxic plasma level of the drug has been reached. Blood level determinations should also include the measurement of active metabolites (e.g., imipramine is converted to desipramine, amitriptyline [Elavil] to nortriptyline). Some characteristics of tricyclic drug plasma levels are described as follows.ImipramineThe percentage of favorable responses correlates with plasma levels in a linear manner between 200 and 250 ng/mL, but some patients respond at a lower level. Levels above 250 ng/mL yield no improved favorable re-sponse, and adverse effects increase.NortriptylineThe therapeutic window (the range within which a drug is most effective) is between 50 and 150 ng/mL. The response rate decreases at levels above 150 ng/mL.DesipramineLevels above 125 ng/mL correlate with a higher percentage of favorable responses.AmitriptylineDifferent studies have produced conflicting results with regard to blood levels, but they range from 75 to 175 ng/mL.Procedure for Determining Blood ConcentrationsThe blood specimen should be drawn 10 to 14 hours after the last dose, usually in the morning after a bed-time dose. Patients must have received a stable daily dose for at least 5 days for the test to be valid. Some patients who metabolize cyclic drugs unusually poorly may have levels as high as 2,000 ng/mL while taking normal dosages and before showing a favorable clinical response. Such patients must be monitored closely for cardiac adverse effects. Patients with levels above 1,000 ng/mL are generally at risk for cardiotoxicity.Monoamine Oxidase InhibitorsPatients taking monoamine oxidase inhibitors (MAOIs) are instructed to avoid tyramine-containing foods because of the danger of a hypertensive crisis. A baseline normal blood pressure (BP) must be recorded, and the BP must be monitored during treatment. MAOIs can also cause orthostatic hypotension as a direct drug adverse effect unrelated to diet. Other than their potential for elevating BP when taken with certain foods, MAOIs are relatively free of other adverse effects. A test used both in a research setting and in current clini-cal practice involves correlating the therapeutic response with the degree of platelet MAO inhibition.LithiumPatients receiving lithium should have baseline thyroid function tests, electrolyte monitoring, a WBC, renal function tests (specific gravity, BUN, and creatinine), and a baseline ECG. The rationale for these tests is that lithium can cause renal concentrating defects, hypothyroidism, and leukocytosis; sodium depletion can cause toxic lithium levels; and about 95 percent of lithium is excreted in the urine. Lithium has also been shown to cause ECG changes, including various conduction defects.Lithium is most clearly indicated in the prophylactic treatment of manic episodes (its direct antimanic effect can take up to 2 weeks), and it is commonly coupled with antipsychotics for the treatment of acute manic episodes. Lithium itself may also have antipsychotic activity. The maintenance level is 0.6 to 1.2 mEq/L, al-though acutely manic patients can tolerate up to 1.5 to 1.8 mEq/L. Some patients respond at lower levels; others require higher levels. A response below 0.4 mEq/L is probably a placebo effect. Toxic reactions can occur with levels above 2.0 mEq/L. Regular lithium monitoring is essential; a narrow therapeutic range ex-ists beyond which cardiac problems and CNS effects can occur.Blood for lithium level determination is drawn 8 to 12 hours after the last dose, usually in the morning after the bedtime dose. The level should be measured at least twice a week while stabilizing the patient's condi-tion and can be determined monthly thereafter.CarbamazepineA pretreatment CBC, including a platelet count should be done. Reticulocyte count and serum iron tests are also desirable. These tests should be repeated weekly during the first 3 months of treatment and monthly thereafter. Carbamazepine can cause aplastic anemia, agranulocytosis, thrombocytopenia, and leukopenia. Because of the minor risk of hepatotoxicity, LFTs should be done every 3 to 6 months. The medication

should be discontinued if the patient shows any signs of bone marrow suppression as measured with periodic CBC. The therapeutic level of carbamazepine is 8 to 12 ng/mL, with toxicity most often reached at levels of 15 ng/mL. Most clinicians report that levels as high as 12 ng/mL are hard to achieve. Table 7.4-7 summa-rizes one P.261

suggested protocol for laboratory monitoring of patients taking carbamazepine.Table 7.4-7 Laboratory Monitoring of Patients Taking Carbamazepine

Test Frequency1. Complete blood count (CBC) Before treatment and every 2 weeks for the first

2 months of treatment; thereafter, once every 3 months

2. Platelet count and reticulocyte count Before treatment and yearly3. Serum electrolytes Before treatment and yearly4. Electrocardiogram Before treatment and yearly5. Aspartate aminotransferase (SGOT), alanine aminotransferase (SGPT), lactate dehydrogenase (LDH) alkaline phosphatase

Before treatment and every month for the first 2 months of treatment; thereafter, every 3 months

6. Pregnancy test for women of childbearing age Before treatment and as frequently as monthly in noncompliant patients

(Reprinted from MacKinnon RA, Yudofsky SC. Principles of the Psychiatric Evaluation. Philadelphia: JB Lippincott; 1991:108, with permission.)ValproateSerum levels of valproic acid and divalproex (Depakote) are therapeutic in the range of 45 to 50 ng/mL. Above 125 ng/mL, adverse effects occur, including thrombocytopenia. Serum levels should be determined periodically, and LFTs should be run every 6 to 12 months.TacrineTacrine (Cognex) can cause liver damage. A baseline of liver function should be established, and follow-up serum transaminase levels should be determined every other week for about 5 months. Patients who develop jaundice or who have bilirubin levels above 3 mg/dL must be withdrawn from the drug.Provocation of Panic Attacks With Sodium LactateUp to 72 percent of patients with panic disorder have a panic attack when administered IV injection of sodium lactate. Therefore, lactate provocation is used to confirm a diagnosis of panic disorder. Lactate provocation has also been used to trigger flashbacks in patients with posttraumatic stress disorder. Hyper-ventilation, another known trigger of panic attacks in predisposed persons, is not as sensitive as lactate provocation in inducing panic attacks. Carbon dioxide (CO2) inhalation also precipitates panic attacks in those so predisposed. Panic attacks triggered by sodium lactate are not inhibited by peripherally acting β-adrenergic receptor antagonists (beta-blockers), but are inhibited by alprazolam (Xanax) and tricyclic drugs.Drug-Assisted InterviewInterviews with amobarbital (Amytal) have both diagnostic and therapeutic indications. Diagnostically, the interviews are helpful in differentiating nonorganic and organic conditions, particularly in patients with symptoms of catatonia, stupor, and muteness. Organic conditions tend to worsen with infusions of amobar-bital, but nonorganic or psychogenic conditions tend to get better because of disinhibition, decreased anxi-ety, or increased relaxation. Therapeutically, amobarbital interviews are useful in disorders of repression and dissociation for example, in the recovery of memory in psychogenic amnestic disorders and fugue, in the re-covery of function in conversion disorder, and in facilitation of emotional expression in posttraumatic stress disorder. Benzodiazepines can be substituted for amobarbital in the infusion. The procedure is outlined in Table 7.4-8.Lumbar PunctureLumbar puncture is useful in patients who have a sudden manifestation of new psychiatric symptoms, espe-cially changes in cognition. The clinician should be especially vigilant when fever or neurological symp-toms, such as seizures are present. Lumbar puncture is of use in diagnosing CNS infection (e.g., meningitis).Urine Testing for Substance AbuseA number of substances may be detected in a patient's urine if the urine is tested within a specific (and vari-able) period after ingestion of the substance. Knowledge of urine substance testing is becoming crucial for

practicing physicians in view of the controversial issue of mandatory or random substance testing. Table 7.4-9 provides a summary of substances of abuse that can be detected in urine.

Table 7.4-8 Drug-Assisted Interview Procedure1. Have patient recline in an environment in which cardiopulmonary resuscitation is readily available

should hypotension or respiratory depression develop. 2. Explain to patient that medication should help him or her relax and feel like talking. 3. Insert a narrow-bore needle into a peripheral vein. 4. Inject a 5% solution of sodium amobarbital (500 mg dissolved in 10 mL of sterile water) at a rate no

faster than 1 mL/min (50 mg/min). 5. Begin interview by discussing neutral topics: often, it is helpful to prompt the patient with known

facts about his or her life. 6. Continue infusion until either sustained lateral nystagmus or drowsiness is noted. 7. To maintain the level of narcosis, continue infusion at a rate of 0.5 to 1.0 mL/5 minutes (25 to 50

mg/5 minutes) 8. Have the patient recline for at least 15 minutes after the interview is terminated, until the patient can

walk without supervision. 9. Use the same method every time to avoid dosage errors.

Laboratory tests are also used to detect substances that may be contributing to cognitive disorders. Table 7.4-10 is an outline of therapeutic, toxic, and lethal levels of substances most commonly implicated in cog-nitive disorders.Other Laboratory TestsLaboratory tests not already discussed are covered in Table 7.4-11 in terms of their indications and signifi-cance in medical conditions that affect behavior. See Chapter 11 for information about testing for HIV.Table 7.4-9 Substances of Abuse That Can Be Tested in UrineSubstance Length of Time Detected in UrineAlcohol 7-12 hoursAmphetamine 48 hoursBarbiturate 24 hours (short-acting)

3 weeks (long-acting)Benzodiazepine 3 daysCannabis 3 days to 4 weeks (depending on use)Cocaine 6-8 hours (metabolites 2-4 days)Codeine 48 hoursHeroin 36-72 hoursMethadone 3 daysMethaqualone 7 daysMorphine 48-72 hoursPhencyclidine (PCP)8 daysPropoxyphene 6-48 hoursP.262

Table 7.4-10 Blood Level Data for Clinical Assessment

SubstanceTherapeutic or

Normal (%)Blood Levels

Toxic (%) Lethal (%)Acetaminophen (Tylenol) 1.0-2.0 mg 15.0 mg 150.0 mgAcetylsalicylic acid (salicylate)

10-30.0 mg >39.0 mg 50.0 mg

Aminophylline (theophylline)

1.0-2.0 mg 3.0-4.0 mg 21.0-25.0 mg

Amitriptyline (Elavil) 5.0-20.0 µg >50.0, µg 1.0-2.0 mgAmphetamines 2.0-3.0 µg 50.0 µg 200.0 µgArsenic 0.0-2.0 µg 0.10 mg 1.5 mgBarbiturates

   Short-acting 0.1 mg 0.7 mg 1.0 mg   Intermediate-acting 0.1-0.5 mg 1.0-3.0 mg >3.0 mg   Phenobarbital 1.5-3.9 mg 4.0-6.0 mg 8.0->15 mg   Barbital 1.0 mg 6.0-8.0 mg >10.0 mgBromide 5.0-30 mg 50-150 mg 200 mgCarbamazepine (Tegretol) 0.8-1.2 mg >1.5 mg Chloral hydrate 0.2-1.0 mg 10.0 mg 25.0 mgChlordiazepoxide (Librium) 0.1-0.3 mg 0.55 mg 2.0 mgChlorpromazine (Thorazine) 0.05 mg 0.1-0.2 mg 0.3-1.2 mgCocaine 90.0 µg 0.1-2.0 mgCodeine 2.5-12.0 µg 20.0-60.0 µgDesipramine (Norpramin) 15.0-30.0 µg >50.0, µ g 1.0-2.0 mgDiazepam (Valium) 0.05-0.25 mg 0.5-2.0 mg >2.0 mgDigoxin 0.06-0.20 µg 0.21-0.90 µg 1.5 µgDiphenhydramine (Benadryl)

1.0-10.0 µg 0.5 mg >1.0 mg

Doxepin (Sinequan) 10.0-25.0 µg 50.0-200.0 µg >1.0 mgEthanol 100.0 mg (legal

intoxication)350.0 mg

Glutethimide (Doriden) 0.02-0.08 mg 1.0-8.0 mg 3.0-10.0 mgHaloperidol (Haldol) 0.05-0.9 µg 1.0-4.0 mg Imipramine (Tofranil) 15.0-25.0 µg 50.0-150.0 µg 0.2 mgLead 0.0-30.0 µg 130 µg 110.0 -350.0 µgLithium 0.42-0.83 mg (0.6-1.2

mEq/L)1.39 mg (2.0 mEq/L) >3.47 mg (>4.0 mEq/L)

Lysergic acid diethylamide (LSD)

0.1-0.4 µg

Meperidine (Demerol) 0.03-0.10 mg 0.5 mg 3.0 mgMeprobamate 0.8-2.4 mg 6.0-10.0 mg 14.0-35.0 mgMercury 0.0-8 µg 100 µg 600.0 µgMethadone (Dolophine) 30.0-110.0 µg 0.2 mg >0.4 mgMethamphetamine 0.02-0.06 mg 0.06-0.5 mg 1.0-4.0 mgMethanol 20.0 mg >89.0 mgMethaqualone (Quaalude) 0.3-0.6 mg 1.0-3.0 mg >3.0 mgMethylphenidate (Ritalin) 1.0-6.0 µg 80.0 µg 230.0 µgMorphine 10.0 µg 5.0-400 µg (free morphine

from heroin)Nortriptyline (Pamelor) 12.0-16.0 µg 0.05 mg 1.3 mgOxycodone (Percodan) 1.7-3.6 µg 20.0-500.0 µg Paraldehyde 2.0-11.0 mg 20.0-40.0 mg >50.0 mgPentazocine (Talwin) 0.01-0.06 mg 0.2-0.5 mg 1.0-2.0 mgPerphenazine (Trilafon) 0.5 µg 100.0 µg Phencyclidine (PCP) 0.7-24.0 µg 100.0-500.0 µgPhenytoin (Dilantin) 1.0-2.0 mg 2.0-5.0 mg >10 mgPrimidone (Mysoline) 0.5-1.2 mg 5.0-8.0 mg 10.0 mgPropoxyphene (Darvon) 5.0-20.0 µg 30.0-60.0 µg 80.0-200.0 µgPropranolol (Inderal) 2.5-20.0 µg 0.8-1.2 mgQuinidine 0.03-0.6 mg 1.0 mg 3.0-5.0 mgQuinine 0.18 mg 1.2 mgThioridazine (Mellaril) 0.10-0.15 mg 1.0 mg 2.0-8.0 mgTrifluoperazine (Stelazine) 0.08 mg 0.12-0.3 mg 0.3-0.8 mg(Reprinted from Winek L. Drug and Chemical Blood-Level Data. Pittsburgh: Fisher Scientific; 1985, with permission.)

Table 7.4-11 Other Laboratory Tests

TestMajor Psychiatric

Indications CommentsAcid phosphatase Organic workup for

cognitive disordersIncreased in prostate cancer, benign prostatic hyper-trophy, excessive platelet destruction, bone disease

Adrenocorticotropic hormone (ACTH)

Organic workup Increased in steroid abuse; may be increased in seizures, psychotic disorders, Cushing's disease, and in response to stressDecreased in Addison's disease

Alanine aminotransferase (ALT) (formerly called serum glutamic-pyruvic transaminase [SGPT])

Organic workup Increased in hepatitis, cirrhosis, liver metastasesDecreased in pyridoxine (vitamin B6) deficiency

Albumin Organic workup Increased in dehydrationDecreased in malnutrition, hepatic failure, burns, multiple myeloma, carcinomas

Aldolase Eating disordersSchizophrenia

Increased in patients who abuse ipecac (e.g., bulimic patients), schizophrenia (60%-80%)

Alkaline phosphatase Organic workupUse of psychotropic medications

Increased in Paget's disease, hyperparathyroidism, hepatic disease, hepatic metastases, heart failure, phenothiazine useDecreased in pernicious anemia (vitamin B12 defi-ciency)

Ammonia, serum Organic workup Increased in hepatic encephalopathyAmylase, serum Eating disorders May be increased in bulimia nervosaAntinuclear antibodies Organic workup Found in systemic lupus erythematosus (SLE) and

drug-induced lupus (e.g., secondary to phenoth-iazines, anticonvulsants); SLE can be associated with delirium, psychotic disorders, mood disorders

Aspartate aminotransferase (AST) (formerly SGOT)

Organic workup Increased in heart failure, hepatic disease, pancreati-tis, eclampsia, cerebral damage, alcohol dependenceDecreased in pyridoxine (vitamin B6) deficiency, ter-minal stages of liver disease

Bicarbonate, serum Panic disorderEating disorders

Decreased in hyperventilation syndrome, panic disor-der, anabolic steroid abuseMay be elevated in patients with bulimia nervosa, in laxative abuse, in psychogenic vomiting

Bilirubin Organic workup Increased in hepatic diseaseBlood urea nitrogen (BUN) Delirium

Use of psychotropic medications

Elevated in renal disease, dehydrationElevations associated with lethargy, deliriumIf elevated, can increase toxic potential of psychiatric medications, especially lithium and amantadine (Symmetrel)

Bromide, serum DementiaPsychosis

Bromide intoxication can cause psychosis, hallucina-tions, deliriumPart of dementia workup, especially when serum chloride is elevated

Caffeine level, serum Anxiety Evaluation of patients with suspected caffeinismCalcium (Ca), serum Organic workup

Mood disordersPsychosisEating disorders

Increased in hyperparathyroidism, bone metastasesIncrease associated with delirium, depression, psy-chosisDecreased in hypoparathyroidism, renal failureDecrease associated with depression, irritability, delirium, long-term laxative abuse

Carotid ultrasound Dementia Occasionally included in dementia workup, espe-

cially to rule out multi-infarct dementiaPrimary value is in search for possible infarct causes

Catecholamines, urinary and plasma

Panic attacksAnxiety disorders

Elevated in pheochromocytoma

Cerebrospinal fluid (CSF) Organic workup Increased protein and cells in infection, positive VDRL result in neurosyphilis, bloody CSF in hemor-rhagic conditions

Ceruloplasmin, serum; copper, serum

Organic workup Low in Wilson's disease (hepatolenticular disease)

Chloride (CI), serum Eating disordersPanic disorder

Decreased in patients with bulimia nervosa and psy-chogenic vomitingMild elevation in hyperventilation syndrome, panic disorder

Cholecystokinin (CCK) Eating disorders Compared with controls, blunted in bulimic patients after eating meal (may normalize after treatment with antidepressants)

CO2 inhalation; sodium bicarbonate infusion

Anxiety Panic attacks produced in subgroup of patients

Coombs test, direct and indirect Hemolytic anemias secondary to psy-chotropic medications

Evaluation of drug-induced hemolytic anemias, such as those secondary to chlorpromazine, phenytoin, levodopa, and methyldopa

Copper, urine Organic workup Elevated in Wilson's diseaseCortisol (hydrocortisone) Organic workup

Mood disordersExcessive level may indicate Cushing's disease asso-ciated with anxiety, depression, and a variety of other conditions

Creatine phosphokinase (CPK) Use of antipsychoticsUse of restraintsSubstance abuse

Increased in neuroleptic malignant syndrome, intra-muscular injection, rhabdomyolysis (secondary to substance abuse), patients in restraints, patients expe-riencing dystonic reactions; asymptomatic elevations seen with use of antipsychotics

Creatinine, serum Organic workup Elevated in renal diseaseInhibits prolactin

Dopamine (DA) (L-dopa stimulation of dopamine)

Depression Test used to assess functional integrity of dopaminer-gic system, which is impaired in Parkinson's disease, depression

Doppler ultrasound ImpotenceOrganic workup

Carotid occlusion, transient ischemic attack (TIA), reduced penile blood flow in impotence

Echocardiogram Panic disorder 10%-40% of patients with panic disorder show mitral valve prolapse

Electroencephalogram (EEG) Organic workup Seizures, brain death, lesions; shortened rapid eye movement (REM) latency in depressionHigh-voltage activity in stupor; low-voltage fast ac-tivity in excitement; in functional nonorganic cases (e.g., dissociative disorders), alpha activity is present in the background, which responds to auditory and visual stimuliBiphasic or triphasic slow bursts seen in dementia of Creutzfeldt-Jakob disease

Epstein-Barr virus (EBV); cy-tomegalovirus (CMV)

Organic workupChronic fatigueMood disorders

Part of herpesvirus groupEBV is causative agent for infectious mononucleosis, which can manifest with depression and personality changeCMV can produce anxiety, confusion, mood disor-dersEBV associated with chronic mononucleosislike syn-

drome associated with chronic depression and fa-tigue; may be association between EBV and major depressive disorder

Erythrocyte sedimentation rate (ESR)

Organic workup An increase in ESR represents a nonspecific test of infectious, inflammatory, autoimmune, or malignant disease; sometimes recommended in the evaluation of anorexia nervosa

Estrogen Mood disorder Decreased in menopausal depression and premen-strual syndrome; variable changes in anxiety

Ferritin, serum Organic workup Most sensitive test for iron deficiencyFolate (folic acid), serum Alcohol abuse

Use of specific medi-cations

Usually measured with vitamin B12 deficiencies asso-ciated with psychotic disorders, paranora, fatigue, agitation, dementia, deliriumAssociated with alcohol dependence, use of pheny-toin, oral contraceptives, estrogen

Follicle-stimulating hormone (FSH)

Depression High normal in anorexia nervosa, higher values in postmenopausal women; low levels in patients with panhypopituitarism

Glucose, fasting blood (FBS) Panic attacksAnxietyDeliriumDepression

Very high FBS associated with deliriumVery low FBS associated with delirium, agitation, panic attacks, anxiety, depression

Glutamyl transaminase, serum Alcohol abuseOrganic workup

Increased in alcohol abuse, cirrhosis, liver disease

Gonadotropin-releasing hormone (GnRH)

DepressionAnxietySchizophrenia

Decreased in schizophrenia; increased in anorexia nervosa; variable in depression, anxiety

Growth hormone (GH) DepressionSchizophrenia

Blunted GH responses to insulin-induced hypo-glycemia in depressed patients; increased GH re-sponses to dopamine agonist challenge in schizo-phrenic patients; increased in some patients with anorexia nervosa

Hematocrit (Hct); hemoglobin (Hb)

Organic workup Assessment of anemia (anemia may be associated with depressive and psychotic disorders)

Hepatitis A viral antigen (HAAg)

Mood disordersOrganic workup

Less severe, better prognosis than hepatitis B; may present with anorexia nervosa, depression

Hepatitis B surface antigen (HBsAg); hepatitis Bc antigen (HBcAg)

Mood disordersOrganic workup

Active hepatitis B infection indicates greater infec-tivity and progression to chronic liver diseaseMay present with depression

Holter monitor Panic disorder Evaluation of panic-disordered patients with palpita-tions and other cardiac symptoms

Human immunodeficiency virus (HIV)

Organic workup CNS involvement: acquired immune deficiency syn-drome (AIDS) dementia, personality change due to a general medical condition, mood disorder due to a general medical condition, acute psychotic disorders

17-Hydroxycorticosteroid Depression Deviations detect hyperadrenocorticalism, which can be associated with major depressive disorderIncreased in steroid abuse

5-Hydroxyindoleacetic acid (5-HIAA)

DepressionSuicideViolence

Decreased in CSF in aggressive or violent patients with suicidal or homicidal impulsesMay indicate decreased impulse control and predict suicide

Iron, serum Organic workup Iron-deficiency anemiaLactate dehydrogenase (LDH) Organic workup Increased in myocardial infarction, pulmonary in-

farction, hepatic disease, renal infarction, seizures,

cerebral damage, megaloblastic (pernicious) anemia, factitious elevations secondary to rough handling of blood specimen tube

Lupus anticoagulant (LA) Use of phenothiazines An antiphospholipid antibody, which has been de-scribed in some patients using phenothiazines, espe-cially chlorpromazine

Lupus erythematosus (LE) test DepressionPsychosisDeliriumDementia

Positive test result associated with SLE, which may manifest with various psychiatric disturbances, such as psychotic disorders, depressive disorders, delir-ium, dementia; also tested for with antinuclear anti-body (ANA) and anti-DNA antibody tests

Luteinizing hormone (LH) Depression Low in patients with panhypopituitarism; decrease associated with depression

Magnesium, serum Alcohol abuseOrganic workup

Decreased in alcohol dependence; low levels associ-ated with agitation, delirium, seizures

MAO, platelet Depression Low in depressionMCV (mean corpuscular vol-ume) (average volume of a red blood cell)

Alcohol abuse Elevated in alcohol dependence, vitamin B12, folate deficiency

Melatonin Mood disorder with seasonal pattern

Produced by light and pineal gland and decreased in mood disorder with seasonal pattern

Metal (heavy) intoxication (serum or urinary)

Organic workup Lead apathy, irritability, anorexia nervosa, confusionMercury psychosis, fatigue, apathy, decreased mem-ory, emotional lability, “mad hatter†�Manganese manganese madness, Parkinsonlike syn-dromeAluminum dementiaArsenic fatigue, blackouts, hair loss

3-Methoxy-4-hydroxyphenylglycol (MHPG)

DepressionAnxiety

Most useful in research; decreases in urine may indi-cate decreases centrally

Myoglobin, urine Phenothiazine useSubstance abuseUse of restraints

Increased in neuroleptic malignant syndrome; in phencyclyine (PCP) cocaine, or lysergic acid diethy-lamide (LSD) intoxication; in patients in restraints

Nicotine AnxietyNicotine addiction

Anxiety, smoking

Nocturnal penile tumescence Erectile disorder Quantification of penile circumference changes, pe-nile rigidity, frequency of penile tumescenceEvaluation of erectile function during sleepErections associated with rapid eye movement (REM) sleepHelpful in differentiation between organic and func-tional causes of impotence

Parathyroid (parathormone) hormone

AnxietyOrganic workup

Low level causes hypocalcemia and anxietyDysregulation associated with wide variety of cogni-tive disorders

Phosphorus, serum Organic workupPanic disorder

Increased in renal failure, diabetic acidosis, hy-poparathyroidism, hypervitamin DDecreased in cirrhosis, hypokalemia, hyperparathy-roidism, panic attack, hyperventilation syndrome

Platelet count Use of psychotropic medications

Decreased by certain psychotropic medications (car-bamazepine, clozapine, phenothiazines)

Porphobilinogen (PBG) Organic workup Increased in acute porphyriaPorphyria-synthesizing enzyme Psychosis

Organic workupAcute panic attack or a cognitive disorder can occur in acute porphyria attack, which may be precipitated by barbiturates, imipramine

Potassium (K), serum Organic workupEating disorders

Increased in hyperkalemic acidosis; increase is asso-ciated with anxiety in cardiac arrhythmiaDecreased in cirrhosis, metabolic alkalosis, laxative abuse, diuretic abuse; decrease is common in bulimic patients and in psychogenic vomiting, anabolic steroid abuse

Prolactin, serum Use of antipsychotic medicationCocaine usePseudoseizures

Antipsychotics, by decreasing dopamine, increase prolactin synthesis and release, especially in womenElevated prolactin levels may be seen secondary to cocaine withdrawalLack of prolactin rise after seizure suggests pseudo-seizure

Protein, total serum Organic workupUse of psychotropic medications

Increased in multiple myeloma, myxedema, lupusDecreased in cirrhosis, malnutrition, overhydrationLow serum protein can result in greater sensitivity to conventional doses of protein-bound medications (lithium is not protein bound)

Prothrombin time (PT) Organic workup Elevated in significant liver damage (cirrhosis), pa-tients with lupus anticoagulant, which can be found in certain patients receiving antipsychotic medica-tions, especially chlorpromazine

Reticulocyte count (estimate of red blood cell production in bone marrow)

Organic workupUse of carbamazepine

Low in megaloblastic or iron deficiency anemia and anemia of chronic diseaseMust be monitored in patient taking carbamazepine

Salicylate, serum Psychotic disorder due to a general medical condition with halluci-nationsSuicide attempts

Toxic levels may be seen in suicide attempts and may cause psychotic disorder due to a general medi-cal condition with hallucinations

Sodium (Na), serum Organic workup Decreased with water intoxication syndrome of inap-propriate antidiuretic hormone secretion (SIADH)Increased with excessive salt intake; diabetesDecreased in hypoadrenalism, myxedema, conges-tive heart failure, diarrhea, polydipsia, use of carba-mazepine, anabolic steroidsLow levels associated with greater sensitivity to con-ventional dose of lithium

Testosterone, serum ImpotenceHypoactive sexual de-sire disorder

Increased in anabolic steroid abuseFollow-up of sex offenders treated with medroxypro-gesteroneMay be decreased in organic workup of impotenceDecrease may be seen in hypoactive sexual desire disorderDecreased with medroxyprogesterone treatment

Thyroid function tests Organic workupDepression

Detection of hypothyroidism or hyperthyroidismAbnormalities can be associated with depression, anxiety, psychosis, dementia, delirium

Urinalysis Organic workupPretreatment workup of lithiumDrug screening

Provides clues to cause of various cognitive disor-ders (assessing general appearance, pH, specific gravity, bilirubin, glucose, blood, ketones, protein, etc.); specific gravity may be affected by lithium

Urinary creatinine Organic workupSubstance abuseLithium use

Increased in renal failure, dehydrationPart of pretreatment workup for lithium

Venereal Disease Research Syphilis Positive (high titers) in secondary syphilis (may be

Laboratory (VDRL) positive or negative in primary syphilis)Low titers (or negative) in tertiary syphilis

Vitamin A, serum DepressionDelirium

Hypervitaminosis A is associated with a variety of mental status changes

Vitamin B12, serum Organic workupDementia

Part of workup of megaloblastic anemia and demen-tiaB12 deficiency associated with psychosis, paranoia, fatigue, agitation, dementia, deliriumOften associated with chronic alcohol abuse

White blood cell (WBC) Use of psychotropic medications

Leukopenia and agranulocytosis associated with cer-tain psychotropic medications, such as phenoth-iazines, carbamazepine, clozapineLeukocytosis associated with lithium and neuroleptic malignant syndrome