In nursing school, it is drilled into our heads that a urinary tract infection (UTI) can cause a change in mental status in the elderly, but they never mentioned that a UTI or other infectious agent can cause an increase in psychosis in persons with serious mental illness (SMI) of any age.
When our SMI population show up in the ER or our offices for complaints of increased symptoms, they often end up with an increase their daily dose of antipsychotic medications, which in most cases is never lowered and just raised each time there is an issue.
Perhaps if we considered the symptoms to be more related to the infection, we could temporarily increase their antipsychotic while they are treated with an antibiotic until their symptoms return to baseline. With the high price these patients are paying with their bodies, in regards to metabolic syndrome, it is in the best interest of our patient and our duty to use the smallest dose of an antipsychotic to best control the symptoms of SMI. If we keep increasing the dose without looking into the possibility of an infection causing the current increase of symptoms and this increase may only be transient, we are not protecting our patients and are doing them a disservice.
Current research in the fields of schizophrenia, bipolar disorder, depression, OCD, and Tourette’s is suggesting that symptoms and, in some cases, the origin of the disorders could be linked to various infections.
It is often indicated that cytokines and other inflammatory response cells are involved. Is it such as stretch to think that a current infection could trigger these inflammatory responses and increase symptoms in the SMI population? In fact, it’s known that stress (physical or mental) could trigger the inflammatory response. This could indicate that the endocrine system is involved and hormonal changes, such as cortisol, could then trigger the inflammatory response system and increase symptoms.
We then need to consider the spectrum of everything. As we are finding in medicine, nothing is quite black or white and often exist on a spectrum. We could then assume that the current infection, as well as the SMI, would also exist on a spectrum. Would a mild infection cause mild symptoms or would a mild infection cause major symptoms? I would guess that would depend on the spectrum of the SMI in the individual patient.
The question now is how do we proceed from here? What labs do we draw and which values do we use to determine if the SMI patient is experiencing even a slight infection? With the over-use of antibiotics, do we give an antibiotic or wait for the infection to pass and increase their psychiatric medication? If inflammation from the infection is causing the increased symptoms, would it be better to prescribe and anti-inflammatory medication?
These are all questions that are being researched, but in the meantime, what do we do as psychiatric nurses or APRN’s when these patients show up on our doorstep? I believe that it is important for all of us to recognize that this current increase in symptoms may be transient and whether there is clear evidence that they need an antibiotic or not, we should keep in mind that when this passes, we should try to decrease their psychiatric medications back to their baseline levels to avoid overmedicating.
Below, are several links to articles related to this subject matter. I encourage you to browse these and then find your own to help you form your own opinion on the matter, and maybe, if you find this to be a necessary step in the research and treatment of SMI, to help voice your concern.
Thank you for your time and consideration,
Bernadette Noel Sisk, RN, BSN (Student Psychiatric Mental Health Nurse Practitioner, University of Akron)
http://www.ncbi.nlm.nih.gov/books/NBK83686/
http://www.psychiatrictimes.com/articles/infectious-agents-schizophrenia-and-bipolar-disorder
http://www.ncbi.nlm.nih.gov/pubmed/12480495
http://www.cmu.edu/news/stories/archives/2012/april/april2_stressdisease.html
http://www.todaysdietitian.com/newarchives/111609p38.shtml
http://www.hsph.harvard.edu/gsh-lab/research/inflammation/