From the Editor

Lab tests in psychiatry: How much is enough?


James Randolph Hillard, MD


Here’s a horrifying thought: What if psychiatrists were internists? Only by historical accident is psychiatry its own specialty, separate from internal medicine.

Our 19th- and 20th-century predecessors practiced in state mental hospitals and treated most patients with psychotherapy rather than drugs. Today, most inpatient psychiatry is practiced in general hospitals, and we do at least as much pharmacotherapy as psychotherapy. If psychiatry were getting started today, it probably would an internal medicine subspecialty.

When I was in medical school, one psychiatry attending had been a surgeon before his psychiatry residency. When I said his two specialties seemed very different, his response was, “Not really.” Psychiatrists and surgeons “treat patients,” whereas other specialists—say, internists—prefer to “solve problems.”

During my residency, the surgeons called internists “fleas” because all they seemed to do was hop around in packs drawing blood. This stereotype—if it was ever true—is probably less accurate today, with so many internists becoming proceduralists rather than cognitive specialists.

But still . . . if we were internists, we undoubtedly would do more diagnostic tests. Psychiatry’s standard of care is to do lab tests when patients are hospitalized but very seldom in outpatient settings. If we were internists, we would do lab tests before starting any outpatient on any treatment. Everyone would get an extensive “workup” to “rule out” numerous highly improbable diagnoses.

The article in this issue by Drs. Richard Rosse and Stephen Deutsch addresses intelligent lab testing before starting patients on psychotropics. I do not want to give away the ending, but these authors recommend more testing than most of us do and less than we probably would be doing if we were—horror of horrors!—internists.