**7. General treatment considerations for hyponatremia in psychiatric illnesses**

Here, we aim to describe general considerations of hyponatremia by going over symptoms, treatment, and cautions.

## **7.1 Summary of general symptoms of hyponatremia**

Symptoms of hyponatremia can be thought of as severe, moderate, and mild. Severe symptoms are red flag signs that include seizure and changes in cognition that can rapidly progress to coma and death. These symptoms are classically correlated with serum levels of less than 120. As such, these are the constellation of symptoms that would require hospitalization. Moderate and mild symptoms differ in severity but include flu like symptoms of headache, myopathy, and general malaise; these symptoms are observed mostly with sodium serum level ranges from 120 to 135. Lastly, there are patients who have low serum levels but are generally asymptomatic, with minimal changes in gait or sensorium [20].

#### **7.2 Treatment of hyponatremia and cautions**

When treating hyponatremia, it is important to recognize that there is a high risk of morbidity and mortality in conditions where hyponatremia develops within 48 h, post-op hyponatremia in female and pediatric populations, patients with history of cerebral pathology, as well as those presenting with psychosis (because they could have ingested large amounts of water). Regardless of symptom severity, it is important to note that increasing serum sodium level by 4–6 mEq/L in 24 h can reverse symptoms, and the rate should never exceed 8 mEq/L in a day, as rates faster than this can increase risk of demyelination [20]. Asymptomatic hyponatremia, if mild, may be left untreated.

Interventions commonly used in the context of treating hyponatremia include fluid restriction, increasing dietary salt, potassium replacements, hypertonic saline, and vasopressin antagonists, with selection based on the etiology and severity of the hyponatremia. Fluid restriction is most helpful in the context of volume overload (such as heart failure or cirrhosis), SIADH, renal failure, or if the patient has polydipsia. The amount of fluid restriction is determined often with nutritional consultation; this is the gold standard approach in treatment of SIADH. Patients may initially start with fluid restriction to 500 mL/d. Pharmacotherapy is typically considered if serum sodium has not improved with fluid restriction over 48 h [21].

Pharmacotherapy includes a broad range of options, including dietary salts and oral salt tablets, potassium replacements and vasopressin antagonists. Dietary salts and oral salt tablets are generally utilized for patients with mild to asymptomatic symptoms with SIADH. Potassium replacements are helpful when patients are developing conditions that are causing hypokalemic states as well, such as inappropriate diuretic uses and excessive vomiting. These may be associated with feeding and eating disorders, and additional considerations for the treatment of those

**141**

frequency of hyponatremic episodes in the long run.

*Hyponatremia and Psychiatric Diseases DOI: http://dx.doi.org/10.5772/intechopen.90011*

with volume deficits.

the patient.

treatment.

**8. Conclusion**

disorders may include 1:1 supervision for prevention of continued vomiting, and consultation with nutrition to minimize risk of refeeding during early hospitalization. Vasopressin antagonists will cause water loss, making it non-ideal for patients

The clinician must always be wary of any contributing factors causing the hyponatremia; for example, if the patient has adrenal insufficiency, glucocorticoid replacement will be crucial. In this case, endocrinology consultation may be appropriate. Likewise, if the patient has drug induced SIADH, it is important to re-visit the necessity of the drugs and to find replacements if able; common culprits include SSRIs like fluoxetine and sertraline [20]. The clinician and the patient should have a conversation about the risks, benefits, and alternatives to continuing treatment with an offending agent and informed consent should be documented whether the medication is maintained or switched. In patients with psychogenic polydipsia associated with antipsychotic medication use, treatment of the underlying psychotic disorder coupled with behavioral intervention to limit water intake may decrease the frequency of hyponatremic episodes and lessen morbidity. In patients with substance use disorders, particularly alcohol use disorder, psychoeducation and motivational interviewing surrounding their substance use disorder and risks of hyponatremia, including increased risk of seizure, may be a helpful part of decreasing use of substance. These patients should also be offered medication assisted treatment for their substance use disorder when appropriate and desired by

In sum, hyponatremia in psychiatric conditions is best treated in a comprehensive, multi modal approach. With many etiologies, including SIADH, endocrine pathologies, feeding and eating disorders, and delirium, consultation with different medical specialties and nutritional teams may augment and improve the treatment of hyponatremia. Regardless of etiology, psychoeducation and involvement of the patient in shared decision making is essential in understanding the future course of

Hyponatremia is a complex electrolyte disturbance which can both manifest with psychiatric symptoms, and can be associated with psychiatric disease itself. Eating disorders, psychotic illnesses, and substance use disorders are some of the more common psychiatric conditions encountered in practice that are associated with hyponatremia. The mechanisms that lead to hyponatremia vary, and at times hyponatremia may be a result of a drug side effect or drug-drug interaction. Given the potential for hyponatremia to cause significant morbidity and potential mortality, clinicians are urged to consider screening for plasma sodium in patients at risk of hyponatremia, such as patients in the three categories of psychiatric conditions described above. Treatment considerations include: (1) understanding the underlying etiology of the hyponatremia, (2) asymptomatic mild hyponatremia may not need treatment, (3) fluid restriction is the initial treatment of choice for SIADH, (4) hypertonic saline is used to correct moderate-severe hyponatremia, but should be done only under the guidance of medical teams to avoid demyelination syndromes, (5) there may be other considerations, such as 1:1 supervision for feeding-eating disorders, (6) specialty consultation may be appropriate in determining course of treatment, such as nutrition for advancement of diet, or endocrinology for concomitant adrenal pathology. Treatment of hyponatremia consists of various acute interventions, with consideration that treatment of the underlying psychiatric condition may help to diminish or eliminate the

#### *Hyponatremia and Psychiatric Diseases DOI: http://dx.doi.org/10.5772/intechopen.90011*

*Weight Management*

**illnesses**

urgency of its management.

symptoms, treatment, and cautions.

**7.1 Summary of general symptoms of hyponatremia**

asymptomatic, with minimal changes in gait or sensorium [20].

**7.2 Treatment of hyponatremia and cautions**

mild, may be left untreated.

a known compensatory mechanism for cerebral edema, which may place young women at increased risk of neurological impacts of hyponatremia with MDMA use. Further, a metabolite of MDMA, 4-hydroxy-3-methoxymethamphetamine (HMMA), is documented to stimulate ADH release, which can worsen hyponatremia. These are vital considerations given the potential sequela of seizure, and the

**7. General treatment considerations for hyponatremia in psychiatric** 

Here, we aim to describe general considerations of hyponatremia by going over

Symptoms of hyponatremia can be thought of as severe, moderate, and mild. Severe symptoms are red flag signs that include seizure and changes in cognition that can rapidly progress to coma and death. These symptoms are classically correlated with serum levels of less than 120. As such, these are the constellation of symptoms that would require hospitalization. Moderate and mild symptoms differ in severity but include flu like symptoms of headache, myopathy, and general malaise; these symptoms are observed mostly with sodium serum level ranges from 120 to 135. Lastly, there are patients who have low serum levels but are generally

When treating hyponatremia, it is important to recognize that there is a high risk of morbidity and mortality in conditions where hyponatremia develops within 48 h, post-op hyponatremia in female and pediatric populations, patients with history of cerebral pathology, as well as those presenting with psychosis (because they could have ingested large amounts of water). Regardless of symptom severity, it is important to note that increasing serum sodium level by 4–6 mEq/L in 24 h can reverse symptoms, and the rate should never exceed 8 mEq/L in a day, as rates faster than this can increase risk of demyelination [20]. Asymptomatic hyponatremia, if

Interventions commonly used in the context of treating hyponatremia include fluid restriction, increasing dietary salt, potassium replacements, hypertonic saline, and vasopressin antagonists, with selection based on the etiology and severity of the hyponatremia. Fluid restriction is most helpful in the context of volume overload (such as heart failure or cirrhosis), SIADH, renal failure, or if the patient has polydipsia. The amount of fluid restriction is determined often with nutritional consultation; this is the gold standard approach in treatment of SIADH. Patients may initially start with fluid restriction to 500 mL/d. Pharmacotherapy is typically considered if serum sodium has not improved with fluid restriction over 48 h [21]. Pharmacotherapy includes a broad range of options, including dietary salts and oral salt tablets, potassium replacements and vasopressin antagonists. Dietary salts and oral salt tablets are generally utilized for patients with mild to asymptomatic symptoms with SIADH. Potassium replacements are helpful when patients are developing conditions that are causing hypokalemic states as well, such as inappropriate diuretic uses and excessive vomiting. These may be associated with feeding and eating disorders, and additional considerations for the treatment of those

**140**

disorders may include 1:1 supervision for prevention of continued vomiting, and consultation with nutrition to minimize risk of refeeding during early hospitalization. Vasopressin antagonists will cause water loss, making it non-ideal for patients with volume deficits.

The clinician must always be wary of any contributing factors causing the hyponatremia; for example, if the patient has adrenal insufficiency, glucocorticoid replacement will be crucial. In this case, endocrinology consultation may be appropriate. Likewise, if the patient has drug induced SIADH, it is important to re-visit the necessity of the drugs and to find replacements if able; common culprits include SSRIs like fluoxetine and sertraline [20]. The clinician and the patient should have a conversation about the risks, benefits, and alternatives to continuing treatment with an offending agent and informed consent should be documented whether the medication is maintained or switched. In patients with psychogenic polydipsia associated with antipsychotic medication use, treatment of the underlying psychotic disorder coupled with behavioral intervention to limit water intake may decrease the frequency of hyponatremic episodes and lessen morbidity. In patients with substance use disorders, particularly alcohol use disorder, psychoeducation and motivational interviewing surrounding their substance use disorder and risks of hyponatremia, including increased risk of seizure, may be a helpful part of decreasing use of substance. These patients should also be offered medication assisted treatment for their substance use disorder when appropriate and desired by the patient.

In sum, hyponatremia in psychiatric conditions is best treated in a comprehensive, multi modal approach. With many etiologies, including SIADH, endocrine pathologies, feeding and eating disorders, and delirium, consultation with different medical specialties and nutritional teams may augment and improve the treatment of hyponatremia. Regardless of etiology, psychoeducation and involvement of the patient in shared decision making is essential in understanding the future course of treatment.
