**4. Low serum sodium from other medical conditions contributing to mental health conditions**

Exclusive relationships between hyponatremia, depression symptoms, and cognitive impairments have been reported in patients with chronic kidney disease who are also undergoing hemodialysis [12]. In DSM-5 [1], major depressive disorder is defined as a change from previous functioning that includes 5 or more of the following symptoms over a 2-week period of time such as depressed mood, diminished interest in activities, significant change in weight, insomnia or hypersomnia, psychomotor agitation or retardation, loss of energy, feelings of worthlessness, decreased ability to concentrate, and recurrent thoughts of death. Major neurocognitive disorder is characterized by significant cognitive decline from a previous level of functioning in one or more cognitive domains including complex attention,

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

over the course of the day.

**implicated in hyponatremia**

be monitored for by clinicians.

executive function, learning and memory, language, perceptual motor, or social

**5. Drug side effects and drug-drug interactions affecting serum sodium** 

Among the classes of medications used to treat psychiatric conditions there are many side effects and interactions that may alter serum sodium. This is a critical consideration as many of the symptoms of hyponatremia, particularly generalized malaise and alterations in appetite can mimic symptoms of depression. A recent case report documented duloxetine induced hyponatremia, including symptoms such as "unsteady gait, dizziness, nausea, general malaise and poor appetite," resolved by discontinuing duloxetine [14]. Serotonin Norepinephrine Reuptake Inhibitors (SNRIs), such as duloxetine, have been associated with syndrome of inappropriate antidiuretic hormone (SIADH) with resulting hyponatremia. Hyponatremia results from an inappropriately high release of antidiuretic hormone (ADH) from the posterior pituitary, which results in an excess retention of water and a low serum osmolality. In particular SNRIs act primarily to inhibit the reuptake of both serotonin and noradrenaline, and in experimental models it has been shown that both serotonin and noradrenaline can result in the increased release of ADH (in rat models serotonin (5-HT) activated 5-HT1A receptors cause sympathoexcitation of 5HT1C and 5HT2 receptors and the release of ADH; also stimulation of the paraventricular and supraoptic nuclei with norepinephrine can increase release of ADH within the serum) [14]. Therefore, through these mechanisms it is hypothesized that SNRIs cause SIADH in patients, a life-threatening side effect that must

A case report of a patient diagnosed with schizophrenia, taking desmopressin and meloxicam identified that NSAIDs can significantly augment hyponatremia

**5.1 Antidepressants and non-steroidal anti-inflammatory drugs (NSAIDs)** 

**in patients being treated for psychiatric conditions**

Hyponatremia has also been reported in association with catatonia and delirium, highlighting the profound effect that hyponatremia can have on one's mental status [13]. As defined by DSM 5 [1], catatonia includes a clinical picture dominated by three or more of the following symptoms including stupor, catalepsy (passive induction of posture held against gravity), waxy flexibility (slight, even positioning by examiner), mutism, negativism (opposition or no response), posturing, mannerism (odd, circumstantial caricature of normal actions), steryotypy (repetitive, abnormally frequent, non-global directed movements), grimacing, agitation, echolalia (mimicking another's speech), and echopraxia (mimicking another's movements). Mechanisms of hyponatremia leading to catatonia are not well elucidated. Based on case reports, it has been demonstrated multiple times that catatonia and delirium do occur in the context of hyponatremia. Some hypothesize that vasopressin regulation mediates the development of hyponatremia when one has catatonia with psychosis. While others argue that because only some Addison's disease patients develop hyponatremia (potential implication of aldosterone as regulator of sodium and water balance in the distal tubules and collecting ducts of the kidneys) and only some of those develop catatonia that therefore there is a presence of susceptibility of unknown reasons with hyponatremia causing catatonia [13]. DSM 5 [1] defines delirium as a disturbance in attention, awareness, and cognition that develops over a short period of time and tends to fluctuate in severity

cognition that interfere with independence in everyday activities.

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

*Weight Management*

of death.

**3.3 Obessive compulsive disorder (OCD)**

present as a neurological emergency [11].

**mental health conditions**

decreased need for sleep, pressured speech, flight of ideas, distractibility, increased goal directed activity, and excessive involvement in activities that have a high potential for painful consequences such as gambling, sexual indiscretions, and unrestrained buying sprees. The presence of mania distinguishes bipolar I from bipolar II; in bipolar I a patient must meet criteria for a manic episode, which may have been preceded or followed by a hypomanic or major depressive episode. Additionally, as defined by DMS 5 [1], bipolar disorder type II is diagnosed when the individual meets criteria for a current or past hypomanic episode and a current or past major depressive episode. A hypomanic episode is defined by DSM 5 [1] as a distinct period of abnormally and persistently elevated, expansive or irritable mood with increased activity or energy lasting at least 4 days with three or more of the following symptoms present including inflated self-esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increased goal directed activity, and excessive involvement in activities that have a high potential for painful consequences such as gambling, sexual indiscretions, and unrestrained buying sprees. Major depressive episode includes 5 or more of the following symptoms over a 2-week period that represent a change from previous functioning such as depressed mood, diminished interest in activities, significant change in weight, insomnia or hypersomnia, psychomotor agitation or retardation, loss of energy, feelings of worthlessness, decreased ability to concentrate, and recurrent thoughts

Obsessive-compulsive disorder as defined by DSM 5 [1] is characterized by the presence of obsessions, compulsions or both. Obsessions are recurrent or persistent intrusive thoughts that cause marked anxiety or distress that individuals try to ignore or suppress by performing compulsions such as repetitive behaviors or mental acts including hand washing, praying, or checking behaviors. The obsessions and compulsions are time consuming, and distressing, and are not attributed to another medical condition. An interesting case of an Indian woman has been reported in the literature, where her behaviors of excessive water intake, intrusiveness, excessive washing, cleaning, checking and perfectionism led to a diagnosis of OCD. She had experienced recurrent seizures with no benefit from antiepileptic medication, and only after further assessment it was discovered that her urge to drink excessive water led to consumption of 7 L of water producing hyponatremia and seizure [11]. This case is important because it highlights how a psychiatric condition (OCD) can

**4. Low serum sodium from other medical conditions contributing to** 

Exclusive relationships between hyponatremia, depression symptoms, and cognitive impairments have been reported in patients with chronic kidney disease who are also undergoing hemodialysis [12]. In DSM-5 [1], major depressive disorder is defined as a change from previous functioning that includes 5 or more of the following symptoms over a 2-week period of time such as depressed mood, diminished interest in activities, significant change in weight, insomnia or hypersomnia, psychomotor agitation or retardation, loss of energy, feelings of worthlessness, decreased ability to concentrate, and recurrent thoughts of death. Major neurocognitive disorder is characterized by significant cognitive decline from a previous level of functioning in one or more cognitive domains including complex attention,

**136**

executive function, learning and memory, language, perceptual motor, or social cognition that interfere with independence in everyday activities.

Hyponatremia has also been reported in association with catatonia and delirium, highlighting the profound effect that hyponatremia can have on one's mental status [13]. As defined by DSM 5 [1], catatonia includes a clinical picture dominated by three or more of the following symptoms including stupor, catalepsy (passive induction of posture held against gravity), waxy flexibility (slight, even positioning by examiner), mutism, negativism (opposition or no response), posturing, mannerism (odd, circumstantial caricature of normal actions), steryotypy (repetitive, abnormally frequent, non-global directed movements), grimacing, agitation, echolalia (mimicking another's speech), and echopraxia (mimicking another's movements). Mechanisms of hyponatremia leading to catatonia are not well elucidated. Based on case reports, it has been demonstrated multiple times that catatonia and delirium do occur in the context of hyponatremia. Some hypothesize that vasopressin regulation mediates the development of hyponatremia when one has catatonia with psychosis. While others argue that because only some Addison's disease patients develop hyponatremia (potential implication of aldosterone as regulator of sodium and water balance in the distal tubules and collecting ducts of the kidneys) and only some of those develop catatonia that therefore there is a presence of susceptibility of unknown reasons with hyponatremia causing catatonia [13]. DSM 5 [1] defines delirium as a disturbance in attention, awareness, and cognition that develops over a short period of time and tends to fluctuate in severity over the course of the day.
