Medical Differential for Patient Presenting with Depressive Symptoms

When a patient, especially one without a history of depression, presents with depressive symptoms, it is important to consider if those symptoms are a result of another medical condition. Depressive symptoms that are more likely to be in this category include:

  •  Fatigue/low energy
  •  Trouble initiating or maintaining sleep
  •  Hypersomnia
  •  Significant change in appetite, leading to change to weight
  • Poor concentration
  • Depressed mood

When someone presents with new onset depressive symptoms, it is important to obtain a thorough history, conduct a review of systems to determine if there are abnormal findings in other body systems, obtain a family history, and perform a physical exam. These can point the provider in the right direction in terms of a differential diagnosis. Medical conditions that can mimic symptoms of depression include:

  • Hypothyroidism
  • B12 deficiency
  • Iron deficiency anemia
  • Autoimmune disorders – fibromyalgia, lupus
  • Sleep apnea
  • Seasonal allergies
  • Medication side effect – ex: pain medication, beta blockers, Accutane, Chantix

If there is a concern for a medical condition leading to depressive symptoms, consider appropriate lab tests and imaging studies to confirm or rule out the diagnosis. To be clear, not everyone who presents with depressive symptoms needs to have other medical conditions ruled out, just in situations when it makes sense clinically.

Case Study:
9 year old female who presents with fatigue and low energy and trouble with concentration x 2 months. She reports she does not understand why she feels so tired because she sleeps 7-8 hours per night. The daytime fatigue is causing her to feel sad some days because it is affecting her energy level with her 1 year old and at work. She does not have a history of depression. Medically she is healthy except she experienced significant blood loss during her delivery.

Next Steps?
Given that she does not have a history of depression, it is important to rule out other medical causes for her symptoms. Basic labs are ordered and show low Hb/Hct. Additional studies ordered to assess for iron-deficiency anemia and confirm the diagnosis. She is started on iron supplementation and encouraged to eat more iron- rich foods in her diet and sees improvement in her symptoms over the next 3 months.
It is hopeful that this discussion and case example give clearer guidelines on when to consider a medical workup for a patient presenting with classically depressive symptoms. One take home point is that it is important to conduct a brief review of systems even in a patient presenting with depressive symptoms as her chief complaint.

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