Many patients are referred to me as a psychiatrist to treat their depression. The new patients that come to me for depressive symptoms usually expect that I will be recommending and prescribing an antidepressant for their depressive symptoms because that is what a psychiatrist does, right? Not always.
Often times these patients come to me having gone through several antidepressant trials without any successful resolution of their depressive symptoms. Well sometimes the symptoms are caused by something other than depression. This morning I reviewed labs that I ordered on a young woman patient that I saw earlier this week for depression. Sure enough, her labs show she has iron-deficiency anemia. Prescribing an antidepressant in her case would not do anything about relieving all of the fatigue that she has been experiencing. She has a long history of depression, but that does not mean it should be assumed that her current episode of fatigue should be attributed to depression. I will prescribe iron for her at this time and coordinate care with her primary care doctor for further assessment of the cause of her iron-deficiency anemia. We will meet to monitor her response to iron treatment and continue to assess for psychiatric symptoms.
There are many other physical illnesses that can present similar to how depression is experienced in some patients. For example, this past winter there must have been an increase in cases of mononucleosis locally, as I picked up a couple cases of mono when doing labs on patients. For patients with a history of depression, the patient and their providers may be inclined to think that whenever symptoms of fatigue occur that it is due to a recurrence of their depression. My patients appreciate that we are thorough in assessing for other conditions before starting any psychiatric medication.
Another example this past year was of a young woman who was referred to me because she was suicidal. She reported to me that the main reason for her suicidal thinking was unbearable facial pain. She had been diagnosed with TMJ syndrome but wasn’t experiencing any relief of her pain. I did the usual psychiatric assessment of her and also assessed her facial pain symptoms. I advised her that her facial pain symptoms are more consistent with a diagnosis of Trigeminal Neuralgia than of TMJ syndrome. Although skeptical, she agreed to let me start her on Tegretol to treat Trigeminal Neuralgia. When she returned for her follow-up a week later, she started to cry when she expressed gratitude for relieving her facial pain. She was frustrated that her Trigeminal Neuralgia was never diagnosed before and that she was unnecessarily put on many pain medications in attempt to bring her relief of the pain. That was six months ago and her facial pain has not returned. She now wants to try tapering the antidepressant that she was put on previously and I agree that it is time to make this change.
These are just a few of my recent examples of how a thorough assessment of my patient’s symptoms reveals that there is more to their subjective complaints of depression than the patient thought. I am sure that many psychiatrists have similar examples of how other pathologies, such as thyroid disorders, cancers, neurological disorders, to name a few, have been the cause, or at least a contributing factor, to symptoms perceived by the patient as depression. As physicians, we as psychiatrists look beyond just symptoms and carefully look for cause and contributing factors of the presenting chief complaint of depression. An antidepressant isn’t always the answer to what appears to be depression.