Differential diagnoses of depression
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Depression, one of the most commonly diagnosed psychiatric disorders,[2][3] is being diagnosed in increasing numbers in various segments of the population worldwide.[4][5] Depression in the United States alone affects 17.6 million Americans each year or 1 in 6 people. Depressed patients are at increased risk of type 2 diabetes, cardiovascular disease and suicide. Within the next twenty years depression is expected to become the second leading cause of disability worldwide and the leading cause in high-income nations, including the United States. In approximately 75% of suicides, the individuals had seen a physician within the prior year before their death, 45–66% within the prior month. About a third of those who died by suicide had contact with mental health services in the prior year, a fifth within the preceding month.[6][7][8][9][10]
There are many psychiatric and medical conditions that may mimic some or all of the symptoms of depression or may occur
Many psychiatric disorders such as depression are diagnosed by
Misdiagnosis or missed diagnoses may lead to lack of treatment or ineffective and potentially harmful treatment which may worsen the underlying causative disorder.[23][24] A conservative estimate is that 10% of all psychological symptoms may be due to medical reasons,[25] with the results of one study suggesting that about half of individuals with a serious mental illness "have general medical conditions that are largely undiagnosed and untreated and may cause or exacerbate psychiatric symptoms".[26][27]
In a case of misdiagnosed depression recounted in
Autoimmune disorders
- food grains, most notably wheat, and also rye and barley. Current research has shown its neuropsychiatric symptoms may manifest without the gastrointestinal symptoms.
- "However, more recent studies have emphasized that a wider spectrum of neurologic syndromes may be the presenting extraintestinal manifestation of gluten sensitivity with or without intestinal pathology."[29]
- Lupus: Systemic lupus erythematosus (SLE), is a chronic autoimmune connective tissue disease that can affect any part of the body.[30] Lupus can cause or worsen depression.[31]
Bacterial-viral-parasitic infection
- bacterium transmitted by the Deer tick (Ixodes scapularis). Lyme disease is one of a group of diseases which have earned the name the "great imitator" for their propensity to mimic the symptoms of a wide variety of medical and neuropsychiatric disorders.[32][33] Lyme disease is an underdiagnosed illness, partially as a result of the complexity and unreliability of serologic testing.[34]
- "Because of the rapid rise of Lyme borreliosis nationwide and the need for antibiotic treatment to prevent severe neurologic damage, mental health professionals need to be aware of its possible psychiatric presentations.[35]
- Syphilis; the prevalence of which is on the rise, is another of the "great imitators", which if left untreated can progress to neurosyphilis and affect the brain, can present with solely neuropsychiatric symptoms. "This case emphasises that neurosyphilis still has to be considered in the differential diagnosis within the context of psychiatric conditions and diseases. Owing to current epidemiological data and difficulties in diagnosing syphilis, routine screening tests in the psychiatric field are necessary."[36]
- eggs of the pork tapeworm via contact with contaminated fecal matter or eating infected vegetables or undercooked pork.[37] "While cysticercosis is endemic in Latin America, it is an emerging disease with increased prevalence in the United States."[38] "The rate of depression in those with neurocysticercosis is higher than in the general population."[39]
- vectors for disease transmission to humans are various species of mosquito.[44][45] WNV which is endemic to Southern Europe, Africa the Middle East and Asia[46] was first identified in the United States in 1999. Between 1999 and 2006, 20,000 cases of confirmed symptomatic WNV were reported in the United States, with estimates of up to 1 million being infected. "WNV is now the most common cause of epidemic viral encephalitis in the United States, and it will likely remain an important cause of neurological disease for the foreseeable future."[47]
Blood disorders
- Anemia: is a decrease in normal number of red blood cells (RBCs) or less than the normal quantity of hemoglobin in the blood.[48] Depressive symptoms are associated with anemia in a general population of older persons living in the community.[49]
Chronic fatigue syndrome
Between 1 and 4 million Americans are believed to have
CFS is underdiagnosed in more than 80% of the people who have it; at the same time, it is often misdiagnosed as depression.[53]
Dietary disorders
- H2. Approximately 50% of those affected exhibit the physical signs of irritable bowel syndrome.[54]
- "Fructose malabsorption may play a role in the development of depressed mood. Fructose malabsorption should be considered in patients with symptoms of major depression...."[55]
- "Fructose and sorbitol reduced diet in subjects with fructose malabsorption does not only reduce gastrointestinal symptoms but also improves mood and early signs of depression."[56]
Endocrine system disorders
Dysregulation of the
HPT and HPA axes abnormalities observed in patients with depression (Musselman DL, Nemeroff CB. 1996) | ||||
HPT axes irregularities:
HPA axes irregularities:
|
Adrenal gland
- Addison's disease: also known as chronic adrenal insufficiency, hypocortisolism, and hypocorticism) is a rare endocrine disorder wherein the adrenal glands, located above the kidneys, produce insufficient steroid hormones (glucocorticoids and often mineralocorticoids). "Addison's disease presenting with psychiatric features in the early stage has the tendency to be overlooked and misdiagnosed."[58]
- adrenal glands, or more rarely, an ectopic hormone-secreting tumor. Depression is a common feature in diagnosed patients and it often improves with treatment.[59]
Thyroid and parathyroid glands
- thyrotoxicosis.
- Hashimoto's thyroiditis: also known chronic lymphocytic thyroiditis is an autoimmune disease in which the thyroid gland is gradually destroyed by a variety of cell and antibody mediated immune processes. Hashimoto's thyroiditis is associated with thyroid peroxidase and thyroglobulin autoantibodies[60]
- Hashitoxicosis
- Hypothyroidism
- Hyperthyroidism
- Hypoparathyroidism; can affect calcium homeostasis, supplementation of which has completely resolved cases of depression in which hypoparathyroidism is the sole causative factor.[61]
Pituitary tumors
Tumors of the
"... patients with pituitary disease were diagnosed and treated for depression and showed little response to the treatment for depression".[67]
Pancreas
- Hypoglycemia: an overproduction of insulin causes reduced blood levels of glucose. In one study of patients recovering from acute lung injury in intensive care, those patients who developed hypoglycemia while hospitalized showed an increased rate of depression.[68]
Neurological
CNS Tumors
In addition to pituitary tumors, tumors in various locations in the central nervous system may cause depressive symptoms and be misdiagnosed as depression.[28][69]
Post concussion syndrome
Pseudobulbar affect
Multiple sclerosis
Neurotoxicity
Various compounds have been shown to have neurotoxic effects many of which have been implicated as having a causal relationship in the development of depression.
Cigarette smoking
There has been research which suggests a correlation between cigarette smoking and depression. The results of one recent study suggest that smoking cigarettes may have a direct causal effect on the development of depression.[80] There have been various studies done showing a positive link between smoking, suicidal ideation and suicide attempts.[81][82]
In a study conducted among nurses, those smoking between 1-24 cigarettes per day had twice the suicide risk; 25 cigarettes or more, 4 times the suicide risk, than those who had never smoked.[83][84] In a study of 300,000 male U.S. Army soldiers, a definitive link between suicide and smoking was observed with those smoking over a pack a day having twice the suicide rate of non-smokers.[85]
"Current daily smoking, but not past smoking, predicted the subsequent occurrence of suicidal thoughts or attempt."[86]
"It would seem unwise, nevertheless, to rule out the possibility that smoking might be among the antecedent factors associated with the development of depression."[87]
"Abstinence from cigarettes for prolonged periods may be associated with a decrease in depressive symptomatology."[88]
"The stress induction model of smoking suggests, however, that smoking causes stress and concomitant negative affect."[89]
Medication
Various medications have been suspected of having a causal relation in the development of depression; this has been classified as "organic mood syndrome". Some classes of medication such as those used to treat hypertension, have been recognized for decades as having a definitive relationship with the development of depression.[90]
Monitoring of those taking medications which have shown a relationship with depression is often indicated, as well as the necessity of factoring in the use of such medications in the diagnostic process.[91]
- Topical blood brain barrier where it may have neurotoxic effects.[92]
- Interferons; proteins produced by the human body, three types have been identified alpha, beta and gamma. Synthetic versions are utilized in various medications used to treat different medical conditions such as the use of interferon-alpha in cancer treatment and hepatitis C treatment. All three classes of interferons may cause depression and suicidal ideation.[93]
Chronic exposure to organophosphates
The neuropsychiatric effects of chronic organophosphate exposure include mood disorders, suicidal thinking and behaviour, cognitive impairment and chronic fatigue.[94]
Neuropsychiatric
Bipolar disorder
- contraindicated as it may exacerbate hypomania, mania, or cycling between moods.[95][96] There is ongoing debate about whether this should be classified as a separate disorder because individuals diagnosed with major depression often experience some hypomanic symptoms, indicating a continuum between the two.[97]
Nutritional deficiencies
Nutrition plays a key role in every facet of maintaining proper physical and psychological wellbeing. Insufficient or inadequate nutrition can have a profound effect on mental health. The emerging field of nutritional neuroscience explores the various connections between diet, neurological functioning and mental health.
- Vitamin B6: pyridoxal phosphate (PLP), the active form of B6, is a cofactor in the dopamine serotonin pathway, a deficiency in vitamin B6 may cause depressive symptoms.[98]
- Vitamin D deficiency is associated with depression
Sleep disorders
- Insomnia: While the inability to fall asleep is often a symptom of depression, it can also in some instances serve as the trigger for developing a depressive disorder.[104][105] It can be transient, acute or chronic. It can be a primary disorder or a co-morbid one.
- Wittmaack-Ekbom's syndrome, is characterized by an irresistible urge to move one's body to stop uncomfortable or odd sensations. It most commonly affects the legs, but can also affect the arms or torso, and even phantom limbs.[106] Restless Leg syndrome has been associated with Major depressive disorder. "Adjusted odds ratio for diagnosis of major depressive disorder... suggested a strong association between restless legs syndrome and major depressive disorder and/or panic disorder."[107]
- Sleep apnea is a sleep disorder characterized by pauses in breathing during sleep. Each episode, called an apnea, lasts long enough for one or more breaths to be missed; such episodes occur repeatedly throughout the sleep cycle. Undiagnosed sleep apnea may cause or contribute to the severity of depression.[108]
- Circadian rhythm sleep disorders, of which few clinicians are aware, often go untreated or are treated inappropriately, as when misdiagnosed as either primary insomnia or as a psychiatric condition.[109]
See also
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Early onset of CRSD, the ease of diagnosis, the high frequency of misdiagnosis and erroneous treatment, the potentially harmful psychological and adjustment consequences, and the availability of promising treatments, all indicate the importance of greater awareness of these disorders.
Bibliography
- A Dose of Sanity: Mind, Medicine, and Misdiagnosis by Sydney Walker. ISBN 0-471-19262-7
External links
- Strategies for Reducing the Misdiagnosis of Bipolar Depression-Charles M. Bowden M.D.
- Late-Stage Neuropsychiatric Lyme Borelliosis Differential Diagnosis and Treatment Archived 2016-07-31 at the Wayback Machine
- Toxoplasmosis Parasite May Trigger Schizophrenia And Bipolar Disorders
- 10 Signs of depression