Differentials
Adjustment disorder with depressed mood
SIGNS / SYMPTOMS
This is a subsyndromal depression with a clearly identified precipitating event. It usually does not require medicine and resolves with resolution of the acute stressor.
INVESTIGATIONS
DSM-5-TR.
Substance-/medication- or medical illness-associated and other depressive disorders
SIGNS / SYMPTOMS
Depressive symptoms that fall short of diagnostic criteria for major depressive disorder due to concurrent substance use, medication side effects, or somatic medical illness, or for other specifiable or unspecifiable reasons.
INVESTIGATIONS
Medical history and physical, chemistry, haematological, and other tests to rule out or diagnose somatic medical illness; review and monitoring of prescription drugs for possible side effects; toxicology screen for evidence of substance abuse.
Bipolar disorder
SIGNS / SYMPTOMS
In this condition, major depressive disorder is accompanied by or interspersed with one or more manic, hypomanic, or mixed episodes.
INVESTIGATIONS
ICD-11, DSM-5-TR.
Premenstrual dysphoric disorder (PMDD)
SIGNS / SYMPTOMS
PMDD is characterised by depressed mood, anxiety, and irritability during the week before menses and resolving with menses. PMDD also has prominent pain symptoms.
INVESTIGATIONS
ICD-11, DSM-5-TR.
Grief/bereavement
SIGNS / SYMPTOMS
Depressive symptoms may be transiently present in normal grief. The duration and expression of normal grief varies among racial/ethnic groups.[145]
Symptoms more consistent with depression include inappropriate guilt regarding actions surrounding death of loved one, persistent thoughts of death (survivor's feelings that he or she would be better off dead or should have died with the deceased person are considered a normal part of grief), morbid preoccupation with worthlessness, marked psychomotor retardation, prolonged and marked functional impairment, and hallucinations. Transiently hearing the voice of or seeing the deceased person is considered within normal limits of bereavement.
Note that ICD-11 introduced prolonged grief disorder as a new diagnostic category, which describes a pathologically persistent and disabling reaction to bereavement, exceeding social, cultural and religious norms.[2]
According to DSM-5-TR and ICD-11, if the patient has a full syndrome of major depressive disorder, a recent loss or state of bereavement does not preclude the diagnosis or preclude the benefits of antidepressant treatment. However, a psychotherapeutic approach aimed at bereavement is likely to be more successful than standard psychotherapeutic approaches for depression.[146]
INVESTIGATIONS
ICD-11, DSM-5-TR.
Dementia
SIGNS / SYMPTOMS
Dementia is characterised by cognitive (memory) changes, psychiatric symptoms, personality changes, problem behaviours, and changes in day-to-day functioning.
INVESTIGATIONS
A mini-mental state examination or neuropsychiatric testing should be conducted if the diagnosis is uncertain.[147]
Focused laboratory testing (i.e., thyroid-stimulating hormone level, vitamin B12 level) should be considered for reversible causes of dementia.
Anxiety disorders
SIGNS / SYMPTOMS
Anxiety disorders frequently occur along with depression. Generalised anxiety disorder (GAD) is characterised by excessive worry, muscular tension, fatigue, autonomic hyperactivity, and increased vigilance; patients with anxious depression may appear to have GAD.[148] Specific anxiety disorders (i.e., panic disorder, social phobia, obsessive-compulsive disorder, PTSD) should also be considered.
INVESTIGATIONS
ICD-11, DSM-5-TR.
Alcohol-use disorder
SIGNS / SYMPTOMS
Patients often may complain of insomnia, nightmares, poor memory, and nervousness.
INVESTIGATIONS
Various screening tools are in wide use, including the CAGE questionnaire and the Alcohol Use Disorders Identification Test (AUDIT).[149]
Anorexia nervosa
SIGNS / SYMPTOMS
Eating disorders such as anorexia nervosa are more common in women and characterised by disturbance in the perception of body weight, size, or shape, and refusal to maintain healthy body weight.
INVESTIGATIONS
ICD-11, DSM-5-TR.
Hypothyroidism
SIGNS / SYMPTOMS
Associated signs and symptoms include weight gain, constipation, and fatigue.
INVESTIGATIONS
An elevated serum thyroid-stimulating hormone level suggests hypothyroidism.
Medicine adverse effects
SIGNS / SYMPTOMS
Patients should be asked about use of glucocorticoids, interferon, levodopa, propranolol, and oral contraceptives. Results from studies investigating whether isotretinoin increases the incidence of depression and/or suicidal ideation are conflicting; signs and symptoms of depression should be monitored during and after treatment with isotretinoin.[150]
INVESTIGATIONS
These effects may be temporally associated with medicine initiation race.
Cushing's disease
SIGNS / SYMPTOMS
This disease is associated with progressive obesity, dermatological manifestations, signs of adrenal androgen excess, and proximal muscle wasting.
INVESTIGATIONS
Elevated 24-hour urinary free cortisol level.
Vitamin B12 deficiency
SIGNS / SYMPTOMS
This deficiency is associated with macrocytic anaemia, paraesthesia, numbness, and impaired memory.
INVESTIGATIONS
Reduced serum vitamin B12 level.
Obstructive sleep apnoea (OSA)
SIGNS / SYMPTOMS
Depressive symptoms are a common consequence of OSA, and can be reversed by treatment directed at the OSA.[151]
INVESTIGATIONS
Sleep study.
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