TCPR: So I’m interviewing a patient in the clinic; I have only 45 minutes to do a thorough psychiatric evaluation. I’m rushed; I don’t have enough time to really learn all I want to know. It would be great if there were a list of specific red flags to say, “OK, this person has a medical disorder that’s either complicating or generating a lot of the ‘psychiatric’ symptoms I am seeing.”
Dr. Schildkrout: Well, there are some specific red flags that indicate you are definitively dealing with a medical disorder. I’m thinking of signs like slurred speech, clouding of consciousness, overt confusion, or physical abnormalities that you can see from across the room, such as jaundice or an abnormal gait. But many clinic patients won’t have these signs. Then you’re mainly looking for clues that there is something atypical about this presentation or this patient. Your job is to think beyond the DSM and to keep the possibility of a medical disorder in mind. Many patients are not getting regular medical care, so although you are not a PCP, you may be the one doctor they actually see. As a physician, it makes sense to do a mental status exam and a medical review of systems, even if you do them quickly. These may reveal something that is new.
TCPR: I agree. Let’s start with depression, which is something we commonly see in outpatient practice. What are your thoughts about potential medical issues masquerading as depression?
Dr. Schildkrout: It’s always important to distinguish depression from apathy. Depression is a disturbance of mood, whereas apathy is about motivation. Apathy is impairment in the process of getting yourself going, of initiating, and then following through. The two are related in that when you’re depressed, you don’t have a zest for life and don’t feel as invested in doing things. So it’s easy to confuse the two. People who have apathy may talk less, may not engage in activities, and they may not even initiate conversation. And this may be interpreted as depression. But if you ask somebody who’s simply apathetic what they’re feeling, they will tell you, “No, I’m not depressed.” Apathy is more associated with brain phenomena, so this is something to definitely consider in your older patients (Epstein J and Silbersweig D, J Neuropsychiatry Clin Neurosciences 2015;27(1):7–18. doi:10.1176/appi.neuropsych.13120370).
TCPR: So apathy is something we might attribute to a medical condition?
Dr. Schildkrout: Yes, apathy is related to neural circuitry of the frontal lobes. A person who is apathetic could have an underlying medical problem such as a frontal lobe tumor, frontal dementia, chronic subdural hematoma, or normal pressure hydrocephalus. Apathy could also be related to traumatic brain injury (TBI).
TCPR: So a patient may volunteer something like, “I had a concussion” or “I was in a bad auto accident,” and you can ask screening questions like, “Have you had a head injury?” or “Have you ever been knocked unconscious?” Then you’re faced with, “OK so it’s happened; now what?” Is it the TBI that has worsened the psychiatric condition, or is it the psychiatric condition that is causing the cognitive problem?
Dr. Schildkrout: Right, the TBI could be completely irrelevant. Or, as we know, there is the potential for secondary gain after a head injury. But there’s also the interaction of a head injury with any antecedent psychiatric disorder, making a psychiatric condition worse. Or, the TBI could be significant in itself. Sorting this out is what makes our job so complicated. First, try to figure out how serious the head injury was. Ask how long the person was unconscious and how long was the period of amnesia afterwards. What’s the last thing the patient remembers from before the injury, and when did their memory resume afterwards? Second, determine what the patient was like before the head injury compared to what the patient is like now. Has there been a change in personality? If you haven’t known the patient over time, then you don’t know whether the person you’re seeing is now substantially different than before the injury. To get that information, you have to talk to family members or friends and also try to get surrogate measures like work history, school history, grades, social involvement, and so on.
TCPR: That’s very important information. Getting back to depression, are there any other features that increase your index of suspicion that there’s a medical problem?
Dr. Schildkrout: It’s important to note whether the age of onset is typical, or whether the first episode came on later in life. Having no family history of mental illness is also a red flag. Also, pay attention if there are a lot of physical symptoms that accompany the depression, such as significant weight change, arthritis, headaches, cough, gastrointestinal symptoms, gait instability, and so on.
TCPR: OK, let’s say we have a late-onset depression patient without a family history and it’s a first episode. We have ascertained that our patient is experiencing depression and not apathy. What kinds of questions should that bring up?
Dr. Schildkrout: Some of the things I’d be thinking of include sleep disorders which are very common; underlying malignancies like pancreatic and lung cancer; endocrine disorders such as hypothyroidism; multiple sclerosis; and early Parkinson’s disease. Many medical diseases can present with depression, so you have to cast a wide net looking for clues. I would ask my patient, “How has your general health been? Do you have any physical complaints? Have you had constipation? How is your sleep? How do you feel when you wake up in the morning?” I realize that depression alone may cause problems in many of these areas, so you have to inquire carefully about the severity of the symptoms.
TCPR: Let’s say something suddenly something jumps out at you and now you’re thinking maybe Parkinson’s. Where are your questions headed to try and ascertain that potential condition?
Dr. Schildkrout: If I have a depressed patient and I’m thinking, “Hmm, maybe this is the beginning of Parkinson’s,” then physically I’ll watch this person very carefully. Is there any paucity of movement? A tremor? How is the person’s gait? Is their voice soft? I’m also going to ask more specifically about changes in handwriting, which can get smaller with Parkinson’s disease, and about constipation, which is also common. I’d ask questions about sleep such as, “Have you ever fallen out of bed?” and “Does your partner complain that you move a lot in your sleep or act out your dreams?” REM sleep behavior disorder is often a prodrome of Parkinson’s and can begin up to 10 years in advance. Patients don’t necessarily talk about these nighttime behaviors because they may feel embarrassed. REM sleep behavior disorder can be an important harbinger of a later onset of Parkinsonian spectrum disorder—including some disorders that are rare, like multiple systems atrophy and so on (Kalia LV and Lang AE, The Lancet 2015;386(9996):896–912. doi:10.1016/S0140–6736(14)61393–3).
TCPR: You also mentioned endocrine and thyroid disorders as possible causes of depression. What kinds of questions would you ask to identify those symptoms?
Dr. Schildkrout: For the thyroid disorders, I’d ask about whether the person has noticed any change in temperature sense, being especially hot or cold. Do they fight with a partner about the bedcovers or how to set the thermostat? There is often a drying and coarsening of skin or hair with hypothyroidism and a thinning with hyperthyroidism. I’d ask about hair loss and nail cracking, as well as recent weight gain or loss, fatigue, and constipation. Hypothyroidism classically presents with depression, but in older individuals especially, hyperthyroidism also can present as depression. Anxiety, irritability, and insomnia can accompany thyroid disorders, so I would be asking more specific questions about those areas as well.