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Depression

Medical Mimics of Depressive Disorders in College Students

Sometimes depression is not depression but a manifestation of a medical problem.

Key points

  • The presence of medical symptoms such as severe fatigue with depression may warrant a medical evaluation.
  • Communication among therapists, psychiatric providers, and primary care providers is critical when a medical problem exacerbates depression.
  • Parents may need to advocate for students with psychiatric and medical problems to get the care they need.

“I’ve never felt more depressed, tired, and unmotivated in my life. It’s hard to get out of bed. What should I do?”

Becca’s mother panics when she hears her daughter’s voice. Becca had an episode of depression in high school and saw a therapist; she also took an antidepressant for a year. Is this a recurrence of depression?

“I think you need an urgent visit to the campus counseling center.”

Becca visits the counseling center the next day. The therapist is concerned that Becca looks severely depressed and has not done any schoolwork in the last week. She makes an appointment for her to see me, a campus psychiatrist.

When I see Becca, I am struck by how tired she seems. During the session, she sits on the couch and starts lying down. It is hard for her to keep her eyes open.

I ask, “How long have you been this tired?”

She responds, “It’s been about three weeks. It started with a sore throat, which went away, but now I’m sleepy all the time. I feel depressed, too.”

I respond, “It’s possible a medical problem is making you tired and depressed. Let’s get you checked out at the student health care center.”

She meets with a primary care doctor, who orders lab work that reveals she has mononucleosis, a viral illness that often affects young adults. The doctor writes a letter to her professors so she can have extensions for her work. She goes home for a week and does her classwork online while she recovers.

She returns to my office six weeks after her diagnosis. She is smiling and says she is feeling much better. “I was worried my depression was coming back, but it turns out the mono was making me feel down and tired. Thanks for seeing me and sending me to the primary care doctor. I don’t think I need to restart an antidepressant. I’m feeling much better.”

When Medical Conditions Lead to Depression

How often do psychiatrists encounter medical causes of depressive symptoms? I was unable to find data on this, but I did find an article that reviews typical medical mimics of psychiatric disorders and reports that people with prior psychiatric disorders are more likely to have physical symptoms attributed to a mental health disorder, leading to an incomplete medical evaluation. Medical gaslighting, the dismissal of medical symptoms as minor or mental health–related, is more likely to happen to women and people of color. As psychiatrists, we must always listen to reports of medical symptoms, such as Becca’s sore throat, as a clue to what might be going on.

Most of the college students I see do not have any serious health problems. However, before prescribing an antidepressant, I generally check to see if they have had a recent physical exam to make sure we are not missing a medical cause of depression. Sometimes a mental health problem is a manifestation of an undiagnosed medical problem. I’m going to focus on medical mimics of depression, but for any psychiatric problem—anxiety, psychosis, and bipolar disorder—there can be medical mimics as well. Psychiatrists, whose training includes four years of medical school and four years of residency, must act as detectives to identify biological, psychological, and social causes of a patient’s symptoms.

Becca is not the only patient I have seen with either the onset or exacerbation of depression as a result of a medical problem. Leo comes to my office after studying abroad in South America. His mood had been good on an antidepressant, but, since his return, he is tired, down, and vomiting frequently. I suspect hepatitis and send him to our student health care center, where he is diagnosed with hepatitis A, from which he fully recovers. We never had to adjust his medication.

Ella recovers from COVID-19, but has the onset of depression, including severe insomnia as a result of her heart racing and anxious feelings at night. She is evaluated for thyroid problems and cardiac disease, but none are found. When she comes to me for treatment, I prescribe mirtazapine, a nighttime antidepressant with antianxiety effects. Her sleep improves and her depressive and anxiety symptoms diminish. The palpitations eventually stop.

Viral illnesses like mononucleosis, hepatitis A, and COVID-19 are not the only medical causes of depressive symptoms and fatigue. Deficiencies in nutrients like iron and vitamin B12 can contribute to malaise. Sleep disorders like sleep apnea and narcolepsy are risk factors for depression. Endocrine disorders such as hypothyroidism can contribute to fatigue and depression. Autoimmune diseases like systemic lupus erythematosus are less common but also can manifest with feelings of fatigue that can be mistaken for depression. I have seen all of these conditions cause or exacerbate depression in patients.

What happens if depression is still present after medical symptoms resolve? Students who get medical treatment but continue to have psychiatric issues may benefit from therapy and/or psychiatric medication.

Collaboration Is the Key to Treatment

Communication among therapists, psychiatric providers, and primary care providers in a campus health system is critical when a medical problem causes or contributes to depression. I am grateful my patients can be evaluated at our campus health care center quickly. Students give consent for therapists, psychiatrists, and primary care providers on campus to verbally communicate. Mental health providers on campus can view primary care provider notes. Off-campus providers can communicate with on-campus providers with a release of information.

Should you as a parent be part of the collaborating team? If your student is having difficulty accessing either psychiatric or medical treatment or is too depressed to find a provider, you should work with your student to find the care they need. Many campus counseling centers and health care centers have case managers who can link your child with services on or off campus. Ask your student to sign a release of information form if you feel it would be beneficial to speak with their provider or a case manager.

We as psychiatrists and you as parents have an important role as advocates in ensuring our college students get the medical and psychiatric care they need.

To find a psychiatrist, visit the Psychology Today Therapy Directory.

©2022 Marcia Morris, all rights reserved.
Details have been altered to protect patient privacy.

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