Alarmed by his elevated blood pressure (177/99 mm Hg) and worsening physical symptoms, Mr. D finally consents to baseline laboratory testing. Blood glucose is 306 mg/dL (normal 70 to 110 mg/dL), and glycosylated hemoglobin is 12% (normal
Mr. D, who now weighs 270 lbs, is diagnosed as having hypertension and type 2 diabetes mellitus. Clinic doctors start him on metformin, 500 mg bid titrated to 1,000 mg bid, and glyburide, 5 mg/d, to control his glucose, and lisinopril, 10 mg/d, to control his hypertension, reduce cardiovascular risk, and preserve renal function. Clinicians also order Mr. D to follow an 1,800-calorie, American Diabetes Association-approved diet. We stop quetiapine and bupropion.
Mr. D’s diabetes and hypertension diagnosis, combined with his habitus and history of easy bruising, suggest Cushing’s syndrome. Doctors rule out this disorder based on a 24-hour free cortisol reading of 59 mg/L and normal dexamethasone suppression. Lab findings suggest he is not taking stimulants away from work.
The authors’ observations
Ideally, Mr. D should have undergone laboratory testing after the initial intake visit, before psychotropics were started. Routine vital signs also should have been taken.
Symptoms of major depressive disorder and early type 2 diabetes are strikingly similar (Table 1). For example, early diabetes symptoms such as fatigue can mimic depression or other medical problems. In one study of 69 diabetic patients who were referred by their primary care doctors to a psychiatric clinic, 57 had not been diagnosed as having diabetes before referral.9
Aside from its medical complications, diabetes also doubles the risk of comorbid depression, which can alter diabetes’ course and outcome.10
Earlier laboratory testing could have uncovered Mr. D’s comorbid stimulant abuse, which also can mimic depression and complicate its treatment.11 Signs of amphetamine withdrawal—such as dysphoric mood, fatigue, insomnia or hypersomnia, increased appetite, and psychomotor retardation—can be mistaken for depression (Table 1).
Patients with Cushing’s syndrome may present with nonspecific complaints of fatigue, decreased energy, apathy, depressed mood, and hypersomnia. A 24-hour free cortisol reading and dexamethasone suppression testing can differentiate Cushing’s syndrome from depression.
Costly, unnecessary care. Missing a medical cause of apparent psychiatric symptoms can lead to unnecessary treatment and needless expense. A complete metabolic profile and urine drug screen—approximately $60—could have saved the nearly $5,000 spent on treating Mr. D’s “resistant” depression ( Table 2).
Psychiatrists need to watch for potential medical problems and for cormorbidities associated with mental illness. Patients with frequent mental distress—defined as ≥ 14 mentally unhealthy days within 30 days—were found to be more likely to smoke, drink heavily, and be physically inactive and obese than were mentally healthy persons. Mentally distressed patients also were more likely to lack health care coverage and to engage in multiple adverse behaviors, increasing their risk for mental and physical illness.12
Ensuring proper medical care. Based on our experience with Mr. D, routine vital signs—including BMI, weight, blood pressure, and pulse rate—should be recorded at each visit. At intake, we recommend that psychiatrists:
- find out when the patient last saw a primary health provider other than in the emergency room, and whether the patient is receiving preventive medical care
- assess for unhealthy lifestyle habits (smoking, drug use, poor diet) or family history of serious medical illnesses.
Educate patients about the interplay between physical and mental illness to help them understand the importance of seeing a primary care doctor. Finally, be familiar with local indigent health clinics and their fee scales.
Table 1
Medical symptoms that mimic depression
| Symptom | Amphetamine withdrawal | Cushing’s syndrome | Diabetes |
|---|---|---|---|
| Anxiety | × | ||
| Dysphoric mood | × | ||
| Fatigue | × | × | × |
| Hypersomnia | × | ||
| Increased appetite | × | × | |
| Insomnia | × | ||
| Irritability | × | × | |
| Muscle aches and cramps | × | ||
| Psychomotor retardation | × | ||
| Vivid, unpleasant dreams | × | ||
| Weakness | × | ||
| Weight gain or loss | × |
The cost of treating Mr. D’s ‘resistant depression’
| Medication/dosage | Start date | Stop date | Approximate cost |
|---|---|---|---|
| Citalopram, 20 mg/d | 10/3/03 | 10/24/03 | $58.50 |
| Sertraline, 25 to 200 mg/d | 10/24/03 | 12/24/03 | $283.00 |
| Sertraline 150 mg/d, with lithium, 225 to 675 mg/d | 12/24/03 | 2/6/04 | $343.00 |
| Tranylcypromine, 10 mg each morning, 20 mg at bedtime | 2/27/04 | 4/20/04 | $322.00 |
| Bupropion (sustained release) up to 450 mg/d | 5/7/04 | 8/30/04 | $372.00 |
| Bupropion (sustained release), 450 mg/d, plus quetiapine, 25 mg/d | 8/30/04 | 11/8/04 | $554.00 |
| Total cost of psychotropics | $1,932.50 | ||
| Total cost of office visits ($95 X 30 visits) | $2,850.00 | ||
| TOTAL COST OF TREATMENT | $4,782.50 | ||
| Source: Walgreens Co. retail prices in Wichita, KS | |||
Follow-up: 30 lbs in 4 months
Mr. D has lost >30 lbs over 4 months, and his blood pressure and serum glucose are normal. BMI is now 32, in the lower range of clinical obesity. He feels more energetic and active, no longer reports excessive sedation and apathy, and has stopped taking stimulants. His depressive symptoms have remitted.