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Section 3: Medical - Mental Health Differential Diagnosis

Physicians who are general practitioners have at their disposal numerous articles and guidelines to help heighten their awareness of mental health symptoms and diagnoses - even when their patients identify their problems as medical complaints. In this regard, generalists have a broader based perspective where patients seek help for physical complaints when the true problem is psychological or emotional in nature, or vice versa.

Mental health clinicians are well advised to keep their own reminders in this area. If mental health clinicians encounter deepening signs of depressive illness, a diagnosis made too quickly or too facilely may miss potential physical causes for the depression.

Depressive symptoms are often the initial symptoms of some physical diseases, the aftermath of trauma, or side effects from prescribed medications. When the medical illness goes untreated, psychiatric treatment only addresses the symptoms – leaving untreated potentially severe and life-threatening medical problems.

For instance, research has found that biologic relationships exist between malignancies (cancers) and depressive syndromes. Depressive symptoms are associated with cancer in up to 50% of cases. On many occasions the onset of depression is the first indication of undetected carcinoma (cancer). The depressions exhibited by the patient range from adjustment disorder with depressed mood to major depression.

The responsibility here lies in conducting a thorough enough assessment to direct the patient to the kind and level of resources that will best target the real problems. Whereas all physicians receive at least a rudimentary introduction to mental health problems, most mental health clinicians are largely untrained and unskilled in looking for the signs and symptoms that could be indicative of underlying physical illnesses.

This is a period in history when millions of Americans are without insurance and forego necessary preventive medical care. Clients can present for a counseling session through their Employee Assistance Program or at a low-cost mental health center as their first point of entry into the medical system. This means that even a beginning mental health clinician can be placed in the position of needing to be attuned to signs that suggest a more serious medical problem.

There are numerous examples of lifesaving referrals from mental health professionals to medical specialists. Some particularly powerful examples were:

- A severely depressed woman admitted to a psychiatric unit in a medical hospital for severe headaches that her primary care physician ruled to be psychosomatic. Fortunately, the team quickly sought another opinion and her malignant brain tumor was treated surgically with success.

- A successful differential medical diagnosis of an older depressed gentleman who had decreased appetite and fatigue, which turned out to be the result of stomach cancer.

- A Nurse Clinical Specialist in Psych/Mental Health cautioned a friend to seek medical help rather than an antidepressant for the hopelessness she was feeling in her pain management treatment. Her back pain had persisted and she had a cracked rib. As the nurse suspected, her diagnosis was Multiple Myeloma, a malignant cancer of the plasma cells and bone marrow which ultimately took her life.

In some cases, the depressive symptoms are caused by the frustration, discomfort and hopelessness these patients experience secondary to their physical symptoms. There may be reluctance - a kind of denial process - among some practitioners to diagnosis severe and terminal illnesses. It is, therefore, the role of all healthcare professionals to be cognizant of such possibilities.

Moreover, many illnesses exist together. When two or more medical conditions present simultaneously, they are said to be co-morbid.

What often prevents adequate diagnosis from either medical or mental health practitioners is incomplete information. Depression - and medical or other psychiatric illnesses - may be linked biologically, psychologically - or may appear to be entirely unrelated. For this reason, a thorough assessment is one that considers the presence of physical illness or other physiological factors, in addition to the presence of a mental or emotional disorder.





While this subject area is of tremendous importance for any clinician who wishes to provide a thorough assessment of a client's problems, it is outside the scope of this training. For clinicians who require further training in this area, it is recommended that's course on this topic be considered: DIFFERENTIAL DIAGNOSIS: IDENTIFYING COMMON MEDICAL CONDITIONS FREQUENTLY MISDIAGNOSED AS MENTAL HEALTH PROBLEMS.

Before moving to a discussion of the development of a clinical impression, there is one other area that warrant some examination: the use of measures in assessment.