Before a psychiatric diagnosis can be made, it has to survive a medical workup. This is one of the most important, and most consistently missed, steps in mental health care.
The brain runs on glucose, oxygen, hormones, nutrients, and an immune system it shares with every other organ. When any of those inputs are disrupted, the brain produces symptoms indistinguishable from psychiatric illness.
Examples of what gets missed every day:
⚕️ Hypothyroidism can present as depression. Studies show up to 26.2% of depressed patients have abnormal thyroid function. Treating the thyroid condition should be the first step.
⚕️ Hyperthyroidism can look like anxiety or mania: racing thoughts, insomnia, irritability, and palpitations mimicking panic disorder or hypomania.
⚕️ Iron deficiency can mimic ADHD or depression. Iron is important in dopamine synthesis, and testing without ferritin levels routinely misses this etiology.
⚕️ B12 deficiency can manifest as depression, cognitive decline, and in severe cases psychosis. Neurological impairment can occur at levels considered normal by standard reference ranges.
⚕️ Sleep apnea can present as depression and ADHD: cognitive fog and low energy are driven by chronic hypoxia and fragmented sleep.
⚕️ POTS and dysautonomia can look like anxiety, depression, and cognitive dysfunction, driven by cerebral hypoperfusion when upright, not primary psychiatric illness.
⚕️ PANDAS/PANS manifests as sudden-onset OCD, tics, anxiety, and behavioral change in children. The hallmark is dramatic onset, often overnight, following streptococcal or other infection.
⚕️ Autoimmune encephalitis can present as psychosis. 75% of anti-NMDA receptor encephalitis patients first present to a psychiatrist. It is treatable, but can be fatal when missed.
⚕️ Cushing's disease can look like bipolar disorder: cortisol excess produces mood instability, insomnia, and cognitive impairment.
Here's what a basic workup for any psychiatric condition should include:
→ CBC, CMP, TSH, free T4, B12, folate, vitamin D, iron studies with ferritin, fasting glucose, HbA1c, lipid panel, CRP, urinalysis, toxicology screen.
Suspected POTS:
→ Orthostatic vitals (supine, sitting, standing at 1, 3, and 10 minutes); tilt table test if indicated.
Suspected PANDAS/PANS:
→ Throat culture, rapid strep, ASO titer, anti-DNase B antibody, CBC with differential, ANA, ESR, CRP, mycoplasma IgM/IgG.
First-episode psychosis:
→ Add ANA, anti-NMDA antibodies, HIV, RPR, neuroimaging.
Treating a medical condition as a psychiatric one can cost years of a patient's life. The most evidence-based first step in mental health care is ruling out the medical conditions that produce psychiatric symptoms. We should be doing it every time.
Follow me Britton Ashley Arey, MD MBA for evidence-based perspectives on psychiatry, mental health, and the science of the mind.
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