Pictorial Case Study: Depression and anxiety

The case

A 53-year-old man, who was normally well and had a known diagnosis of vitiligo, presented in the surgery, saying he had felt low for the past six months. He described early morning waking, decreased appetite, feelings of hopelessness, poor concentration, and lethargy and anhedonia. The onset of symptoms corresponded to a reduction in working hours and with a holiday looming he was increasingly anxious.

What is the diagnosis, management and differential diagnosis?

Diagnosis and management
The initial diagnosis seemed to be depression and anxiety, but routine blood tests were undertaken to exclude thyroid disease.

Results revealed an Hb of 4.7g/dl, with MCV 137fl while other initial tests were normal. Subsequent vitamin B12 measurement was 30ng/l, making the diagnosis pernicious anaemia. Intrinsic factor and parietal cell antibodies were positive. On examination, he had the characteristic smooth tongue.

He was admitted to hospital and was treated with hydroxocobalamin 1mg injections, initially three times weekly and later three-monthly. The patient recovered with no psychiatric symptoms and his recent Hb was 11.3g/dl.

Possible different diagnoses

  • Depression.
  • Endocrinopathies - hypothyroidism, hypercalcaemia, Cushing's disease.
  • Infections, such as post-viral fatigue or syphilis.
  • Drugs: in particular, steroids or beta-blockers.

Differential diagnosis

  • Sadness severe or persistent enough to impact on daily life.
  • Occurs at any age but usually during mid-teens, 20s or 30s.
  • Symptoms include poor concentration, fatigue, loss of sexual desire, menstrual abnormalities.


Contributed by Dr Majid Saeed, a GP registrar in Englefield Green, Surrey.

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