A one-year prospective study followed 52 adult Lyme disease patients who presented with erythema migrans (EM) rashes. Participants reported a range of somatic symptoms, including fatigue, headaches, joint pain, muscle pain, and cognitive complaints.
Patients with more severe physical symptoms also had higher scores on the Beck Depression Inventory–II (BDI-II). The BDI-II is commonly used as a screening tool to identify patients who may benefit from further psychological evaluation for depression.
BDI-II Scores Correlate With Somatic Symptoms
“There was a good to excellent direct correlation between the BDI-II score and the total number of symptoms,” writes Wormser, “suggesting that the BDI-II scores were reflecting somatic rather than affective depressive symptoms.”
The authors caution that when using the BDI-II in patients with Lyme disease, infection-related physical symptoms must be carefully considered when interpreting results. Brain fog, fatigue, sleep disruption, and pain can all inflate depression screening scores without representing a primary mood disorder.
When Is a Mental Health Referral Appropriate?
If depression is suspected after appropriate clinical assessment, the authors recommend referral for psychological evaluation.
In the study, one patient was referred for a depression evaluation at the six-month visit based on BDI-II results. This individual had a prior history of depression during pregnancy. After receiving care from a mental health professional between the six- and twelve-month visits, the patient’s symptoms improved by the twelve-month follow-up.
Clinical Perspective
These findings highlight a critical distinction: elevated depression screening scores in Lyme disease patients may reflect the burden of physical illness rather than a primary mood disorder. Clinicians who refer patients to psychiatry based solely on BDI-II scores — without accounting for somatic symptom overlap — risk mislabeling infection-driven suffering as psychiatric illness.
This does not mean depression should be dismissed when it is present. But it means that screening tools designed for general populations may not perform accurately in patients carrying a significant somatic burden from active or persistent infection.
Frequently Asked Questions
Can Lyme disease symptoms inflate depression screening scores?
Yes. The BDI-II includes items covering fatigue, sleep disturbance, concentration difficulty, and appetite changes — all of which overlap with Lyme disease symptoms and can elevate scores without a primary mood disorder.
Does a high BDI-II score mean a Lyme patient is depressed?
Not necessarily. This study found that higher scores correlated with somatic symptom burden rather than affective depression. Clinical judgment is needed to interpret results in context.
Should Lyme patients still be screened for depression?
Yes. Depression does occur in Lyme disease. But clinicians should distinguish between infection-driven somatic symptoms and primary mood disorders before making a psychiatric diagnosis or referral.
When is a psychiatric referral appropriate for Lyme patients?
When depression is suspected after clinical assessment that accounts for the somatic effects of infection — not based solely on screening scores that may be inflated by physical symptoms.
References
- Wormser GP, Park K, Madison C, et al. Evaluation of prospectively followed adult patients with erythema migrans using the Beck Depression Inventory–Second Edition. Am J Med. 2019;132(4):519–524.
this seems a little confusing. The depression is real but not caused by the infection/co-infection. It is caused by overthinking the future of one’s life and the quality one will have with no absolute answers.
The depressive symptoms appeared related to the illness rather than a clinical diagnosis of depression. The Beck Depression Inventory cannot tell the difference between clinical depression and somatic issues related to the illness.
Dr Cameron,
A loved one has in the last 7 mos experienced leg cramps, progressing into fasiculations, numbness/tingling, burning, and leg weakness. Depression also. Will see a neurologist soon. Not sure if it is CIPD, MS, or much worse. Read your website and Dr Tedone’s (winningthefight.org) where he strongly feels it contributes/causes ALS and many neurodegenerative diseases? Therefore want to get the test for Borrelia infection. You are the expert. Please advise where to go for the most accurate test for Lyme Disease? Is it at iGenex? If it is negative should testing be repeated again? If it’s positive, what are the proper antibiotics and for how long? Have you seen these antibiotics work on neurological symptoms? Please help us with your expertise. Most neurologists we’ve briefly talked to don’t believe there is a link! Lastly, if we would like a phone consultation with you, how do we get in touch with you? Thanks, Joe at he****@*****lo.edu
It can be so frustrating too see your loved one ill for 7 months. The list of possible diagnoses can be overwhelming at the beginning. The laboratory testing can be frustrating at the start. Even specialty labs are not as reliable as we would like. I see patients with similar presentations. Call my office at 914 666 4665 with questions.