Fatigue: Do You Feel Tired All the Time? Is it Depression or Something Else?

Fatigue – Is it Depression or Something Else?

“I am tired all the time. It feels like having brain fog. Most days, I’m so tired that I can not even get up in the morning, can not focus,  and procrastinate. The time I spend working about being tired is making me tired.”

This is what Kevin* said to me when he called to make an appointment. When I met Kevin, he was a 47-year old man, married and working in commercial real estate. He had seen several doctors to address this issue and he had also been in therapy for 4 years. His primary care doctor thought that he may have depression since he had been complaining of low energy and motivation for so long. His doctor prescribed him Zoloft and had recently doubled the dose a month before I saw him. After doing a thorough psychiatric assessment, I determined that he did not have any signs or symptoms of depression. I suspected an underlying medical issue. Here are some of the potential medical causes of feeling tired that I considered.

1. Medication Side Effects

Here is a partial list of the medications that can cause fatigue: antihypertensives, Parkinson meds, antibiotics (even the common ones like Cipro), H2 blockers, SSRIs (can often cause dysphoria, especially in patients with ADHD or who are elderly), steroids, muscle relaxants, narcotics, sulfonamides, interferon, and Sustiva.

2. Hormones

Hormones, such as abnormal levels of testosterone or estrogen can cause low energy, fatigue, and even depression. In male patients, suspect low testosterone if the person is complaining of new-onset complaints of feeling tired which came on gradually and when there was no history of family history of depression. Checking total testosterone is helpful but only part of the story. Total testosterone can often be normal even when free testosterone is abnormal. Always check free testosterone. Suspect hypogonadism if the patient is cold even in the spring and summer, if there is a decrease in an overall sense of well being, and if there is a decrease in sex drive from the baseline. Low testosterone is not normal, even in an older patient and treating this can make you a hero in the eyes of your patient.

3. Thyroid Disease

Low thyroid may cause fatigue. Abnormal thyroid levels are very common and screening for this is essential. Treatment is extremely effective but the patient must realize that it can take months to “kick in”. I had one patient on the inpatient unit who became suicidal when her Synthroid didn’t help her mood. No one told her that it could take months for the treatment to be effective. Also, I like to be pretty aggressive when replacing the thyroid. People use different TSH levels but one of my former mentors at Mass General Hospital, Dr. Jonathon Alpert, recommends to treat anything TSH that is above 6.1 rather than the typical 20 used in most labs as abnormal. I have had excellent results when I headed his advice.

4. Ovarian Cancer

Always think OVARIAN CANCER with women who present with fatigue or other symptoms of depression. Ovarian cancer is awful and kills patients. Often, one of the first symptoms of ovarian cancer is depression and it can precede the diagnosis of ovarian cancer for many months or even years before the cancer is discovered and when treatment for the cancer is too late.

5. Sleep Disorders and Apnea

Sleep disorders such as restless leg syndrome, periodic leg movement, and sleep apnea can disturb your sleep and lead to fatigue. Even though you may be sleeping seven to eight hours, you may not be receiving effective rest.

Conclusion

Kevin said that he had been having a diminished interest in sex for the past fourteen months. In addition, during the consultation, Kevin answered “yes” to feeling a bit cold even in warm weather. I suspected his symptoms may be related to a gradual decline in some of his hormones and ordered several blood tests.

It turned out that Kevin had low testosterone. I referred him to an endocrinologist, a doctor who specializes in hormone disorders such as low testosterone, diabetes, and thyroid disorders. He was started on hormone replacement. Within six weeks, his energy and fatigue had improved significantly. I also tapered him gradually off the Zoloft which may have been exacerbating his low sex drive and low energy. At the next followup, he was feeling back to normal and he continued treatment with his endocrinologist.

Depression can cause you to feel tired or fatigued; however, your doctor should always evaluate you for underlying medical disorders that may be causing your symptoms as well.  This is a shortlist of some of the items to consider when a patient presents feeling tired all the time.

If you have any questions about whether medications or illness may be causing or exacerbating energy level, please feel free to contact Dr. Scott Shapiro.

Scott Shapiro, MD, Board-Certified Psychiatrist in NYC, provides comprehensive counseling + treatment for fatigue, low energy, feeling tired, anxiety, depression and adult ADD + ADHD. If you have any questions, please contact Dr. Shapiro at 212-631-8010 or scott@scottshapiromd.com.

 

*Disclaimer: All details about any people or patients have been changed in regard to all details, age, gender, and geography to protect confidentiality.