Why Am I Tired All the Time? Depression Fatigue Explained

Written by Rachel De La Merced and reviewed by Board Certified Psychiatric Nurse Practitioner Kate Filippelli, PMHNP who specializes in evidence-based psychiatry practices with personalized treatment plans for all mental health challenges, including psychiatric medication management, research-based supplements and behavioral interventions for major depressive disorder, bipolar disorder, anxiety, panic, OCD, ADHD and eating disorders.

 

If you have been asking yourself, “Why am I tired all the time?”, depression may be one possible explanation. Fatigue is one of the most common and disabling symptoms of depression and is often the reason someone seeks medical care in the first place.

In primary care clinics across 15 countries, 45%-95% of people with major depression initially reported physical symptoms such as pain or fatigue rather than mood symptoms. [1] Depression-related fatigue is also different from simply feeling sleepy. It can involve a lack of physical and mental energy, reduced motivation, and difficulty thinking or concentrating.

In our clinical experience at Remedy Psychiatry, we frequently see patients who initially seek help because they feel exhausted rather than because they recognize that they may be depressed. For some patients, fatigue and low motivation have become so familiar that they begin to view them as their normal baseline rather than potential symptoms of a treatable condition.

What Does Depression Fatigue Feel Like?

Depression fatigue is often described as feeling physically or mentally drained even after getting enough sleep. Everyday activities may require significantly more effort than they normally would.

Depressive fatigue can involve:

• Low physical energy
• Difficulty getting started on tasks
• Reduced motivation
• Mental exhaustion or “brain fog”
• Difficulty concentrating
• Feeling physically heavy
• Needing more effort to complete everyday responsibilities

Fatigue can also continue after other depressive symptoms begin to improve, making it an important residual symptom to monitor. [1]

If you are wondering, “what does depression feel like?” exhaustion may actually be one of the first symptoms you notice. Not everyone experiences depression as intense sadness. Some people primarily notice that they no longer have the energy or motivation to do things they normally enjoy.

As a psychiatric nurse practitioner at Remedy Psychiatry, I often ask patients to look beyond how many hours they are sleeping and consider how much effort it takes to get through their day. Needing tremendous effort to complete tasks that used to feel routine can be an important clue that something more than ordinary tiredness may be going on.

How Is Depression Fatigue Different From Other Causes of Tiredness?

Fatigue can have many causes, so feeling tired does not automatically mean you have depression.

The symptoms that most strongly distinguish depression-related fatigue from other fatigue conditions are accompanying mood symptoms, particularly loss of interest or pleasure, depressed mood, guilt, and feelings of worthlessness. [2]

With depression, fatigue may occur alongside:

• Low mood or hopelessness
• Loss of interest or pleasure
• Feelings of guilt or worthlessness
• Difficulty concentrating
• Changes in appetite
• Changes in sleep
• Social withdrawal

By comparison, conditions such as myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) can involve prolonged fatigue, post-exertional malaise, unrefreshing sleep, and orthostatic intolerance. [3]

Sleep disorders can also cause significant daytime fatigue. For example, obstructive sleep apnea may involve loud snoring, witnessed pauses in breathing, nonrestorative sleep, and excessive daytime sleepiness. [4-5]

Depression and Sleep

The relationship between depression and sleep can be complicated. Depression may cause insomnia, hypersomnia, or sleep that does not feel restorative. Someone may sleep for eight or nine hours and still wake up feeling exhausted. Another person may struggle to fall asleep or wake repeatedly throughout the night. Sleep problems can also worsen concentration, mood, and energy, making it difficult to determine whether poor sleep is contributing to depression or depression is contributing to poor sleep.

Medical Conditions Can Cause Fatigue Too

Because fatigue is nonspecific, persistent tiredness shouldn’t automatically be attributed to depression. Medical conditions can cause fatigue or contribute to depressive symptoms.

Research suggests that a significant proportion of people presenting with depressive symptoms may also have an underlying medical condition contributing to their symptoms. [6]

Possible contributors include:

Hypothyroidism: Fatigue is common with an underactive thyroid and may occur alongside weight gain, feeling unusually cold, and cognitive slowing. [7]

Anemia: Iron deficiency and other forms of anemia can cause significant fatigue and reduced energy. [4]

Sleep disorders: Obstructive sleep apnea and insomnia should be considered when sleep quality or daytime sleepiness is a concern. [4-5]

Medications and substances: Certain medications, including some beta-blockers, glucocorticoids, opioids, and sedating medications, can contribute to fatigue. Substance use or withdrawal may also play a role. [6]

Vitamin deficiencies and systemic illness: Vitamin B12 or folate deficiency and certain cardiovascular, kidney, liver, autoimmune, and infectious conditions can also contribute to persistent fatigue. [6,8]

At Remedy Psychiatry, we recognize that persistent fatigue deserves more than simply assuming someone is depressed. During an evaluation, we consider the broader clinical picture, including sleep, medications, substances, medical history, and other symptoms, so that potential contributors are not overlooked.

Atypical Depression and Excessive Fatigue

Some depressive symptoms may provide additional clues about the type of depression someone is experiencing.

Atypical depression can involve hypersomnia, increased appetite, weight gain, and a heavy feeling in the arms or legs known as leaden paralysis. [9] These symptoms can make depression fatigue particularly noticeable. Excessive sleep and appetite changes can also be important when evaluating whether depression may be related to bipolar disorder rather than unipolar depression.

Why Bipolar Depression Should Not Be Overlooked

When someone presents with depression and significant fatigue, it is important to consider the possibility of bipolar disorder before beginning antidepressant treatment.

Hypersomnia and increased appetite are sometimes referred to as “reverse neurovegetative” symptoms and are more common in bipolar depression than in unipolar depression. [9]

Other factors that can raise concern for bipolar disorder include a history of hypomania or mania, depression beginning at a young age, multiple previous depressive episodes, a family history of bipolar disorder, psychotic symptoms, or antidepressants causing hypomania or failing to improve symptoms. [10-11] This is one reason a comprehensive psychiatric evaluation is important when fatigue and depression occur together.

Depression vs Burnout

It can also be difficult to distinguish depression vs burnout, especially when someone is exhausted by work or ongoing responsibilities.

Burnout is generally associated with chronic stress, particularly workplace stress, while depression can affect multiple areas of life regardless of whether you are working or taking time off.

If your exhaustion improves substantially after rest or time away from work, burnout may be contributing. If you continue feeling exhausted, hopeless, disconnected, or unable to enjoy things outside of work, depression may also need to be considered. The two can occur together, so persistent symptoms should not automatically be dismissed as burnout.

High-Functioning Depression and Fatigue

Someone experiencing high functioning depression may continue going to work, maintaining relationships, and completing responsibilities while privately struggling with exhaustion and low mood.

Although high functioning depression is not a formal clinical diagnosis, the term can describe people who appear to function normally despite experiencing significant depressive symptoms. This can make depression fatigue especially easy to overlook. You may be meeting your responsibilities while using nearly all of your energy simply to get through the day.

In our clinical practice at Remedy Psychiatry, some of the most important conversations happen with patients who tell us, “I’m functioning, but I’m exhausted.” Maintaining a job or keeping up with responsibilities does not mean depression is not affecting you. Treatment can help patients move beyond simply getting through the day toward having the energy and capacity to actually engage in their lives.

Seasonal Affective Disorder Can Cause Fatigue

Seasonal affective disorder is another form of depression that can cause significant changes in energy and sleep. People with the winter pattern of seasonal affective disorder may experience increased sleep, low energy, social withdrawal, difficulty concentrating, and increased appetite or carbohydrate cravings. If your fatigue and mood changes consistently appear during the same season each year, discussing this pattern with a healthcare professional may be helpful.

When to Seek Help for Depression

Knowing when to seek help for depression can be difficult when fatigue seems like the only problem.

Consider seeking a professional evaluation if fatigue:

• Persists for several weeks
• Interferes with work, school, relationships, or daily activities
• Occurs alongside persistent sadness or loss of interest
• Is accompanied by significant sleep or appetite changes
• Makes it difficult to care for yourself
• Continues despite adequate rest
• Is accompanied by feelings of hopelessness or worthlessness

If you are experiencing suicidal thoughts, especially with a plan or intent, seek immediate help.

Can Depression Go Away on Its Own?

It is natural to wonder, can depression go away without treatment?

Some mild depressive symptoms may improve over time, particularly when they are connected to a temporary stressor. However, persistent depression can continue for months or longer and may become more difficult to manage without appropriate treatment. Persistent fatigue should therefore not simply be ignored or assumed to be something you have to live with.

How Is Depression Fatigue Treated?

Depression treatment depends on the underlying cause, the severity of symptoms, and the individual’s medical and psychiatric history.

When depression is contributing to fatigue, treatment may include psychotherapy, antidepressant medication, or a combination of approaches. Medication selection can sometimes take fatigue and sleep symptoms into account. For example, certain antidepressants may be more activating, while others may be more sedating and potentially useful when insomnia is prominent. [12]

However, medication should be selected by a qualified healthcare professional based on the person’s complete clinical picture rather than fatigue alone.

If an underlying medical condition, sleep disorder, medication effect, or substance use is contributing to fatigue, addressing that cause is also an important part of treatment.

Overall 

Depression fatigue can involve much more than sleepiness. It may feel like having no physical or mental energy, struggling to get started, losing motivation, or needing tremendous effort to complete everyday tasks.

Because fatigue can also result from sleep disorders, thyroid problems, anemia, medications, nutritional deficiencies, and other medical conditions, persistent tiredness deserves a thoughtful evaluation.

Whether you are experiencing depression, burnout, atypical depression, seasonal affective disorder, or another cause of fatigue, identifying the underlying reason is the first step toward finding appropriate support.