# Depression, fatigue may fuel each other



## David Baxter PhD (Jun 21, 2004)

Depression, Fatigue May Fuel Each Other
Friday, June 18, 2004
by Jennifer Warner, WebMD Medical News     

_Having One May Dramatically Increase the Risk of Developing the Other_

June 18, 2004 -- Depression and fatigue may feed off each other in a vicious cycle that makes it hard to determine where one begins and the other ends, according to a new study. 

Researchers found people who are depressed are more than four times as likely to develop unexplained fatigue, and those who suffer from fatigue are nearly three times as likely to become depressed. 

Although researchers have long suspected that depression and unexplained fatigue are related, the nature of the relationship between the two common conditions is unclear. 

But the study, published in the current issue of _Psychosomatic Medicine_, suggests that depression and fatigue may act as independent risk factors for each other. 

*Depression and Fatigue Linked*
In the study, researchers used information on more than 3,200 people who participated in the World Health Organization's study of psychological problems and were monitored for one year. 

Researchers found people who were depressed at the start of the study were more than four times as likely to have an episode of unexplained fatigue during that year. 

In addition, those participants who were suffering from fatigue at the start of the study were nearly three times as likely to develop depression during the study. 

Researchers say fatigue and the psychological disorder of depression are not the same, and the two have different risk factors. However, they may have some overlap. 

"One can possibly understand how a fatigued person can start feeling psychologically distressed because of his or her condition, but the opposite is more difficult to explain," writes researcher Pertos Skapinakis, MD, of the University of Ioannina in Greece, and colleagues. 

Researchers say examining the role of physical activity may be an important factor in helping to explain the association between the two conditions in the future. 

"Physical activity is known to have a protective effect on depression," writes Skapinakis. "It has also been suggested that physical deconditioning might be an important factor in the development of unexplained fatigue." 

Source: Skapinakis, P. _Psychosomatic Medicine_, May/June 2004; vol 66: pp 330-335.


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## sammy (Aug 2, 2004)

> Depression and fatigue may feed off each other in a vicious cycle that makes it hard to determine where one begins and the other ends



ain't that the truth! But I have underactive thyroid, so get fatigued, but the condition is supposed to depress the mood too.
As quite a postive person, I fight it....(fairly well...I look outwards most of the time)...but it can be depressing, the frustration, of not being able to do what you want to do...the things you used to do... very depressing sometimes..


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## David Baxter PhD (Aug 2, 2004)

sammy said:
			
		

> > Depression and fatigue may feed off each other in a vicious cycle that makes it hard to determine where one begins and the other ends
> 
> 
> ain't that the truth! But I have underactive thyroid, so get fatigued, but the condition is supposed to depress the mood too.


It's not as common for some reason as it used to be but at one time every new admission to a psychiatric hospital or to the psych ward of a regular hospital would be screened with the standard tests for thyroid fundtion. This is because, as you know, an underactive thyroid (hypothyroidism) mimics the symptoms of depression, including depressed mood; conversely, an overactive thyroid (hyperthyroidism) can mimic mania (as in bipolar disorder or manic-depressive disorder) and in severe cases even schizophrenia or schizoaffective disorder.

In most cases, thyroid syndromes are not difficult to treat, fortunately, at least once the fluctuations in thyroid functioning are stabilized.

Are you taking throxin supplements, sammy?


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## sammy (Aug 3, 2004)

Yes, I've been put up to 200mcg daily of replacement thyroxine about 8 weeks ago. 
I crashed last year and my TSH level went off the scale 99+ (so of course physically I was a wreck).
The doctors had to start me back slowly on thyroxine, and gradually got me back up to 150mcg daily, which I had been on previously.
The TSH came down to 23 (approx), but then in about May, my last blood test result, it had gone up too 77!! The doctor couldn't explain that... I had been taking my tablets daily and correctly.
I have some suspicion that they were not true thyroxine.
The pharmicist had counted them into a plastic bottle and they were quite flat tiny tablets with no name on them...unlike any I had been given before....
I did mention that to my doctor and showed her a sample- she didn't comment on that- but had no explanation for what had happened...
But put me up to 200mcg.
Used a different pharmicist where the thyroxine is in bubble strip packets.
I began to feel more 'normal' after a couple of weeks, but still have extreme fatigue at times, and other symptoms, ...and recently very bad oedema around my ankles and even my feet and toes!
I have a blood test and doctors appt. on Friday- so hope to talk this over with her.


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## David Baxter PhD (Aug 3, 2004)

It may just have been a mistake by the pharmacist of course... or it may be a generic versus branded medication thing.

It used to be thought that generic and brand name medications were identical. However, a recent very large scale study of Luvox in Ottawa showed that the generic was significantly LESS effective in managing symptoms of OCD than the brand name version. The primary or "active" ingredient(s) were the same but the researcher hypothesized that the other ingredients used to construct, preserve, or stabilize the primary ingredients may have had an effect on absorption or uptake, or something along those lines.

It may be worth asking your doctor whether s/he knows of anything like this with the thyroxin you're taking.

Good luck with your appointment...


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## Daniel (Aug 5, 2004)

Yes, psychiatrists and psychologists should mention exercise more.  If the patient does not have enough energy to exercise regularly even with anti-depressants, there are stimulants (drugs usually for ADHD or narcolepsy) that are prescribed to depressed patients to boost physical energy.

I forget the book, but one psychiatrist wrote that exercise along with therapy is best for patients that do not respond well to medications.  There are lots of such books at Amazon.com with titles like Conquering Depression and Anxiety Through Exercise.   Here is an excerpt from an editorial review of the book that says one study showed exercise being more effective than Zoloft in the long term:



> Getting into more specific questions, he cites evidence that aerobic and anaerobic exercise are equally effective, even for the most severely depressed. In terms of the relative efficacy of exercise and Zoloft, he offers only one study (and of only this one drug) as evidence that exercise has longer-lasting effects in elevating mood than the drug. While Johnsgard is a proselytizer, he’s not dogmatic—he acknowledges that exercise alone is not always enough to deal with depression or anxiety, that it should be used in conjunction with psychotherapy, and that in some cases it just isn’t effective.



For anxiety, I would think that going for a walk or run could help mitigate the physical, fight-or-flight symptoms of an anxiety attack.   I always go for a walk when I feel stress from a looming deadline.

Maybe one reason psychiatric hospitals and psychiatric day programs are so effective at mood stabilization is that they combine at least five different therapies:

1.  talking one-on-one with a therapist
2.  group therapy
3.  medications
4.  exercise 
5.  art therapy


Also, just being outside may help:



> The stimulation of being outdoors and in a pleasant setting may enhance mood, and exposure to light has been shown to be therapeutic in seasonal depression.
> The Physician and Sportsmedicine: Exercise Against Depression


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## David Baxter PhD (Aug 6, 2004)

For cases of mild to moderate depression, I wouldn't argue with very much of what you say, Daniel. However, for more seriously depressed patients, while it may well be true that they might feel better if they got out and went for a walk, the problem is that they aren't able to do that - they have difficulty even summoning up the psychological (not physical) strength to get out of bed, let alone out of the house. Indeed, that is one of the defining characteristics of severe depression.

In acute depression, medication is almost always necessary, in my opinion, to boost psychological resources to the point where these other remedies - exercise, CBT, etc. - are realistic options for the individual. But once the depression starts to lift, I would agree that these are essential to accomplish the changes in lifestyle and thought patterns to fully recover from depression and to maintain that recovery (i.e. relapse prevention).


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## Daniel (Aug 6, 2004)

Yes, simply reading depressing lyrics makes it easy to see the limits of exercise:

It seems no one can help me now,
I'm in too deep; there's no way out
This time I have really led myself astray

--"Runaway Train," Soul Asylum


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## David Baxter PhD (Aug 6, 2004)

I love that song! To me, it really captures adolescent depression and hopelessness - pity the group really didn't have anything else that was nearly as good.

On the other side of the coin was REM's "Everybody Hurts", equally powerful...


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## sammy (Aug 6, 2004)

When I worked as a psychiatric nurse, one of the things I had to do was to take patients for walks in the grounds, or from the rehab ward, to the pub across the road... but, to be honest, I felt as though they were not enjoying it, that we were forcing them into it as a sort of regime that we thought would do them good, and it may have been to make some of the professionals feel they were doing something useful, because they didn't quite know what to do for many of the patients...
Maybe it was because some of them were so drugged up, that they couldn't feel or enjoy anything


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## Bo (Oct 16, 2004)

Hm.  I'm a little curious, is there a medical condition just called "fatigue"?  Unexplained fatigue has been a central trigger of my more major depressive episodes, and also seems to be a symptom of my depression at all.  I've had all the blood tests done, nothing wrong there.

I've just started taking a multi-vitamin in the last week or so, and I would swear it's making a difference, but I'm no doctor.


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## David Baxter PhD (Oct 16, 2004)

Hi, Bo... of course there can be a fatigue syndrome without depression, but they often do seem to go together, probably in part because if the sleep cycle is interrupted or not functioning well, serotonin production also seems to get messed up. On the other hand, chronic fatigue (not necessarily talking about Chronic Fatigue Syndrome here) may also be a sign of _dysthymia_, which is basically chronic low depression that may not be even recognized as depression by the individual -- if the person has been in that state for months or years, it may simply feel "normal".

If there is a physical cause for chronic fatigue, it may not be revealed in the usual phsyical examination or blood tests. For example, one of the psychiatrists here in Ottawa has suggested that B12 deficiencies underly many chronic low energy-fatigue conditions (as well as some depression) and that the usually accepted "normal" range  for B12 is in his opinion set too low. Another condition that may contribute is hypoglycemia, which, as one of my clients this week put it, is one of the most underdiagnosed medical conditions.

If you feel that the vitamins are helping, you may well be correct. Also see the posts on omega-3 essential fatty acids (EFAs) elsewhere in this forum.


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## Bo (Oct 16, 2004)

I switched family doctors a few years ago because I felt that there were some avenues that had not been explored properly.  I know that we checked my blood sugar levels, and my thyroid.  I aslo did a sleep apnea test at the hospital.  My energy level has been a constant concern that no one has really tried to address yet.  It's interesting to see that more attention is being payed to the fatigue aspect of depression.  For me, it is the number reason for missed time at work, and I feel it is the number one obstacle on my road to recovery.  I'll keep taking the vitamins, and perhaps ask my doctor for further advice on B12.

I'll also follow your advice and check out the posts on EFAs.  Thanks!


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