Chronic Fatigue: When Depression, Anxiety or Asthenia Are Behind It

What Counts as Chronic Fatigue?

Ordinary tiredness is linked to exertion and goes away after sleep, a weekend or a vacation. Chronic fatigue is tiredness that persists for weeks and months, depends little on how much you do, does not go away after rest and interferes with work and everyday activities. People describe it like this: "I wake up already tired," "I only have enough energy for work," "everything takes effort."

It is important to distinguish physical fatigue, such as muscle weakness and tiring quickly when moving, from mental fatigue: reduced motivation, difficulty concentrating, a feeling of "brain fog" and reluctance to start anything. They often occur together, but when mental fatigue, reduced interest and low mood predominate, this points toward mental health causes.

Fatigue as a symptom, not a diagnosis

In most cases, chronic fatigue is not an illness in its own right but a symptom that has a cause. The doctor's job is to find it. Sometimes there are several causes at once: for example, lack of sleep due to anxiety, iron deficiency and depression all at the same time.

Which Physical Causes Need to Be Ruled Out

Before linking fatigue to mental health, the body needs to be checked. Many physical illnesses begin with weakness and tiredness, and missing them is dangerous. It is best to start with a general practitioner, who will take your medical history, examine you and order basic tests.

An initial work-up usually includes a complete blood count, iron studies, blood glucose, thyroid hormones, a blood chemistry panel, vitamin B12 and other tests as indicated. If you snore and stop breathing during sleep, you need to be tested for sleep apnea. It is also important to review the medications you take: fatigue can be a side effect of some drugs.

• Anemia and iron deficiency
• Underactive thyroid
• Diabetes and glucose metabolism disorders
• Obstructive sleep apnea
• After-effects of viral infections
• Liver, kidney or heart disease
• Medication side effects

Which Mental Health Conditions Cause Chronic Fatigue

If tests have not revealed any physical causes, the next step is to assess your mental state. Fatigue is one of the key symptoms of depression: according to ICD-10 and DSM-5, reduced energy and increased fatigability are among the core criteria for a depressive episode. A person may not feel sad at all and instead complain specifically of powerlessness, exhaustion and lack of motivation.

Chronic anxiety is also draining. Constant muscle tension, anticipation of trouble, racing thoughts and poor sleep sap your energy, even if you are doing almost nothing physically. In generalized anxiety disorder, fatigue is directly included in the diagnostic criteria.

Depression

Signs that point to depression: fatigue comes with low mood or loss of interest, lasts more than two weeks, is worse in the morning than in the evening, and is accompanied by problems with sleep and appetite, feelings of guilt and difficulty concentrating. Sometimes depression shows up mainly as physical complaints, which is called masked depression.

Asthenic syndrome

Asthenia is a state of increased fatigability and exhaustion with irritable weakness, in which a person tires quickly from any effort, tolerates noise and bright light poorly, and becomes tearful and irritable. It can occur after illness, under chronic stress and with overwork. In ICD-10, a similar condition is described as neurasthenia.

Burnout and lack of sleep

Burnout is linked to chronic workplace stress and shows up as exhaustion, cynicism and reduced effectiveness. Chronic sleep deprivation, including from the habit of going to bed late and using your phone at night, is also one of the most common sources of constant tiredness.

How Chronic Fatigue Syndrome Differs From Mental Fatigue

Chronic fatigue syndrome, or myalgic encephalomyelitis (ME/CFS), is a separate illness that ICD-10 classifies under diseases of the nervous system. Its key feature is post-exertional malaise: after physical or mental effort, the condition worsens sharply a few hours later or the next day and takes days to recover. Unrefreshing sleep, problems with thinking and memory, and sometimes dizziness on standing are also typical.

ME/CFS is not a mental disorder and not "laziness," and it cannot be treated with advice to "push yourself to exercise more." However, people with this illness often develop secondary anxiety and depression, and in that case help from a psychiatrist and psychotherapist improves quality of life. The diagnosis is made by a doctor after other causes have been ruled out; the NICE guideline on ME/CFS emphasizes the importance of careful energy management.

What to Do If You Constantly Have No Energy

The first step is not to blame everything on age, work or personality. Get checked by a general practitioner, especially if the fatigue appeared recently, is getting worse or comes with weight loss, fever, pain or shortness of breath. If your test results are normal, take an honest look at your sleep, mood and anxiety, without telling yourself "everyone feels like this."

At the same time, you can support yourself through lifestyle. This does not replace treatment, but it improves your condition whatever the cause. The main thing is not to try to make up for fatigue with caffeine, energy drinks and alcohol: they give a short-term boost but ultimately deepen exhaustion and disrupt sleep.

1. Have the basic tests your general practitioner orders
2. Go to bed and get up at the same time
3. Get out into daylight in the first half of the day
4. Add gentle, regular activity if you do not have post-exertional malaise
5. Cut down on caffeine and give up energy drinks and alcohol
6. Plan your activities with breaks, and do not use up all your energy in the first few hours
7. Keep a diary of your sleep, mood and energy levels

How a Psychiatrist Helps With Chronic Fatigue

A psychiatrist assesses whether your fatigue has a mental health cause: depression, an anxiety disorder, asthenia, sleep disorders, or misuse of alcohol or sedatives. They take your test results into account and gather a detailed history. Treatment depends on the cause: psychotherapy, including cognitive behavioral therapy, normalizing sleep, and for depression or anxiety, medication when indicated, which is chosen only by a doctor.

The online format is convenient when you have almost no energy to travel. At Psychiatry Online, the psychiatrist assesses your condition during a video appointment, reviews your test results, draws up a treatment plan and monitors your progress. If you have not yet been examined, the doctor will tell you what needs to be checked in person and by whom.

When to see a doctor

• Fatigue has lasted more than a month and does not go away after rest
• You wake up tired even if you have slept enough
• Low mood and loss of interest have joined the fatigue
• Constant anxiety and tension do not let you relax
• You have started drinking more coffee, energy drinks or alcohol to keep going
• Your test results are normal, but your condition is not improving
• You have started thinking that life has become meaningless

Questions and answers

Reviewed by

Pavel Kornilov, MDPsychiatrist

Depression, anxiety disorders, OCD, bipolar disorder; online medication selection and adjustment.