Back here to follow up on my post from last week on sleep disturbances and talk about decreased energy; the second most prominent feature of depression that I frequently discuss with my patients. Now I know we all wish we had more energy… and there are LOTS of things you can do to improve your energy, but I’d like to focus on how it relates to depression.
Decreased energy (anergia), decreased motivation (avolition) and excessive sleepiness (hypersomnia) are common symptoms of depression. Before we can go on discussing proper treatment for depression, or any mental health concern, we need to take some common medical causes of these symptoms off the table. Untreated sleep apnea, for example, most often presents as “daytime sleepiness” and people who are prescribed nighttime oxygen (CPAP) experience a change in their energy levels. Sleep studies (polysomnography) are MUCH more available and convenient these days and I will often prescribe these for patients. Beta blockers, commonly prescribed for high blood pressure, can zap energy and worsen depression. Hypothyroidism, decreased cardiac function, and other medical problems can also potentiate or mimic depression. This list goes on and on… the bottom line here is that there is a lot of correlation and overlap between brain and body and both need to be considered.
Once we have effectively considered medical causes for anergia, avolition, and hypersomnia, we can discuss proper treatment for depression. It is not always intuitive for many providers to prescribe an antidepressant for someone whose main complaint is decreased energy; but it is amazing how much some people come to life with a simple, low dose SSRI like fluoxetine (Prozac) or sertraline (Zoloft). However, for many others whose primary symptoms of depression are anergia and avolition, an SSRI is not always adequate. As a next step, I’ll often prescribe bupropion (Wellbutrin) which works on dopamine (to increase pleasure amongst other things) and norepinephrine (ie. adrenaline) instead of or in addition to an SSRI. While that may sound like a golden ticket, it is not without its own potential negative side effects. Some people may tend to become TOO activated and, though their energy and mood may improve, they might experience heightened anxiety. Others may find themselves a little more “passionate” about certain things or possibly more easily irritated.
When my patients are too sluggish to function, perhaps one of the best classes of medications are called serotonin-norepinephrine reuptake inhibitors (SNRI’s). These medications, like venlafaxine (Effexor), desvenlafaxine (Pristiq), duloxetine (Cymbalta), milnacipran (Savella), can really get people off the couch while also controlling their anxiety. These medications should be prescribed cautiously though and monitored consistently as they can also increase blood pressure and should not be discontinued abruptly. With the proper dose and monitoring, they are very effective in treating decreased energy and motivation in depression.
One of the biggest benchmark studies in psychiatry related to antidepressants is called the STAR*D trial, which evaluated 4 “levels” of antidepressant treatment. This trial is older (2008), but it involved more than 4,000 patients across 43 locations, so most psychiatry providers tend to appreciate its recommendations (and its shortcomings). You can read more about this study here. In summary, unfortunately, ⅓ of patients who received all 4 levels of treatment never experienced remission from their depression. All of us in the psychiatry field wish these numbers were a little more encouraging, but if nothing else it has fueled some exciting research and forced consideration of alternative treatments (ketamine, psilocybin, Transcranial magnetic stimulation, etc.)
For example, in more recent years, some of the medications traditionally used to treat psychotic illness (aka antipsychotics) have been cleared by the FDA and used successfully as adjuncts for depression. These were not included in the STAR*D trial, but have some good evidence at this point (here's at least one large systematic review from 2023).
So, back to speaking about energy... Many traditional antipsychotic medications were notorious for causing sedation (fluphenazine, chlorpromazine etc), and would completely rob energy and motivation. However, many newer formulations of these medications almost eliminate sedation (Cariprazine, aripiprazole, and more) and can bring people back to life by treating depressive symptoms and ultimately helping clear brain fog and improve energy. Antipsychotic medications are no longer just for psychosis.
In psychiatry, more than any other specialty of medicine, we tend to use many medications that are “off label”, meaning they are not approved by the FDA for certain indications. While this sounds scary (and it can be if not approached in a thoughtful manner), it is also sometimes necessary and extremely helpful for my patients. Modafinil (Provigil) or armodafinil, for example, is a stimulant with less abuse potential that can help clear brain fog and increase energy. This is a controversial strategy, but for the right case, these can be helpful. Without getting into the political side of things…certain medications need to have adequate funding to undergo trials that would yield an FDA approval; not to mention the amount of lag time it takes for that to happen (close to 10 years on average). That said, there are options that I have and will prescribe under the right circumstances.
Lastly, I want to touch on one problem that I am encountering OFTEN. Many of my patients who fail to achieve success in restoring their energy levels begin self-diagnosing ADHD/ADD. This is because in addition to anergia, depression causes impaired cognitive function and focus problems. The result is patients who take stimulants as a bandaid for their anergia without properly treating depression first. My point here is that it’s critical that we properly tease apart ADHD from depression and treat them each properly. While many patients do need to be treated with both antidepressants and stimulants for their conditions, many also likely don’t NEED to be reliant upon a stimulant for energy - there are better options. Not to mention, improper prescribing of stimulants is causing a massive drug shortage and a real problem for those patients with severe ADHD. Here’s an interesting article with more on that. (Also a topic for a future post.)
Don’t forget that decreased energy and motivation that can’t be explained by a medical condition or basic necessities like sleep and diet are very often symptoms of depression. Fortunately, with a combination of therapy and medication(s) most people can experience remission of their symptoms and enjoy a newfound energy level.
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