My doctor can't help with my chronic tiredness. What should I do next?
September 21, 2018 3:27 AM   Subscribe

For about a year now, I've been suffering from near constant tiredness (and protracted periods of melancholy). At first, I thought I was just overworked, but a long relaxed summer did nothing to improve my condition. A few weeks ago, I went to my doctor. Our first meeting was great: he drew up a list of hypotheses about the cause of my symptoms, and ordered some tests. However, none of the tests gave us a diagnosis, and in our second meeting, the doctor said that I was probably just stressed out, and (rather unhelpfully) recommended a few early nights with a glass of wine. I think the doctor has concluded that there's nothing medically wrong with me, but I'd like to keep looking for a diagnosis. So … what now? Details below ...

I'm a man, early thirties. No other relevant health conditions. I live in British Columbia, and have good health insurance.

The doctor tested for:
- Low testosterone
- Thyroid problems
- Sleep apnea
- Anemia
It seems that I don't have any of these conditions. I asked the doctor whether I could have depression. He said that this diagnosis is unlikely, because I was sitting up straight, smiling, and looking him in the eye (!).

My questions:
(a) Is it likely that I have depression, given that my main symptom is tiredness rather than sadness?
(b) Are there other possible diagnoses that I should consider?
(c) Since my doctor is no longer being helpful, it might be a good idea for me to see someone else. But who? A psychiatrist, perhaps?

Thank you in advance for your help!
posted by anonymous to Health & Fitness (31 answers total) 9 users marked this as a favorite
My best friend has had chronic severe depression with near constant suicidal ideation for over a decade. But he is perfectly capable of " sitting up straight, smiling, and looking [someone] in the eye". Tiredness is also a very common symptom of depression.

So yeah, it would probably be good to get a second opinion from someone more knowledgeable about mental health. A referral to a psychiatrist would be good - I'm not sure how things are in BC but in Ontario the wait time to see a psychiatrist can be quite long if there isn't one associated with your doctor's office.
posted by Secret Sparrow at 3:42 AM on September 21, 2018 [9 favorites]

I'm a woman, but when I had similar symptoms my doctor also checked my thyroid and vitamin D levels. My vitamin D was ridiculously low, and supplementing that helped. Not sure if thyroid issues are a dude thing, but vitamin D is a definite possibility.
posted by jeoc at 3:49 AM on September 21, 2018 [8 favorites]

I'd certainly want to rule out sleep apnea. It's less common in people your age, but hardly unheard of. (I was diagnosed at 33; apparently I have a really big tongue that can fall back and block my airway.) It can even cause depression, for that matter.

A few early nights with a glass of wine is a simple way to see if you're just not getting enough sleep, though. The summer was relaxing, but how many hours of uninterrupted sleep were you actually getting? Perhaps not enough. Try getting 9-10 hours for a few days in a row. If you're still tired you'll have ruled out insufficient sleep, which after all is the most common cause of fatigue.
posted by Anticipation Of A New Lover's Arrival, The at 3:50 AM on September 21, 2018 [2 favorites]

Regarding jeoc's suggestion about vitamin d, if it's low and your calcium level is high, that could implicate one or more over-reducing parathyroid glands (there are four), which sit on but are different from your thyroid gland. Tiredness, kidney stones and brain fog are hyperparathyroidism symptoms. However, you don't fit the profile--mid 50s female--but there are exceptions.
posted by carmicha at 4:19 AM on September 21, 2018 [2 favorites]

Yes, my depression often manifests as severe fatigue without sadness. I am also someone who can be smiley and chatty while in the midst of it and people wouldn't think I was depressed.

Not a doctor so can't say what you have but they describe mine as atypical depression. I was offended for years by that description (what, I can't even do depression properly?) but actually it's the perfect description for me - a combo of excessive sleepiness and tiredness and mood responding to positive events (in my case, making me able to easily fake being fine).

But yes to vit D as well, that can make you feel half dead.
posted by kitten magic at 4:33 AM on September 21, 2018 [6 favorites]

Vitamin D was my first thought, but frankly, your doctor sounds like an idiot if they think someone sitting up straight is enough to rule out depression. What they should have done is given you a checklist like this one - or one like it - that is clinically recognised, validated, and used all over the world. Rather than your ability to smile, FFS. Have a crack at that checklist, see what the results are.

It's also worth considering your personal stress levels. How is work? How is home? Are you exercising, sleeping, eating well? It would be helpful, also, if the doctor also did the "standard" things like blood pressure etc. Also consider asking about viruses, that can leave you feeling tired like glandular fever.

Hang in there, and best of luck.
posted by smoke at 4:35 AM on September 21, 2018 [6 favorites]

After years of seeking help for almost constant fatigue with no real answer I found that diet seemed to be really important. Looking back I don't think a single doctor asked me specifics about my eating habits. I do much better with no sugar and low carbs. Not at first of course, the first few weeks felt as if my blood had been stolen in the night, but eventually diet and exercise were the answer for me. Blood sugar levels can really mess with you.
posted by InkaLomax at 4:36 AM on September 21, 2018 [3 favorites]

Another person here who had the same symptoms but a vitamin D problem.
posted by Ms. Moonlight at 5:37 AM on September 21, 2018 [2 favorites]

Could also be low B12. This summer I started to feel exhaustion and low mood (not depression exactly, but sort of feeling like a lot of things were pointless). Once I started supplementing with B12, it lifted in about a week.
posted by barnoley at 5:48 AM on September 21, 2018 [6 favorites]

What they should have done is given you a checklist like this one - or one like it - that is clinically recognised, validated, and used all over the world

I would also recommend trying a mood tracker app (iMoodJournal is decent for IOS) for a couple of weeks. If you notice patterns in when you feel most tired or listless it could indicate this is mental health related.
posted by capricorn at 6:37 AM on September 21, 2018 [1 favorite]

It could be a vitamin deficiency or a mental health issue. That doctor sounds like an idiot.
posted by Green Eyed Monster at 6:42 AM on September 21, 2018 [1 favorite]

My girlfriend had being tired all the time as one of the big markers of bipolar disorder, and is doing much better since getting the diagnosis. It could also be depression, anxiety, or something like chronic fatigue syndrome. I recommend talking to another doctor.
posted by bile and syntax at 7:11 AM on September 21, 2018 [1 favorite]

Nthing diet. I used to have terrible fatigue. The first thing that really helped was cutting out sugar. Over time, I changed to a low fat, vegan diet with very little processed food of any kind, and I just don't have that problem anymore.
posted by FencingGal at 7:20 AM on September 21, 2018 [1 favorite]

The "can you sit up and smile" test would have never caught my low-grade, persistent depression. Indeed, no doctor ever did, even though in hindsight I clearly see I'd had symptoms for fifteen years. What did catch it is the Burns Depression Test (PDF link) from Feeling Good.

It's only 25 questions long, so it won't take you long to answer, and I hope you give it a shot!
posted by shirobara at 7:45 AM on September 21, 2018 [1 favorite]

You live in BC and they didn’t test you for Vitamin D deficiency??? You should definitely get tested for that. It very common around these parts (I’m in Seattle) and can cause chronic exhaustion.
posted by lunasol at 7:45 AM on September 21, 2018 [5 favorites]

Have you seen a sleep specialist?
posted by bq at 8:15 AM on September 21, 2018 [1 favorite]

Since you have ruled out sleep apnea, you might want to go back to your sleep medicine specialist, too. If you ruled out the apnea through your GP, find a sleep specialist (I would recommend one who is a neurologist rather than a pulmonologist) to see if it's a different kind of sleep disorder. Additionally the Epworth Sleepiness Scale is a screening tool that looks at the extent of your sleepiness.

And yes, depression is very often an issue that is related to daytime sleepiness.
posted by Stewriffic at 8:16 AM on September 21, 2018 [1 favorite]

I know you said thyroid problems, but did the doctor run a test for Hashimoto's? Basically antibodies attack your thyroid gland and stresses it out. It's more common in women than men, but it's still with checking for. My thyroid panel came back well within normal, but I'm now on a maintenance synthroid dose and it has made a world of difference.
posted by Bistyfrass at 8:33 AM on September 21, 2018 [2 favorites]

For me vitamin D deficiency was a big one. Almost everyone today is somewhat deficient in it, but for whatever reason I am much more prone to exhaustion and side effects from the lack than most people are. I'm not big on vitamins, but for me Vitamin D3 is an absolute must during the day. If I forget to take it for a while I eventually hit a wall and for a moment I get confused as to why I'm so tired and then I realize- OH I've been forgetting to take my D3! Then within a few days of taking higher doses to replenish my levels I'm back to normal again.

Water- Dehydration is barely noticeable and it's amazing how much energy we lack when we're dehydrated and don't know it. In fact, I learned that a trick to go to sleep at night is to not drink water before bed and it does help in going to sleep earlier (though a state of permanent dehydration throughout the day is incredibly unhealthy and raises cancer risks). Eating water based foods and drinking water throughout the day is helpful.

Sleep- Most of us don't get enough. Some people need up to 10 hours a day just to be able to function well. Everyone is different, but we're fed the lie that everyone needs the same amount. Someone who needs 9 hours and consistently gets only 7.5 will feel exhausted all the time.

These account for most people's exhaustion, but because our society has made it "normal" to go without sunlight and lack sleep etc, they are often completely stumped as to what's wrong.

I hope at least one of these things help you and if not maybe they will lead you to whatever the problem may be.
posted by fantasticness at 8:48 AM on September 21, 2018 [2 favorites]

Adding a Vitamin D supplement is low risk, maybe 1,000 IU/ day. Age 9-70: adequate intake, 600 IU/day; maximum safe upper level of intake, 4,000 IU/day Give it some time to see if it helps. Your body makes Vit. D in sunlight, and sunshine means getting outdoors, which is beneficial.

Vitamin B12 deficiency can cause tiredness. I now make sure I eat red meat at least once a week and eggs a couple times a week, and it has helped my tiredness quite a bit. If you are vegetarian, you can take supplements though I think they are not vegan, you just don't have to eat meat.

The advice about sleep is very good, also drinking enough water, and really reducing sugars and white flour. Whatever nutrition advice you follow, make sure you eat lots of vegetables and whole grains if you do eat grain.

Doctors under-diagnose depression in men. A trial of an anti-depressant is low-risk, though there may be disagreement with that assessment. Take the Depression Tests excellently linked above. People take anti-depressants for exhaustion.

Your doctor is poorly informed about depression. I hope you feel better.
posted by theora55 at 9:37 AM on September 21, 2018 [2 favorites]

If you feel that depression is a candidate for a real underlying problem, there is NO way that your GP doctor can know that it's not. How you feel, and how well you can convince yourself to function, are definitely areas that they can't claim expertise in. I suggest following up with a different doctor (either GP, or psychologist/therapist or psyciatrist, depending on what you want most and how your insurance handles a "new request for mental health services") and discuss with that person, "here's what's going on in my life, and here's how it impacts me and how I feel about that, and how I used to feel vs now and why I suspect depression" and yes your primary symptom is tiredness but if you approach the appointment as "am I depressed" instead of "why am I tired" you may get different outcomes.
posted by aimedwander at 9:46 AM on September 21, 2018 [1 favorite]

Did they do other blood tests? You could have a low-grade infection or an autoimmune issue depending on your white blood cell count and sedimentation rate and other blood tests. I would not stop here or resort to wine therapy as an answer. I do not think the doctor ruled out depression with any clinical certainty. If you can, I would see a psychiatrist to get a real answer.
posted by *s at 10:07 AM on September 21, 2018 [2 favorites]

Primary care docs can be pretty helpless around mental health issues. To try to help them with that there has been a lot of effort on getting primary care offices to use screening tools to identify these issues. The most widely used in the US for depression is the PHQ-9 (Patient Health Questionnaire with 9 items).

You can find it all over the web as well as scoring instructions. It does *not* diagnose depression, just identifies people at risk, so if you take it, and have a score that suggests depression might be an issue, it would certainly make sense to get an appointment with a mental health provider and discuss your concerns.

If you go to an MD (psychiatrist, primary care doc), the emphasis will likely be on medication. If you go to psychologist or some other non-MD type professional, there will likely be an emphasis on non-medication based approaches, though all practitioners should encourage you to get consultation around medication for depression, if that appears to be a likely diagnosis. Research tends to suggest having both therapy and medication yields the best outcomes.

Please note, I'm a mental health professional, but not your mental health professional. The above is not meant to be psychological advice.
posted by jasper411 at 10:28 AM on September 21, 2018 [3 favorites]

Here's some information about Chronic Fatigue Syndrome. It is normal to be depressed about being fatigued all the time and unable to live as you once did.
posted by bryon at 11:56 AM on September 21, 2018 [1 favorite]

Prescription strength Vitamin D made a huge difference for me. Normal levels start at 40 ish, I was at 15 before starting supplement. Now I'm at 36 and taking a way smaller dose of D once a week.
posted by Hermione Granger at 12:28 PM on September 21, 2018 [1 favorite]

You can have low iron without being anemic. You can even be in range with your iron levels but still be too low, since the range is ridiculously huge. Ask to have your ferritin levels checked and demand copies of the results. Optimal is above 50. Don't let them dismiss you if you're too low. A lot of doctors, especially primary care doctors, will see that your results are "normal" and conclude that you're healthy. In practice its not this simple, especially with the different vitamin and nutrient levels. Sometimes you really need to advocate for yourself, hard as it may be.
posted by Amy93 at 10:10 AM on September 22, 2018 [1 favorite]

Update from the anon OP:
Thank you, everyone!

The PHQ-9 test (recommended by jasper411) and the Burns depression test (recommended by shirobara) both suggest that I am moderately depressed. So I think I'll ask my doctor for a referral to a mental health professional.

I think I will also try supplements for vitamin D, vitamin B12 and iron.

If neither of these approaches is helpful, I'll try some of the other suggestions!

Thanks again.
posted by LobsterMitten at 10:41 AM on September 22, 2018

Everyone saying to just start taking vitamin supplements is missing the point that you need to get a complete blood panel before you start taking them. Supplementing with Vit D or with B12 will artificially raise your levels.

I had debilitating, chronic fatigue that has been largely addressed by a diagnosis of pernicious anemia. Taking all of the B12 in the world will yes, raise my B12 levels but won't help me at all. My body doesn't make intrinsic factor, which is what you need to absorb B12. Oral supplements at any dose are useless to me; I have to inject ampules of manufactured B12.

I am fortunate to have caught this after 10 years because I had already had symptoms of neuropathy. It would never have been caught at all if when tested, my B12 level was artificially normal.

Find a better diagnostician.
posted by DarlingBri at 10:42 AM on September 22, 2018 [3 favorites]

One point Feeling Good establishes early on is that "Depression can mimic a great number of medical disorders because your mood swings often create a wide variety of puzzling physical symptoms." However, it's also the case that "many treatable illnesses may initially masquerade as depression." So you're doing exactly the right thing to pursue help for both your mental and physical health! I personally was greatly helped by the exercises in Feeling Good -- you don't have to wait to find a mental health professional to get started if the idea of CBT interests you, although it's incredibly helpful to have a good one. Feel free to MeFi mail me if you want to talk about it!
posted by shirobara at 5:55 PM on September 22, 2018 [1 favorite]

I walked around with mild depression for years. For me I believe it was nutritionally based. I tested positive for mthfr, a slight genetic mutation which in basic terms means, among other things, that I don't metabolize B vitamins very well. It's a relatively common condition and can be detected via blood test from your GP. I began supplementing with a good B complex. At the same time, based on other blood work I also started supplementing with vitamin D. Keeping up on my nutrition has made a world of difference. Best of luck.
posted by vignettist at 8:38 PM on September 22, 2018

You mentioned the things the doc looked for and I didn’t see WBC or lymphocytes. Did they check for that? Are they high?

This may sound far out, but I had high numbers on both and was tested several times in two months. Long story short, I am living with chronic lymphocytic leukemia. I mention this only because extreme fatigue is a common side effect when the disease progresses. It’s unkikely you have that, but if your doctor didn’t get you a complete blood count, then they should have.

This may be scary; I apologize. CLL is not a death sentence. I often forget about it until my six month checkup.
posted by tcv at 5:54 AM on September 29, 2018

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