- Why am I so tired, and how do I beat fatigue?
- Depression and Loss of Energy: a Waiting Game
- How to Fight Depression Fatigue
- Why depression makes you tired
- Depression Makes You Tired
- How Depression Causes Brain Fog
- How Does Depression Cause Fatigue?
- Depression or chronic fatigue syndrome?
- Get a diagnosis
- Practise good sleep hygiene
- Stick to a sleep routine
- Move a little
- Take in some sunlight
- Eat for energy
- Avoid alcohol
- Take a nap
- Work on your posture
- Focus on what gives you pleasure
- The Fix
- Management of Residual Fatigue in Depression
- Fatigue after depression responds to therapy. What are the next steps?
Why am I so tired, and how do I beat fatigue?
Share on PinterestDoctors will ask a series of questions when diagnosing fatigue to determine the cause.
Fatigue is a difficult issue for doctors. It may be a physical problem rather than a psychological one.
The following conclusion from a research paper on psychological fatigue highlights the need for a partnership to be developed between doctor and patient for proper diagnosis.
“Patients consulting for tiredness are likely to report symptoms of psychological distress and attend more frequently than other patients.
They tend to view the problem as physical while their doctors view the problem as psychological. Having established that there is no physical problem, doctors may need to focus more on sharing ideas and explanations when patients complain of being ‘tired all the time.'”
When patients present with fatigue, doctors will try to develop a more precise description of symptoms, typically by asking the following types of questions:
- Have you felt drowsy, or has the fatigue been more a feeling of weakness? – the answer can give clues to the diagnosis because drowsiness may be a symptom of a sleep disorder, while weakness may be a sign of a neuromuscular cause.
- During the past month have you often been bothered by feeling down, depressed, or hopeless? – positive answers may indicate depression.
- Has your fatigue developed gradually or suddenly?
- Does your tiredness come in cycles? – for example, depression is indicated if the fatigue is worst in the morning but persists all day, whereas fatigue associated with exercise suggests a neuromuscular issue.
- What are your concerns about the fatigue? What do you think may be the cause? – the doctor may be looking for a connection with any distressing life events, for example.
More general questions are designed to elicit information regarding psychological or lifestyle issues. There may be questions about relationships and any recent bereavements or upheavals related to employment or housing. The doctor may also ask about a patient’s diet and exercise.
The doctor might take a ‘sleep history’ to work out whether a sleep disorder is leading to the fatigue:
- How much sleep do you get each night?
- Do you have trouble getting to sleep or do you wake up during the night?
- Has anyone told you that you snore?
- Has anyone noticed that you stop breathing for short periods of time during sleep?
These sleep history questions are designed to determine the sleep quality, quantity, patterns, and sleep routine.
The doctor may also examine a patient physically or check their mental state to find physical and mental causes. If no specific cause is indicated, there is a set of standard tests used to help narrow down the diagnosis. Based on the patient’s complaints, these may include:
- full blood count
- erythrocyte sedimentation rate or C-reactive protein
- liver function tests
- urea and electrolytes
- thyroid stimulating hormone and thyroid function tests
- creatine kinase
- urine and blood tests for glucose
- urine test for protein
One of the top health problems I talk to people about is chronic fatigue or extremely low energy levels. From generalized fatigue to the more serious chronic fatigue syndrome (CFS), this epidemic of extreme tiredness is hitting a record amount of people. Chronic fatigue syndrome by itself affects more than 1 million Americans, more people in the United States than multiple sclerosis, lupus, and many forms of cancer.
These statistics don’t even take into account all the people struggling with daily low-grade fatigue. Fatigue also can be very dangerous, with around 20% of fatal car accidents involving driver fatigue. Many people will brush off their low energy levels as just part of getting older, which makes it difficult to distinguish between what is common and what is “normal.”
While fatigue is common, it’s certainly not biologically normal. This false assumption makes many people settle for feeling lousy and tired most of their lives. Fatigue can affect every aspect of your life: your family, friends, job and activities will suffer. In this article I want to share with you the eight main culprits of chronic fatigue that I see in my practice and tips on how to overcome it:
1. Macronutrient Imbalances
Macronutrients are fats, proteins and carbohydrates. Your body runs on these three macronutrients, and we need proper ratios of each one to suit your diet and lifestyle.
One of the most common macronutrient deficiencies in the West is low fat consumption. Since the latter part of the 20th century, fat has been cut out of the standard American diet and that caloric deficit has been replaced with refined carbohydrates, specifically grains. When you’re in sugar-burning mode, you get the inevitable sugar crash, leaving you with mood swings, irritability, weight loss resistance, and fatigue.
When I refer to fat, I’m not talking about margarine or some other kind of bad fat. Coconut oil, avocados, eggs, and, if you eat meat, grass-fed beef and wild-caught salmon, are all great forms of whole food fat for your energy! From a biochemical standpoint, your body’s best and slowest-burning form of energy is fat. Furthermore, your brain is made of 60% fat and 25% cholesterol, so nourishing that precious organ is the cornerstone to overcoming fatigue. Although more rare, inadequate amounts of protein and carbohydrates will also contribute to low energy levels.
2. Micronutrient Deficiencies
Our bodies are alive and functioning because of biochemistry. When we don’t nourish them with the specific nutritional requirements that make health possible, it can start with you feeling tired and lethargic. Some nutrient deficiencies that I see on a regular basis in patients that are fatigued are iron, vitamin D and vitamin B deficiencies. Each one of these nutrients can be checked by a simple blood lab and should be considered when you are struggling with low energy.
3. Poor Gut Health
Known as the “second brain,” your gastrointestinal system is essential and often overlooked factor in your energy levels. You don’t necessarily have to have noticeable gut symptoms to have an underlying chronic gut issue. Your gut-brain axis is a complex web of communication between these two vitally important systems when it comes to your energy levels.
If your body is bogged down with conditions like permeability of the gut lining (leaky gut syndrome), small intestinal bacterial overgrowth (SIBO) or just generalized imbalances in your gut bacteria (dysbiosis), it can drain your energy significantly. When these conditions are resolved, energy levels and vitality are restored back to normal. Interestingly enough, chronic gut dysfunctions are also linked to fatigue’s stubborn partner, weight loss resistance.
4. Inflammatory Foods
The foods we eat are dynamically instructing our biochemistry and our energy levels. Our meals are either helping or hurting your energy levels; there’s no neutral food when it comes to your body’s function. It’s no secret that refined foods, excess carbohydrates and empty calories will negatively affect your health, and that will typically begin by zapping your energy levels. The infamous “sugar coma” can only be stopped if you stop eating what is fueling your low energy!
Underlying intolerance to foods like gluten, gluten-free grains and dairy can also cause fatigue. If you’re suffering from fatigue, start by eliminating the inflammatory foods in your diet and try kick starting it off with my real food challenge here.
The word “toxin” has become so cliched and ubiquitous in the health community that the common person reading this article will probably roll their eyes right about now. The reality, though, is that our world today IS alot more inundated with substances that are toxic to our health. We are not genetically adapted to this onslaught of toxicity, and our energy levels are typically the first “check engine light” that something is not right. With a comprehensive health history and the use of proper diagnostic testing we can rule out common toxicities like heavy metals or plastics; if you don’t want to wait for tests, there are ways to reduce toxins in your life now.
6. Hormonal Dysfunctions
Our body’s different systems communicate through an intelligent web of hormonal pathways. A properly functioning endocrine (hormonal) system is essential for your energy levels. Two relatively common hormonal pathway dysfunctions that I find in people who are struggling with low energy levels are hypothalamic-pituitary-adrenal dysfunction (adrenal fatigue) and low thyroid function. There are many different reasons for low thyroid function.
Every pharmaceutical drug has side effects and one of the most common side effects that I see is fatigue. Common medications given for blood pressure, cholesterol, pain, diabetes, acid reflux and depression can all cause chronic fatigue. It amazes me how little people know about the side effects of the drugs they take every day. If you’re on any medications, I would recommend finding out if fatigue is one of the side effects.
If your medication is causing or adding to your fatigue, discuss with your doctor about what other options you have. My gain goal as a functional medicine practitioner is to get people healthy so they don’t have to be on the common medications that cause fatigue and other side effects.
8. Poor Sleep
Sure, this sounds like an obvious one! Yes, it’s true, if you’re just staying up too late at night because you’re watching your favorite reality show and drinking tons of caffeinated beverages, stop it. Go to bed earlier. But many people don’t know they aren’t sleeping well, and even if they do, they can’t fall asleep or stay asleep even if they tried.
Sleep disorders like insomnia and sleep apnea affects millions of people around the world with very little options in the mainstream model of care. Dealing with the underlying issues that are causing the sleep disorder is essential to restore your energy levels. For mild insomnia, herbs like valerian and chamomile can be effective. For sleep apnea, CPAP machines work for some people, and allow them to get the rest they need to regain their energy.
While breathing machines and herbal medicines may be effective in the short term, ultimately the question should be asked, “Why do I have this problem in the first place?” For my patients, when we deal with the individual root mechanisms of their poor sleep and low energy, they’re able to reverse sleep disorders and sleep apnea sustainably.
Customized Health Solutions
Obviously this isn’t a complete list of everything that could be causing low energy. In functional medicine, it’s my goal to investigate the multifaceted nature of conditions like chronic fatigue. If you notice, the eight causes of low energy are connected, just like your body. For example, toxins can cause hormonal imbalances, which can cause poor sleep. Eating inflammatory foods can damage your gut health which will can cause a micronutrient deficiency.
There are many different pathways and possibilities for fatigue, or any chronic health concern, for that matter. These different dysfunctions needs to clinically “untangled” and dealt with on an individual basis. Taking into account the individual instead of a generalized “one-size-fits-all” approach is the only way I have seen the consistent, reliable and sustainable resolution of health problems like fatigue.
Depression and Loss of Energy: a Waiting Game
Depression and loss of energy — it is the beginning of a waiting game that does not end well.
Sometimes depression is born from loss of achievement, loss of goals, and loss of positive feelings about oneself. When low energy plays a role, a person who is not blessed with high drive and physical energy can see a spiral into depression start quickly. But even people with more energy lose it while bearing the weight of the losses. And, without a lot of energy, people begin to wait for things to get better around them rather than take action to make change.
Spiraling — the word makes it seem like a gentle way to go down, but when it comes to depression, going down is hard to stop, and once at the bottom, reversing the spiral takes intention and support. I hear about this often from my younger depressed clients — those adults who started out of high school or college ready to be successful but who found the world did not fulfill the vision they had.
Jeremy (not his real name) was one such young man. He never had to work too hard to get a passable grade point and was popular enough to have a solid romantic relationship. He was ready happy with his life. But, as commonly happens, the college romance did not last, which made him feel down in the dumps. Then the company he worked for, facing hard times, cut his hours. He now did not earn enough to live on but he expected the company, not himself, to change and he took no action. He waited for work to increase his hours, but in the meantime he felt like a failure, and the waiting sapped him. His self esteem, already suffering from being single again, took another hit as he saw his money dwindle to nothing. He started to isolate himself from friends without funds for fun and without a date to go along. Waiting was his enemy. Without meaningful activity beyond limited work hours, that isolation increased his depressed mood.
Waiting also intensified the mental and physical fatigue, so he slept later in the morning, since he did not have to get to work early. He began to think he had a lot of time every day to work on his situation, so he did not start on possible job hunting and, as the day melted away, it was too easy to let himself decide that tomorrow was a good day to start fresh. But that waiting also increased his fear that nothing could change and his mood became very depressed. That depression and his situation robbed him of the very things he needed to reverse the spiral: meaningful work (purpose, as well as money), positive interactions with others, pride in his achievements, sense of competency, and a feeling of being loved.
This spiral is one I have seen repeatedly in young adults who have not met with easy success out of high school or college. They often did not have to work at jobs during those years to obtain phones or cars or clothes or do costly activities, such as attend concerts or sporting events. One young man I worked with as he finished high school, Casen (again, a pseudonym), felt literally terrified of applying for a part time job so that he could begin developing job skills and a resume and have some spare cash. Without classroom demands, he moved into waiting mode: waiting to apply to community college, waiting for a job that might fall into his lap. (The job that a friend would provide not that Casen would go search for, since the friend said he could get his boss to hire Casen). Waiting did not bring him the job or the college acceptance letter, and he felt even more scared and more depressed. And he judged himself rather mercilessly: believing he would never succeed. That negative mindset robbed him of even more energy, and the more time he spent watching shows on his laptop, the less energy he had to reverse the downward spiral to depression.
What can be done about this? It is typical that an outside force will help. If you are reading this you might be saying to yourself phrases like, “Yeah — the outside force of getting evicted or starving! That would work!” If so, you would be correctly identifying motivators! At times, though, a person in a downward spiral ends up living with family or friends who are being helpful to them in averting disaster, but the pattern of waiting on something outside themselves does not change until motivation can pick up.
How is it possible to reverse the spiral? Raising energy is a primary initial goal — with or without motivation. To start the spiral on an upward trend, simply:
Stop telling yourself negative things: you only reinforce the belief they are true. Interfere with negativity, saying , “Stop! I choose to believe I will solve this!”
Stop isolating. Get in contact with people, any interaction with others will help you also get outside of your own negative thoughts or mood.
Stop talking about your own life for a short while. When you only ruminate on your troubles, they seem larger. Ask someone else about his or her life. Hearing about another’s life, you can look at your reactions. I love the saying that troubles shared are cut in half and joys shared are doubled.
Then start the upward spiral with attention to developing a sense of purpose. Don’t assume this is a a deep spiritual quest. In fact, it can be initially as simple as scheduling your day and meeting some regular commitments. An important brain change toward a less depressed mood occurs results from intentional activity. You get a blip of glutamate, an activating neurochemical, and one of dopamine, the feel-good neurochemical, and the combination is energizing. The bigger the step you take, the more you get. And any action will supply enough energy to do a little more.
Try the following:
If you are underemployed — set a daily schedule that begins with a reasonable wake up time.
Have a pattern to the day what news show you listen to or watch, when you have your coffee, when you feed a pet or meet a friend for tea.
Leave the house — you might have to start with leaving your room and interacting with others in your home- but forcing yourself toward less isolation is important.
At work, be sure to talk to your colleagues and ask them how they are; It improves the chance of a positive social exchange that can increase your self-esteem a bit and moves the spiral upward a fraction.
Set small goals — like walking the dog an extra 5 minutes — and notice you achieved them. There’s a bit more glutamate and dopamine!
Do something physical. When you move your depressed body you gain energy rather than lose it, so even a few minutes of tidying up can raise enough energy to do a bit more.
The above ideas tend to work best when you are working with another person who supports you, such as a therapist, a 12-Step sponsor, or a good friend who knows your goals and will help you keep track of them.
As you stop the waiting game — that passive waiting for life to change without you doing something to change it — the spiral reverses. You will be surprised that you will slowly feel your energy rise so you will be more able to take the next steps toward success.
How to Fight Depression Fatigue
Living with major depression can be challenging when you’re also dealing with fatigue, a common depression symptom. Not only can fatigue disrupt your daily routine, it can also make it harder to take the steps needed to get depression under control.
“Major depression causes a total lack of energy that doctors call ‘anergia,’” says Stephen Geisler, MD, an assistant professor of psychiatry at Hofstra North Shore–LIJ School of Medicine in Long Island, N.Y. “This lack of energy can lead to mental, emotional, and physical fatigue that’s difficult to treat.”
Left untreated, fatigue can contribute to longer and more severe depression, according to a research review published in 2014 in the journal Depression and Anxiety. It’s also one of the main causes of disability in depression, says Dr. Geisler. For these reasons, taking steps to conquer fatigue is an important aspect of depression treatment.
How Is Depression Fatigue Treated?
Depression fatigue may be linked to poor sleep, lack of activity, or commonly used antidepressant medications called SSRIs and SNRIs. Even after other depression symptoms have responded to treatment, fatigue is likely to linger.
The first step to finding an effective way to fight depression fatigue is talking with your doctor. Your doctor will want to make sure your fatigue is not caused by another medical condition or the medication used to treat it.
“If fatigue is caused by your antidepressant, your doctor may switch you to an antidepressant that is less likely to cause fatigue and more likely to treat it,” Geisler says. “There are also some stimulant-type drugs that may be added to your treatment plan to help reduce fatigue.”
In addition to consulting your doctor, talk with your therapist about strategies you could make to reduce fatigue. These may include staying active, participating in fun activities with friends and loved ones, pacing yourself, and setting realistic goals for the day.
Helpful Lifestyle Changes Can Fight Depression Fatigue
You can also make healthy lifestyle choices that may help reduce fatigue:
Get moving. “Getting exercise can help reduce fatigue by promoting better sleep,” Geisler says. Exercise may also directly increase energy. Just one 30-minute session of aerobic exercise can stimulate feelings of increased energy, according to a review of research on exercise and fatigue published in Fatigue: Biomedicine, Health & Behavior.
Eat well. Retooling your diet may also help recharge you. A diet higher in fat has been found to increase daytime sleepiness, whereas a diet higher in carbohydrates can boost alertness, according to a small study that involved healthy adults who were normal sleepers. In addition, according to the Harvard School of Public Health, the type of carbohydrates you choose makes a difference when you are trying to get more daytime energy. Go for whole grains, fruits, and vegetables, which are more slowly digested than carbs like white bread, pasta, candies, pastries, and sodas.
Practice good sleep habits. Sleep hygiene is another important part of managing fatigue when you have depression, Geisler says. Sleep hygiene refers to sleep habits that promote a healthy amount of sleep, including:
- Avoiding stimulants like alcohol and caffeine for about six hours before bed
- Not eating heavy meals before bed
- Avoiding daytime naps
- Establishing a regular sleep schedule
- Getting regular exercise, but not right before bedtime
- Keeping your bedroom quiet, dark, and comfortable
- Using your bedroom only for sleep and sex (no smartphones and other gadgets)
If you’re struggling with depression fatigue, talk with your healthcare providers about medications or lifestyle changes that may help. Fatigue can make depression worse and may even increase your risk for a depression relapse, so enlist your entire team to help you fight it off.
Why depression makes you tired
Anxiety, tiredness, and negative thoughts are seen as the symptomatic triad of depression. Even though depression is a psychological disorder, it can trigger somatic (physical) symptoms including loss of energy. Often, this sense of constant exhaustion unleashes a vicious cycle that can maintain depression for years. Chronic tiredness, a physical disorder, is often confused with depression because the symptoms are so common. Each, however, can trigger the other, so it’s possible to develop both.
Being depressed is tiresome
“My problems commenced when I had to leave University. I suffered from a flu-like condition, which led to panic attacks, depression and complete exhaustion for a couple of months,” wrote an anonymous user on a medical forum.
“I am taking mirtazapine which helps me get a full night’s sleep now, but I still lack the energy that I need to do things. When I do feel well enough to get out and about and do something with my day or go out for the evening it exhausts me and results in me needing to recover for a few days,” wrote another user.
Reports such as these are abundant all over the internet. They’re not even surprising given 1 in 10 Americans are affected by depression at some point, and 80% of the clinically depressed are not receiving any kind of treatment.
“Some of my patients have been surprised and shocked when I’ve told them they were depressed,” says clinical psychologist Angel Adams. “They think it’s something else. If they have a lack of energy or fatigue, they might just think they’re doing too much. Sometimes they think, ‘It’s just this illness’ or ‘I had a break-up with somebody’, but really they’re experiencing depression as well as the illness or the grief reaction.”
Many of us simply don’t understand what depression looks like. “People don’t quite understand that you can still function and have depression,” says Adams. “A lot of people think if you have depression you’re going to quit your job and so on, but many people continue to work, continue to function but to a very different degree. You don’t have to be suicidal to be depressed. You can just be clinically depressed and think, ‘This is the way my life is.’”
Depression affects appetite and sleep — both vital to generating and replenishing energy. In most cases, patients report insomnia and getting less sleep, though sleeping too much will also ruin your mood and energy levels.
Even when patients do get reasonable hours of sleep (six is considered the bare minimum), most report waking up “unrefreshed” and tired throughout the day. That may be because depressed people don’t get the same kind of quality sleep as everybody else. Researchers who scanned the brains of the clinically depressed found:
- it takes much longer to get off to sleep,
- the total sleep time is reduced,
- there is little or no deep sleep,
- REM sleep occurs earlier in the night,
- they awaken more frequently during the night, which may last long enough for the person to be aware of these awakenings, and
- the person wakes up earlier in the morning and can’t get back to sleep, even when they are very tired.
Scientists assess sleep by measuring the brain activity. Depending on the frequencies of the measured electrical signals, sleep can be divided into different stages. A normal person will go from stage one to four when falling asleep, and and then follow the reverse order when waking up. The fifth stage is called rapid eye movement sleep (REM) because the eyes move frantically — it is in this sleep stage that we dream.
Dreams are very important to our psychological well being. Even when we have repetitive dreams of everyday occurrences, this sort of dreams help the mind ‘put things in order.’ Here’s an enlightening account by sleep researcher Rosalind D. Cartwright, from the book The Twenty-four Hour Mind: The Role of Sleep and Dreaming in Our Emotional Lives (public library):
“The more severe the depression, the earlier the first REM begins. Sometimes it starts as early as 45 minutes into sleep. That means these sleepers’ first cycle of NREM sleep amounts to about half the usual length of time. This early REM displaces the initial deep sleep, which is not fully recovered later in the night. This displacement of the first deep sleep is accompanied by an absence of the usual large outflow of growth hormone. The timing of the greatest release of human growth hormone (HGH) is in the first deep sleep cycle. The depressed have very little SWS and no big pulse of HGH; and in addition to growth, HGH is related to physical repair. If we do not get enough deep sleep, our bodies take longer to heal and grow. The absence of the large spurt of HGH during the first deep sleep continues in many depressed patients even when they are no longer depressed (in remission).
She continues, “The first REM sleep period not only begins too early in the night in people who are clinically depressed, it is also often abnormally long. Instead of the usual 10 minutes or so, this REM may last twice that. The eye movements too are abnormal — either too sparse or too dense. In fact, they are sometimes so frequent that they are called eye movement storms.”
There’s another pattern related to REM sleep in the depressed: they don’t remember what they dreamed or have a tough time recalling fragments. Thus, the mood-regulating function of dreaming may be disrupted in the depressed brain.
It may all be rooted in stress
It’s not clear what causes depression, but prolonged stress seems to play a major role. When we’re stressed, the brain is flooded with the stress hormone cortisol. If stress remains heightened for a long time, there will be more cortisol and less dopamine and serotonine, the lack of which have been linked with depression. So, stress might exhaust the brain and lead to depression, which seems to trigger vicious cycles: you’re depressed, so you become more stressfed out; you have trouble sleeping, so you feel tired; you feel tired so you don’t feel like doing anything meaningful anymore. It really is terrible, and once the circle is complete, most people have a hard time breaking free.
This is why depression can be very cruel, and serious medical attention needs to be considered. Both depression and insomnia can be treated with antidepressants. The most antidepressants belong to the class called selective serotonin reuptake inhibitors (SSRIs), and insomniacs who start taking one of those drugs often find relief for their sleeping problems. Non-pharmaceutical methods of addressing insomnia can also help with depression. A few short tips that might help include:
- exercising during the day, but avoid doing so two hours before planning to go to bed,
- avoid caffeine (coffee, tea, energy drinks) and alcohol,
- use deep-breathing exercises to relieve anxiety.
Remember: feeling tired all the time isn’t solely confined to depression. In fact, a slew of physical disorders can cause these lethargic moods. Before visiting a psychiatrist, the best course of action is to first have basic blood tests. The doctor will then be able to check for infection, anemia, and thyroid problems, which could all be relevant.
Hopefully this, article helps explain why depression makes you tired.
Constantly exhausted? Easily irritated by the teasing joke your friend made? Can’t concentrate on that daunting project you’re working on?
Brain fog, which often comes along with depression, is a serious condition that can have harmful effects on all aspects of your life.
Depression Makes You Tired
Depression is one of the most common mental health struggles in the US. Some experiences that could stem from depression are hopelessness, excessive feelings of guilt, insomnia, and, of course: brain fog and fatigue.
Cognitive Dysfunction: aka Brain Fog
In the context of depression, brain fog is formally referred to as “cognitive dysfunction.” Over 85% of people with depression experience this symptom.
As anyone who’s experienced brain fog or depression knows, symptoms of cognitive dysfunction can include:
- problems with planning and coordination
- difficulty remembering things
- slow reactions to your environment
- trouble paying attention
Depression, brain fog, and fatigue, or chronic tiredness, go hand in hand. It’s a vicious cycle: when you have depression, brain fog makes you spend extra energy to get through the day, which in turn makes you feel even more tired. Then you feel ineffective, which worsens your depression even more and interferes with sleep. It’s a revolving door that breeds fogginess.
Or The Other Way Around?
The direction of causality hasn’t been determined, but there are 100% concrete links between inflammation, brain fog, and depression – these links may go beyond just the cognitive and emotional factors in depression’s brain fog.
Other diseases that may involve autoimmune and/or inflammatory processes also correlate with brain fog. (Think chronic fatigue syndrome, fibromyalgia, or rheumatoid arthritis.)
So some doctors and scientists now believe inflammation may be a significant root of depressive symptoms – though not the only one.
This would make depression and brain fog siblings, instead of parent and child — both results of the same underlying processes.
What Brain Fog Feels Like
We hear the term ‘brain fog’ a lot these days, but what exactly is brain fog? Brain fog isn’t a medical condition on its own but it can be a sign of several different medical conditions, including depression. It is a collection of symptoms, including memory problems, irritability, inability to concentrate, and poor motivation. It can feel like you’re losing control of your own brain.
If you’ve ever experienced brain fog, you’ll know that its intensity can vary from day to day, even from one minute to the next! On a brain-foggy day, you might feel like the outside world is moving too fast for you to keep up with.
It can also be extremely frustrating if you can’t remember the right word, or if you always forget whether you’ve locked the door in the morning. You know it’s just mental fog, you know it’s not who you are. But with long-standing depression, it starts to feel like you’ve just become slow and sluggish.
What Fatigue Feels Like
Fatigue, like brain fog, can be a product of many different physical and mental conditions. It can be very tricky to describe to others because it’s often mistaken as simply feeling tired.
But fatigue is much more than just tiredness. People experiencing fatigue often feel tired even after light exertion. Getting through an average day seems like a marathon. And waking ‘unrefreshed’ is a big indicator that your feeling dead may be a more complex issue.
How Depression Causes Brain Fog
Because mental fog can be a symptom of a variety of different medical conditions and not just depression, the relationship between the two isn’t entirely clear. We do, however, have some ideas.
Cognitive and Emotional Factors
Depression disturbs the balance of the ‘feel good’ chemicals in the brain, called serotonin, and can result in a chronic sense of sadness and lack of wellbeing. But that’s not the whole story.
Your upbringing can also set you up with a lack of self-compassion, which the helplessness of brain fog amplifies into a self-hating or hopeless thought loop. Studies show that these dejected emotional states can relate to elevated inflammatory chemicals that make you feel even more foggy.
Another suspect is depression medication, such as antidepressants. These pharmaceutical drugs work to restore the balance of chemicals in the brain and, hopefully, relieve depression symptoms.
Ironically, however, these medicines seem to contribute to brain fog as a side-effect because of the biochemical changes they cause in the brain. If you think that your antidepressants may be the real culprit, it is worth tracking when you experience a brain fog episode. If the brain fog follows shortly after taking your pills, then you might be onto something. Tracking your symptoms, in general, can help you figure out small ways to counter the fog.
How Does Depression Cause Fatigue?
Depression and fatigue go together, like your morning PB & J. The reason why the two are so interdependent is because of the underlying factors that simultaneously feed both.
Research shows that depression negatively affects the brain’s reward system by changing the the amount of dopamine, a neurotransmitter involved in feelings of pleasure, reward, and motivation. A disrupted reward system can make it hard to see the point in spending any energy, on anything, which manifests as fatigue.
Insomnia, which is characterized by trouble falling or staying asleep, is closely related to depression. The relationship is actually bi-directional. This means that insomnia increases the likelihood of depression because it deprives us of energy and sleep’s physical repairs. And being depressed, in turn, makes it harder to get a good night’s sleep, partly because of the restless cycle of negative thoughts. The end-product is, as you might’ve guessed, unbeatable fatigue.
Long story short, depression is tightly related to both fatigue and brain fog in a never-ending triangular relationship. But there are ways to break the spell!
Being open and honest about your struggles can be a crucial step in your recovery process. It allows you to track your symptoms and find ways to address them.
And an open attitude toward your struggle allows you to share your concerns with someone you can trust.
We’ll end on a note to those who love someone struggling with brain fog: remember that helping is just as important as being helped – if you think your loved one might be struggling, don’t be afraid to reach out for support. Recovery starts with these small steps.
Written by: Janan Mostajabi and Christina Beck
Written By: Christina Beck December 11, 2019
Depression or chronic fatigue syndrome?
Chronic fatigue syndrome (CFS) is characterized by prolonged, debilitating fatigue that does not improve with rest and may be worsened by physical and mental activity. This fatigue must be present for at least 6 months. This syndrome affects more than 1 million individuals in the U.S. and shares symptoms with many medical and psychiatric illnesses, particularly depression.
Keeping in mind that a patient who presents with fatigue could have depression and CFS, follow DSM-IV-TR criteria for major depressive disorder to help identify clinical factors that distinguish the 2 disorders.1
1 Depressed mood
Individuals with major depressive disorder report being depressed most of time and often cannot provide a reason or identify a loss to explain their depressed mood. CFS patients are more likely to report feeling discouraged and depressed because a lack of energy leaves them unable to complete tasks.
2 Diminished interest in activities
Depressed patients typically report a loss or lack of interest in pleasurable activities. CFS patients say they would engage in favorite activities more if their energy level would allow it.2
3 Weight loss and decreased appetite
A depressed patient may report no interest in food or may overeat. CFS patients are interested in food but find shopping and meal preparation fatiguing. Their nutritional intake may consist of fast food or easily prepared meals.
Depressed patients will report poor sleep or excessive sleep (insomnia or hypersomnia). CFS patients experience unrefreshing sleep regardless of how long they sleep.
5 Fatigue or loss of energy
Patients with major depressive disorder will report fatigue regardless of the task. They often view all tasks as equally difficult. CFS patients present with overwhelming fatigue. They express a desire to do more but are physically unable. These patients experience postexertional malaise typically worsening 12 to 48 hours after an activity and lasting for days to weeks.2 Therefore, CFS patients may avoid normal activity.3
6 Feelings of worthlessness or guilt
Guilt in major depressive disorder is often delusional and broad, extending to all areas of life. CFS patients will report guilt caused by their inability to be more active. They may feel they are letting their family or co-workers down. Some people—including some health care providers—do not regard CFS as a “real disease;” others may criticize these patients’ work and daily activity level, therefore increasing guilt.
7 Diminished ability to think or concentrate
In depressed patients, this symptom should improve with antidepressant therapy. In patients with CFS, antidepressants often do not improve concentration or memory.
8 Thoughts of death and suicide
Depressed patients often will have suicidal ideation and believe life is hopeless. CFS patients can become depressed and suicidal because of the condition’s prolonged debilitating symptoms. They may qualify suicidal thoughts with, “If I have to live like this for the rest of my life, I’d rather be dead.”
9 Medical complaints
Depressed and CFS patients often present with medical complaints and require a medical workup. Chronic symptoms— such as muscle pain, headache, multijoint pain without swelling or redness, sore throat, and tender lymph nodes—constitute some of the core symptom criteria of CFS.3 These symptoms may overlap with depressed patients’ somatic complaints.
History of symptom onset and complete medical workups are important to make an accurate diagnosis. Rule out other medical disorders such as fibromyalgia, chronic mononucleosis, hypothyroidism, and subacute infections in patients who present with prolonged fatigue.
Depression leaves you feeling constantly exhausted (Picture: Liberty Antonia Sadler for Metro.co.uk)
I’m tired. I’m really, really tired.
And it’s not the sort of tired an early night, a triple-shot coffee or a jog around the park can fix.
I’m tired because I live with clinical depression.
Please don’t call me a ‘service user’ – I’m a mental health patient
For me, constant fatigue is one of the worst symptoms of mental illness. It saps the joy out of life and makes everything feel 20 times harder.
The relationship between depression and sleep is a ‘chicken and egg’ situation.
Depression can cause sleep problems, and sleep problems can cause depression, setting up a vicious circle that’s hard to escape.
As is the way with so many mental health problems, the underlying causes of depression fatigue are hazy.
‘It’s likely to be a complex interaction between genetic, biological and environmental factors,’ says Dr Elin Davies, a psychiatrist with online psychiatric service Psychiatry-UK.
‘We know, for example, that people with depression spend less time in deep sleep, and more in the less restorative REM sleep (the dream state), and that they produce less of the hormone cortisol, which helps us get going in the morning.’
Medication can play a part, too: the tablets I take have a sedative effect and make me feel permanently fuzzy.
I know I’m not alone in struggling with depression fatigue, so how can we cope with the mental and physical exhaustion and still function as human beings?
Get a diagnosis
Sounds obvious, huh? But feeling tired all the time is a major symptom of depression, so if you’re constantly knackered and think you may be depressed, it’s worth seeing your GP.
‘When people recover from depression, biological functions like sleep usually return to normal, so it’s important to get a skilled diagnosis and appropriate treatment,’ says Dr Davies.
Practise good sleep hygiene
Create an environment that will help you drift off to sleep (Picture: Ella Byworth for metro.co.uk)
Sleep hygiene means making sure your body and your environment are conducive to sleep.
It might mean taking a relaxing bath before bed, or leaving your window open to let some air in, or leaving your phone downstairs overnight.
Stick to a sleep routine
There’s a temptation to stay up late until you pass out from tiredness, and then lie in bed until mid-morning, but it’s really important to stick to a regular bedtime and getting-up time.
This helps to programme your brain and body clock into a routine that ensures you’re getting enough sleep.
Move a little
Notice that I don’t say ‘get some exercise,’ because when you’re severely depressed, it’s next to impossible.
But there’s a strong link between physical activity and improved sleep, so if you can, build a little movement into your day – even if it’s just walking to the end of the garden and back.
Take in some sunlight
SAD is a common problem for people in winter months (Picture: Mmuffin for Metro.co.uk)
Exposure to daylight, particularly in the morning, is known to improve night-time sleep, so try to spend some time in natural light every day.
‘A lack of daylight can be a particular factor in depression in the winter months, when the sun sets so early, affecting circadian rhythms,’ Dr Davies confirms.
I keep a SAD lamp on my desk so I can top up my light levels on days when it’s hard to get outside.
Eat for energy
It can be hard to eat well when you’re lacking both appetite and motivation, but relying on caffeine and sugar could be making us feel more tired by causing unnatural blood sugar surges and disturbing sleep.
When I’m struggling to stick to a healthy diet, I take a daily multivitamin to supplement my meals.
When I’m not sleeping well, it’s tempting to self-medicate with wine before I go to bed, but it’s a habit I’m trying to break.
‘Many people drink because they think it helps them get to sleep, but they don’t realise how disruptive alcohol is to sleep; it actually causes more problems than it solves,’ says Dr Davies.
Take a nap
I hate being the sort of person who naps, but a short daytime sleep is scientifically proven to recharge our batteries and lift our mood.
It helps give me the energy I need to function when my kids come home from school.
Work on your posture
Depression puts you in a slump physically as well as mentally, but poor posture could be making you feel even more lethargic.
The theory is that if your spine is out of alignment, your body is working harder to compensate, so it’s no surprise that it can sap energy.
It takes a conscious effort to correct my posture, but I notice the difference when I do.
Focus on what gives you pleasure
Depression is a thief, stealing the enjoyment from life – but there’s merit in continuing with the things that normally make you happy, even if it’s hard work.
‘Work out what small things still give you some pleasure, and make yourself do them, whether you feel up to it or not, as this can break the cycle of avoidance and apathy,’ Dr Davies explains.
It might be something really tiny (for me, it’s stroking the cat) but reminding yourself that even in the depths of depression, there are pleasures to be found in life that can give your spirits a small but significant boost.
MORE: Why I couldn’t admit to having postnatal depression – not even to myself
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Management of Residual Fatigue in Depression
The management of residual fatigue in depression may be summarized in five steps:
Make a definitive diagnosis that it is residual fatigue.
Deal with contributing factors.
Acknowledge the importance of fatigue, establish a clear attribution, and collaboratively design a treatment plan.
Start graded exercise.
If necessary, start specific medication.
1. Differential diagnosis. Excessive daytime sleepiness (EDS). EDS may be due to insufficient or unsatisfactory sleep (including sleep apnea). Asking about sleep quality and amount (initial, middle, or late insomnia) must be part of the interview with any depressed patient. It is important also to consider hangover from hypnotics, be it over the counter (antihistaminics) or prescribed (especially zolpidem). Finally, we must remember that many psychotropics, besides hypnotics and anxiolytics, may induce EDS. Causes of EDS are listed in Table 1.
CAUSES OF EDS
Insufficient or poor quality sleep
– antidepressants (paroxetine, mirtazapine, TCAs)
– antipsychotics (clozapine, olanzapine, quetiapine, typicals)
– antihistamines (remember OTCs)
Sedatives and hypnotics
– bensodiazepines and muscle relaxants
– hypnotics (zolpidem)
Fatigue from medical causes. Most physical illnesses may cause fatigue. However, here we are dealing with a mental healthcare population or a primary care population that is supposed to have regular medical check-ups. Thus, we only mention those medical causes of new fatigue that could be at work in an apparently healthy or stable patient. It is important to consider medications for physical conditions, like beta-blockers, antithyroid drugs, cytokines (interferon), immunosuppressants, and anti-cancer medications. Medical causes of fatigue are listed in Table 2.
MEDICAL CAUSES OF FATIGUE
Chronic diseases, e.g., COPD
Drug therapy, e.g., antihypertensives, cytokines (interferon), anticancer
Antidepressant- and psychotropic-induced fatigue. Serotonergic agents should be suspected of causing fatigue, especially if the fatigue was not present or was less marked at the beginning of treatment. It is important to keep in mind that besides SSRIs, all tricyclic antidepressants (TCAs), venlafaxine, and now duloxetine have serotonin reuptake inhibiting action. Fatigue is not an unusual complaint with anticonvulsants and is a widely known response to antipsychotics and likely related in that case to decreased dopaminergic drive but also to other mechanisms (Table 3).
SRIs (SSRIs, venlafaxine, TCAs)
– increased serotonin seems to be a factor in central fatigue
– if an SRI is indispensable, sertraline
– decreased dopamine seems to be a factor in central fatigue
2. Lifestyle factors contributing to fatigue.23 A sedentary lifestyle with physical deconditioning is a common cause of fatigue; this will not improve easily with interventions other than exercise. Overwork also needs to be taken into account, and we must differentiate fatigue from the exhaustion caused by overwork or a hectic lifestyle that will only improve with rest. Drug and alcohol abuse are causes patients often do not volunteer, and this needs to be actively addressed. Withdrawal from nicotine, caffeine, and stimulants like cocaine needs to be considered. Finally, it is indispensable to ask patients in detail about their eating habits for the assessment of residual fatigue. Lifestyle factors associated with fatigue are listed in Table 4.
LIFESTYLE CONTRIBUTING FACTORS TO FATIGUE
Drug and alcohol abuse/withdrawal (includes caffeine and nicotine)
Inappropriate diet (fad diets, skipping meals)
3. Cognitive intervention. Structured cognitive behavioral therapy (CBT) is always an option for residual depression;24–26 however, here we are discussing a cognitive intervention to be performed by the medication prescriber and directed specifically to fatigue. This intervention in residual fatigue is, to a large extent, modeled on those for somatoform disorders, CFS, and fibromyalgia.27–29 We acknowledge the importance of the fatigue and the impairment it causes and address patient’s anxiety by establishing a causal attribution. We reassure the patient but also let him exteriorize his complaints. Jointly we design a treatment plan and recruit the patient’s collaboration to change contributing factors and to follow the exercise plan (Table 5).
Acknowledge the fatigue, avoid minimizing it, establish attribution
Reassure the patient; let him “play the sick role”
Discuss stressors and patient’s coping skills
Challenge unhealthy cognitions
Collaboratively design a treatment plan
4. Graded exercise. Besides improving physical condition, sustained exercise may improve mood itself. Exercise is usually part of CBT protocols modified for patients with somatoform disorders, CFS, or fibromyalgia.30,31 It is important to start with a comfortable intensity and warn patients against going over schedule, because if they get sore they are more likely to stop exercising (Table 6).
Aerobic exercise (jogging, aerobics, biking, swimming, treadmill, walking at a brisk pace), 4 to 5 times x week
Start with 5 to 15 min at a comfortable level (roughly half the maximum recorded HR), adding 1 to 3 min per week
Warn patients against exceeding scheduled duration of exercise
If increased fatigue, keep the same level of exercise for another week.
5. Pharmacological interventions. There are practically no prospective studies addressing the specific effects of medications on residual fatigue. However, the experience in treatment-resistant depression with medications like stimulants, thyroid preparations, and more recently with selegiline and modafinil, plus the increasing knowledge of the treatment of fatigue in conditions like CFS, MS, fibromyalgia, or human immunodeficiency virus (HIV) infection, allows us to extract some suggestions in this regard. Possible medication management are discussed next and are listed in Table 7.
Switch to or add bupropion
– depending on patient’s profile, consider
– methylphenidate (half ADHD dose or less)
– modafinil 100–200mg daily (check for permanence of the effect)
– l-thyroxine (25–50mcg daily)
– amantadine 100mg daily or bid
– selegiline 5mg daily or bid (MAOI!)
– pergolide (scarce evidence)
– granisetron, ondansetron (expensive, scarce evidence)
Bupropion. This antidepressant has a unique mechanism of action that involves dopaminergic and noradrenergic actions. Clinically, it has an alerting effect and interferes with sleep if taken close to bedtime. It has also proved useful in attention deficit disorders. In depression, bupropion does not seem to affect the psychomotor performance.32 Though we do not know of prospective studies that address its specific effect on energy in depressed patients, bupropion seems to be effective in fluoxetine-resistant CFS.33
SSRIs. Compatible with the proposed role for serotonin in central fatigue, these antidepressants at best seem to have no positive effect on fatigue per se. Paroxetine in depressed cancer patients improved depression but not fatigue.34 Citalopram, in idiopathic chronic fatigue, showed no difference with placebo.35 As mentioned above, one third of depressed patients who responded to fluoxetine had fatigue as a residual symptom. In a comparison with exercise in CFS, fluoxetine improved depression only, while graded exercise improved fatigue.36 A double-blind study did not show difference among fluoxetine, paroxetine, and sertraline regarding fatigue.37
If an SSRI is considered indispensable in patients with marked fatigue (e.g., because of significant anxiety), some suggest that the best choice is sertraline, because of its mild dopaminergic action. Sertraline improved fatigue in depressed patients with MS, though fatigue improvement seemed to be due primarily to changes in mood.38
Stimulants. Stimulants have a questionable intrinsic antidepressant effect; however, they have been used as augmenting agents in depression. There is a growing body of experience with stimulants to improve fatigue in medical conditions like stroke, MS, cancer, HIV infection, and in elderly patients. Recent studies include D-amphetamine in HIV and CFS and patient-controlled methylphenidate administration in cancer.39,40 Stimulants seem better indicated for patients with medical contributors to fatigue or with significant psychomotor retardation.
Modafinil. This agent, approved for the treatment of narcolepsy, is widely used to improve alertness in other conditions. There are reports of augmentation with modafinil in partial response in depression41 and in the treatment of fatigue in MS.42 A relatively large placebo-controlled study of modafinil for fatigue in depression showed modafinil separating from placebo at Week 2 but not at Week 6.43 In another study, modafinil was comparable to caffeine on alertness and performance during sleep deprivation.44
Amantadine and dopaminergic agents. Amantadine, an anti-Parkinsonian medication with unclear mechanism of action, has shown positive results in the fatigue of MS, but there is debate regarding the clinical significance of these findings.45 The dopamine agonists, pergolide and cabergolide, seem to be useful as adjunct to treatment-resistant depression; pergolide, a D1 and D2 agonist, improved fatigue in Parkinson’s disease patients while bromocriptine, a D2 agonist, did not.46 Selegiline, a MAO inhibitor used in Parkinson’s disease, improved vigor in CFS without showing an antidepressant effect.47
Thyroid hormones. Thyroid preparations have long been used as augmentation in depression treatment. There also has been permanent debate within and outside of psychiatry regarding the usefulness of giving thyroid hormones to individuals with TSH levels within the laboratory normal range. Now there is new information suggesting that hypothyroidism is a relative state. Variation of thyroid function tests within an individual over time seems to be small and much narrower than laboratory range; thus, clinically important disease might be present in individuals with normal or raised TSH concentrations.48 In at least one study, giving l-thyroxine (50mcg) to euthyroid individuals improved depression and fatigue, especially in women, without drug-induced hyperthyroidism.49
Serotonin-3 receptor antagonists. These medications are mainly used as antiemetic in chemotherapy. 5-HT3 receptors are ubiquitous and present in areas that relate to depression, with high concentrations in area postrema, tractus solitarius, caudatus, nucleus accumbens, amygdala, and hippocampus. Ondansetron and tropisetron have been reportedly beneficial and well tolerated in CFS and fibromyalgia; however, a significant barrier to gaining more clinical experience is their high price.50–52
Fatigue after depression responds to therapy. What are the next steps?
Fatigue and depression can be viewed as a “vicious cycle”: Fatigue can be a symptom of major depression, and fatigue can be a risk factor for depression.1 For example, fatigue associated with a general medical condition or traumatic brain injury can be a risk factor for developing major depressive disorder (MDD).1-3 It isn’t surprising that fatigue has been studied as a predictor of relapse after previous response to treatment in patients with MDD.
Despite the observed association between fatigue and depression, their underlying relationship often is unclear. The literature does not differentiate among fatigue associated with depression, fatigue as a treatment-emergent adverse effect, and fatigue as a residual symptom of depression that is partially responsive to treatment.4,5 To complicate the situation, many medications used to treat MDD can cause fatigue.
Patients often describe fatigue as (1) feeling tired, exhausted, or drained and (2) lacking energy and motivation. Fatigue can be related to impaired wakefulness but is believed to be a different entity than sleepiness.6 Residual fatigue can affect social, cognitive, emotional, and physical health.
We reviewed the literature about fatigue as a symptom of MDD by conducting a search of Medline, PubMed, and Google Scholar, using keywords depression, fatigue, residual symptoms, and treatment. We chose the papers cited in this article based on our consensus and because these publications represent expert opinion or the highest quality evidence available.
Residual fatigue has an effect on prognosis
Fatigue is a common symptom of MDD that persists in 20% to 30% of patients whose symptoms of depression otherwise remit.4,7-9 Several studies have linked residual fatigue with the overall prognosis of MDD.5 Data from a prospective study demonstrate that depressed patients have a higher risk of relapse when they continue to report symptoms of fatigue after their symptoms of depression have otherwise entered partial remission.10 Another study demonstrated that the severity of residual symptoms of depression is a strong predictor of another major depressive episode.11
In a large-scale study, the prevalence of residual fatigue after adequate treatment of MDD in both partial responders and remitters was 84.6%.12 The same study showed that one-third of patients who had been treated for MDD had persistent and clinically significant fatigue, which could suggest a relationship between fatigue and selective serotonin reuptake inhibitors (SSRIs) and other antidepressants.
Another study demonstrated that 64.6% of patients who responded to antidepressant treatment and who had baseline fatigue continued to exhibit symptoms of fatigue after an adequate trial of an antidepressant.13
Studies have shown that the neuronal circuits that malfunction in fatigue are different from those that malfunction in depression.14 Although the neurobiology of fatigue has not been determined, decreased neuronal activity in the prefrontal circuits has been associated with symptoms of fatigue.15
In addition, evidence from the literature shows a decrease in hormone secretion16 and cognitive abilities in patients exhibiting symptoms of fatigue.17 These findings have led some experts to hypothesize that symptoms of fatigue associated with depression could be the result of (1) immune dysregulation18 and (2) an inability of available antidepressants to target the underlying biology of the disorder.2
Despite the hypothesis that fatigue associated with depression might be biologically related to immune dysregulation, some authors continue to point to an imbalance in neurotransmitters—norepinephrine, histamine, dopamine, acetylcholine—as being associated with fatigue.14 For example, a study demonstrated that drugs targeting noradrenergic reuptake inhibition were more effective at preventing a relapse of fatigue compared with serotonergic drugs.19 Another study showed improvement in energy with an increase in the plasma level of desipramine, which affects noradrenergic neurotransmission.20
Inflammatory cytokines also have been explored in the search for an understanding of the etiology of fatigue and depression.21 Physical and mental stress promote the release of cytokines, which activate the immune system by inducing an inflammatory response; this response has been etiologically linked to depressive disorders.22 Furthermore, studies have demonstrated an elevated level of inflammatory cytokines in patients who have MDD— suggesting that MDD is associated with a chronic low level of inflammation that crosses the blood−brain barrier.23
Clinical considerations: A role for rating scales?
Despite the significance of residual fatigue on the quality of life of patients who have MDD, most common rating scales, such as the Hamilton Depression Rating Scale24 and the Montgomery-Åsberg Depression Rating Scale,25 have limited sensitivity for measuring fatigue.26 The Fatigue Associated with Depression (FAsD)27 questionnaire, designed according to FDA guidelines,28 is used to assess fatigue associated with depression. The final version of the FAsD includes 13 items: a 6-item experience subscale and a 7-item impact subscale.
Is the FAsD helpful? The experience subscale of the FAsD assesses how often the patient experiences different aspects of fatigue (tiredness, exhaustion, lack of energy, physical weakness, and a feeling that everything requires too much effort). The impact subscale of the FAsD assesses the effect of fatigue on daily life.