Mental Health or something else?

Not Every Symptom Is Mental Health

Tips That May Help You Avoid Excessive Psychiatric Medication Use

By Zlatoslava Karga, DNP, PMHNP-BC

One of the most important things I want my patients to understand is that not every uncomfortable emotion, difficult period, lack of motivation, or episode of fatigue represents a psychiatric disorder.

And not every change in how you feel means that you need another medication—or that the medication you already take needs to be increased.

Human beings are supposed to experience ups and downs.

Sometimes, Being Sad Is a Normal Part of Being Human

Imagine that you learn that a close friend is seriously ill. Someone you love dies. A relationship ends. You lose a job. Your child moves away. Something important in your life changes.

You may feel sad.

You may sleep differently. You may think about the situation repeatedly. You may cry. You may temporarily have less interest in your usual activities.

That does not automatically mean that something has gone wrong with your brain.

Sometimes sadness is an appropriate response to what has happened.

These periods can also be important moments of reflection. We think about what matters to us, what we have lost, what we want to change, and how we want to move forward.

The goal of psychiatric treatment should not necessarily be to eliminate every uncomfortable human emotion.

Before Calling It Depression, Look at Your Life

Patients sometimes tell me:

“I’m tired all the time.”

“I have no motivation.”

“I can’t concentrate.”

“I don’t want to do anything after work.”

These symptoms absolutely can occur with depression. But depression is not the only possible explanation.

Consider something as ordinary as your commute.

Suppose you drive 45 minutes or an hour each way through heavy traffic.

For that entire drive, your brain has to remain alert. You are watching cars around you, anticipating unpredictable drivers, navigating traffic, dealing with noise, perhaps worrying about being late, and possibly handling phone calls or other distractions.

Then you arrive at work already mentally fatigued.

Now imagine that the job itself is repetitive and no longer interesting to you. Perhaps you have been passed over for a promotion. Maybe you have conflicts with coworkers or management. Perhaps you simply don’t feel that your work has meaning anymore.

Then you sit down in front of your computer, open an email—and stare at it.

You cannot make yourself start.

Is that depression?

Maybe.

But it may also be fatigue, chronic stress, burnout, sleep deprivation, frustration, or a very understandable loss of motivation in an environment that is no longer rewarding.

Increasing an antidepressant cannot shorten your commute, resolve a workplace conflict, give you meaningful work, or restore hours of lost sleep.

Sometimes we need medication.

Sometimes we need to change something in our lives.

And sometimes we need both.

Your Body Can Make You Feel “Depressed”

Another important concept is that your brain is part of your body.

We sometimes talk about “mental health” and “physical health” as though they exist in completely separate buildings. They do not.

Your immune system is constantly monitoring your body. White blood cells and specialized immune cells—including natural killer (NK) cells—help identify infections and abnormal cells.

When the immune system becomes activated by illness or inflammation, chemical signals can affect the brain as well. This can contribute to what researchers sometimes call sickness behavior: fatigue, increased desire to sleep, decreased activity, reduced appetite or motivation, and a desire to withdraw and rest.

Think about how you feel shortly before developing a cold or another infection. Sometimes your first thought is simply:

“Why am I so tired today?”

Your body may be telling you something.

This does not mean that every episode of fatigue is caused by your immune system. It means that fatigue is a symptom with many possible causes—and psychiatric illness is only one of them.

Your Thyroid Can Look Surprisingly Psychiatric

The thyroid is one of my favorite examples of why psychiatric symptoms deserve a broader medical assessment.

Thyroid hormones influence energy, metabolism, sleep, cognition, and mood.

When thyroid function is too low, some people experience fatigue, increased sleep, slowed thinking, weight gain, reduced motivation, and depressive symptoms. Hair and skin changes, cold intolerance, constipation, and other physical symptoms may provide additional clues.

When thyroid activity is excessive, people may experience anxiety, restlessness, insomnia, tremor, palpitations, irritability, and agitation.

In unusual cases, thyroid disease can produce much more dramatic psychiatric symptoms, including mania or psychosis.

There is actually an interesting historical psychiatric reference called “Prasad’s Syndrome.” It traces back to a 1985 report by A. J. Prasad describing a manic presentation associated with Hashimoto’s thyroiditis. The larger lesson from this and subsequent medical literature is not that thyroid disease explains every case of mania. It certainly does not. Rather, it reminds clinicians that medical illnesses can occasionally imitate—or contribute to—what initially appears to be a primary psychiatric disorder.

That is why medical history, laboratory evaluation when indicated, and careful differential diagnosis matter.

Vitamins and Other Medical Conditions Matter Too

Vitamin deficiencies and other medical conditions can also contribute to symptoms that overlap with depression.

Vitamin D deficiency, anemia, iron deficiency, vitamin B12 or folate deficiency, sleep disorders, hormonal changes, infections, medication side effects, chronic pain, and numerous other medical problems can affect energy, concentration, sleep, and mood.

Again, this does not mean:

“I am tired, therefore I must have a vitamin deficiency.”

It means:

Don’t diagnose yourself from one symptom.

Fatigue deserves context.

Sometimes the Problem Is the Environment

Before assuming that your brain needs another medication, look around you.

Where do you live?

Who do you live with?

How well do you sleep?

Is your bedroom actually quiet?

Do neighbors, traffic, televisions, pets, children, phones, or other disturbances repeatedly interrupt your sleep?

Are you exposed to uncomfortable temperatures, odors, poor ventilation, or other environmental irritants?

There is even a recognized concept called sick building syndrome, in which people report symptoms associated with time spent in a particular building or indoor environment.

Your environment affects your nervous system more than you may realize.

Do a “Life Scan” Before Assuming You Need More Medication

When you notice yourself feeling slightly down, tired, distracted, irritable, or unmotivated, I want you to become curious rather than immediately frightened.

Ask yourself:

What has changed?

How am I sleeping?

Am I physically sick?

Have I been eating normally?

Am I exercising at all?

Am I under unusual stress?

How much time am I spending commuting?

Do I hate my job right now?

Am I dealing with conflict at home?

Have I experienced a loss?

Am I grieving?

Am I working too many hours?

Have I started a new medication or supplement?

Could there be a medical issue worth discussing with my primary-care clinician?

Do I need medication—or do I need rest, boundaries, medical evaluation, environmental changes, therapy, or a change in circumstances?

Sometimes the answer really is medication.

But medication should not automatically become our answer to every variation in the human experience.

When Symptoms Should Not Be Minimized

There is another side to this discussion that is equally important.

I do not want patients using this article to dismiss serious depression or another psychiatric condition.

Persistent or progressively worsening depression, inability to function, severe hopelessness, major changes in sleep or appetite, self-neglect, suicidal thoughts, self-harm, psychosis, mania, or significant changes in behavior deserve prompt professional assessment.

If you are having thoughts of suicide or harming yourself, do not simply wait to see whether the symptoms improve on their own. Seek immediate professional or emergency support.

And please do not abruptly stop, reduce, or change prescribed psychiatric medications based on an article—or because you have decided that your symptoms must be caused by something else. Medication changes should be discussed with your treating clinician.

What I Want You to Bring to Our Sessions

This is why I appreciate when my patients come to an appointment and tell me the whole story, rather than simply saying:

“My depression is worse. Can we increase my medication?”

Tell me:

“I’m exhausted, but I’ve also been commuting two hours every day.”

“I haven’t been sleeping because my neighbors are keeping me awake.”

“My motivation disappeared after I was passed over for a promotion.”

“I’ve been feeling down since my friend became ill.”

“I’m sleeping ten hours and I’m still exhausted.”

“Nothing in my life changed, but suddenly I feel completely different.”

Those details matter.

They help us distinguish between psychiatric symptoms, normal human responses, environmental stress, medication effects, and possible medical conditions.

Psychiatric medication can be enormously helpful and, for some people, lifesaving. The point is not to be afraid of medication.

The point is to use it thoughtfully.

Your brain does not exist separately from your body, your relationships, your work, your environment, your sleep, your losses, or your life circumstances.

So when something changes in how you feel, don’t automatically ask only:

“Which medication do I need?”

First ask:

“What is my mind and body trying to tell me—and what else has changed in my life?”

Sometimes that question leads us to medication.

Sometimes it leads us somewhere completely different.

And good mental healthcare requires that we remain open to both possibilities.

⸻

Important Disclaimer

This article is for general educational purposes and is not a substitute for individualized medical or psychiatric evaluation. Do not start, stop, reduce, or increase psychiatric medication without discussing the change with your prescribing clinician. New or significant fatigue, mood changes, cognitive changes, anxiety, or other symptoms may warrant medical evaluation. If you are experiencing suicidal thoughts, thoughts of harming yourself or someone else, severe mania, psychosis, or another psychiatric emergency, seek immediate emergency assistance.

Selected References and Further Reading

The concepts discussed in this article are supported by a growing body of literature examining the relationship between physical health, immune function, nutritional deficiencies, endocrine disorders, and psychiatric symptoms. The following references are provided for patients and clinicians who would like to explore these subjects further.

Thyroid Disease and Psychiatric Symptoms

Prasad AJ. (1985). Manic presentation in Hashimoto’s thyroiditis. Clinical Notes On-Line, 1, 66.

This is the original case report subsequently associated with the term “Prasad’s Syndrome.” It described a manic presentation occurring in association with Hashimoto’s thyroiditis.

Weiner MJ, Kennedy C. (1988). Prasad’s syndrome. British Journal of Psychiatry, 152, 438–439. doi:10.1192/bjp.152.3.438b.

This correspondence specifically discusses Prasad’s earlier report and the relationship between thyroid disease and an apparent psychiatric presentation.

Samuels MH. (2014). Psychiatric and cognitive manifestations of hypothyroidism. Current Opinion in Endocrinology, Diabetes and Obesity, 21(5), 377–383. doi:10.1097/MED.0000000000000089.

This review discusses the effects of hypothyroidism on mood and cognition. Importantly, the evidence is considerably stronger for neuropsychiatric effects of overt hypothyroidism than for mild or subclinical thyroid abnormalities.

Bode H, et al. (2021). Association of hypothyroidism and clinical depression: A systematic review and meta-analysis. JAMA Psychiatry.

This large systematic review and meta-analysis included more than 348,000 participants and found an association between hypothyroidism and clinical depression. The association was stronger for overt hypothyroidism than for subclinical hypothyroidism.

Vitamin D and Depressive Symptoms

Anglin RES, Samaan Z, Walter SD, McDonald SD. (2013). Vitamin D deficiency and depression in adults: Systematic review and meta-analysis. British Journal of Psychiatry, 202, 100–107. doi:10.1192/bjp.bp.111.106666.

This systematic review and meta-analysis involving more than 31,000 participants found that lower vitamin D concentrations were associated with depression. The authors appropriately emphasized that an association does not by itself prove that vitamin D deficiency causes depression.

Vitamin D deficiency and depressive symptoms: Meta-analysis of studies. (2023).

This later meta-analysis similarly found an association between vitamin D deficiency and depression/depressive symptoms while emphasizing that the precise direction and mechanism of the relationship remain uncertain.

This distinction is important. Low vitamin D may contribute to symptoms in some patients, but finding a low vitamin D level does not mean that every depressive disorder is caused by vitamin D deficiency or that vitamin D should replace appropriate psychiatric treatment.

Vitamin B12 and Neuropsychiatric Symptoms

Sahu P, Thippeswamy H, Chaturvedi SK. (2022). Neuropsychiatric manifestations in vitamin B12 deficiency. Vitamins and Hormones, 119, 457–470. doi:10.1016/bs.vh.2022.01.001.

Vitamin B12 deficiency can have important neurological and psychiatric manifestations. Reported presentations include problems with concentration and cognition as well as depression, anxiety, delirium and, in some cases, psychotic symptoms.

This is another reason that a clinician evaluating new or unexplained psychiatric symptoms should remain attentive to possible medical contributors rather than assuming that every symptom necessarily represents worsening of a primary psychiatric disorder.

The Immune System, Fatigue, and “Sickness Behavior”

Dantzer R, Kelley KW. (2007). Twenty years of research on cytokine-induced sickness behavior. Brain, Behavior, and Immunity, 21(2), 153–160. doi:10.1016/j.bbi.2006.09.006.

This review describes the phenomenon known as sickness behavior. During immune activation, inflammatory signaling can affect the brain and contribute to fatigue, sleepiness, reduced appetite, decreased social activity, and other behavioral changes.

This is particularly relevant to our discussion because several of these symptoms overlap with symptoms clinicians evaluate when considering depression.

The important message is not that fatigue means your immune system is fighting an infection. Rather, it demonstrates how closely the immune system, nervous system, sleep, energy, and behavior are interconnected.

⸻

A Final Clinical Perspective

The research above illustrates the central message of this article:

A symptom is not a diagnosis.

Fatigue can occur with depression—but also with sleep deprivation, anemia, vitamin deficiencies, infection, inflammation, thyroid disease, medication effects, chronic stress, an exhausting commute, or simply an unsustainable lifestyle.

Poor concentration can occur with ADHD or depression—but it can also occur when someone is sleep deprived, physically ill, overwhelmed, burned out, grieving, or profoundly uninterested in what they are being asked to do.

Anxiety can be psychiatric—but physical illnesses, thyroid abnormalities, medications, stimulants, sleep deprivation, hormonal changes, and other medical conditions can also produce or intensify anxiety-like symptoms.

This does not mean that psychiatric diagnoses are somehow less real. Nor does it mean that laboratory testing will provide an explanation for every psychiatric symptom.

It means that good psychiatric care requires curiosity.

Before automatically adding another medication or increasing a dose, we should ask:

What changed?

What else is happening in this person’s body?

What is happening in this person’s life?

How are they sleeping?

What medications and substances are they taking?

What medical conditions should be considered?

Is this a psychiatric disorder, a medical condition, a normal response to difficult circumstances—or some combination of all three?

Sometimes, after considering all of these questions, the appropriate answer is still psychiatric medication.

And that is perfectly appropriate.

The goal is not to avoid medication.

The goal is to make sure we are treating the right problem.