Is exhaustion the beginning of depression?

I have struggled with depression in the past. I have been feeling tired at times lately, and have noticed that when I am very tired, old depressive thoughts can start creeping in… which got me to wondering… could exhaustion be the beginning of depression?

According to Beyond Blue reports, depression is becoming an increasing problem in medicine, and indeed society. The extent may be underestimated in doctors, hidden by ignoring signs, self-medicating with alcohol or other drugs, or failing to seek help, for fear of stigmatisation and the risk of having our right to practice revoked.

Is depression the new normal, in reaction to an increasingly challenging world?

Or is there something simple underlying at least some of it, that we can perhaps look at and deal with?

Could fatigue and exhaustion be an underlying cause of depression?

I woke up this morning feeling exhausted, overwhelmed, and down. I was reactive, teary, and just did not have the energy to get ready to go and do something that I had been very much looking forward to. I tried to convince myself, make myself, jolly myself out of it, had several cups of herbal tea, but I just could not do it. So my husband went out without me. I dissolved in a flood of tears, laid down, closed my eyes, and woke up an hour later, feeling lovely.

Now I am not for a minute trying to detract from the seriousness of major depression, which is a debilitating and life-threatening disease that needs to be treated with the utmost care. But I am wondering if some of the milder, more reactive forms of sadness that many of us suffer from at some time in our lives, could have simple tiredness as their underlying cause.

The practice of medicine can be exhausting. Not only is it physically challenging, in terms of the hours required to study, train for and practise the profession, but it is mentally and emotionally challenging. We have to make split-second, sometimes life-and-death decisions every few minutes, for hours and hours every day. And we are confronted with the full range of human suffering and misery, as a ‘normal’ part of our every working day.

This is not always easy to deal with. No heart can – or should – be hardened to cope with this onslaught. Yet we are not trained how to deal with it and still stay open and loving with people and life. Ironically, when we try and shut down to protect ourselves from being hurt, this opens us up to being physically and emotionally drained by the energies that come at us during our day.

Could our constant exposure to distress be a cause of depression?

I found out yesterday that one of my longstanding patients had died. He was a particular favourite of mine, not that we should have those, but we are human, after all. He was a lovely old man and he always hugged me as he left and told me that he loved me. Last time I saw him he said that he had been diagnosed with cancer and that he may not get to see me again. I got a particularly warm hug that day. Yesterday my staff told me that he had died. They found out when they called to confirm his upcoming appointment, and I was so busy that I did not even have time to stop and feel that.

This morning as I was crying I saw his face before me, and I wondered how many other times I had suppressed grief from such moments, which came out later, perhaps in odd ways like me being impatient with my children, or stayed and festered in my body, without my even being aware of it.

Sleep on it

I did not get enough sleep last night, but in general I do. I notice that when I am tired, I am more prone to take stuff on at work, to take things personally, to react, to be affected by bad behaviours and emotions running high. When I feel rested I am able to rise above all this. I wonder how many of us are like this… we just get really tired and can no longer cope with all that is going on.

There are old sayings like: “Sleep on it” and “Everything will look better in the morning” that suggest we know there is a truth to this. We as doctors are often chronically sleep deprived, particularly in the early years when we are working long hours, doing lots of on call and are trying to study for fellowship exams as well. It is so important that when we start to wobble, we do what we can to take care of ourselves, rather than taking ourselves out with destructive habits like drinking in reaction to how we are feeling, which makes life even harder.

The solution to work stress is not to go out and get smashed, but simply to go home and get some rest when you can. And if you cannot sleep, because you are so exhausted and wired, consider developing a wind-down rhythm in your day.

You need energy to sleep

One of the great frustrations and ironies of being exhausted is that it makes it difficult to go to sleep. We actually need energy to sleep, and if we are exhausted and running on adrenaline and caffeine and nervous energy all day, the body keeps going and cannot shut down just because we now say it is time to sleep.

It is important to try and build a wind-down routine into the rhythm of your day, so that you are not running at 100 miles an hour all day and then expecting to come to a dead stop at bedtime and fall asleep in five minutes!

• Look at what you are eating and drinking before bedtime, especially anything with caffeine in it (this includes chocolate!).
• Consider eating lightly in the evenings, or at least early, so your food has time to digest.
• Alcohol may seem like a good idea, and it may even knock you out in the short term if you drink enough of it, but it is full of sugar, which is a stimulant, and it is also a diuretic, and blocks REM sleep, so you tend to need to get up at night for a pee and find it difficult to get back to sleep.
• Try not to take work home – it rarely gets done anyway and just makes you feel more miserable – if you must do it, do it the next morning when you are fresh.
• Spend the evenings winding down mentally too… don’t watch anything too stimulating on TV, or get too caught up in social media too late.

Timing is everything

The hours of sleep between 9 pm and 1 am are those which refresh, restore and rejuvenate us the most.

If you are pushed for time, and overwhelmed by how much work you have to do, consider going to bed early and getting up early. You will need less sleep, it will be of a better quality, and you will wake feeling refreshed and much more able to do the work that is needed of you.

Depression is a serious illness

It does not come ‘out of the blue’.

Taking simple steps to care for ourselves and to make sure we get as much rest as we can, and at the time of the night which is most effective in caring for us, will help us to stay healthy and happy. And if we feel ourselves starting to slide into the blues, working on this rhythm can support us.

If you start to feel that things are a little out of control and you need support, here are some resources to help you.

We are not designed to do this alone. Help is available. Please ask for it.

Resources

1. Suicide call back service 24/7 Helpline   1300 659 467
2. Lifeline 13 11 14
3. Doctor’s Health Advisory Service 02 9437 6552
4. Beyond Blue 1300 22 4636
5. https://www.beyondblue.org.au/get-support/national-help-lines-and-websites