Rick is a 52-year-old who hasn't felt like himself in the past few months. Whereas Rick used to wake up energized and enjoy making daily goals, he now struggles to get out of bed. Rick's wife has noticed he now tosses and turns during the night, which she thinks has contributed to his mood swings. Rick hasn't initiated sex in two months, which is unusual for him. When Rick sits down to work, he has trouble concentrating, feels anxious, and feels like he would rather be napping. In addition, Rick has skipped his weekly golf days and keeps canceling social dates with friends. Rick is sick of feeling like this and makes an appointment to see his doctor. Rick has symptoms that include:
- Mood swings
- Decreased libido
- Lack of motivation
- Social withdrawal
- Difficulty focusing
- Interrupted sleep and restlessness
Rick's symptoms are common to both depression and low testosterone. When we say someone is depressed, we describe someone as having low energy and no desire to participate in activities that once brought pleasure. These are also symptoms of low testosterone. Therefore, it is essential to rule out physical causes, such as hypogonadism, before treating depression. Especially since common antidepressant medications can cause or worsen sexual complaints.
It is not by accident that studies have documented reduced testosterone concentrations in men with depression and that depressive disorders are one possible cause of hypogonadism. According to research, low testosterone may cause depressed mood in at least a subset of men with hypogonadism. Conversely, men with hypogonadism often have symptoms that include depressed mood, anxiety, insomnia, and poor memory–symptoms that, if not severe, may improve with testosterone replacement therapy (TRT).
Since the brain is full of testosterone receptors, lower than normal testosterone levels have and impact. When you have lower-than-normal testosterone levels, these receptors are, quite literally, left high and dry, which can lead to mood swings, irritability, stress, anxiety, and depression.
If you have low sex drive, fatigue, memory impairment, insomnia, and decreased energy, you could have undiagnosed depression or hypogonadism. Determining whether you have depression or hypogonadism is not always cut and dry.
Symptoms of low testosterone include:
- Decreased libido
- Weight gain
- Difficulty concentrating
- Hot flashes
- Loss of lean muscle mass
Symptoms of depression include:
- Lack of interest in pleasurable activities, such as sex
- Weight loss or weight gain
- Irritability or difficulty concentrating
- Loss of appetite
- Difficulty sleeping
- Sadness or hopelessness
- Suicidal thoughts
Hypogonadism is a Common Disorder as Men Age
By some estimates, about 40% of men >45 years old have hypogonadism. Hypogonadism in men is a chronic medical disorder that occurs when the body does not produce enough testosterone.
Male hypogonadism is associated with specific symptoms that include low libido, erectile dysfunction, diminished frequency of morning erections, and orgasmic disorders. Depressive symptoms occur in 35 to 50% of male patients with hypogonadism. Non-specific manifestations of low testosterone include fatigue, cognitive impairment, and depressed mood.
In addition, some commonly used antidepressant medications can cause or worsen sexual complaints. In men with hypogonadism, mild depressive symptoms may respond to testosterone replacement therapy (TRT). However, severe depressive symptoms do not respond to TRT.
Testosterone plays a vital role for men in maintaining a balanced mood, behavior, self-perception, and quality of life.
Decreased testosterone concentrations in late-onset hypogonadism result in symptoms such as dysphoria (a profound sense of dissatisfaction with life), low vigor (strength, energy, or enthusiasm), vitality, irritability, lack of assertiveness and depression are more likely to be present than in men with healthy testosterone levels.
Patients with hypogonadism often experience feelings of isolation, shame, and alienation. Individuals with hypogonadism often experience incorrect or delays in diagnosis, difficulty finding knowledgeable clinicians, and improper treatment. These experiences often lead to the erosion of the patient's confidence in clinicians and may affect quality of life. Psychotherapy is usually indicated to help patients cope with frustrations over-diagnosis and treatment.
Health psychologists can help patients contend with hypogonadism by educating them about physical and mental health effects. In addition, mental health professionals can aid patients in dealing with the psychological effects often present with hypogonadism.
A significant social stigma is still associated with hypogonadism, making finding appropriate care difficult. Patients may worry that others will question their gender or sexual identity if their condition is revealed. In addition, hypogonadal patients with fertility issues may fear being judged negatively. Since hypogonadism affects mood, patients often have to deal with the double stigma of having a mental health condition and a disorder linked to sexual characteristics.
Depression Can Mimic Hypogonadism in Men
About 4% of the adult male population worldwide suffers from depression. Men with depression have, on average, lower levels of testosterone. Depressive disorders include loss of interest or pleasure in most activities and symptoms of low energy, impaired ability to concentrate or make decisions, weight loss or gain, insomnia or hypersomnia, and sexual dysfunction. Low testosterone in aging males is associated with features of fatigue and depression. Further, 63% of men with a major depressive disorder report a sexual dysfunction, manifesting with decreased libido, erectile dysfunction, and orgasmic disorder. Hence, depression is a comorbid illness that can lead to potentially reversible functional hypogonadism.
Symptoms of depression are present in 35–50% of males with hypogonadism. Conversely, sexual dysfunction can be observed in 63% of men with major depressive disorder, manifesting as decreased libido (40%), erectile dysfunction (32%), and orgasmic disorder (35%). The severity of depression is significantly associated with free testosterone and dihydrotestosterone levels.
Testosterone Therapy Can Improve Mental Health in Hypogonadal Men
A meta-analysis showed that testosterone treatment reduces depressive symptoms in men with hypogonadism, particularly when higher-dosage regimens were applied in carefully selected samples.
Androgen deprivation therapy has been a frequently enacted treatment for prostate cancer over the years. A study of over 100,000 men assessed traits related to mental health and compared those receiving androgen deprivation with a placebo group without cancer. Results showed that in men receiving androgen deprivation, depression, anxiety, malaise, fatigue, and memory difficulties were common and came to be known as androgen deprivation syndrome. This landmark study was instrumental in pinning down symptoms resulting from testosterone deficiency.
Quality of Life and Mood
Hypogonadism can negatively affect quality of life and mood. A large meta-analysis of 23 studies involving 3090 hypogonadal men revealed that treatment with TRT significantly improved the quality of life in hypogonadal men. The improvement in quality of life was not seen to the same degree in men who had symptoms of depression.
Another meta-analysis of 16 studies and 944 subjects looked at the effect of TRT on the overall mood of patients with hypogonadism. Results showed a significant improvement in mood in hypogonadal men who received TRT compared with men who did not receive TRT.
While hypogonadism can negatively affect mood and quality of life, TRT is a means to improve these parameters.
Testosterone is a neuroactive steroid that influences mood and initiation of behavior that increases the likelihood of satisfying a need. Testosterone increases the release of serotonin, which is a central mechanism of anti-depression.
One study of 33 hypogonadal men with mild-moderate depression showed that testosterone gel had a significant reduction of depression and a higher remission rate of subthreshold depression. A more extensive study of 788 older men with hypogonadism had significantly improved depressive symptoms on TRT than placebo.
A meta-analysis that involved 11 studies and 852 participants showed that compared with a placebo, TRT significantly improved depression. Finally, a recent meta-analysis that contained 27 studies and 1890 hypogonadal men revealed TRT significantly reduced depressive symptoms compared with placebo.
Lower testosterone concentrations are correlated with unfocused anxiety. In a study of 3413 hypogonadal men, free testosterone concentration was inversely associated with anxiety. In another study of 2042 male patients with sexual dysfunction, researchers established a correlation between testosterone and free-floating and phobic anxiety.
According to a study, testosterone appears to reduce anxiety. Four channels of anxiolysis have been proposed by which testosterone might reduce anxiety: threat vigilance, reward processing, general fear reduction, and stress resilience.
Testosterone Delivery Considerations
Injectable testosterone delivers a high dose, which can result in initial supratherapeutic testosterone levels following injection. Testosterone levels decline until their lowest, just before the next injection. The large fluctuations in serum testosterone after an injection are not ideal and can result in mood swings or changes in libido. While all injections have testosterone level peaks and valleys, formulations given less frequently at higher doses have the most significant potential to produce unwanted mood swings. Other testosterone modalities, such as oral capsules or topical gels, may be preferred in hypogonadal patients with mental health concerns.
Low testosterone can lead to several changes in your physical and emotional life. Physical manifestations such as decreased libido, erectile dysfunction, and orgasm disorders often get the most attention. However, men with low testosterone commonly have depression, anxiety, irritability, and other mood changes. Testosterone therapy is a treatment option that helps restore normal testosterone levels and treats symptoms of hypogonadism, which often includes psychiatric symptoms. The more common forms of available testosterone therapy are oral capsules, injections, patches, and topical gels.