Low testosterone or depression? How to tell the difference

There's been a surge in interest in men's mental health in recent years, and all for good reason, because we want our fellow men to speak up. But as awareness grows, so does the misdiagnosis. Many non-specialist physicians are quick to diagnose depression without a deeper investigation into the biochemical roots of distress. 

It's a longstanding issue

Historically, mental health frameworks have predominantly been developed through research on women,¹ leading to a skewed understanding when these same models are applied to men. This research shows that women often exhibit internalising disorders like depression and anxiety, whereas men are more likely to show externalising symptoms, such as substance abuse and aggression. These differences are deeply influenced by both biological distinctions and the societal expectations embedded within traditional gender roles.

One significant but frequently overlooked cause is testosterone deficiency (TD),² which can mimic or exacerbate depressive symptoms. This oversight points to a broader issue within the healthcare system, a tendency to treat symptoms rather than underlying causes, particularly in men’s health. As society becomes more attuned to the nuances of mental wellbeing, we're beginning to uncover significant gaps in how mental health issues are diagnosed and treated across genders. It may be high time to refine diagnostic approaches to better reflect and address the unique ways in which men experience psychological distress.

Testosterone and depression

Testosterone has long been recognised as central to male sexual health, but its role in mental health, particularly depression, is gaining attention. Both high and low levels of testosterone have been linked to increased risks among men.²

Studies also differentiate how testosterone levels affect various types of depression. Men with atypical depression, characterised by symptoms like overeating and oversleeping, tend to have lower levels of free testosterone, the type that's not bound and is bioactive in the body.³ On the other hand, men suffering from melancholic depression, marked by persistent sadness and a loss of pleasure, don't always exhibit this pattern.³ There's also evidence that high testosterone levels might be just as problematic, which is one of the reasons why consistent clinical monitoring is essential when on testosterone treatment.⁴

Getting the diagnosis right

It's easy to mistake the symptoms of low testosterone for other mental health issues like depression, anxiety, or ADHD. Most people, including many doctors, might not immediately think of testing for hormonal imbalances when faced with these symptoms. This oversight means patients often start on treatments for mental health conditions without much success, because the real culprit - hormonal imbalance - goes unchecked. The consequences? At best, no improvement; at worst, an aggravation of symptoms due to inappropriate medication.

There’s a real need for a more thorough diagnostic process. Imagine how different the treatment could be with a simple blood test for testosterone levels at the outset. These tests can redirect the treatment plan towards hormone therapy rather than standard psychiatric treatments, potentially saving a lot of time, distress, and ineffective medication trials.

General practitioners have been shown to not use standardised psychiatric instruments to diagnose depression, meaning that at least some diagnoses, around 50%, may be inaccurate. Worth noting that this particular study looked at Australian GPs rather than UK practice.⁵ That leaves some men untreated and still struggling, and others taking antidepressants they may not need, with the side effects that come with them.⁵ Antidepressants, particularly SSRIs, are a go-to solution in the UK, but their interaction with sex hormones can complicate things, affecting everything from sexual function to overall behaviour.⁶

The numan take

Low mood, low energy, and low libido show up in both conditions, which is exactly why testing before treating matters. One important caveat: if you're already taking an antidepressant, keep taking it. Nothing here is a reason to stop, and stopping suddenly can make things worse. Speak to your GP or our clinical team first, and if you're struggling right now, your GP or NHS 111 can help you find support quickly.

References

^{1 Smith DT, Mouzon DM, Elliott M. Reviewing the assumptions about men’s mental health: An exploration of the gender binary. Am J Mens Health [Internet]. 2018 [cited 2024 Aug 20];12(1):78–89. Available from: http://dx.doi.org/10.1177/1557988316630953}

^{2 Määttänen I, Gluschkoff K, Komulainen K, Airaksinen J, Savelieva K, García-Velázquez R, et al. Testosterone and specific symptoms of depression: Evidence from NHANES 2011–2016. Compr Psychoneuroendocrinol [Internet]. 2021 [cited 2024 Aug 20];6(100044):100044. Available from: http://dx.doi.org/10.1016/j.cpnec.2021.100044}

^{3 Smeeth DM, Dima D, Jones L, Jones I, Craddock N, Owen MJ, et al. Polygenic risk for circulating reproductive hormone levels and their influence on hippocampal volume and depression susceptibility. Psychoneuroendocrinology [Internet]. 2019 [cited 2024 Aug 20];106:284–92. Available from: https://pubmed.ncbi.nlm.nih.gov/31039525/}

^{4 Johnson JM, Nachtigall LB, Stern TA. The effect of testosterone levels on mood in men: A review. Psychosomatics [Internet]. 2013;54(6):509–14. Available from: http://dx.doi.org/10.1016/j.psym.2013.06.018}

^{5 Carey M, Jones K, Meadows G, Sanson-Fisher R, D’Este C, Inder K, et al. Accuracy of general practitioner unassisted detection of depression. Aust N Z J Psychiatry [Internet]. 2014 [cited 2024 Aug 20];48(6):571–8. Available from: http://dx.doi.org/10.1177/0004867413520047}

^{6 Pavlidi P, Kokras N, Dalla C. Antidepressants’ effects on testosterone and estrogens: What do we know? Eur J Pharmacol [Internet]. 2021;899(173998):173998. Available from: http://dx.doi.org/10.1016/j.ejphar.2021.173998}