Depression or Low Testosterone? How to Tell Them Apart

Many men rarely say "I'm depressed." Instead they come in saying "I have no energy", "I don't feel like doing anything" or "my sex life has disappeared". Some look things up themselves, conclude it's male menopause and want to top up their hormones and be done with it. I understand, because saying your hormones have dropped sounds easier than admitting your mind is struggling. But these two conditions are treated differently, so telling them apart really matters.

What are these two conditions?

Major depressive disorder (MDD), by DSM-5-TR criteria, means low mood or loss of interest in things you used to enjoy, most of the day, nearly every day, for at least 2 weeks, together with other symptoms such as disturbed sleep or appetite, tiredness, feeling worthless, poor concentration or thoughts of death.

Testosterone deficiency means having symptoms together with a genuinely low testosterone level on repeated morning blood tests. The main symptoms are usually sexual, along with tiring easily and low mood. Read the details in Symptoms of low testosterone.

Overlapping symptoms, and the clues that help

This table helps paint a picture, but in real life many men have both. The TRAVERSE trial, which studied more than 5,000 men with low testosterone, found that about half had significant depressive symptoms, and more than 1 in 10 met the criteria for major depression.

Leans toward depression

• Deep sadness, hopelessness, worthlessness
• No pleasure in anything
• Little interest in sex because of no interest in anything
• May think about death

Leans toward low testosterone

• Flat, irritable, burnt out more than sad
• Can still enjoy some things but lacks energy
• Clearly lower desire and morning erections
• Less muscle, more belly fat

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Many men have both. If you have thoughts of self-harm, call 1323 (mental-health hotline) or 1669 (emergency).

New evidence: how much do hormones help mood?

Older information online often says "for some men, just adjusting hormones restores their vitality", which is only partly true. A sub-analysis of TRAVERSE published in 2024 concluded:

• In men with genuinely low testosterone and low mood, testosterone slightly improved mood and energy compared with placebo.
• In men with true major depression (MDD), testosterone did not significantly improve depressive symptoms.
• The researchers recommended screening every man with low testosterone for depression, and stressed that testosterone is not a primary treatment for depression.

In plain terms: if you have depression, you need treatment for depression. Hormones may help as an add-on if your level is genuinely low, but one cannot replace the other.

Which tests help tell them apart

1. A conversation and mood assessment using screening tools such as 2Q and 9Q (Thailand's standard depression screening questions) or the PHQ-9, including an assessment of suicide risk.
2. A morning total testosterone test between 7 and 10 a.m. while fasting, repeated if low, with LH, FSH and SHBG as appropriate.
3. Tests for conditions that cause tiredness and low mood, such as thyroid disease, anaemia, diabetes and sleep apnoea.
4. A review of medicines and substances, such as alcohol, sleeping pills and opioid painkillers.
5. A discussion of stress, work, relationships and sleep.

How treatment differs

• Depression: psychotherapy such as cognitive behavioural therapy (CBT), antidepressants as assessed by a doctor, exercise, sleep and looking after relationships. If you worry that antidepressants will affect your sex life, this can be managed. Read Antidepressants and sex.
• Low testosterone: start by fixing what can be fixed, such as weight, sleep and medicines. If levels are still low and you have symptoms, TRT may be considered, with a safety monitoring plan.
• Both: treat them together, without using hormones in place of depression treatment.

My warning is this: don't start antidepressants or hormones on your own from reading online. Both have side effects and need someone to monitor them.

Depression

• Psychotherapy, e.g. CBT
• Antidepressants as assessed by your doctor
• Exercise, sleep

Low testosterone

• Fix reversible causes first
• Consider TRT if still low with symptoms

Both

• Treat together
• Hormones do not replace depression treatment

TRAVERSE (2024): testosterone did not significantly help clinical major depressive disorder (MDD).

Your relationship is part of the picture too

When a man loses his sex drive, his partner often thinks "he doesn't love me any more", while he feels ashamed and withdraws. This cycle makes both mood and sex worse. Inviting your partner to talk together helps a lot. The article Common couple problems and how to talk them through has practical example phrases.

When to see a doctor, and how the clinic can help

See a doctor when tiredness, boredom or lack of sex drive has lasted more than 2 weeks and is affecting your work or relationship, and get help immediately if you have thoughts of harming yourself (1323, 1669).

At Dr. Kris Clinic I am a family physician who looks after sexual health, so I can assess mood, hormones and relationships in a single visit, arrange blood tests at the right time, and refer you to a psychiatrist when needed. You can consult at the clinic in Surat Thani or online, and consultations in English are available. If you would rather start by talking to a clinical sexologist, read When to see a clinical sexologist.