What is anemia?
Anemia, most commonly caused3 by iron deficiency worldwide, is a condition when the body cannot effectively process oxygen, meaning your blood cells can’t carry4 enough of it to your body tissues. According to recent studies5, the overall prevalence of anemia in people aged 2 years and older is 9.3%, and is significantly higher in females than in males.
It is the result of several mechanisms that can break down:
- not enough healthy red blood cells (RBCs), which are the cells that deliver oxygen around the body;
- not enough hemoglobin, which is an iron-containing protein inside your RBCs that can actually grab onto oxygen;
- an RBC abnormality that makes RBCs unable to carry oxygen the way they are supposed to.
Types of anemia
There are several types of anemia that can result in major health issues such as (but not limited to) slowed development in children, chronic fatigue, low physical and work performance, or increased risk of infections.
Iron-deficiency anemia
Where due to low iron the body doesn’t get enough hemoglobin and the RBCs cannot bind oxygen correctly.
Vitamin B12 deficiency anemia
Where the DNA synthesis breaks down, which leads to RBCs growing too big and too fast (megaloblastic) or dying all together, thus the body doesn’t have enough good RBCs to carry oxygen.
Folate (vitamin B9) deficiency anemia
Which is similar to B12 deficiency, as folate is another essential element for DNA synthesis.
Anemia of Chronic Disease or Inflammation (ACD/ACI)
Where the body starts handling iron and RBC production differently due to inflammatory signals – not releasing iron from storage, reducing absorption.
Hemolytic & Aplastic anemia
Extremely rare conditions where the body either destroys RBCs or doesn’t make enough of them.
Common symptoms of anemia
Physical: | Mental: |
Weakness and fatigue | Brain fog |
Pale skin | Memory problems |
Headaches | Irritability |
Shortness of breath | Poor concentration |
Palpitations | Low motivation |
Dizziness | Low mood |
What is depression?
Depression (clinically known as Depressive Disorder) is a common mental health condition6 that affects how one feels, thinks, and moves through everyday life, and involves depressed mood and loss of pleasure or interest. It is so much more7 than just being unhappy or sad — it’s a complex condition that presents over a significant length of time and may be severe enough to dramatically impact one’s functioning.
Common symptoms of depression are:
- Persistent low mood, sadness, emptiness
- Loss of interest in what used to bring joy or pleasure
- Feeling hopeless, guilty, worthless
- Negative thinking, rumination
- Slowed thinking, difficulty concentrating and making decisions
- Reduced productivity
- Low energy, changes in sleep, appetite, and libido
- Social withdrawal
- Neglecting hygiene, cleaning, making food
Overlap With Anemia & Misdiagnosis
While clearly defined, the symptoms of depression may overlap with other disorders, including mental health disorders such as Anxiety Disorder, or personality disorders such as Borderline Personality Disorder8, as well as physical conditions. The overlap in symptoms between anemia and depression symptoms is in fact so drastic9, that there is a growing debate10 about the necessity of ruling out this alternative as a part of a differential diagnostic process.
A2019 study11 showed that 35% of women struggling with iron deficiency were misdiagnosed; in most cases with depression. The behavioral patterns check all the diagnostic boxes, and technically, if the boxes are checked — by definition, it’s depression! Only it’s more than depression. Anemia won’t be fixed with a SSRI, at least not long term, unless something else changes.
The Link Between Anemia & Depression
While different specialists would diagnose and treat anemia and depression, their clinical presentation is, in fact, so similar, that we are seeing a lot of research coming out from all around the world, including Japan12, China13, and Iran14, seeking to understand the link or correlation between the two.
For instance, the psychological components of depression like low mood, decreasing motivation, loss of happiness, and deteriorating cognitive function can also be attributed15 to the iron deficiency impairing the neurotransmitter synthesis. A meta-analysis supports16 the idea that low hemoglobin is associated with an increased risk of depression in adults. Even a single dose of IV ferritic carboxymaltose showed17 to improve fatigue, mental state, and cognitive scores in women with iron deficiency.
On the other hand, depressive symptoms are also linked18 to higher odds of anemia, especially in middle-aged and older adults, and antidepressants were also found19 to be working better in some cases when combined with iron supplements.
The main conclusion? Large scale research indicates20 that depression is significantly associated with anemia (supported21 by self-reports), and the link between anemia and depression is not only complex, but bidirectional. Although more longitudinal studies are needed.
Anemia Causing Depression or Depression Causing Anemia?
Iron-deficiency anemia may contribute22 to depressive symptoms by disrupting serotonin — a neurotransmitter involved in mood regulation. Mental and physical states degrade, leading23 to fatigue, low mood, headaches, reduced ability to deal with stress, decreased self-care, achievement, socialization. In someone who has at least some awareness about mental health, this can read as depression. Moreover, some studies suggest anemia can cause24 changes in the brain structure, increasing the risk to mental health.
The same can happen in the other direction. Someone struggling with depression is likely to make poor dietary choices, experience higher levels of stress, and lead an overall unhealthy lifestyle. These factors can result in poor nutrition and decreased iron consumption, decreased absorption, increased inflammation — all of which can put you at risk of developing anemia.
To say that anemia causes depression or vice versa should be an oversimplification, but based on the prevailing research the disorders do seem to be connected. More long-term studies are needed to analyze the connection and the possible implications for treatment.
The Biological Mechanism
No desire to move or socialize? Of course crawling into bed and watching Netflix seems like a better idea. When the body is low on oxygen, it is desperately rationing energy to prioritize the most essential functions. And while joy and dinner parties are optional, heartbeat isn’t.
Oxygen is essential for energy, because it’s directly involved25 in converting glucose into Adenosine Triphosphate (ATP) – the “fuel” your cells need for pretty much everything. Without ATP you would feel like every activity is unreasonably exhausting, because your muscles tire quickly and your heart and lungs must work even harder to compensate. This full-body exhaustion leads to decreased motivation, social withdrawal, and “energy saving” behaviour.
The brain is even worse. It consumes 20% of your oxygen26 and it cannot store energy, thus it needs a consistent fresh supply of oxygen. Without energy the neurons can’t fire correctly, leading to slower thinking, poor concentration, and mental fatigue.
Furthermore, the lack of oxygen prevents the correct synthesis and regulation of serotonin, dopamine, and noradrenaline. This throws a wrench in your mood stability, sleep, motivation, and focus.
Chronic inflammation increases hepcidin, which “locks27” the iron stores, and inflammatory cytokines, which trigger “sickness behaviour” — a downshifting of mood, activity, and drive.
Who Is At Risk?
While anyone can become anemic during their lifetime, there are certain groups that are especially prone28 to developing anemia. If you or your loved ones fall into one or more of these categories, it doesn’t mean you will automatically get anemia, but it does mean that you should pay attention to your body and take action if something feels off.
Women of reproductive age
Loss of blood through menstruation, changes in the way nutrients are distributed in the body during pregnancy, and the complexities of postpartum recovery make women uniquely susceptible to anemia.
Older adults
The rate of chronic disease tends to increase with age, leading to increased risk of ACD or ACI. Older adults also often have a less varied diet, decreased appetite, and dental issues, all of which can result in nutritional deficiencies.
Vegetarians & Vegans
Removing animal-derived products from the diet can lead to Vitamin B12 deficiency over time as internal stores become depleted.
People with chronic illnesses
Chronic illness often means chronic inflammation, which disrupts the proper absorption of iron and prevents the body from using its iron stores.
Athletes
Extraordinary performance requires extraordinary fuel. People who train hard should adjust their diets to account for lost micro-nutrients and higher dietary needs.
Restricted diets
Due to financial strain, lack of access (e.g. food deserts), and/or mental health conditions many people struggle to get enough of the right nutrients into their body.
People experiencing chronic stress
Poor mood can lead to less than ideal dietary choices and stress hormones signal to the body to block iron absorption while simultaneously trapping the available iron into storage.
Diagnosis: How to Tell If Anemia Is Affecting Your Mood
The first step is to pick up on the subtle differences between someone who is depressed and someone who is severely iron deficient, and to get people into the right treatment before their symptoms worsen or become irreversible. A correctly treated patient would be able to see improvements in their mood and general wellbeing rather than wait years for the right diagnosis.
Since iron-deficiency anemia is the most common, your doctor will likely start with an iron panel, along with a complete blood count (CBC). Next suspects are Vitamin B12 deficiency and inflammation. These are relatively less common, but still represent a significant portion of anemia cases. Folate deficiency is quite uncommon in countries with widespread folic acid (Vitamin B9) fortification29, so the decision to test or not will also depend on if there are enough grains, leafy greens and citrus fruits in your diet.
Some key blood tests your doctor might order:
- Hemoglobin (Hgb)
- Hematocrit (Hct)
- Ferritin
- Serum iron
- Transferritin
- Total Iron-Binding Capacity (TIBC)
- Vitamin B12
- Folate
- Mean Corpuscular Volume (MCV)
- C-Reactive protein (CRP)
- Erythrocyte Sedimentation Rate (ESR)
There is no formal recommendation to screen for iron deficiency when diagnosing depression, but it might be helpful to rule out all other possible causes of your particular symptoms, such as underlying deficiencies19 or inflammation. Furthermore, if a patient is working with a physician and a psychiatrist, these specialists should be fully aware of the diagnosis and treatments prescribed by the other to make sure no nuance is lost.
Treatment And Management Of Anemia
Depending on the exact cause treatment for anemia will be different and tailored to an individual’s clinical presentation.
Iron Supplementation or Infusions
It is recommended to take iron on an empty stomach and to combine it with Vitamin C for better absorption. Dairy (any calcium), coffee, tea (and matcha!), wine, high fiber foods, and antacids have the opposite effect. For the best results, you should wait at least 2 hours before eating foods that can block iron absorption.
Vitamin B12 Supplementation or Injections
For some patients a liquid form of the supplement works better as it can bypass some gastrointestinal pathologies that prevent absorption. If oral supplementation doesn’t seem to correct the deficiency, injection is the next best option.
Folate Supplementation
It is best taken on an empty stomach and doesn’t play well with alcohol, which impairs both the absorption and the metabolism of folate.
Treating the underlying cause of inflammation
In cases of ACD/ACI the treatment plan will focus on addressing the underlying disease and inflammation.
With the exception of folate deficiency that improves within a couple of months, treating anemia is a long game. Iron and B12 deficiencies can take 6+ months to be fully corrected, although the first improvements can be seen in a few weeks.
Treating anemia can meaningfully reduce19 the depressive symptoms associated with the underlying deficiency. However, the depressive symptoms can persist, at which point depression requires its own treatment and ongoing care.
Lifestyle Tips For Anemia Recovery & Mental Health
Our health is where small changes can add up in a major way. Sleeping better and eating spinach might seem insignificant when done once, but each step towards a healthier life compounds and builds a future you — full of energy, happy, more resilient.
Nutrition
- Iron-rich foods
Heme iron (better absorption): red meat, organ meats, poultry, fish, and seafood
Non-heme iron (worse absorption): legumes, tofu, leafy greens, nuts, seeds, dried fruit
Combine with Vitamin C
Don’t mix with dairy, calcium, coffee, tea, high-fiber foods, and antacids
Cook with an iron fish
- B12 sources
Animal foods: meat, fish, eggs, dairy
Exercise
- Gentle movement
Walking
Mobility
Yoga
- Progress slowly
Stop before exhaustion hits
Increase duration
Only increase intensity when labs improve
Sleep
- Consistent sleep/wake up time
- Natural light after waking up
- Sleep in a cool dark room
Stress management
- Mindfulness meditations
- Breathing exercises
- Emotional regulation (schedule rest, reduce overload, keep simple routines)
Daily habits
- Hydration
- Balanced meals
- Avoiding skipping meals
When to see a doctor
There is a line between feeling a little off and requiring immediate medical attention. For an average person this line can be blurry, that’s why it’s important to know the warning signs.
If you are experiencing these symptoms, seek immediate medical help:
Physical | Mental |
Severe fatigue | Suicidal thoughts |
Chest pain or shortness of breath | Self-hard behaviours |
Fainting | Severe hopelessness |
Rapid heartbeat | Severe functional shutdown |
Cognitive confusion | Psychotic symptoms |
Both anemia and depression are real medical conditions and should never be self-diagnosed. Please consult a physician if you suspect that you have iron-deficiency anemia that has led to depression symptoms before taking any steps towards treatment. Self-diagnosis and self-prescribed treatment (even supplements!) can cause significant harm.
Preventing recurrence
Once treated, anemia can return again, so it is essential to take preventative steps to protect your health.
- Regular blood work, including CBC, micronutrient panel, and iron panel. The focus area is iron, ferritin, and B12, but having a complete picture can prevent other deficiencies from creeping in.
- Adjust your diet, supplement regimen, and lifestyle to accommodate periods of high physiological demand (pregnancy, intense training, stress).
- Maintain a balanced diet that nourishes your body and optimizes absorption of essential nutrients.
- Stay consistent with your mental health care, especially stress management.
- Recognize the early warning signs and seek medical advice immediately. Trust that you know your body enough to know that something is off.
Conclusion
Anemia and depression are both real and treatable disorders. Both can be measured, diagnosed, and corrected through an optimized treatment plan.
While it does look like anemia can cause depression-like symptoms, it does not mean that all depression cases are caused by anemia or that all anemia patients will develop depression. A holistic approach to testing and treatment can help identify the factors at play and the next steps for a particular patient.
If you recognize yourself in the symptoms described, speak to your physician to discuss the appropriate testing and treatment plan. Getting the correct diagnosis and treatment can lead to significant improvements in mood and energy. The sooner the diagnosis is made, the sooner you can get on a path to feeling better.
