Anxiety & Mood
Apathy: when nothing motivates you
Apathy is a loss of motivation, not laziness. How it differs from depression, what the common causes are and what helps.
In psychiatry, apathy is a loss of motivation: you do less, fewer things interest you and you feel less than before. It is not laziness or a matter of character. It can come with depression, with physical or neurological conditions or with some medicines. Treatment starts from the cause, and often from small, planned steps.
What is apathy?
The word has other meanings too, such as calm indifference. Here we mean apathy as a symptom.
In 2018 an international expert group defined apathy as a reduction in goal-directed activity compared with the person’s own previous level. To speak of apathy, it must:
last at least four weeks,
show in at least two of three areas: behaviour and thinking, emotion, social interaction,
make daily life harder,
not be fully explained by another reason, such as a substance or a major change in life.
In everyday language it sounds like “I don’t feel like doing anything”, “nothing matters to me”, “I can’t get anything started”.
Apathy or depression?
They often occur together, but they are not the same:
In depression there is usually sadness, guilt, pessimism and thoughts of being worthless.
In apathy there is mainly a lack of motivation and a neutral feeling, not necessarily pain.
The distinction has a basis. In a study of 154 patients with neurological conditions (such as Alzheimer’s and Parkinson’s disease), apathy was not related to depression. The researchers concluded that it is a separate condition and that the distinction matters for treatment.
In the assessment I make a simple distinction: “I feel low”, or “I’m not sad, I just can’t get started”? The first points more towards depression. The second may be apathy, but in a young person with difficulties since school it may also be ADHD.
What are the common causes?
Depression and dysthymia. Loss of interest is a core symptom of depression.
Neurological conditions. Apathy is common in conditions of the brain, such as Parkinson’s disease, dementia and stroke.
Physical causes. If needed, the doctor checks with blood tests, for example the thyroid.
Medicines. Apathy has been described in people taking antidepressants of the SSRI class. A 2020 review notes that the link is seen in clinical practice, but better studies are needed. If you take such a medicine and feel “numb”, discuss it with your doctor. Do not stop it on your own.
When I find a physical cause, such as a thyroid disorder, we treat it first. It can mimic depression and make it worse.
Apathy in older age
In an analysis of 16 studies with 7,365 older people without dementia, most with mild cognitive difficulties, those with apathy had about twice the risk of developing dementia in the following years. This does not mean that all apathy is dementia. It means that new apathy at an older age deserves a medical assessment.
What helps
Treating the cause. If there is depression, the depression is treated. If there is a physical or neurological cause, that is addressed. If it seems linked to a medicine, the doctor considers whether a change is needed.
Behavioural activation. This is a simple form of psychotherapy: you record your activities and your mood, and you gradually schedule more pleasant or useful activities. In an analysis of 16 randomised studies with 780 people with depression, it had a large benefit, similar to cognitive therapy, and the benefit remained at follow-up. These studies measured depression, not apathy specifically.
Action comes before mood. If you wait for the will to “arrive”, you may wait a long time. Inactivity reduces the things that give you joy and lowers mood even further. That is why we start from one small, specific step a day, and measure progress in steps, not in motivation.
A few practical steps:
a fixed time for going to bed and waking up
a morning activity outside the home, even a short walk
one meeting a week with someone you enjoy being with
a list of small tasks, from which you choose one a day
Medication, if needed, depends on the cause and is decided with your doctor. Treatment is changed or stopped only together with them.
When to ask for help
The lack of motivation has lasted for weeks and affects your work, studies or relationships.
It comes with low mood, insomnia or hopelessness.
It appeared after a new medicine, a head injury or an illness.
In an older relative, the apathy is new or comes with forgetfulness.
Safety: If apathy appeared suddenly, together with confusion, weakness in one arm, difficulty speaking or a very severe headache, call 166 (ambulance, EKAV) or 112 immediately. If you have thoughts of harming yourself, call 166, 112 or the Suicide Prevention Line 1018.
How I can help
Book a psychiatric assessment, at the practice in Trikala or online. See the page on depression treatment and the article Dysthymia. The first conversation can also take place from your home: see how working with an online psychiatrist works, or book an appointment.
This article is educational and does not replace individual clinical assessment. Do not change or stop any treatment you are already taking without talking to your doctor.
Sources
Robert P, et al. Is it time to revise the diagnostic criteria for apathy in brain disorders? The 2018 international consensus group. Eur Psychiatry. 2018. https://doi.org/10.1016/j.eurpsy.2018.07.008
Marin RS. Apathy: a neuropsychiatric syndrome. J Neuropsychiatry Clin Neurosci. 1991. https://doi.org/10.1176/jnp.3.3.243
Levy ML, et al. Apathy is not depression. J Neuropsychiatry Clin Neurosci. 1998. https://doi.org/10.1176/jnp.10.3.314
van Dalen JW, et al. Association of Apathy With Risk of Incident Dementia: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2018. https://doi.org/10.1001/jamapsychiatry.2018.1877
Petrova NN, Markin AV. Apathy syndrome in depressed patients previously treated with selective serotonin reuptake inhibitors (in Russian, English abstract). Zh Nevrol Psikhiatr Im S S Korsakova. 2020. https://doi.org/10.17116/jnevro2020120011111
Cuijpers P, van Straten A, Warmerdam L. Behavioral activation treatments of depression: a meta-analysis. Clin Psychol Rev. 2007. https://doi.org/10.1016/j.cpr.2006.11.001
