Thanks, Rip. I have not had a bad experience prescribing T because I don't prescribe it. I also haven't seen a patient have a bad outcome from TRT, although we know there are small but real risks with that treatment. I've had a few guys who stopped coming to see me after starting TRT. I have, however, seen more guys who came to me for depression after TRT was insufficient, even if it helped somewhat.
Testosterone is not a factor at all for the majority of my patients. That being said, it is possible that I am missing some low T or patients with T resistance that would benefit. If a patient has more prominent somatic/physical signs of depression: fatigue, sleep disturbance, loss of libido, and increased body fat/sarcopenia, and they are a middle-aged guy and I therefore suspect low T, I will suggest they discuss with their PCP or consider a urology visit or a "healthy aging clinic" (which is like a medical marijuana clinic but for testosterone) if they are really interested in T and their PCP is skeptical or resistant to testing. As a psychiatrist I don't prescribe or manage testosterone therapy. I have had a few patients do great with T and they don't need to come back to see me. Much more often, if they've already had bad enough depression to see me, they have partial benefit from TRT but still have residual depression. I have found that patients with depressive symptoms like continuous low mood, persistent and unrealistic negative thoughts, suicidal ideation, psychosis, etc. generally have Major Depressive Disorder and need psychiatric treatment. They may also need TRT, but that doesn't really do the trick by itself when you have the illness of depression.
I assume that there are lots of guys who see their PCP with low mood and other complaints, get put on T, and never have to come see the psychiatrist in the first place . In fact, most patients with depression don't see a psychiatrist ever, and we know that most SSRI prescriptions are written by PCPs. There are multiple ironies in this. Most of the patients managed for depression by PCPs have mild depression, which has much less benefit from SSRIs compared to severe depression. This means that many don't get much better, which leads to the public and PCPs themselves wondering why SSRIs are so overprescribed and useless, and blaming the psychiatry/big pharma nexus, and wondering if depression is really a thing that needs treatment at all. For the most part, the people who make it to the psychiatrist have bad enough symptoms that meds are useful. Currently, I work at an inpatient psych hospital, and see the most severely depressed patients, among other things. You will have to trust me that the vast majority of the depressed patients I see look markedly different from the guys who show up in your gym who have lost their mojo. If these folks somehow got it together to make it to your gym, you'd quickly see that they were too depressed to train properly and tell them to come back after getting their depression treated.
In other words, the fact that I don't refer for TRT very often is not because I think it doesn't work, but is more a function of the patient population who makes it in to see me. Think of it this way: most guys who have no history of depression and have never had mental illness, but now feel low and draggy know they're not "crazy" and they will resist a referral to psychiatry because they intuitively know that it's not mental illness. They may or may not be right, but they usually are, and most of them are more likely to go see a doc about TRT or come see you to get strong than they are to come see me. And if I'm honest, most people with mild depression don't need a psychiatrist nearly as much as they need a therapist, a good barbell coach, better work/life balance, and a good night's sleep.
OP, as far as I can tell, is one of the guys who should be in the psychiatrist's office (in addition to doing everything else too).
For the people who are reading this and thinking that depression is just a normal fluctuation of mood and not an illness, you're not entirely wrong, it's just that you are not seeing the depression that I am seeing. Sure, lots of people look for a pill not to treat an illness but to provide self-efficacy, and a good psychiatrist keeps their prescription pad in the desk, smiles, and sends them to psychotherapy. Just like when someone wants to get strong and healthy and asks you about "one weird trick," and you smile and hand them SS:BBT3. It's just that we have come to use the word "depression" to describe ennui or malaise in addition to using it to describe an illness that is a major cause of disability and suffering. It's like describing both a back tweak and a vertebral burst fracture as "back pain." Sort of correct, but really misses the mark, and it's not helpful to tell the spinal fracture patient "hey, everybody gets back pain, I had a bad back myself for a while. Try stretching." I was on a surgery rotation once, where one of the surgery residents was presenting a patient to the attending, and when asked about the patient's medical history said "just depression." The senior surgeon said "Just depression, huh? What do you think would be worse, a stroke that gave you weakness on the whole left side of your body, or a stroke that damaged your brain so that you lost the ability to enjoy anything at all?" Pretty much everybody agreed we would choose the hemiplegic stroke, except for one miserable bastard that already didn't enjoy anything (and who probably needed an SSRI). That's not a bad way to think about the illness of depression.
Ok, enough of my soapbox. Time to stop thinking about depression and go train or get some sleep.