Why am I tired all the time? An Australian GP's workup for chronic fatigue

What “tired all the time” actually means

In Australian general practice, “TATT” — tired all the time — is one of the most common presenting complaints in adult general practice. Up to one in four general practice visits include fatigue as a feature, and around 5–7% have fatigue as the main reason for visiting.

The clinical question is not “is tiredness real” — it almost always is — but what pattern of tiredness, with what other features, in what context. Acute fatigue after a viral illness or a few rough weeks at work is different from a slow erosion of energy over six months. Daytime sleepiness — falling asleep watching television or driving — points toward a sleep disorder. Effort fatigue — being wiped out by minor exertion — points toward a cardiovascular, respiratory, or metabolic cause. Cognitive fatigue with a flat mood points toward depression or burnout.

The Royal Australian College of General Practitioners’ tiredness resource and Therapeutic Guidelines both recommend a structured history before any bloods are taken. That is genuinely where most diagnoses are made.

A. Core clinical — what the GP is actually looking for

A thorough first appointment for persistent fatigue covers seven domains. None of these are skippable.

• Sleep. How long, how broken, snoring, witnessed apnoeas, restless legs, shift work, bedtime screen exposure, caffeine after noon. Obstructive sleep apnoea is under-diagnosed in Australia, particularly in women.
• Mood and stress. Validated screening with the PHQ-9 for depression and GAD-7 for anxiety. Depression presents as fatigue more often than as low mood, especially in men.
• Diet, iron load, and menstruation. Heavy menstrual bleeding is the leading cause of iron deficiency in adult women in Australia. Vegetarian or vegan eating patterns require active attention to iron and B12. NPS MedicineWise covers AU-tier iron deficiency assessment.
• Medications and substances. Beta-blockers, opioids, antihistamines, mirtazapine, benzodiazepines, gabapentinoids, and some antidepressants all cause fatigue. So can alcohol, cannabis, and high daily caffeine that masks accumulated sleep debt. Cross-check with the Australian Medicines Handbook.
• Recent infections. Post-viral fatigue after Epstein–Barr, influenza, COVID-19, or other respiratory viruses can persist for weeks to months. A subset develop ME/CFS — see the NICE NG206 guideline for the current case definition.
• Weight, breathlessness, swelling. Cardiac failure, anaemia, and chronic kidney disease can present as fatigue alone in early stages.
• Endocrine pattern. Cold intolerance, dry skin, constipation, hair thinning, and weight change point to thyroid disease. Polyuria, thirst, and weight loss point to diabetes.

Red flags that change urgency: unintentional weight loss, drenching night sweats, fever, palpable lymph nodes, painless lumps, breathlessness on minor exertion, bleeding (rectal, urinary, vaginal outside expected menses), or new neurological symptoms. Any of these warrants prompt rather than routine investigation.

The first-round Australian general practice panel typically includes a full blood examination and film, ferritin and iron studies, thyroid stimulating hormone, vitamin B12 and folate, vitamin D, fasting glucose or HbA1c, urea and electrolytes, liver function tests, C-reactive protein, and a coeliac serology (tissue transglutaminase IgA with total IgA) if the diet and bowel history fit. A targeted urinalysis is added if there are urinary symptoms. Iron studies are mandatory if anaemia or heavy periods are present — haemoglobin alone misses iron-deficiency without anaemia, which is enough to cause real fatigue.

B. Evidence appraisal and controversies

The biggest controversies in the fatigue workup are about what not to do.

Routine extended panels. Adding vitamin B6, B1, magnesium, zinc, cortisol, or comprehensive hormone panels to a first-round workup has no demonstrated benefit and produces a large number of incidental abnormalities that lead to further unnecessary testing. Australian general practice reviews consistently recommend a targeted panel based on history.

Salivary cortisol and “adrenal fatigue”. “Adrenal fatigue” is not a recognised medical condition in mainstream endocrinology. The Endocrine Society of Australia and its international counterparts hold that the term is not supported by evidence and the salivary-cortisol patterns sold as proof are non-specific. Genuine adrenal insufficiency (Addison’s disease, secondary adrenal insufficiency) is a serious diagnosis made through morning cortisol, ACTH stimulation testing, and specialist evaluation — not the same entity, and it is managed by an endocrinologist.

The food-intolerance panel. IgG food-intolerance panels are marketed widely. The Australasian Society of Clinical Immunology and Allergy advises against them. IgG to food antigens reflects exposure, not pathology, and acting on the results produces unnecessary dietary restriction. Coeliac disease is the food-related cause of fatigue worth ruling out, with serology and biopsy where appropriate.

Chronic Lyme in Australia. The Department of Health position is that there is no evidence of locally acquired Lyme disease in Australia, and prolonged antibiotic treatment for fatigue attributed to chronic Lyme is not supported. Where a tick-borne illness is suspected after overseas travel, the workup goes through infectious diseases, not direct consumer testing.

Methylation, mitochondrial supplements, intravenous nutrient drips. These are marketed for chronic fatigue but the evidence base in non-deficient adults is weak. Iron, B12, and vitamin D should be replaced when deficient — that is a real, trial-supported intervention. Routine high-dose supplementation in people whose levels are already normal does not improve fatigue in randomised studies.

The honest picture: the boring first-round workup catches most of the high-yield diagnoses. Where it does not, the next step is revisiting the history, not widening the panel.

C. Australian operations — what the visit actually looks like

A focused fatigue workup in Australian general practice usually takes:

• One long consultation (Medicare item 36 or 44) for history, examination, mood screening, and ordering bloods.
• A short follow-up consultation (item 23) once results are back, to interpret them and agree on a plan.
• A GP Management Plan (item 721) if a chronic condition is identified — particularly type 2 diabetes, sleep apnoea, or depression — to access subsidised allied-health visits.

(MBS / PBS items verified 2026-05-15 via WebSearch — workspace egress to mbsonline.gov.au + pbs.gov.au still blocked; spot-check confirms current.)

Routine fatigue bloods are bulk-billed pathology under Medicare for Schedule 4 indications. Vitamin D testing is restricted to specific clinical indications under MBS item 66833 — routine screening in asymptomatic adults is not reimbursed. Iron studies, thyroid function, and HbA1c are funded in the presence of clinical indication.

If sleep apnoea is suspected, the AU pathway is now a home sleep study (MBS item 12250) ordered by a GP after eligibility screening; lab-based polysomnography (item 12203) is for complex cases via a sleep physician. CPAP is funded through state programs in Victoria (VAEP) and Queensland (MASS) for eligible patients, and otherwise privately purchased; the Sleep Health Foundation has current pathway resources.

For depression or anxiety identified during the workup, a Mental Health Treatment Plan (items 2715 or 2717) unlocks ten subsidised psychology sessions per calendar year.

D. Integrative considerations

Where lifestyle factors are clearly contributing, several non-pharmacological interventions have moderate evidence in unselected adults with persistent fatigue.

Intervention	Evidence on fatigue	Quality of evidence
Improving sleep regularity, dark bedroom, no caffeine after noon, no screens 60 min before sleep (Sleep Health Foundation)	Substantial in deconditioned adults	Moderate (consistent across trials)
Graded exercise for fatigue without an active medical cause	Moderate improvement in unselected adults	Moderate (NICE guidance is more cautious in ME/CFS)
Mediterranean-pattern eating with adequate protein and iron	Modest improvement, larger if correcting deficiency	Moderate
Mindfulness-based stress reduction (8-week programme)	Small to moderate improvement in fatigue scales	Moderate
Cognitive behavioural therapy for insomnia (CBT-I) when sleep is the limiting factor	Substantial improvement	Strong
Vitamin B12 supplementation when deficient	Substantial in deficient adults	Strong
Vitamin B12 supplementation when level is normal	No reliable effect	Weak
Iron supplementation when ferritin is low	Substantial	Strong
Iron supplementation when ferritin is normal	No reliable effect, possible harm	Weak
High-dose multivitamin or “energy” supplements in non-deficient adults	No reliable effect	Weak
Acupuncture for chronic fatigue	Inconsistent	Weak

The integrative version of this conversation does not replace the workup — it sequences after it. The order that matches the AU evidence: sleep first, mood second, then diet and movement, then targeted supplementation only when a deficiency exists.

Where post-viral fatigue or suspected ME/CFS is the picture, the NICE NG206 guideline emphasises an individualised, energy-management approach (the original “graded exercise” recommendation has been revised). Australian practice is broadly aligned, and a referral to a chronic-fatigue-experienced specialist or rehabilitation physician is appropriate.

When to call sooner rather than later

Book a non-routine appointment, or use a GP-after-hours service, if fatigue is accompanied by any of:

• Unintentional weight loss over a few weeks
• Drenching night sweats or unexplained fever
• New lumps in the neck, armpit, or groin
• Blood in stool, urine, or coughed up
• Sudden breathlessness, chest pain, or palpitations
• A change in bowel habit lasting more than three weeks in an adult over 50
• New numbness, weakness, double vision, or trouble speaking

Sudden severe headache, chest pain, sudden weakness, or loss of consciousness needs an ambulance — call 000.

What this article is and is not

This is general health information drawn from current Australian general practice guidelines, supplemented by international references where AU resources are silent or older. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about which tests to order, how to interpret results, and what treatment to start are made with your own GP, who knows your history and can examine you.

For Australian consumer-friendly summaries covering the same ground: HealthDirect and Better Health Channel.

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Sources cited

1. RACGP — Red Book (Guidelines for preventive activities in general practice), 10th ed.
2. RACGP — Tiredness clinical resource (Australian Family Physician)
3. Therapeutic Guidelines (eTG)
4. Australian Medicines Handbook
5. NPS MedicineWise — Iron deficiency
6. HealthDirect — Tiredness and fatigue
7. Better Health Channel — Fatigue causes
8. Sleep Health Foundation — Obstructive Sleep Apnoea
9. Endocrine Society of Australia
10. Endocrine Society — clinical practice guidelines
11. ASCIA — IgG food-intolerance testing position
12. Department of Health — Lyme disease in Australia
13. Coeliac Australia — clinician guidance
14. Medicare Benefits Schedule (MBS)
15. Better Access Initiative — Mental Health Treatment Plans
16. Nicholson et al. — Fatigue in adults systematic review (BMJ Open 2018)
17. Stadje et al. — diagnostic spectrum of fatigue in primary care (Br J Gen Pract 2016)
18. NICE NG206 — ME/CFS diagnosis and management