Let's talk about thyroid

[firedoor]

Please share your thoughts and experiences regarding the use of thyroid hormone in treating depression . Is it underutilized?

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[nitemagi]

How about you share your thoughts first?

 

[whopper]

I haven't given it out yet to treat depression. There is data supporting it's use for antidepressant augmentation, but given there's plenty of choices, I usually go with buspirone or Lamictal first because they're cheap, and low maintenance (no labs), and not known to cause side effects such as weight gain.

 

[firedoor]

How about you share your thoughts first?

What is this, truth or dare?

I've attempted to augment using thyroid with a few patients but insurance would not cover T3 (but would cover Synthroid) and those patients were ultimately noncompliant.

At level 3 of STAR*D I believe that T3 outperformed and was better tolerated than lithium augmentation (similiar to Wellbutrin SR vs Buspar at level 2, respectively).

Stahl postulates that "thyroid hormones have many complex cellular actions, including actions that may boost trimonoaminergic neurotransmitters as downstream consequences of thyroid's known abilities to regulate neuronal organization, arborization, and synapse formation".

Dr. Frederick Goodwin is a proponent of using thyroid hormone in bipolar depression (I believe he uses Synthroid?).

I'd imagine that thyroid is less utilized at least partly due to the fact that, as Whopper stated, there are effective and easier to use agents such as lamictal and buspar. Nonetheless, given its relative safety, I would surmise that thyroid augmentation might have an important place in our armamentarium (e.g. before an MAOI or augmentation with an atypical). And given T3's (albeit modest) performance in STAR*D, I'm curious if thyroid hormone is perhaps worthy of more attention in psychiatry.

 

[Majesty]

What makes you think thyroid hormone supplementation is so safe?

 

[firedoor]

What makes you think thyroid hormone supplementation is so safe?

Knowledge.

 

[Encephalopathy]

There's a large body of data that's pretty clear that T3 augmentation is safe and effective. We're talking about a natural hormone here and we're just pushing free T3 levels to the upper limit of normal (or slightly above).

I like to augment with Cytomel if the TSH is >4, especially if the depression is accompanied by hypothyroid symptoms, i.e. fat, fatigued, constipated, hair falling out, etc. I've found it especially effective for pts who have a normal TSH and free T4 but a low free T3.

I start with 25 mcg and when that is tolerated bump it up to 50 mcg. I have had a couple pt's develop mild anxiety and tremor at 50, which resolves after decreasing to 37.5.

Synthroid can also work but has a longer time to steady state and also negatively feeds back to the pituitary, whereas T3 does not for whatever reason. Also, I believe there are some patients who may have some type of enzymatic conversion problem from T4 to T3 (hence pts with only a low FT3 as mentioned above) and in this population giving Synthroid wouldn't make sense. Plus, all the psychiatric research is using Cytomel.

I've found the biggest problem with using thyroid augmentation is trying to explain what you're doing to the patient's PMD. But I think as physicians we should not be intimidated from using effective evidence based treatments for our patients just because they may be perceived as the purview of other specialties. Psychiatric symptoms are frequently the initial presentation of endocrine disorders.

 

[Real Psychiatry]

Nice thread...thank you Firedoor.

There are small studies indicating that T3 augmentation is associated with normalizing the brain's bioenergetic metabolism which is decreased in depressed patients. However there appears to be reponders and non responders to this effect.

I found that my biggest barrier to trying to start T3 augmentation was cost. I also found that some psychiatrists were leary of starting thyroid but seemed more ready to augment with Lithium (even though T3 has a better risk/benefit ratio). Is this because Lithium is more familiar in the armamentarium of the psychiatrist? Choosing a medication based on familiarity or its close cousin "comfort zones" can definitely come in the way of evidence based practice

 

[Encephalopathy]

I'm surprised cost and insurance companies have been a problem for those trying to prescribe T3. Liothyronine is generic and per Epocrates costs ~$1.75 for a 50 mcg tab.

Compare that to Lexapro at $3.66 for 10 mg or Abilify 5 mg for $17.

 

[Daimon Michiko Doctor X]

Honestly it is from personal experience depression also involves generalized aches and pains which I later found out it would do to hypercalcaemia. Then the weight gain/loss which is also part of the parathyroid hormone out of wack.

 

[SeniorWrangler]

I find it very helpful, but 50mcg is a really big dose. Seriously, 50mcg of T3 is a therapeutic dose for hypothyroidism in some patients, and it's going to suppress the thyroid significantly. If you do that, you need to taper it off, just stop abruptly. Also, some patients will get jittery since T3 is immediately active but has a fairly short duration of effect.
EDIT: Should say "don't just stop abruptly"

 

[PistolPete]

Interesting discussion. I've never used Cytomel, nor ever seen it prescribed. So, assuming baseline TSH is normal, I can prescribe 25 or 50mcg with confidence and just monitor TSH levels every few months?

 

[Merovinge]

Interesting discussion. I've never used Cytomel, nor ever seen it prescribed. So, assuming baseline TSH is normal, I can prescribe 25 or 50mcg with confidence and just monitor TSH levels every few months?

Agreed, I only saw it done once in all of residency and have worked with some pretty seasoned and cowboy type prescribers. Certainly saw a lot more TCAs and MAOIs than T3

 

[milesed]

Tried it a few times when in training and saw no improvement. I did see improvement when adding Ritalin.

 

[Salpingo]

No one really seems to talk about it, but I've worked with people who would give up their right foot before they gave up their Synthroid (or even consider lowering it). Weight loss, laxative, energy booster, all in one.

 

[clausewitz2]

No one really seems to talk about it, but I've worked with people who would give up their right foot before they gave up their Synthroid (or even consider lowering it). Weight loss, laxative, energy booster, all in one.

I have also seen people get crushingly depressed when switched from a T3/T4 blend to Synthroid alone. Granted, mostly people who needed total thyroid hormone replacement on account of not having a thyroid anymore, but it does make me inclined to try Cytomel where appropriate when I get a bit further along in training.