Testosterone for depression?

[sunlioness]

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Anyone ever hear of using testosterone injections for depression? Got a patient here today who recently moved into the area and was being prescribed this by a previous psychiatrist. I told him I wasn't comfortable continuing the Rx and offered him a referral to endocrinology to evaluate his need for the injections. He declined and wanted a second opinion from a psychiatrist to continue the shots. He was also on twice the max dosage I've ever prescribed of a stimulant. Had a good bit of benzos on board too. He was asking for more stimulant and I told him I'd actually want to taper it, and well, he scheduled with someone else for that too. I was just wondering if anyone'd ever heard of the testosterone thing before.

 

[F0nzie]

Anyone ever hear of using testosterone injections for depression?

http://www.antiaginggroup.com/

Left column under "potential Testosterone benefits". *Ahem* "restore enthusiasm for life".

 

[vistaril]

Anyone ever hear of using testosterone injections for depression? Got a patient here today who recently moved into the area and was being prescribed this by a previous psychiatrist. I told him I wasn't comfortable continuing the Rx and offered him a referral to endocrinology to evaluate his need for the injections. He declined and wanted a second opinion from a psychiatrist to continue the shots. He was also on twice the max dosage I've ever prescribed of a stimulant. Had a good bit of benzos on board too. He was asking for more stimulant and I told him I'd actually want to taper it, and well, he scheduled with someone else for that too. I was just wondering if anyone'd ever heard of the testosterone thing before.

testosterone has no indications for a pt who does not have endocrine abnormalities......this is not something a psychiatrist needs to be managing or prescribing.

it just sounds like you and him arent a good fit in other ways though, so he should probably just go elsewhere

 

[billypilgrim37]

I'm sure you were about as heartbroken he wanted to seek care elsewhere as I imagine I would be.

 

[sunlioness]

http://www.antiaginggroup.com/

Left column under "potential Testosterone benefits". *Ahem* "restore enthusiasm for life".

Ah, well there you go then. 🙄

Yeah, I don't honestly think this patient will be a "good fit" for anyone in our group. But maybe when he stops looking around, someone can get him on some sort of right track.

I'm sure you were about as heartbroken he wanted to seek care elsewhere as I imagine I would be.

I'm still a little sniffly. 😉

 

[whopper]

http://journals.lww.com/psychopharm...cular_Testosterone_Supplementation_to.16.aspx

This study showed no significant effect of testosterone though the sample sizes were small.

 

[ghost dog]

Ah, well there you go then. 🙄

Yeah, I don't honestly think this patient will be a "good fit" for anyone in our group. But maybe when he stops looking around, someone can get him on some sort of right track.



I'm still a little sniffly. 😉

Perhaps "Doc420" is branching out into Psychiatry ? 😎

http://doc420.com/medical-marijuana-guide

 

[PikminOC]

Perhaps "Doc420" is branching out into Psychiatry ? 😎

http://doc420.com/medical-marijuana-guide

teehee

 

[DJspreadsheet]

I see no problem drawing testosterone levels in the appropriate populations and it's something I intend on doing. If it's low, give them testosterone. You don't need to be an endocrinologist to do that. I know many family docs do it, and from the patients I've talked to, they all describe an elevation in mood, less fatigue/lethargy.

We talk about finding medical causes for certain psych manifestations, well, you got one. Low testosterone men often-times come in with a dysthymic picture. Rather than throwing an SSRI at them, how about trying to correct the hormonal abnormality? We are doctors after all.

 

[BobA]

I see no problem drawing testosterone levels in the appropriate populations and it's something I intend on doing. If it's low, give them testosterone. You don't need to be an endocrinologist to do that. I know many family docs do it, and from the patients I've talked to, they all describe an elevation in mood, less fatigue/lethargy.

We talk about finding medical causes for certain psych manifestations, well, you got one. Low testosterone men often-times come in with a dysthymic picture. Rather than throwing an SSRI at them, how about trying to correct the hormonal abnormality? We are doctors after all.

While I like the idea of playing real doctor as much as the next guy, I don't think there's enough evidence about the risk/benefit ratio to know if it's a good idea for a psychiatrist to prescribe testosterone for mood. Complicating matters, this is a huge market for drug companies who will skew the evidence base with selective publication.

When you give someone testosterone for something like depression you may be committing them to a lifetime of taking testosterone supplementation. The exogenous testosterone suppresses endogenous testosterone production and leads to testicular atrophy and the natural ability to produce testosterone may not come back.

If they have hypogonadism they should see an endocrinologist who can make the call if the patient needs what could turn out to be a lifetime of taking a testosterone supplement.

 

[DJspreadsheet]

While I like the idea of playing real doctor as much as the next guy, I don't think there's enough evidence about the risk/benefit ratio to know if it's a good idea for a psychiatrist to prescribe testosterone for mood. Complicating matters, this is a huge market for drug companies who will skew the evidence base with selective publication.

When you give someone testosterone for something like depression you may be committing them to a lifetime of taking testosterone supplementation. The exogenous testosterone suppresses endogenous testosterone production and leads to testicular atrophy and the natural ability to produce testosterone may not come back.

If they have hypogonadism they should see an endocrinologist who can make the call if the patient needs what could turn out to be a lifetime of taking a testosterone supplement.

With regard to evidence and risk/benefit, I think we're comfortable as psychiatrists with nebulous data.

As far as endogenous suppression, I'm talking about treating the patients that are genuinely below reference-range. I'm not talking about hot-rodding up someone, just fixing their oil leak. If someone is 38 yrs old with test levels 50% below normal, I don't forsee a circumstance that they'd miraculously start making the juice on their own. They're gonna need supplementation.

 

[shan564]

I see no problem drawing testosterone levels in the appropriate populations and it's something I intend on doing. If it's low, give them testosterone. You don't need to be an endocrinologist to do that. I know many family docs do it, and from the patients I've talked to, they all describe an elevation in mood, less fatigue/lethargy.

We talk about finding medical causes for certain psych manifestations, well, you got one. Low testosterone men often-times come in with a dysthymic picture. Rather than throwing an SSRI at them, how about trying to correct the hormonal abnormality? We are doctors after all.

A couple of years ago, I was listening to a psychiatrist on the radio who was taking calls from people (I swear this wasn't Frasier). He was talking about depression, and at one point, somebody called in to say how bright-light therapy is the greatest thing in the world and how well it worked for her... and basically suggested that everybody should try it. The psychiatrist did a great job of explaining that this is only effective for SAD, and she responded with something like "oh yeah, come to think of it, that's what my psychiatrist told me too... and I did have SAD."

I think of testosterone as being something similar. As DJ said, it doesn't take an endocrinologist to see that testosterone supplements might help somebody who has low testosterone levels. But my concern is that it'd get blown out of proportion and there'll be news reports and fancy websites telling people that testosterone is known as a cure for depression (without the key qualification that it only works if you had low levels to start with). All of that madness would convolute our genuine medical advice.

I'm not saying that we shouldn't use testosterone if somebody needs it. Just that we should proceed with caution.

 

[st2205]

The attending on my endocrine rotation wanted to crucify the FP guys for prescribing testosterone to people who didn't really have hypogonadism. He especially seemed to emphasize too many people Basing their diagnosis off of a random testosterone level rather than an early am one.

 

[vistaril]

Anyone ever hear of using testosterone injections for depression? Got a patient here today who recently moved into the area and was being prescribed this by a previous psychiatrist. I told him I wasn't comfortable continuing the Rx and offered him a referral to endocrinology to evaluate his need for the injections. He declined and wanted a second opinion from a psychiatrist to continue the shots. He was also on twice the max dosage I've ever prescribed of a stimulant. Had a good bit of benzos on board too. He was asking for more stimulant and I told him I'd actually want to taper it, and well, he scheduled with someone else for that too. I was just wondering if anyone'd ever heard of the testosterone thing before.

I've had more than one patient transfer care to our clinic with the exact same regimen from psych: testosterone, klonopin, and adderall.

that combination is not uncommon unfortunately.

The last person I got like that I said I wasn't going to prescribe testosterone because I don't know anything about that. I told him I'd continue the stimulant. I think I tapered the benzo(maybe? or at least some?) and added an antidepressant at some point.

 

[shan564]

The attending on my endocrine rotation wanted to crucify the FP guys for prescribing testosterone to people who didn't really have hypogonadism. He especially seemed to emphasize too many people Basing their diagnosis off of a random testosterone level rather than an early am one.

Good point. Before we prescribe something that's outside our area of expertise, we should make sure that we know the right way to do it.

 

[vistaril]

I see no problem drawing testosterone levels in the appropriate populations and it's something I intend on doing. If it's low, give them testosterone. You don't need to be an endocrinologist to do that. I know many family docs do it, and from the patients I've talked to.

ummm....this is *not* justification for a psychiatrist doing this. Endocrinology is MUCH more under the scope of family medicine than it is psychiatry. Our scope and comfort level to treat these sort of things is *not* the same as a family medicine physician or general internist.

 

[DJspreadsheet]

ummm....this is *not* justification for a psychiatrist doing this. Endocrinology is MUCH more under the scope of family medicine than it is psychiatry. Our scope and comfort level to treat these sort of things is *not* the same as a family medicine physician or general internist.

I'm not convinced that testosterone supplementation is something whose pitfalls and hurdles can't be understood by a diligent psychiatrist.

 

[vistaril]

I'm not convinced that testosterone supplementation is something whose pitfalls and hurdles can't be understood by a diligent psychiatrist.

so(and I don't know the answer to this)-is there a workup for low T? I would guess there is more to it than just drawing a testosterone leveld and supplementing above a certain number. If there isn't, there doesn't seem much to endocrinology

 

[billypilgrim37]

Gotta agree with Vistaril here. That's simply outside our scope of practice. Whether we could do it or not is really beside the point.

 

[BobA]

The rush to prescribe testosterone to men, kinda brings back memories of prescribing estrogen to post-menopausal women. . . that didn't turn out too well.

Without good quality adequately powered, long-term RCT's I don't think we can say there's a good enough understanding of the risk/benefit ratio.

And this is outside our scope of practice (although I wish it weren't).

 

[birchswing]

I've dealt with this myself. Prescribing testosterone for low testosterone is not the slam-dunk idea it seems like. You could be dealing with a pituitary tumor, varicocele, XXY syndrome, side effects of medications, and more I don't know of.

I saw both a family doctor and endocrinologist and neither considered all these factors. I had to insist on testing that discovered my situation was much different than what the doctors had thought.

Also, one solution that does not reduce the body's endogenous testosterone production (as testosterone supplements do) is Clomid.

I was surprised that both my family doctor and endo tried putting me on testosterone without finding out what was really wrong. Starting testosterone is a huge decision that I think shouldn't be taken as lightly as it is, especially when there are simpler alternatives.

Edit: I was only 28 when I was to be put on it lifelong. Would have been a very bad decision, IMO.

 

[birchswing]

so(and I don't know the answer to this)-is there a workup for low T? I would guess there is more to it than just drawing a testosterone leveld and supplementing above a certain number. If there isn't, there doesn't seem much to endocrinology

I forget the names of the hormones, but rather than just testing for testosterone, there are tests that look at hormones the pituitary gland is releasing. It can send out signals that show it is demanding the testes produce more testosterone, which tends to indicate primary hypogonadism, and if it's not sending out that signal, it tends to indicate secondary hypogonadism. I'm sure there's more to it than that, but I dealt with this a couple of years ago, and that was one of the tests I ended up getting the endo to write for me. There's also doing a head MRI to look for a pituitary tumor if your pituitary gland isn't producing that hormone that causes the testes to produce testosterone.

 

[birchswing]

With regard to evidence and risk/benefit, I think we're comfortable as psychiatrists with nebulous data.

As far as endogenous suppression, I'm talking about treating the patients that are genuinely below reference-range. I'm not talking about hot-rodding up someone, just fixing their oil leak. If someone is 38 yrs old with test levels 50% below normal, I don't forsee a circumstance that they'd miraculously start making the juice on their own. They're gonna need supplementation.

Here's just one circumstance where microsurgery can help men make their own testosterone:
http://www.sciencedaily.com/releases/2011/06/110616142726.htm

This is why I double-check everything doctors recommend.

 

[OldPsychDoc]

....I'm not talking about hot-rodding up someone, just fixing their oil leak....

Best analogy ever.

 

[michaelrack]

Agree with birchswing and vistaril. A doctor shouldn't be treating male hypogonadism unless he is familiar with its workup (especially the evaluation for a pituitary/hypothalamic etiology) and treatment (monitoring for adverse effects of testosterone therapy). It's not rocket science and I guess a psychiatrist can learn how to do it, but prescribing testosterone is not part of a typical psychiatry practice.

By the way, a proper evaluation of hypogonadism involves a physical exam. I don't think many psychiatrists are going to feel comfortable examing a patient's genitals.

Throwing testosterone supplementation at low testosterone levels is as bad as throwing an SSRI at low mood- you really should do some type of evaluation and come up with a proper diagnosis first.

 

[DynamicDidactic]

A couple of years ago, I was listening to a psychiatrist on the radio who was taking calls from people (I swear this wasn't Frasier). He was talking about depression, and at one point, somebody called in to say how bright-light therapy is the greatest thing in the world and how well it worked for her... and basically suggested that everybody should try it. The psychiatrist did a great job of explaining that this is only effective for SAD, and she responded with something like "oh yeah, come to think of it, that's what my psychiatrist told me too... and I did have SAD."

the most commonly cited meta analysis Golden et al. (2005) , using the most rigorous RCTs, found a significant effect of bright light therapy (LT) for treating seasonal and nonseasonal depression.

Meta-analyses revealed that a significant reduction in depression symptom severity was associated with bright light treatment (eight studies, having an effect size of 0.84 and 95% confidence interval [CI] of 0.60 to 1.08) and dawn simulation in seasonal affective disorder (five studies; effect size=0.73, 95% CI=0.37 to 1.08) and with bright light treatment in nonseasonal depression (three studies; effect size=0.53, 95% CI=0.18 to 0.89).

a more detailed meta analysis of LT on nonseasonal depression only was conducted by Tuunainen, Kripke, & Endo (2004). The authors found a significant effect using a fixed-effects model but fell below the significance level when using a more conservative random-effects model.

There is very good empirical evidence that LT is very useful in treating nonseasonal depression. I know this was not the point of your post but I felt I needed to chime in with some accurate information.

 

[Soggun]

I don't think many psychiatrists are going to feel comfortable examing a patient's genitals.

I'm going to go out on a limb and say examining a patient's genitals also *may* be another thing that is outside the scope of our practice.

 

[SuperSoccer19]

I see no problem drawing testosterone levels in the appropriate populations and it's something I intend on doing.

What year medical student/pre-med are you in such that you needed to use a future tense?

 

[DJspreadsheet]

What year medical student/pre-med are you in such that you needed to use a future tense?

4th

 

[DebDynamite]

I have drawn T levels in patients that I intended to refer to their PCP. Specifically, these were guys who had a the habitus that often accompanies low T, trusted me and came to me more often, much, much more often, than their primary (one didn't even have a PCP). If you draw the lab, you have to document why and then what you did with the value. I am not sure I would draw a T level on someone who could not end up with endo. There are too many reasons that it could be low, that are outside the scope of our practice.

That said, I was on an addictions rotation with an addictionologist who drew testosterone levels frequently, and treated frequently. He was actually an internist. His rationale was that the population he treated needed every bit of help they could get, and to ignore a low T would be negligence on his part. He pointed out that individuals in recovery are having a hard enough time staying clean, and to supplement a low T would help with motivation. I certainly did not see him running algorithms as to why the T was low.

 

[BobA]

I have drawn T levels in patients that I intended to refer to their PCP. Specifically, these were guys who had a the habitus that often accompanies low T, trusted me and came to me more often, much, much more often, than their primary (one didn't even have a PCP). If you draw the lab, you have to document why and then what you did with the value. I am not sure I would draw a T level on someone who could not end up with endo. There are too many reasons that it could be low, that's just outside the scope of our practice.

That said, I was on an addictions rotation with an addictionologist who drew testosterone levels frequently, and treated frequently. He was actually an internist. His rationale was that the population he treated needed every bit of help they could get, and to ignore a low T would be negligence on his part. He pointed out that individuals in recovery are having a hard enough time staying clean, and to supplement a low T would help with motivation. I certainly did not see him running algorithms as to why the T was low.

I don't know what kind of addicts you were working with, but methadone will cause decreased testosterone levels.

I certainly know about people who see me much more frequently than their PCP (most of the vets I see at the VA)!

http://jcem.endojournals.org/content/90/1/203.full

 

[DebDynamite]

That's correct- opiate addicts who were also on and off methadone.

 

[vistaril]

I have drawn T levels in patients that I intended to refer to their PCP. Specifically, these were guys who had a the habitus that often accompanies low T, trusted me and came to me more often, much, much more often, than their primary (one didn't even have a PCP). If you draw the lab, you have to document why and then what you did with the value. I am not sure I would draw a T level on someone who could not end up with endo. There are too many reasons that it could be low, that are outside the scope of our practice.

That said, I was on an addictions rotation with an addictionologist who drew testosterone levels frequently, and treated frequently. He was actually an internist. His rationale was that the population he treated needed every bit of help they could get, and to ignore a low T would be negligence on his part. He pointed out that individuals in recovery are having a hard enough time staying clean, and to supplement a low T would help with motivation. I certainly did not see him running algorithms as to why the T was low.

thats a totally different situation because he is an internist....of course he is qualified to treat low T, and nobody would argue he isn't.