Hypothyroidism depression with

A number of medical conditions are associated with high rates of depression (see Table 3.4). In some instances, the distinction between MDD and depression due to a general medical condition is largely academic with little bearing on treatment selection. For example, pancreatic cancer may induce depression directly through the release of tumor-secreted substances however, depression in the pancreatic cancer patient is treated with conventional antidepressant medications. In other cases, the diagnostic distinction bears important treatment implications. One commonly cited example is depression occurring in association with hypothyroidism. Patients with depression and hypothyroidism do not respond to antidepressant treatment alone but require a thyroid hormone supplement. 

The addition of liothyronine 25 micrograms daily was found to increase the speed and efficacy of imipramine in relieving depression. Similar results have been described in other studies with desipramine or amitriptyline but the reasons are not understood. One possible explanation is that the patients had overt or subclinical hypothyroidism, which after correction with liothyronine allowed them to overcome an impaired response to tricyclic antidepressants." However, adverse reactions have also been seen. A patient being treated for both hypothyroidism and depression with thyroid 60 mg and imipramine 150 mg daily complained of dizziness and nausea. She was found to have developed paroxysmal atrial tachycardia. A 10-year-old girl with congenital hypothyroidism, well controlled on desiccated thyroid 150 mg daily, developed severe thyrotoxicosis after taking imipramine 25 mg daily for 5 months for enuresis. The problem disappeared when the imipramine was withdrawn. In another patient the effect of levothyroxine was lost and hypothyroidism developed when dosulepin was started. ... 

Treatment of Manic—Depressive Illness. Siace the 1960s, lithium carbonate [10377-37-4] and other lithium salts have represented the standard treatment of mild-to-moderate manic-depressive disorders (175). It is effective ia about 60—80% of all acute manic episodes within one to three weeks of adrninistration. Lithium ions can reduce the frequency of manic or depressive episodes ia bipolar patients providing a mood-stabilising effect. Patients ate maintained on low, stabilising doses of lithium salts indefinitely as a prophylaxis. However, the therapeutic iadex is low, thus requiring monitoring of semm concentration. Adverse effects iaclude tremor, diarrhea, problems with eyes (adaptation to darkness), hypothyroidism, and cardiac problems (bradycardia—tachycardia syndrome). 

The symptoms of hypothyroidism maybe confused with symptoms associated with aging, such as depression, cold intolerance, weight gain, confusion, or unsteady gait. The presence of these symptoms should be thoroughly evaluated and documented in the preadministration assessment and periodically throughout therapy. 

The adult brain is endowed with nuclear as well as cytosolic and membrane T3 receptors that have been visualized by autoradiography and studied biochemically [30-33]. Both neurons and neuropil are labeled by [ 1251]T3, and the labeling is selective across brain regions. Functionally, one of the most prominent features of neural action of thyroid hormone in adulthood is subsensitivity to norepinephrine as a result of a hypothyroid state [27], These changes may be reflections of loss of dendritic spines in at least some neurons of the adultbrain. Clinically, thyroid hormone deficiency increases the probability of depressive illness, whereas thyroid excess increases the probability of mania (Ch. 52) in susceptible individuals [27],... 

Causes of psychogenic ED include malaise, reactive depression or performance anxiety, sedation, Alzheimer s disease, hypothyroidism, and mental disorders. Patients with psychogenic ED generally have a higher response rate to interventions than patients with organic ED. 

Quigley s group in Cork, Ireland, have concluded that normal aging is associated with changes in motility but the pattern is varied and no clear clinical consequence can be identified (67). More important in their view are the pathophysiological influences, including depression (and treatment with anti-cholinergics and opiates), hypothyroidism, and chronic renal failure. 

Thyroid Hormone (Thyroxine, Synthroid). The most common use of thyroxine in bipolar patients is the treatment of lithium-induced hypothyroidism. Approximately 5% of patients receiving long-term lithium treatment ultimately develop hypothyroidism. When this occurs, the patient with bipolar disorder may present with symptoms of a depressive episode. Therefore, periodic thyroid axis monitoring, that is, a serum thyroid stimulating hormone (TSH) test, is required for all patients taking lithium and should always be performed when the bipolar patient experiences a depressive episode. 

The next step in the management of the depressed bipolar patient is to evaluate thyroid function. This is especially important for patients treated with lithium in order to rule out lithium-induced hypothyroidism. When this occurs, the addition of thyroid hormone replacement may relieve the depressive symptoms without any additional changes to the bipolar treatment regimen. 

Use with caution in the foiiowing Elderly or debilitated severe impairment of hepatic, pulmonary or renal function myxedema or hypothyroidism adrenal cortical insufficiency CNS depression or coma toxic psychoses prostatic hypertrophy or urethral stricture acute alcoholism delirium tremens or kyphoscoliosis. Naloxone may not be effective in reversing respiratory depression. 

A common mistake is to treat bipolar depression in the same manner that one treats unipolar depression, overlooking the need for a mood stabilizer. In bipolar depression, the first pharmacological intervention should be to start or optimize treatment with a mood stabilizer rather than to start administering an antidepressant medication. In addition, thyroid function should be evaluated, particularly if the patient is taking lithium. Subclinical hypothyroidism, manifested as an increased thyroid-stimulating hormone level and normal triiodothyronine and thyroxine levels, may present as depression in affectively predisposed individuals. In such cases, the addition of thyroid hormones may be beneficial, even if there is no other evidence of hypothyroidism. 

Thyroid deficiency (hypothroidism) has been connected to cretinism and myxedema. Cretinism occurs when hypothyroid children are born intellectually handicapped, are small, and have coarse hair and thick skin. Myxedema, seen in older hypothyroid people, is characterized by subcutaneous semifluid deposits, causing puffiness of the hands and face. The basal metabolism of these patients is depressed to 30 0% below normal, and their body temperature and pulse rate are also reduced. Women suffering from hypothyroidism may give birth to children afflicted with cretinism. 

A normal response is an increase in plasma TSH of 5 to 15 pU/mL above baseline. A response of less than 5 pU/mL above baseline is generally considered to be blunted (some laboratories consider a response below 7 pU/mL to be blunted) and may be consistent with a major depression. An abnormal test is found in approximately 25% of patients with depression. A blunted TSH response (especially in conjunction with an abnormal DST) may help in confirming the differential diagnosis of a major depressive episode and support continued antidepressant treatment. An increased baseline TSH or an augmented TSH response (higher than 30 pU/mL), in conjunction with other thyroid indices, might identify patients with hypothyroidism, mimicking a depressive disorder. These patients may benefit most from thyroid replacement therapy. 

Depression as an emotion is common and usually short-lived. As a symptom it can occur in most psychiatric disorders as well as other medical conditions, e.g. hypothyroidism, Parkinson s disease. As an illness, major depressive disorder (MDD), it is less common but, nevertheless, moderate to severe forms affect 5-10% of people in their lifetime and milder forms 20-30%. After a first episode, prophylaxis is required for at least 6 months and ideally 12 months to prevent relapse. This should usually be with the dose of antidepressant to which the patient initially responded. Those with recurrent episodes require prophylaxis over many years. 

Thyroid dysregulation has also been reported in depressed patients. Up to 25% of depressed patients are reported to have abnormal thyroid function. These include a blunting of response of thyrotropin to thyrotropin-releasing hormone, and elevations in circulating thyroxine during depressed states. Clinical hypothyroidism often presents with depressive symptoms, which resolve with thyroid hormone supplementation. Thyroid hormones are also commonly used in... 

Since thyroid illness is commonly associated with depression, especially in women, it has long been observed that treating the thyroid abnormalities also can reverse the depression. This is especially true for treating hypothyroidism with thyroid hormone replacement (either T3 or T4). It has even been observed that giving supplemental thyroid hormone to depressed patients unresponsive to first-line antidepressants but without overt hypothyroidism can boost the antidepressant response of the first-line antidepressant (thyroid combo in Fig. 7—30). Thyroid hormone is also commonly administered to bipolar patients resistant to mood stabilizers, particularly those with rapid cycling (see discussion of combinations for bipolar disorders below). 

As with all forms of long-term therapy, adherence to the prescribed dosage of levothyroxine is not always optimal, and an unwarranted fear of thyroid-induced osteoporosis can add to this lack of adherence. Inadequacy of thyroxine replacement therapy is not always easily recognized. Several patients were reported with clearly inadequate or excessive consumption of levothyroxine despite a correct prescription. All patients had depression, which could be an additional susceptibility factor by promoting lack of adherence, and the resulting hypothyroidism or hyperthyroidism could further aggravate the depression (12). 

In a review of lithium-induced subclinical hypothyroidism (TSH over 5 mU/1, free thyroxine normal), a prevalence of up to 23% in lithium patients was contrasted with up to 10% in the general population. It was stressed that subclinical hypothyroidism from any cause can be associated with subtle neuropsychiatric symptoms, such as depression, impaired memory and concentration, and mental slowing and lethargy, as well as with other somatic symptoms. Management guidelines were discussed (628). 

Q2 In addition to poor memory, factors which suggest a diagnosis of hypothyroidism include cold intolerance, cold extremities, slowed reflexes, low resting heart rate, slow thought processes, depression and sleepiness/lack of energy, appetite suppression associated with weight gain and raised blood lipids, which may lead to increased atherosclerosis. 

The adverse effects of lithium in elderly patients include cognitive status worsening, tremor, and hypothyroidism. The authors suggested that divalproex is also useful in elderly patients with mania and that concentrations of divalproex in the elderly are similar to those useful for the treatment of mania in younger patients. They noted that carbamazepine should be considered a second-line treatment for mania in the elderly. A partial response would warrant the addition of an atypical antipsychotic drug. For bipolar depression, they recommended lithium in combination with an antidepressant, such as an SSRI. They also noted that lamotrigine may be useful for bipolar depression. Electroconvulsive therapy (ECT) may also be useful, but there have been no comparisons of ECT and pharmacotherapy in elderly patients with bipolar depression. 

No patients with depression had clinical hypothyroidism and the sole patient with overt hypothyroidism had no depressive symptoms. 

Thyroid hormones are frequently affected by lithium, but rarely in a clinically significant way. Changes in certain laboratory tests of thyroid function are common but seldom require discontinuation of treatment. However, approximately 5 percent of patients develop hypothyroidism, which some clinicians elect to treat with thyroid supplementation while continuing lithium (Weber, Saklad, and Kastenhol 1992). Periodic thyroid function monitoring is important, not only from a safety standpoint but to rule out (in the bipolar individual with depressed or mixed-state features), that hypothyroidism is not the cause of symptoms. 

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