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Q: Doc' Says Thyroid is Within the Normal Range
Your web site triggered my SO to have a thyroid test done to see if his symptoms
of lack of energy, tired, etc, were related to his thyroid. He is 50 years old,
been treated for bipolar for over 20 years. Very compliant with meds of which he
takes, lithium, tegretol, pomolar, zoloft and zyprexa! Whew! His
doctor recently added wellbutrin to this mix and this medication dosage was also
confirmed by another doctor who he sought out for a second opinion. His
test results were: TSH 2.376, T4 4.9, T3 uptake 32, and thyroxine indes 1.5.
I compared these to your case results and It looks like he could use some
thyroid medication. His doctor dismissed the results and said all was within
normal range. Should he challenge him, based on his results or forget about it?
I appreciate hearing your opinion. Thank you and also for this wonderful
web site and your work.
Sincerely,
Dear Ms. K' --
Thanks for the supportive comments. In this case, though, is there enough
data on thyroid approaches to support trying thyroid as a mood stabilizer?
Well, as you read, there is the data from Bauer and Whybrow using T4 alone as a
mood stabilizer, so that's clearly already established in the literature as a
mood stabilizer option, although it's very rarely used (e.g. have I ever seen
someone come into my practice, or the hospital where I work, who was on high
dose T4 as per these researchers' work? -- nope, not once, and I've seen a whole
lot of other approaches come through!) So although there is a precedent in
the literature for high dose T4, there really isn't in terms of common clinical
practice.
Okay, that said, now we come to T3/T4 thyroid as a mood
stabilizer. I hope you were seeing in what I've written that this approach
is even less tested, and perhaps on that basis less common (although
since the T4 approach above is already at a denominator of zero, I can't say how
much less common!)
So, the point is that both of these approaches are
probably so rarely used, especially mine, that they're going to sound very
foreign to most practicing psychiatrists (again, especially mine). Since
your SO's results are not very strikingly near the outer limits of the
"normal range", this too understandably damps any likelihood that a
practicing psychiatrist will look at the numbers and be moved to add thyroid
hormone.
Now, what do you do from there? Well, if the
regimen your SO was on was a little more conventional, I'd urge caution in
"challenging" the doc' with this thyroid stuff. But since his
regimen is unusual also, given that there are three antidepressants in
there (Pamelor (I presume, from pomolar); Zoloft; and now Wellbutrin), some
further comment may be warranted. Since bipolar disorder is clearly known
to be exacerbated by antidepressants; and since the debate in psychiatry is
whether to keep any antidepressants going, if things are going well
-- as opposed to adding a 3rd when things are not going well, presumably, based
on the addition of the new antidepressant -- .... I think it's fair to
wonder out loud a little bit, and perhaps while wondering, wonder about some
approaches that might be equally uncommon but theoretically as warranted for
consideration as a 3-antidepressant approach.
Not having seen your SO or any more of his history, I
should be very cautious to presume to comment. I'm trying to focus my
comments around what's common, given that the thyroid approach is not, and how
this reflects on what you should do. All that said, however, generally the
best policy is not to "challenge" but to wonder out loud while being
appreciative of current efforts to help, and see if over time some dialog can be
maintained around the generally well-accepted principles of focusing on mood
stabilizers as the backbone of treatment (e.g. lithium, Zoloft, and Zyprexa),
while using antidepressants with caution. Good luck with that.
Dr. Phelps
Published May, 2003 |