Doc' Says Thyroid is Within the Normal Range
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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. 



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


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