Transcription
Hey guys, it's Dr. Child's here. Today, I want to talk about depression and hypothyroidism and the connection between both of these disease states. The reason I want to talk about this is because there is definitely known to be a connection between them, for sure. But the connection is not well established, and we'll talk about what I mean by that in just a minute here.
But the reason this is important is because it's very possible for patients to have thyroid disease, hypothyroidism, Hashimoto's, etc., and suffer from depression, and to still have that depression despite being treated for their thyroid. So this raises lots of questions, and it's definitely not an or. It's definitely not normal. So it becomes an issue as to what is causing depression in each case, because the thyroid could be part or all of that, or it could be something related or unrelated to the thyroid as well. So you sort of have to have enough information to know when it's the thyroid, when it isn't, and how to deal with all of these things. So that's, that's sort of the, the crux of what we're gonna be talking about here today. So let's, let's jump in here and talk about the connection between these two things.
So as I said before, science and doctors, they know that there is this connection. It's taught in medical schools that one of the, one of the starting, or I should say, one of the characteristic symptoms of hypothyroidism is depression. So when you are being worked up for depression, one of the things that your doctor should be doing is he should be checking for your thyroid. And the reason for that is thyroid disease is felt to be a reversible cause of depression, as is B12 deficiency, right? And so what do I mean by that? I mean, if you have these conditions, if you treat this condition, and that's causing your depression, the depression should go away. So, but then what happens is people, they get diagnosed with the condition, they get the treatment, but then the depression doesn't go away. So then what do we do? So that's what, that's what we're gonna be talking about.
So here are some of the connections that we know. Um, here's some of the facts that we know suggest that there is a strong connection between depression and hypothyroidism. Number one, hypothyroid patients and and depressed patients exhibit similar symptoms. You know, we know that that doesn't necessarily mean that they're related, but you know, there's some smoke there. The fact that depressive symptoms may be eliminated in some patients with the use of thyroid hormones. Now, this is important because it extends to those who don't even have thyroid disease. Now, what I mean by that is thyroid hormone, especially T3, can be used as a novel treatment to treat depression, all right? So it's very important. We'll talk about that a little bit later. Number three, the fact that thyroid hormone can be given as a standalone depression medication, even instead of antidepressants, but also it can be used to augment existing antidepressants. So kind of going back with number two. Number four, the fact that thyroid hormone influences serotonin production in brain tissue, and this, of course, as you probably know, is the same target that antidepressants go after. So the antidepressant medication, it falls into the class of something known as SSRIs, which stands for selective serotonin reuptake inhibitors. So it's the general consensus has felt that depression is at least caused in part by changes to serotonin levels, and therefore, if we target these serotonin levels, then, you know, you can fix depression. Now, that ends up being more complex, so I'm not going to really get into that, but that's, that's what it's believed right now. I'm not, I'm not convinced that's entirely true, but, you know, here we are. Number five, the fact that TRH, which is part of the hypothalamic control of thyroid hormone, is sensitive to serotonin, okay? So what that means is this: low serotonin may stimulate an increase in TRH, and high serotonin may reduce TRH production. So basically, what this means is this: let's say you have depression, and, and let's just assume for now that low serotonin, well, in depressive states, you will have low serotonin. That's the assumption we're making. So in that setting, that low serotonin stimulates TRH, okay? And TRH then stimulates TSH. So what this is telling you is there may be a connection between your mood and your body's ability to stimulate thyroid hormone production through TRH, TSH, and then the thyroid hormones. So that's pretty interesting, and there is this connection. So it is, there is some evidence to show that TRH is sensitive to serotonin, which is pretty cool. Um, and that may explain why thyroid hormone can be used as a standalone treatment, and that may also explain, in part, why depression is a side effect of low thyroid hormone. So these are the facts that we have when it comes to your, when it comes to depression and when it comes to your thyroid.
Now, this isn't the whole picture, okay? And so the way that I like to look at depression, though, is as a manifestation of some other disease, okay? So I don't call depression a disease per se. Now, sometimes there can be congenital issues which result in depression, or something you're born with, or some sort of genetic issue. But many times, it's caused by something else. So it is the manifestation of something else. Now, it could be the manifestation of a hormone imbalance. So that could be from menopause, that could be from low testosterone, that can be from thyroid disease. I mean, you get the picture. Hormone imbalance itself can cause depression. Depression can be caused from nutrient deficiencies, especially B12 deficiency. Inflammatory states can cause depression, just systemic wide inflammation. Gut dysfunction, intestinal dysbiosis, increased intestinal permeability, etc. All of these gut issues can result in depression as well.
So what we have now is depression. I think it's more helpful to think of depression as a symptom, not as a disease. It's most likely a symptom of some other issue, and that tends to hold true for the majority of people, not everybody, but, but a lot of it. I shouldn't even say majority, just, let's just say a lot of people. What happens is when I take on a new patient or I treat them, we start to just fix a lot of the, the things that we see that are obviously, you know, abnormal. So if there's thyroid disease, we treat the thyroid disease. There's B12 deficiency, we give B12. If we just start giving the body back what it needs, most of the time, those symptoms, such as depression, they get cleaned up in the process. And then if anything remains after that, then I can sort of know, okay, let's focus more on this or let's focus more on that, because this isn't being cleaned up with, with the balancing of these other issues.
So it's important to remember that depression isn't caused by one single thing, okay? It can be, but that isn't always the case. And it might be, as is the case in many of you listening to this right now, that you may have depression caused by multiple issues. So, for instance, you may be in menopause. You may also have hypothyroidism. You may also have B12 deficiency. You may also have gut dysfunction and constipation or bloating. So that's not an abnormal presentation for many patients with thyroid disease, as many of you probably know. So do you think that it makes sense that if multiple things are contributing to depression, that treating one of those will fix the whole problem? And of course, the answer is no. So this is sort of the way that you need to be thinking about this.
So the next question is, well, how are you supposed to treat it if you have thyroid disease and you have depression? Now, this is where things get a little interesting. There are, there are many studies that have that have looked at this, and, and the reason they've looked at this is because of this: they, there are many doctors who have noticed that patients who present with hypothyroid symptoms, including depression, get placed on treatment with thyroid hormone, and yet they still manifest, they still have these symptoms. So, so you either have to say, well, are we treating the person correctly? Or is their depression caused by some other cause? Or some other issue? And this is where things can get complicated. However, this, this should help guide you.
There are several studies that show that many patients do better and have an improvement in their quality of life and a reduction in depressive symptoms when they use T3 in addition to T4. Okay? And I've talked about this before, but essentially, what you need to know is that T3, there are some states, some genetic polymorphisms, especially the DIO2 polymorphism. And what this does is it prevents the deionization of T4 and can the conversion of T4 to T3, specifically in brain tissue. So it's possible. And by the way, this is, this is this polymorphism is seen in up to 12% of the population. So this is, you know, there's a pretty, a fairly large amount of people who have this issue. So what this means to you, if you have this issue, is that if we, if I give you T4, your doctor gives you T4, your body, all of your tissues in your body, with the exception of your brain, may get sufficient thyroid hormone. So your whole body looks good, and yet you still have depression. So the only way to bypass this is to either provide T3. And your body does this by itself, right? You're, you probably remember that your body is producing some amount of T3, usually 20% of total. But if you have thyroid disease, there's hypothyroidism or Hashimoto's, your, your thyroid is unable to produce that T3 anymore, which means you have to get it some other way. And if your body can't convert it in your brain to T3, then the only way to get it to your brain is to provide that this person with T3 medication. And this may explain why there are so many patients who do so much better on this medic, on T3 medication when it's added to T4.
So one of the things that I would recommend is, if you fall into this category, is try just adding a small amount of T3 to your T4 medication. Now, the beauty of this is you can do this without causing any negative side effects, and you can do this with still managing your TSH. So it's, it's fairly straightforward. You would just drop a little bit your, your existing T4 dose and just add T3 to it. So five to ten mics per day of liothyronine or Cytomel. You can read more about it. I've links here that you can kind of go to and learn about all that. And if you want to learn about this DIO2 polymorphism, you can read about it here. And so on and so forth.
Now, the problem is, a lot of physicians, for whatever reason, they either aren't aware of this polymorphism, they don't understand the genetic component, or they're scared to use T3. I really don't understand where the logic is or how, what their thought process is. But some of them will just not use T3. If you fall into this category, and your doctor is unable to, or unwilling, I should say, to to write it, then you may need to look into another physician or get a second opinion or something like that.
And then there's another thing that we need to discuss, and that is, what if you don't have this polymorphism? What if you, you, you're taking thyroid medication, you have adequate T3 levels, but you're still having depression? Well, there's a lot of other things that could be contributing as well. And so what I have here is this is a list of potential causes of persistent hypothyroid symptoms in you thyroid patients receiving LT4. Let me break that down so it makes more sense. So what this means is, if this is a list of conditions that if present, may cause you to continue to have hypothyroid symptoms despite being on quote unquote adequate or normal amount of levothyroxine or Synthroid. Now, I imagine there's a large number of you who are listening to this, you may fall into this category, because usually you wouldn't be searching for stuff like this unless you had this problem. So this is a, this is something that you definitely want to take a look at and go through it. And so we talked about the most relevant to this discussion would be B12, folate, iron deficiency, and a couple of other things here, like stress and sleep. Now, some of these other things will cause hypothyroid symptoms, but may not specifically cause depression. However, I've provided it here because they're still important. You know, another one being celiac disease, could be dietary related, adrenal insufficiency. I mean, these are all really important things to be evaluated for. But it's never normal. It's never, never, never normal for you to be on thyroid hormone, for you to have normal labs, and yet still have symptoms of hypothyroidism. That needs to be evaluated. If it's not being evaluated by the physician you're working with, search for another physician, because something is wrong. It's not okay to be in that that scenario, okay? So that's, that's sort of the bottom line here.
Now, like I said, specifically B12, iron deficiency, folate deficiency, stress, sleep, alcohol consumption, and then celiac disease. Those are specific to hypothyroidism. But our, sorry, to depression. But some of these other things can so cause like fatigue, and they can cause weight gain, and so on and so forth. So those are the two main things that you want to look for if you have depression, if you have thyroid disease.
So let's talk about the next section here, which is Hashimoto's and depression and other mood disorders. So there is a, a clear association between mood disorders, such as depression and anxiety, in those who have Hashimoto's. And so what studies have done is they've looked at those people who have Hashimoto's and they've looked at normal controls, and they say, okay, what is the rate of anxiety and depression in the people who have Hashimoto's? What is the rate of depression, anxiety, and those who don't? And what it turns out is there's something like a three to five, I can't remember the exact number, but a high, much higher risk of developing these mood disorders in patients who have Hashimoto's compared to normal controls. So what does that tell you? Well, that's not clear. But, but I take that to, I take that to indicate that there are many patients with Hashimoto's who are likely needing to be treated with thyroid hormone who aren't being treated with thyroid hormone. However, so that's probably a big thing. But another very important point is that it's, some studies have shown that thyroid antibodies by themselves can cause depression or other mood issues. So what does that mean? It means there's probably some cross-reactivity in brain tissue or neurons or something. We don't really know, but there's some interference that occurs with thyroid antibodies and brain tissue somehow, okay? Maybe not brain tissue, but maybe serotonin, or maybe, maybe some neurotransmitter or something like that. But it seems that those antibodies, and we know that antibodies can cause problems outside of the thyroid, like for instance, we know, and studies have shown this, that patients who have thyroid antibodies have a higher risk of developing some cancers, especially breast cancer. So those antibodies that are present are doing more than just damaging your thyroid gland if you have Hashimoto's.
So one form of treatment in addressing depression in patients with Hashimoto's is not only to normalize the, the thyroid function, but to also do your best to reduce the antibodies themselves, right? So antibody reduction would then be considered a therapy. Now, I've included a bunch of therapies that I use, that they range in in terms of their effectiveness at reducing antibodies, however, they're so worth it. So I talked about some of these: vitamin D supplementation, the use of low-dose naltrexone, certain supplements, and even the use of thyroid medication can all potentially drop these antibodies. So you can read more about the link on how to do that there. But just realize that if you have Hashimoto's, it's going to be a little bit more difficult for you to handle depressive symptoms, potentially, not always, but, but potentially. And you need to address it both ways. So you need to look at the thyroid function, and then you also need to address antibody levels themselves, if possible. So that's that section.
The next section is using T3 thyroid hormone for depression, not sure why that went down, if you don't have thyroid disease. So what does that mean? If you recall, in the very beginning of this discussion, I mentioned that thyroid hormone can be used as a standalone medication or treatment for depression, okay? And the studies are, are very clear on that. And we'll talk about that in just a minute, because it, some of the treatments mirror very closely how I'd recommend, how I recommend some patients use T3 for weight loss, which is really interesting, and that's a connection that I, that I just found out recently, so we'll talk about that in a minute. But going back to the studies for a minute, so there are several studies that show that the, that using that thyroid hormone can be used in addition to SSRIs, such as Paxil, etc., all of those. And those patients who take the combination of thyroid hormone and Paxil or SSRIs show an increase or an improved response and or a reduction in their depressive symptoms. Okay? So there's a clear, a clear benefit to doing, to using thyroid hormone with SSRIs in patients who don't respond to just SSRIs. Now, if possible, I would recommend, if you can, that you try to avoid starting with an SSRI. And the reason for that is they can be very difficult to get off of, they may cause some serious withdrawal symptoms. It just doesn't make sense to use them unless you have to. Now, at the same time, I realize that there are some patients out there who use SSRIs, they're life-changing to these people, I get that, and I respect that. But if you can avoid it, I would suggest you, you try to do that if possible, to start with, or you can always go back to them later or try it again later.
Now, which thyroid medications tend to be most effective to treat, to treat depression? That's pretty clear. The medication that is the most effective would be any medication that contains pure T3. So medications that fall into this category include Cytomel and orally, liothyronine. So Cytomel being the brand name, liothyronine being the generic medication. But also sustained release T3, sometimes referred to as SR T3. So these are just medications which contain the pure, and strongest, and most active thyroid hormone, T3. These are not the same medications as levothyroxine, Synthroid, Thyro-T3, etc. Completely different.
So how do you go about using these? How do you go about using T3 if you have depression? What are you supposed to do? So there have been, what's interesting to me is that, and this is where the weight loss thing comes in, is that I've been, I've been long recommending the use of T3 in short, sort of super physiologic dosages to help with weight loss, and then the T3 can be reduced at a later time. And what's interesting is that I've come to a similar set of guidelines as psychiatric or psychiatrists have come to in regards to using T3 to treat depression. So this is, this is very interesting. And if you follow these guidelines, you can use T3 even if you don't have depression, and you can do it safely without risking any negative side effects. The most common side effects cited for the use of T3 and the suppression of TSH being cardiac or heart problems, and then of course, the reduction in bone density. So you can read the, the study that this came from and the guidelines that these guys are using, and they're adapted, and then I've kind of put my own, putting my own words, the way that I, that I use it here. So let me talk about those.
So if you fall into this category, the best way to use T3, yeah, it's okay to use this, but, but use it in this way. So first, close monitoring of thyroid lab tests, including TSH, free T3, and free T4. It's very important that you order the free thyroid hormones in addition to the TSH. If you're dosing simply based off the TSH, it's most likely not going to work. And it's okay in these studies. Well, we'll get to that in a minute. Number two, slow titration. Titration of T3 at 25 micrograms and increasing based on tolerance and over a period of weeks. So titration, meaning how, titration is a word that we use to describe a slow process of increasing the dose over time. That's essentially what that means. So starting, and I generally start at 12.5, but they started at 25, whatever, that's fine. But starting at a low dose and then increasing over time. Number three, set the goal TSH at the lower limit of normal. So this is interesting. So generally speaking, endocrinologists, PCPs, conventional physicians, they don't like it when your TSH gets low. But in this, they're saying it's okay to set the TSH a little bit at the low end of normal, just make sure you monitor it. So that's number three. Number four, is maintaining free T3 in the upper limit of the reference range. Now, I generally say above the 50th percentile of that reference range, but in weight loss and depression, we're probably talking the top 10, top 20 percent. Okay? So very, very, very tippy top of that free T3 reference range, whatever number we're on. I think. Number five, close monitoring of bone density with DEXA scanning in patients who are postmenopausal. So what this is going to do is this is going to allow you to monitor your bone density to make sure that the thyroid that you're taking is not impacting or causing bone loss in any way, okay? Now, what's interesting is that there have been observational studies, which just means that there have been patients who fit this category, and doctors have just watched them, they checked their bones, they've checked their labs, they've done all these things. So they observed them over some period of time, and in this case, it's two years. And we doctors have observed patients taking 50 micrograms to 150 micrograms of T3 per day, and in these observational studies, they did not have any negative side effects on heart, which would be cardiac, or skeletal, which would be bone tissues. However, it's worth noting that this length of time was only about two years. So when you start taking it for longer than that, it's hard to say if it's technically safe or not. But again, as long as you follow these things and work with your doctor, it should be probably okay. So anyway, that's pretty interesting.
On a quick note here, to another, I say another interesting point is that T3 has also been shown to be what I would refer to as a rescue medication in treating severe bipolar disorder in patients who have failed multiple, we're talking like ten plus different types of mood-stabilizing medication. So obviously T3 has some effect on neurological tissue that's, that's pretty profound. And again, I talked about here the DIO2 polymorphism, which may account for some psychiatric issues in patients. So imagine a scenario in which you are a patient that just has depression, and it's because of this DIO2 polymorphism, which, remember, even if your body's producing normal amounts of T4, it may not be, your, your body may not be so tuned, let's say, to convert that T4 to T3 in your brain tissue, and you may just have depression. So it may be that clinical depression, at least in part, and I'm talking about those people who just have it their whole lives, right? I don't talk about people who get it as a result of, you know, grief or or hormone disorders or whatever. We're talking about people that just have it their whole life. It may be because of, or at least in part from, this polymorphism. Again, not, not sure, but that may explain why some patients, some just respond to T3 medication even though they don't have thyroid disease, you know, by laboratory testing. So anyway, that's a lot of information there, but it's worth discussing.
So the last point, so what are you supposed to do if you, if you have depression, if you have thyroid disease, how do you approach it? So here, here's sort of my, my wrapping it up guidelines for you to take with you. So number one is check your thyroid panel, including free thyroid hormones. Very important. You have to check free T3 and free T4 in addition to your TSH. If you're having trouble getting those tests ordered from your doctor, perhaps it's time to see any new doctor so that you can get those things done. If you're on thyroid medication, consider adding T3 therapy to your regimen. Remember that Cytomel, liothyronine, or even NDT, even in small doses of five to ten micrograms per day, may help reduce depression. Number three, treat nutrient deficiencies such as B12, folate, and iron deficiency. These are all available over the counter. I think B12 shots tend to be superior to B12 supplements in cases or in situations where patients have severe depression, but you can still use oral B12 as well. Focus on reducing circulating thyroid antibodies if you have Hashimoto's. We talked about that. Treat Hashimoto's with thyroid medication if necessary. Remember, some patients are not being treated even though they should. And then of course, ensure that you're sleeping eight hours per night and you're managing your stress with things like, particularly meditation, which has been shown to reduce depression and anxiety.
So if you follow this set of guidelines, I would say that this should improve at least dramatically your mood in the majority of patients. You know, probably 80 plus percent of people should see a significant improvement in their mood just following these set of guidelines of those who have thyroid disease, I should point out. So that's sort of, that's sort of pretty much all I was going to talk about. But I'd like to hear from you guys, specifically if you have depression, if you have thyroid disease, you know, are you suffering from from this sort of issue? Has, has anything worked to help you? Let me know. It's always good to to have comments and questions because it helps other people know that they're not alone. And this, there is a tendency for some patients to feel a little bit, let's say, ostracized, I think, when they go to their physician because they know something's wrong intuitively, and yet sometimes it's, it's their symptoms are dismissed as either being depression or some other cause. And so it's important to know that these are not normal symptoms to have, right? So that's why we need to talk about them. But anyway, if you have any questions or if you have anything like that, please leave them below. I'd love to hear about it. I'll try and get to all the questions if I can, and if I have time. Otherwise, I hope that I hope you guys found this helpful.