Archive for the ‘psychiatric drugs’ Category

So is it your thyroid after all?

Wednesday, November 30th, 2011

Is this woman depressed, hypothyroid or both?

On November 21, 2011, The New York Times had an article entitled “For Some, Psychiatric Trouble May Start in Thyroid." As a mental health therapist who is hypothyroid, my wife has a particular interest in this subject and pointed out the article for me.

The premise, put forth by Dr. Russell Joffe, a New York psychiatrist, and a group of his professional peers, is that subclinical hypothyroidism may play a significant role in depression. A Brown University professor of psychiatry and human behavior also commented on this connection asking, “Is there an underlying thyroid problem that causes psychiatric symptoms, or is it the other way around?

From the endocrinology side, Dr. James Hennessey, at Beth Israel Deaconess Medcsl Center in Boston, noted "Psychiatric symptoms can be vague, subtle and high individual."

A study, published five years ago by Chinese researchers, gave six months worth of  thyroid hormone replacement therapy (see links below for the NIH's info sheet on this medication, levothryroxine and other info from, to patients with subclinical hypothyroidism and found improvements in brain scans, memory and executive functions.

sketch of the thyroid gland

So how is this condition diagnosed? and what does your thyroid do anyway? Most of us are familiar with this two-lobed, twenty to sixty gram,two-inch structure, located in the front of our necks and wrapped around our windpipe. It's a hormone producing gland with two products, thyroxine or T4 and its active hormone, triiodothyronnine or T3. I've always thought of its function as a major regulator of metabolism, but in reality that's only one of its duties: it does control how speedily we use energy, but also has a role in how we make proteins, how we react to other hormones and how our bodies handle calcium.

I've spent much of today reading about the thyroid; some things I knew; some I hadn't reviewed since med school basic science classes (1962-1964) and other were brand-new to me. Fetal development of the gland is stimulated by two other hormones released by the hypothalamus and pituitary and those are at high enough levels to cause the fetus to make T4 in clinically significant amounts by 18-20 weeks of gestation. The active hormone, T3, stays at low levels for another 10 gestational weeks, then increases until term.

The net result, it is felt, is protection of fetal development, especially of the brain, in the event the fetus's mother is herself in a hypothyroid state.

But back to adults and the link between thyroid status and mental health.  One of the crucial measurements of thyroid function is the level of TSH, thyroid stimulating hormone. Normal levels for this pituitary hormone are 0.4 to 5.0 in most labs in the United States; nearly nine years ago, the American Association of Clinical Endocrinologists recommended the doctors consider treating patients whose TSH levels are higher than 3.0. Other scientific groups agreed.

If a TSH level above 5.0 is abnormal, then ~5% of our adult population is hypothyroid. But if that level is reduced to 2.5 to 3.0, then ~20% of us are hypothyroid.

I wonder if a new field of medicine, halfway between the endo folk and the mental health practitioners, is on the horizon.

Issues with Psychiatric Drug use

Saturday, November 26th, 2011

Are drugs always the answer?

An article in the Wall Street Journal for November 16th caught my eye. My wife is a mental health therapist (the non-prescribing variety) and I knew this one would interest her. The title was “Psychiatric Drug Use Spreads: Pharmacy Data Show a Big Rise in Antipsychotic and Adult ADHD Treatments.”

She wasn’t especially surprised to hear that one in five adults were taking at least one psychiatric drug.  But as opposed to anti-anxiety drug use, both of us were struck by the comment that drugs given (and perhaps overused) for kids with ADHD are also increasingly being given to adults.

I went to the Internet to find the data. There’s an enormous company called Medco that provides pharmacy services for greater than 65 million people. I had never heard of the firm, but it’s rated number 35 of the Fortune 500 and in 2009 reported revues just under $60 billion.

Their senior psychiatrist, a Dr. David Muzina, has a great CV, working in major roles at the Cleveland Clinic from 1999 to 2009. I did note his “Summary” claimed “17 year’s of Cleveland Clinic experience as a Staff Psychiatrist,” but he graduated from medical school in 1993, presumably finished his Psychiatry residency in 1997 and then ran an inpatient psych unit at Lutheran Hospital (location unspecified) for two years.

In any case Medco, where Dr. Muzina is a Vice President, in and presumably heading their Neuroscience Therapeutic Resource Center, published an extremely interesting report titled “America’s State of Mind.” (see link below). This summarizes research on the prescriptions of greater than two million people in this country from 2001 to 2010.

The trends are stunning.

Boys and girls, men and women are all now more likely to be taking a drug used for mental health problems. Fifteen percent of adult men are on one or more of these medications and, amazingly, twenty-six percent of adult women.

In reality the ADHD drug use in adults is still comparatively uncommon (less than 2%), but NPR recently reported a severe shortage of Ritalin. Newer drugs which treat ADHD will enter the generic market in 2012; that should save patients considerable amounts of money.

The real impact is in the antidepressant arena: twenty-one percent of women 20 and over take these meds and the percent rises with age. It’s 16% of women ages 20 to 44, 23 percent of those between 45 and 64 and 24% of women over 65 years old. For men in comparable age groups the percent are 8, 11 and 13.

Then there’s regional distribution: what I call the “Middle West” and my own Mountain region have the lowest percentage on mental health drugs while Kentucky, Tennessee, Alabama and Mississippi have the highest.

So how many are actually taking their meds as prescribed? And how many are having serious side effects?

An issue raised in one of the publications is that of patients not taking prescribed dosages of their meds (if any), having increased symptoms and physicians therefore increasing their medication dosage.

Then if they do start taking the drug as prescribed....