• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
Mental health and hormones cady
 

Mental health and hormones cady

on

  • 1,017 views

This lecture on the relevance of hormonal optimization in mental health, was presented by Dr. Cady in Salt Lake City, UT at the 2012 Medical Seminar Series coordinated by World Link Medical.

This lecture on the relevance of hormonal optimization in mental health, was presented by Dr. Cady in Salt Lake City, UT at the 2012 Medical Seminar Series coordinated by World Link Medical.

Statistics

Views

Total Views
1,017
Views on SlideShare
1,015
Embed Views
2

Actions

Likes
1
Downloads
0
Comments
0

2 Embeds 2

http://learnweb.l3s.uni-hannover.de 1
https://www.blackboard.odu.edu 1

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • Depressed mood is the most commonly cited symptom in major depressive disorder. Studies have shown that fatigue and reduced energy are nearly as common as depressed mood. As many as 94%-97% of patients may experience reduced energy and fatigue, while 73% may complain of tiredness. Impaired concentration is also common and occurs in as many as 84% of patients. Hypersomnia, or excessive sleepiness as opposed to physical weariness, is less common and occurs in 10%-16% of patients.
  • Addison ’s disease, like so many medical conditions, has a history of being ignored, hidden, and misunderstood.  It is a rare disease that affects about one in every 100,000 Americans and is usually diagnosed around age forty. 
  • These symptoms correlate to decrease in bioavailable testosterone
  • RIA (in-house after diethylether extraction) Total testosterone - T (RIA) 208-1141ng/dL, average 536+/-153ng/dL Bioavailable testosterone - BT (calculated) 78-470ng/dL, average 236+/-63ng/dL
  • Hypogonadal if TT < 200ng/dL or FT < 0.9ng/dL

Mental health and hormones cady Mental health and hormones cady Presentation Transcript

  • Louis B. Cady, MD – CEO & Founder – Cady Wellness Institute Adjunct Professor – University of Southern Indiana Adjunct Clinical Lecturer – Indiana University School of Medicine Department of Psychiatry Child, Adolescent, Adult & Forensic Psychiatry – Evansville, Indiana Mental Health and Hormones: What in the World do Hormones Have to Do with Current Allopathic Psychiatry? This presentation is © Louis B. Cady M.D. and may not be reproduced or used without permission. World Link Medical is authorized to reprint/duplicate it for 2012 syllabi. (c) 2012 Louis B. Cady, M.D. - all rights reserved
    • VISION: “We dramatically transform the lives of our patients and clients to levels of peak physical and mental health, supporting a lifetime of maximum performance and happiness.”
  • BODY MIND ACTIONS
  • Critical area of concern for men & women. Things that will make them:
    • Tired &/or depressed
    • Unable to cope
    • “ Mean”
    • Stressed
    • Deficient in libido or in the bedroom
    • Demented
  • A Shrink meets the “anti-aging” crowd
    • Patient “complaints”
    • Loss of energy
    • Loss of stamina
    • Loss of libido
    • Weight gain
    • Loss of zest for life
    • Loss of interest in career
    • “ I’ve felt like I’ve been aging since I was 35.”
    • Personal experience
    • Previous state: “energy to burn”
    • “ Snooze bar syndrome”
    • “ Piles syndrome”
    • “ Why can’t I make myself exercise?”
    • Car wash MSE!
  •  
  • Interesting lab values – Cady – 3/11/03: Lab Value Cenegenics Normal a.m.glucose 87 mg/dl 65 – 85 65 – 109 Fasting insulin 3 u U/ml <5 <20 HgB A1C 4.9 % <5.1% < 6.0 % Cholesterol 241 mg/dl <200 <200 Triglycerides 42 mg/dl <120 <150 Cor. Risk ratio 3.3 <4.0 Av = 5 – 6 Homocysteine 7.9 <8.0 5.4-11.4 DHEA-S 148 350 – 500 59 – 452
  • 4
  • Releasing Factors Adrenal Gland Ovaries Testicles Thyroid Liver Testosterone Estrogen Cortisol DHEA Progesterone T3 & T4 GH LH & FSH TSH Prolactin ACTH IGF-1 Pituitary Brain Hypothalamus DHEA
    • Depressed mood 100%
    • Reduced energy : 97% 3
    • Fatigue or loss of energy : 94% 2
    • Impaired concentration: 84% 3
    • Tiredness : 73% 1
    • Hypersomnia : 10%–16% 4 (Insomnia)
    Useful Target Symptoms in MDD 1. Tylee et al. Int Clin Psychopharmacol 1999;14:139-151. 2. Maurice-Tison et al. Br J Gen Pract 1998;48:1245-1246. 3. Baker et al. Comp Psychiatry 1971;12:354-65. 4. Horwath et al. J Affect Disord 1992;26:117-25. 5. Reynolds and Kupfer. Sleep 1987;10:199-215.
  • “ But the doctor told me my thyroid was fine.”
    • Can be “ wnl ” but suboptimal.
    • TSH frequently only thing checked.
    • Nothing known about Free T4 or Free T3.
    • Free T4 can be converted to Reverse T3 under stress (cortisol)
    • Free T4 can be underconverted to T3.
    • Can have normal levels (or slightly elevated levels) of everything and have auto-immune thyroid disease.
  • “ the foot soldier” “ the evil twin ”
  • “ Thyrotropin (Thyroid-Stimulating Hormone or TSH). Measuring TSH is the most sensitive indicator of hypothyroidism. ” (hunh?!) http://www.umm.edu/patiented/articles/how_serious_hypothyroidism_000038_6.htm Accessed: 9/5/2011
  • “ the foot soldier” “ the evil twin ” CORTISOL Se
  • Yes, T-3 DOES get into the brain (Transthyretin = carrier protein )
    • Terasaki, T. and Pardridge, W.M.: Stereospecificity of triiodothyronine transport into brain, liver, and salivary gland: role of carrier- and plasma protein-mediated transport. Endocrinology , 121(3):1185-1191, 1987.
    • http://www.kingpharm.com/uploads/pdf_inserts/Cytomel_PI.pdf .
    • Mooradian, A.D.: Blood-brain transport of triiodothyronine is reduced in aged rats. Mech. Ageing Dev ., 52(2-3):141-147, 1990.
    • Cheng, L.Y., Outterbridge, L.V., Covatta, N.D., et al.: Film autoradiography identifies unique features of [125I]3,3'5'-(reverse) triiodothyronine transport from blood to brain. J. Neurophysiol ., 72(1):380-391, 1994.
    • Rudas, P. and Bartha, T.: Thyroxine and triiodothyronine uptake by the brain of chickens. Acta Vet. Hung , 41(3-4):395-408, 1993.
    Or: The idiocy of T4 only thyroid treatment…
  • Transthyretin (a systemic amyloid precursor) may be protective for Alzheimer’s (Why?) Li X et al. J Neurosci 2011 Aug 31;31(55):12483-90
  • Per HDRS – 17, remission in: 15.9% on Li 24.7% on T3 Per QIDS-SR16, remission in: 13.2% on Li 24.7% for T3 * * Fava & Covino: Augmentation/Combination Therapy in STAR*D Trial, Medscape Psychiatry LEVEL III RESULTS:
  • Fatigue from Adrenal Dysfunction - The Worst Case Scensario: Addison ’s Disease
  • “ Hypoadrenia” : The Adrenal Problem that most conventionally trained physicians don’t know about.
    • Non-Addison ’s hypoadrenia
    • Subclinical hypoadrenia
    • Neurasthenia
    • Adrenal neurasthenia
    • Adrenal apathy
    • Adrenal fatigue
    • “ Adrenal burnout”
    • “ Chronic fatigue syndrome”?!!
    Modern medicine does not recognize it.
  • The state of adrenal exhaustion can be determined Early-stage Chronic Stress Response Mid-stage Chronic Stress Response End-stage (exhausted) Chronic Stress Response
  • DHEA – the critical hormone most doctors never check
    • Produced in the adrenal cortex
      • Humans and primates are unique in secreting large amounts
    • Immune system booster
    • Insulin regulator
    • Energy increase – remarkable
    • Boosts growth hormone
      • 20% in men; 30% in women in one study
        • [Yen, Morales Khorram – one year double-blind placebo controlled crossover experiment – with 100mg DHEA]
    • Antidepressant
  • 334 citations on “DHEA with energy” – as of 07 29 2011
  • Why isn ’t adrenal fatigue diagnosed?
    • Not severe enough to be an emergency
    • Symptoms can be attributed to other things, including “just neurotic” or “avoidant”
    • “ Functional medicine” testing not typically done (& rarely is DHEA-S checked)
    • Modern medicine focuses on the treatment of sickness, not “less than optimal” function.
    • “ Bell Curve” paradigm
  • Neurobiological & neuropsychiatric effects of DHEA & DHEAS [Maninger N et al. Front Neuroendocrinology 2009]
    • DHEA & DHEAS synthesized in adrenals AND BRAIN.
    • Biological actions of DHEA/DHEA-S:
      • Neuroprotection
      • Neurite growth
      • Antagonistic effects on oxidants & glucocorticoids
    • “ accumulating data suggest abnormal DHEA (S) concentrations in several neuropsychiatric conditions.”
  • “ Women’s issues”
  • The Glamorous Grandmother
    • 4/8/11 – 80 yo returned to practice. No real complaints. History of depression. On Pristiq.
      • Daughter “handling her finances”
    • 5/2/11 – “doing terrible.”
      • TSH 3.84, Free T3 2.8 – on 50 MICROgrams T4
      • Fasting BS 120; HgBA1C 6.5%
      • Fasting insulin 36 (!!!) {3 – 25}
      • Progesterone – 0.2 {0.2 – 1.4 follicular}
      • Total testosterone 11
      • DHEA-S = 25 MICROgrams/dL (!!)
        • Age adjusted {10 – 90} . Cenegenics = {c. 500}
        • Rouzier = {400 –females, 600 males}
  • G.G. - interventions 5/2/11 & Follow-up
    • Interventions:
      • DHEA – 25 mg SR q a.m.
      • Progesterone 200 mg/cc, Topiclick – ¼ cc at HS, then increase to ½ cc
      • Testosterone – 8mg/cc Topiclick – 1/4cc topically for one week, then ½ cc
      • Referred to better MD for intervention with AODM.
    • 6/13/2011 – improvement in fatigue. Labs rechecked.
    • 7/11/2011 – “feeling wonderful”
  • G.G. – labs before and after 4/11/11 interventions 7/11/11 changes TSH 3.84 Raise T4 from 50 – 75 ug 0.01 (L) none FT4 1.16 “ 1.24 “ FT3 2.8 “ 3.3 “ Progesterone <0.2 100mg topical HS 0.9 None Testosterone 11 4mg topical 15 4 mg LABIAL DHEA-S 25 25 mg SR n/a continue
  • The glamorous grandmother – post tune-up 9/28/2011 (permission granted to use photos & data) 01/26/2012 Pictures removed for publicly posted slide deck
  • One destigmatizing notion: Estrogen as MAOI
    • Estrogen & Testosterone (!) decrease MAO
      • Luin, VN. Brain Res. 1975;86:273-306
    • Platelet MAO levels inversely correlated to estradiol levels
      • Klaiber EL et al. Psychoneuroendo- crinology. 1997 Oct;22(7):549-58.
    • Estrogen decreases MAO-A & MAO-B
      • Holschneider DP et al. Life Sci. 1998;63(3):155-60
  • Estrogen-related mood disorders – reproductive life cycle factors. Douma SL et al. Adv. Nursing Sci. 2005. 28 (4):364-375
    • “ Clinical recovery from depression postpartum, perimenopause , and postmenopause through restoration of stable/optimal levels of estrogen has been noted.”
  • Symptoms of estrogen imbalances*:
    • Hot flushes or flashes; night sweats
    • Mood swings
    • DEPRESSION, and/or anxiety, panic attacks
    • “ Concentration” issues: Memory, communication, and attention span loss, “brain fog.” (Think: “MORE MAO.”)
    • Insomnia
    • Weight gain – “appetite changes”
    • SOMATIC symptoms : aches and pain
    • General deterioration: Incontinence, digestive disturbances, sensory function loss, aging skin . . . thinning, wrinkles, sagging
    * Adapted from Whitney Gabhart, N.D.
  • The Case of the Crying Cleaner
    • 1/11/12 - Symptoms:
      • Crying/depressed = on Citalopram
      • Hot flashes
      • Night sweats
    • RX:
      • Estradiol – 2 mg @HS
      • Prometrium – 100 mg @HS
      • (continue citalopram)
    • 1/15/12 – RESOLVED
    • IN 2 WEEKS!!! .
    Photo & data used with permission Picture removed for publicly posted slide deck
  • Psychoactive Progesterone*
    • Increases energy and libido
    • Has a calming effect , acting like a benzodiazepine to the brain (HS dosing)
    • Enhances mood
    • Balances blood sugar (appetite)
    • Regulates fluid balance, sodium mineral balance
    • Necessary for fertility
    • Helps relieve menopausal symptoms
    • Decreases risk of endometrial cancer and may help protect against breast cancer, fibrocystic breasts, and osteoporosis
    * Adapted from Whitney Gabhart, N.D.
  • Testosterone: The “sexist” bias against women (e.g., “your loss of sex drive is just natural for your age.”)
    • Fall in the circulating testosterone and the adrenal preandrogens most closely parallel increasing age.
    • Accelerated decrease occurs in the years preceding menopause (like estrogen).
    • Their loss affects: libido , vasomotor symptoms (hot flashes) , mood , well-being , bone structure, and muscle mass.
      • Burd, Bachmann. Androgen replacement in menopause. Curr Womens Health Rep. 2001 Dec; 1(3):202-5.
  • The Case of “Pajama Mama”
    • 40’ish yo MWF, mother, ref by therapist for worsening depression. History of chronic headaches. Mild dep symptoms x 16 years.
    • CC: “I think I need a good medication, and I need to stay on it.”
    • In normal mood state until after birth of second child 14 years prior (@ age 27)
      • Recalls “calling the doctor all the time” and ego-dystonic worries of dropping her baby over a railing ACCIDENTALLY on the stairway at home
    • RX tried
      • fluoxetine– “worked reasonably well”
      • Amitryptline for headaches – “knocked me out”
      • Alprazolam – had her first panic attack ON IT.
      • Tried on duloxetine – no relief.
    • Rx at present – fluoxetine 20 mg; topirimate 100 mg, sumitriptatn as needed
  • The Case of “Pajama Mama” - treatment
    • Fluoxetine gave sexual side effects. Stopped. Escitalopram now at 15 mg. Trazodone 25 mg HS..
      • Topirimate continued for migraines.
    • Psychotherapy: focused on significant dependent personality disorder and relationship with spouse.
      • Increasing limit setting noted. Patient reading her bibliotherapy assignments
    • Escitalopram didn’t work. Back to fluoxetine. IgG Food sensitivities found; diet restrictions instituted.
    • 11/15/2011 – working professionally in her field, has gotten graduate degree, but tired and wrung out. Exhausted at end of day. Was tired on a cruise vacation almost all the time. Went back to room to sleep. Forcing self to exercise.
  • The Case of “Pajama Mama” – lab review
    • TFT’S
      • TSH 0.38 (L) {0.55 – 4.78}
      • Free T4 1.05 {0.80 – 1.76}
      • Free T3 2.9 {2.3 – 4.2}
      • Reverse T3 199 {90 – 350}
    • SEX HORMONES
      • Total testosterone 11 {9 – 55}
      • Free testosterone 1.3 {1.1 – 5.8}
      • SHBG 60 {30 – 155}
      • Progesterone 1.0 {0.2 – 1.4}
      • Estradiol 67 {24 – 284}
    • DHEA-Sulfate 55 {32 – 240}
  • This is what those labs “sound like”
    • “ I must be worse than I think I am, because my daughter made a comment about the members of her family . ‘Mom likes her pajamas.’”
    • “ I’m frustated that I’m not doing great – I don’t know why. There should be no reason why I should think about the way I feel, or wonder, ‘why don’t I want to get up?’ or ‘Why do I feel anxiety?’ I don’t have to give a speech. I don’t have to do anything.”
    • “ I’ve done a lot of right things… I’ve done so many right things. I’ve taken my medicine like I’m supposed to. I’ve tried to change my life and my thinking . I’ve done physical things [exercise] to try to help me.”
  • Pajama Mama – treatment and follow-up
    • All psychotropics kept same
    • Hormones added (11/15/2011):
      • Testosterone – 10/mg/cc – ¼ cc labially daily - increased to ½ cc (5 mg) labially per day.
      • Amour thyroid – ¼ grain x 1 week, then ½ grain
      • DHEA – 25 mg SR micronized daily in a.m.
    • Still tired – 12/13/2011 –
      • New RX: Hydrocortisone – 5 mg twice daily added (a.m. and lunch)
  • PJ Mama – STABLE – 1/17/2012
    • “ I don’t have a hyperactive sense of energy, [but] I’m no longer pajama mama [sic]. I just have the energy to do what I’m supposed be doing, and more, sometimes. But it’s not an odd, hyperactive type thing.”
    • Household budget now fixed and stable. Increased limit setting with husband.
    • [more clinical detail, removed from public access form]
  •  
  • Fast food (low Zn) is bad for you.
    • Fast food = high energy density = low essential micronutrient density, ESPECIALLY ZINC
    • Antioxidant processes are dependent on Zinc
    • Fast food = severe decrease in antioxidant vitamins and zinc, correlating with inflammation in testicular tissue – with underdevelopment of testicular tissue and decreased testosterone levels
    • Decline in male sex steroids not as abrupt as menopause, but equally debilitating
      • Between 40 – 70, average male loses:
        • Nearly 2&quot; of height
        • 15% of bone density
        • 10 – 20 pounds of muscle
    • At 70 yoa, 15% completely impotent
    Testosterone (Men)
  • T vs Cognitive Function Rosario ER. JAMA . 292(2004):1431-2
  • T vs Cognitive Function
    • 400 independently living men, 40-80yo
      • 100 in each age decade
      • MMSE 21-30, average 28
      • TT: 208-1141ng/dL; Bio-avail T 78-470ng/dL
    • HIGHER T = better cognitive performance in OLDEST AGE category
    • Men with lowest 1/5 T = worse than men with highest 1/5 T
    • Highest Bio-available T more significant than TT, age , intelligence level , mood, smoking , and alcohol .
    Muller M. Neurology . 64(2005):866-71
  • T vs Mood in men
    • Study: 278 men, > 45yo, followed 2 years
    • Compared to eugonadal patients, hypogonadal men w/TT < 200ng/dL had
      • 4-fold increase risk of depression
      • Significantly shorter time to depression diagnosis
    • Depression risk inversely related to TT w/statistical significance < 280ng/dL
    Shores MM, Arch Gen Psychiatry . 61(2004):162-7
  • Testosterone and “Prostate Cancer risk”
    • Prostate CA found 2.15 & 2.26 times more likely in lowest compared to highest tertile of total and free testosterone
    • “ . . . there are several papers showing a relationship between LOW testosterone and prostate cancer . Specifically, low testosterone has been associated with high-grade tumors , advanced stage of presentation , and worse prognosis .”
    Morgentaler A. Eur Urol . 50(2006):935-9 Morgentaler A. Urology . 68(2006):1263-7
  • The Case of the Mismanaged Executive - summary
    • 42 year old male ADHD CEO
    • “ So tired I feel like I’m dying.” Depressed.
    • Lab findings – low testosterone, despite multiple pumps of Androgel per day managed by endocrinologist (!). Low thyroid. Low DHEA.
    • RX: Testosterone cypionate IM – 60 mg twice weekly. DHEA – 50 mg SR. Armour thyroid – ½ grain.
    • Clinical status: total resolution of symptoms. No antidepressant used.
  • A synthesis…
    • Holistic Fun with Hormones
  • 50’ish year old female, post-menopausal, on no hormones
    • On aggressive supplement regimen with daily MVI and others
    • Not ill
    • Top rated medical care with previous labs done
    • Nothing identified as seriously abnormal
    • “ Just interested in having my hormones checked.”
  •  
  •  
  •  
  •  
  • Treatment for this “normal” patient
    • Armour thyroid – ¼ grain for 1 week, then ½ grain. (Aiming for T3 in “high 3’s.”
    • DHEA – 25 mg SR micronized, compounded – in a.m.
    • Progesterone – 50 mg SR compounded – at night.
    • Testosterone – 3mg topical per day x 1 wk, then 6 mg. “Decrease dosing as needed for side effects.”
    • Vitamin D – 5,000 IU twice daily x 3 weeks, then decrease to one dose per day.
    • High potency liquid fish oil – 4 grams per day
  •  
  • What’s life like now?
    • “ it’s like the colors of the rainbow have gotten more into the pink.”
    • “ My computer will survive – I use to ‘lose it’ over my computer. I would swear obscenities.”
    • “ I’ve gotten into a zen like mode. Handling everything that life can throw at me.”
    • “ It’s almost as if I’ve taken a pill or drug that jus makes me handle everything that life is throwing at me. I can roll with it.”
    • “ I’m not irritable any more. Time pressure has just gone away.”
  • Key points
    • A predominantly psychiatric view with psychiatric interventions…
      • Will not fix all symptoms
      • You may be unlikely to get anybody else to do it for you, either.
    • STABILIZING THE BIOLOGICAL PLATFORM (the “body”) is critical for full remission and total wellness when hormones are not optimal.
    • Holistic and integrated tx required.
    • Yoking of thyroid, adrenal & sex steroids
  • HOW OBVIOUS DOES IT HAVE TO BE? The Challenge of Empathic Listening & CREATIVE THINKING Ron Hunt lost an eye but suffered no brain damage after a freak accident with a large drill bit. (ABCNEWS.com)
  • “ Sit down before fact as a little child, be prepared to give up every preconceived notion, follow humbly wherever and to whatever abysses nature leads, or you shall learn nothing.” - Thomas H. Huxley
  • Contact information: Louis B. Cady, M.D. www.cadywellness.com www.indianaTMS-cadywellness.com Office: 812-429-0772 E-mail: [email_address] 4727 Rosebud Lane – Suite F Interstate Office Park Newburgh, IN 47630 (USA)