Mental Health and                                           Hormones: What in the                                         ...
“The mind, onceexpanded to thedimensions of largerideas, never returns toits original size.” - Oliver Wendell Holmes
Rationale for this lecture:• Many “mental health” issues are actually  “hormone health issues.”• Contemporary medical prac...
What our patients are telling us:
A Shrink meets the “anti-aging” crowd•   Patient “complaints”         • Personal experience•   Loss of energy             ...
Interesting lab values – Cady – 3/11/03:Lab               Value       Cenegenics   Normala.m.glucose       87 mg/dl    65 ...
4
Useful Target Symptoms in MDD  ♦   Depressed mood 100%  ♦   Reduced energy: 97%3  ♦   Fatigue or loss of energy: 94%2  ♦  ...
“But the doctor told me my thyroid                was fine.”• Can be “wnl” but suboptimal.• TSH frequently only thing chec...
THYROID – this one is kind of         important, gang!• Regulates:  – Temperature  – Metabolism – increases fat breakdown ...
FEEDBACK                                      INHIBITIONSelenium                 CORTISOLrequired! “the foot soldier” “the...
Progress – sort ofGraphic from January 2003 AACE pres release accessed here:http://thyroid.about.com/od/gettestedanddiagno...
AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS      MEDICAL GUIDELINES FOR CLINICAL PRACTICE       FOR THE EVALUATION A...
“Thyrotropin (Thyroid-StimulatingHormone or TSH). Measuring TSH is themost sensitive indicator ofhypothyroidism.” (hunh?!)...
Se                        CORTISOL“the foot soldier” “the evil twin”
Modern Medicine’s Paradigm:Two Standard Deviations – “if you are not     sick, then you must be well.”                    ...
Definition of “normal labs”:            “When your lab            values are as            crappy as            everyone e...
Yes, T-3 DOES get into the brain                  (Transthyretin = carrier protein)    Or: The idiocy of T4 only thyroid t...
Transthyretin (a systemic amyloid precursor)  may be protective for Alzheimer’s (Why?)Li X et al. J Neurosci 2011 Aug 31;3...
LEVEL III RESULTS:  Per HDRS – 17, remission in:         15.9% on Li         24.7% on T3  Per QIDS-SR16, remission in:    ...
•   Early 20’s college student•   Weight gain, fatigue, brain fog•   Saw “numerous” MD’s asking for help•   Told “nothing ...
Don’t forget DELAYED deep tendon   reflexes – delayed relaxation.
The glycemic controlling hormonesCORTISOL-Gets glucose           INSULIN:INTO the blood          -Gets glucosefrom stored ...
W. Wheat      Rice     Big Mac,       Ice cream;Toast, OJ,   cakes,   Fries, Shake   Coke & chips coffee      coffee      ...
Blood sugar goes up due             to cortisol for rescueW. WheatToast, OJ,               Cortisol coffee      secreted b...
Benefits of low-glycemic eating                              H - 32
Glycemic index• A measure of how fast a  carbohydrate triggers a rise in  circulating blood sugar.• The higher the number,...
“The Twinkie Defense”• “A derisive lable for an improbable legal defense.”  [Wikipedia]• Defendant Dan White for San Franc...
Fatigue from Adrenal Dysfunction - TheWorst Case Scensario:             Addison’s Disease
“Hypoadrenia”: The Adrenal Problem that mostconventionally trained physicians don’t know about.•   Non-Addison’s hypoadren...
The state of adrenal exhaustion can            be determined• 21 yo female  college student• Exceptionally  tired in the a...
DHEA – the critical hormone most         doctors never check• Produced in the adrenal cortex    – Humans and primates are ...
348 citations on “DHEA with energy” – as of                 of 8/17/2012
The two “new ones” – 8/17/2012                    - Opioid use has                       increased.                    - C...
Why isn’t adrenal fatigue diagnosed?• Not severe enough to be an  emergency• Symptoms can be attributed to other  things, ...
Neurobiological & neuropsychiatric effects    of DHEA & DHEAS [Maninger N et al. Front                 Neuroendocrinology ...
“Women’s issues”
The Glamorous Grandmother• 4/8/11 – 80 yo returned to practice. No real  complaints. History of depression. On Pristiq.   ...
G.G. - interventions 5/2/11 & Follow-up• Interventions:  – DHEA – 25 mg SR q a.m.  – Progesterone 200 mg/cc, Topiclick – ¼...
G.G. – labs before and after               4/11/11   interventions 7/11/11    changesTSH            3.84      Raise T4 fro...
The glamorous grandmother – post tune-up   Two pictures, after “tine-up” – removed from   presentation posted on internet9...
One destigmatizing notion:            Estrogen as MAOI• Estrogen & Testosterone (!) decrease  MAO  – Luin, VN. Brain Res. ...
Estrogen-related mood disorders –  reproductive life cycle factors.    Douma SL et al. Adv. Nursing Sci. 2005. 28 (4):364-...
Symptoms of estrogen imbalances*: Hot flushes or flashes; night sweats Mood swings DEPRESSION, and/or anxiety, panic at...
The Case of the Crying Cleaner               • 1/11/12 - Symptoms:                 – Crying/depressed = on                ...
Psychoactive Progesterone* Increases energy and libido Has a calming effect, acting like a  benzodiazepine to the brain ...
Testosterone: The “sexist” bias against women  (e.g., “your loss of sex drive is just natural for                       yo...
The Case of “Pajama Mama”•   41 yo MWF, mother of three, ref by therapist for worsening depression.    History of chronic ...
The Case of “Pajama Mama” - treatment• Fluoxetine gave sexual side effects. Stopped.  Escitalopram now at 15 mg. Trazodone...
The Case of “Pajama Mama” – lab review• TFT’S     –   TSH                  0.38 (L)   {0.55 – 4.78}     –   Free T4       ...
This is what those labs “sound like”•   “I must be worse than I think I am, because my daughter made a comment about the m...
Pajama Mama – treatment and follow-up• All psychotropics kept same• Hormones added (11/15/2011):  – Testosterone – 10/mg/c...
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 ...
Testosterone (Men)    • Decline in male sex steroids not as      abrupt as menopause, but equally      debilitating       ...
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: ...
T vs Mood in men• Study: 278 men, >45yo, followed 2 years• Compared to eugonadal patients,  hypogonadal men w/TT <200ng/dL...
Testosterone and “Prostate Cancer risk”• Prostate CA found 2.15 & 2.26 times more  likely in lowest compared to highest te...
Treatment options – not just       “the needle”
State of the art compounding devices
The Case of the Mismanaged          Executive - summary• 42 year old male ADHD CEO. Background in  psychology. Now EXTREME...
Holistic Fun with HormonesA synthesis…
Key points• A predominantly psychiatric view with  psychiatric interventions…  – Will not fix all symptoms  – Unlikely to ...
HOW OBVIOUS DOES IT HAVE TO BE?     The Challenge of Empathic Listening              & CREATIVE THINKING                  ...
“Sit down before fact asa little child,be prepared to give upevery preconceivednotion,follow humbly wherever… nature leads...
Mental health and hormones
Mental health and hormones
Mental health and hormones
Mental health and hormones
Mental health and hormones
Mental health and hormones
Mental health and hormones
Mental health and hormones
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Mental health and hormones

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This is the second of five lectures given by Dr. Cady in Santa Fe, NM for the 2012 IMMH conference. It covers the need to identify the hormonal deficiencies of a patient, and ways to remediate them.

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  • 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 &lt; 200ng/dL or FT &lt; 0.9ng/dL
  • Mental health and hormones

    1. 1. Mental Health and Hormones: What in the World do Hormones Have to Do with Current Allopathic Psychiatry? Louis B. Cady, MD – CEO & Founder – Cady Wellness Institute Adjunct Assoc. Prof. - Indiana University School of Medicine Department of Psychiatry Child, Adolescent, Adult & ForensicFor IMMH – Santa Fe, New Mexico Psychiatry – Evansville, IndianaSeptember 22, 2012 (c) 2012 Louis B. Cady, M.D. - all rights reserved
    2. 2. “The mind, onceexpanded to thedimensions of largerideas, never returns toits original size.” - Oliver Wendell Holmes
    3. 3. Rationale for this lecture:• Many “mental health” issues are actually “hormone health issues.”• Contemporary medical practice is not equipped to handle OPTIMIZATION of these hormones• The literature is CLEAR; conventional practice is frequently the OPPOSITE.• If you don’t go back with this to your town, nobody else will know it either.• You will have to decide how you will cope.
    4. 4. What our patients are telling us:
    5. 5. A Shrink meets the “anti-aging” crowd• Patient “complaints” • Personal experience• Loss of energy • Previous state:• Loss of stamina “energy to burn”• Loss of libido • “Snooze bar• Weight gain syndrome”• Loss of zest for life • “Piles syndrome”• Loss of interest in career • “Why can’t I make myself exercise?”• “I’ve felt like I’ve been aging since I was 35.” • Car wash MSE!
    6. 6. Interesting lab values – Cady – 3/11/03:Lab Value Cenegenics Normala.m.glucose 87 mg/dl 65 – 85 65 – 109Fasting insulin 3 u U/ml <5 <20HgB A1C 4.9 % <5.1% < 6.0 %Cholesterol 241 mg/dl <200 <200Triglycerides 42 mg/dl <120 <150Cor. Risk ratio 3.3 <4.0 Av = 5 – 6Homocysteine 7.9 <8.0 5.4-11.4DHEA-S 148 350 – 500 59 – 452
    7. 7. 4
    8. 8. Useful Target Symptoms in MDD ♦ 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)1. Tylee et al. Int Clin Psychopharmacol 1999;14:139-151. 2. Maurice-Tison et al. Br J GenPract 1998;48:1245-1246. 3. Baker et al. Comp Psychiatry 1971;12:354-65. 4. Horwath etal. J Affect Disord 1992;26:117-25. 5. Reynolds and Kupfer. Sleep 1987;10:199-215.
    9. 9. “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.
    10. 10. THYROID – this one is kind of important, gang!• Regulates: – Temperature – Metabolism – increases fat breakdown – BRAIN FUNCTION – ENERGY• Protects against: – Cardiovascular disease – Fatigue and weight gain – MEMORY LOSS – COGNITIVE IMPAIRMENT
    11. 11. FEEDBACK INHIBITIONSelenium CORTISOLrequired! “the foot soldier” “the evil twin”
    12. 12. Progress – sort ofGraphic from January 2003 AACE pres release accessed here:http://thyroid.about.com/od/gettestedanddiagnosed/ss/normaltsh_5.htm
    13. 13. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS MEDICAL GUIDELINES FOR CLINICAL PRACTICE FOR THE EVALUATION AND TREATMENT OF HYPERTHYROIDISM AND HYPOTHYROIDISM AACE Thyroid Task Force Chairman H. Jack Baskin, MD, MACE Committee Members Rhoda H. Cobin, MD, FACE Daniel S. Duick, MD, FACE Hossein Gharib, MD, FACE Richard B. Guttler, MD, FACE Michael M. Kaplan, MD, FACE Robert L. Segal, MD, FACE Reviewers Jeffrey R. Garber, MD, FACE Carlos R. Hamilton, Jr., MD, FACE Yehuda Handelsman, MD, FACP, FACE Richard Hellman, MD, FACP, FACE John S. Kukora, MD, FACS, FACE Philip Levy, MD, FACE Pasquale J. Palumbo, MD, MACE Steven M. Petak, MD, JD, FACE Herbert I. Rettinger, MD, MBA, FACE Helena W. Rodbard, MD, FACE F. John Service, MD, PhD, FACE, FACP, FRCPC Talla P. Shankar, MD, FACE Sheldon S. Stoffer, MD, FACE John B. Tourtelot, MD, FACE, CDR, USN 2006 AMENDED VERSION This amended version reflects a clarification to specify pertechnetate as the compound attached to 99mTc. ENDOCRINE PRACTICE V ol 8 No. 6 November/December 2002 457
    14. 14. “Thyrotropin (Thyroid-StimulatingHormone or TSH). Measuring TSH is themost sensitive indicator ofhypothyroidism.” (hunh?!) http://www.umm.edu/patiented/articles/how_serious_hypothyroidism Accessed: 9/5/2011
    15. 15. Se CORTISOL“the foot soldier” “the evil twin”
    16. 16. Modern Medicine’s Paradigm:Two Standard Deviations – “if you are not sick, then you must be well.” “NORMAL” OPTIMAL? OPTIMAL
    17. 17. Definition of “normal labs”: “When your lab values are as crappy as everyone else’s.” - Neal Rouzier, MD (World Link Medical Seminar II – Spring 2011)
    18. 18. Yes, T-3 DOES get into the brain (Transthyretin = carrier protein) Or: The idiocy of T4 only thyroid treatment…• 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]3,35-(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.
    19. 19. 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
    20. 20. LEVEL III RESULTS: 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
    21. 21. • Early 20’s college student• Weight gain, fatigue, brain fog• Saw “numerous” MD’s asking for help• Told “nothing is wrong with your thyroid; your labs are fine.”
    22. 22. Don’t forget DELAYED deep tendon reflexes – delayed relaxation.
    23. 23. The glycemic controlling hormonesCORTISOL-Gets glucose INSULIN:INTO the blood -Gets glucosefrom stored OUT of the bloodglycogen -Too little = DM-Good news – & complicationskeeps you from -Too muchdying causes:-Bad news – * Weightgoes up with gainstress * “Crashes”
    24. 24. W. Wheat Rice Big Mac, Ice cream;Toast, OJ, cakes, Fries, Shake Coke & chips coffee coffee H - 30
    25. 25. Blood sugar goes up due to cortisol for rescueW. WheatToast, OJ, Cortisol coffee secreted by adrenals H - 31
    26. 26. Benefits of low-glycemic eating H - 32
    27. 27. Glycemic index• A measure of how fast a carbohydrate triggers a rise in circulating blood sugar.• The higher the number, the greater the blood sugar response.
    28. 28. “The Twinkie Defense”• “A derisive lable for an improbable legal defense.” [Wikipedia]• Defendant Dan White for San Francisco murders of Harvey Milk and mayor George Moscone• Actually, “Twinkies” were used as a symptom of underlying depression, not the cause.• White – found guilty on voluntary manslaughter
    29. 29. Fatigue from Adrenal Dysfunction - TheWorst Case Scensario: Addison’s Disease
    30. 30. “Hypoadrenia”: The Adrenal Problem that mostconventionally trained physicians don’t know about.• Non-Addison’s hypoadrenia• Subclinical hypoadrenia• Neurasthenia• Adrenal neurasthenia• Adrenal apathy• Adrenal fatigue• “Adrenal burnout”• “Chronic fatigue syndrome”?!!
    31. 31. The state of adrenal exhaustion can be determined• 21 yo female college student• Exceptionally tired in the a.m.• Not following IgG food diet
    32. 32. 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
    33. 33. 348 citations on “DHEA with energy” – as of of 8/17/2012
    34. 34. The two “new ones” – 8/17/2012 - Opioid use has increased. - Concomitantly OPIAD has increased. - Testosterone and DHEA are recommended. -Corticotroph def = crucial element of ant. Pituitary failure -Dx with a.m. cortisol w/ stim -TX with HC 20 mg per day, divided doses. -Tx determined by fatigue, BP, BW, skin trophicity
    35. 35. 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
    36. 36. 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.”
    37. 37. “Women’s issues”
    38. 38. 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 = {300 –females, 600 males}
    39. 39. 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”
    40. 40. G.G. – labs before and after 4/11/11 interventions 7/11/11 changesTSH 3.84 Raise T4 from 0.01 (L) none 50 – 75 ugFT4 1.16 “ 1.24 “FT3 2.8 “ 3.3 “Progesterone <0.2 100mg topical 0.9 None HSTestosterone 11 4mg topical 15 4 mg LABIALDHEA-S 25 25 mg SR n/a continue
    41. 41. The glamorous grandmother – post tune-up Two pictures, after “tine-up” – removed from presentation posted on internet9/28/2011 (permission granted to use photos & data) 01/26/2012
    42. 42. 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
    43. 43. 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.”
    44. 44. 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.
    45. 45. 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 4 days!
    46. 46. 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.
    47. 47. 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.
    48. 48. The Case of “Pajama Mama”• 41 yo MWF, mother of three, 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 presentation – fluoxetine 20 mg; topirimate 100 mg, sumitriptatn as needed
    49. 49. 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 on controlling, overbearing, free- spending, financially irresponsible husband. – 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.
    50. 50. 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}
    51. 51. 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.”
    52. 52. 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)
    53. 53. 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.• “He has used anger to shut me down and shut me out from day 1. He still uses anger, but instead of me going away, he goes away. I don’t back down.”
    54. 54. Testosterone (Men) • Decline in male sex steroids not as abrupt as menopause, but equally debilitating –Between 40 – 70, average male loses: • Nearly 2" of height • 15% of bone density • 10 – 20 pounds of muscle • At 70 yoa, 15% completely impotent
    55. 55. T vs Cognitive Function Rosario ER. JAMA. 292(2004):1431-2
    56. 56. 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
    57. 57. 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
    58. 58. 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
    59. 59. Treatment options – not just “the needle”
    60. 60. State of the art compounding devices
    61. 61. The Case of the Mismanaged Executive - summary• 42 year old male ADHD CEO. Background in psychology. Now EXTREMELY stressed.• “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 in 3- 4 weeks. No antidepressant used.
    62. 62. Holistic Fun with HormonesA synthesis…
    63. 63. Key points• A predominantly psychiatric view with psychiatric interventions… – Will not fix all symptoms – Unlikely to get anybody else to do it for you, either.• STABILIZING THE BIOLOGICAL is critical for full remission and total wellness when hormones are not optimal.• Holistic and integrated tx required.• Yoking of thyroid, adrenal & sex steroids
    64. 64. 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)
    65. 65. “Sit down before fact asa little child,be prepared to give upevery preconceivednotion,follow humbly wherever… nature leads, or you shall learnnothing.”- Thomas H. Huxley

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