Management of Hypothyroidism in a Patient
With an Affective Disorder

Michael Bauer, MD
Department of Psychiatry and Behavioral Sciences
Charite University Hospital
Berlin, Germany

A 59-year-old white female was admitted to the psychiatric hospital after an attempted suicide with lethal amounts of venlafaxine, her prescribed antidepressant. Because spontaneous vomiting hindered absorption of the medication, the plasma concentration of venlafaxine did not exceed therapeutic levels. When interviewed, the patient stated that in the past 3 weeks she had experienced a deterioration of mood and increasing abdominal discomfort, which prompted her to discontinue her medication. Ultimately, the abdominal pain grew intolerable, and suicide appeared to be the only way to make it stop.

Medical history: 
Until age 57, the patient had never been seriously ill. Past history included an appendectomy and surgery for extrauterine pregnancy. Upon physical examination, the patient's body weight, blood pressure, glucose, and lipid metabolism were all within normal levels, except for a small goiter and mildly increased low-density lipoprotein (LDL) cholesterol. The patient smokes less than 5 cigarettes per day and does not drink alcohol. There is no family history of mood disorder. Noteworthy biographical events include the expulsion of her family from Poland at the end of World War II. She has worked in a factory as a machine operator for more than 20 years. After divorcing her first husband, she remarried and has been married for 33 years, without children. 

At the age of 57, after the patient's husband was hospitalized for severe cardiac arrhythmia, she became very anxious that he might die. Even after the patient's husband was discharged and his health improved, her anxiety level increased while suffering from sleep deprivation and an inability to concentrate at work. Ultimately, she retired from work to be with her husband full time because she was convinced that something was going to happen to him. In the following weeks, her sleeplessness and anxiety further increased. The patient was also suffering from loss of appetite and was unable to engage in her normal activities for lack of energy, while at the same time feeling restless. The patient also complained of a constant depressed mood. In addition, the patient felt that she should not tell her husband about her state of mind because this might cause further deterioration of his health. 

The patient's husband became increasingly aware of her problems, prompting the couple to see their general practitioner. The general practitioner made a diagnosis of major depression, and the patient was admitted to a psychiatric hospital, where she was started on amitriptyline plus risperidone to control delusional thinking. A month later, she was discharged on citalopram plus risperidone in what appeared to be a stable condition. However, in the following 2 years, 4 further psychiatric hospital admissions became necessary with only a few weeks in-between. Several antidepressant regimens were tried (ie, paroxetine, venlafaxine, clomipramine, clomipramine plus lithium carbonate, moclobemide, mirtazapine, and-presently-venlafaxine, trazodone, and lithium carbonate). Thus far, the patient's depressive symptoms were either not controlled or relapsed soon after the discharge from the unit. During the time of her illness, the patient developed various physical symptoms and developed panic attacks upon leaving her home. She repeatedly reported suicidal thoughts; in fact, previous admission was also prompted by a suicide attempt with an overdose on antidepressant drugs. Finally, a medical work-up revealed hypothyroidism with low thyroxine (T₄) and elevated thyroid-stimulating hormone (TSH) levels. Interestingly, the patient did not have physical complaints related to the thyroid dysfunction, but in the presence of high titers of thyroperoxidase (TPO) and thyroglobulin antibodies, Hashimoto thyroiditis was the likely etiology. The patient has since been treated with levothyroxine 75 µg daily with frequent monitoring of thyroid hormones and TSH. Shortly after initiation of thyroid hormone replacement therapy, the patient's depression significantly improved. 
Upon the final hospital admission, laboratory findings revealed an elevated TSH level of 7.9 IU/mL (normal range, 0.3-4.0), and triiodothyronine (T₃) and T₄ were at the lower limit of normal.