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Saturday, June 14, 2008

Beating Depression

Could you have an overactive or underactive thyroid and not even know it? Millions of Americans--and a high percentage of women in menopause and perimenopause (the decade or so before menopause during which hormonal, emotional, and physical changes begin)--do. Thyroid imbalances are not always easy to recognize. Only recently have physicians even begun to accept that minimal thyroid imbalances have an important effect on mental and physical health.

Do you have any of the following symptoms?
Always fatigued or exhausted
Irritable and impatient
Feeling too hot or too cold
Depressed, anxious, or panicky
Bothered by changes in your skin or hair
At the mercy of your moods
Inexplicably gaining or losing weight
Losing your enthusiasm for life
Sleeping poorly or insomniac

Are you feeling burned out from having acted on an excess of energy for several months? Are you listless, forgetful, and feeling disconnected from your friends and family? Are people telling you that you've changed? Are you taking Prozac® or a similar drug for mild depression but still feeling that your mind and mood are subpar? Or have you been treated for a major depression in the past five years?

If you suffer from more than one of these symptoms or answered yes to one or more of these questions, you could be one of the many people with an undiagnosed thyroid condition. Although some of these symptoms may seem contradictory, all of them can be indications of a thyroid imbalance.

You could also be one of the many people who has been treated for a thyroid imbalance but still suffers from its often-overlooked, lingering effects--effects that may continue to hauntyou even after treatments have presumably restored your thyroid levels to normal. If you've ever been treated for a thyroid imbalance, answer these questions:

Do you feel better but still not quite your old self?
Do you have unusual flare-ups of anger?
Are you less socially outgoing than you used to be?
Are you less tolerant of the foibles of family and friends?
Do you suffer from occasional bouts of mild depression?
Do you have frequent lapses in memory?
Are you often unable to concentrate on what you're doing?
Do you feel older than your chronological age?

If you've had a thyroid problem in the past but still answer yes to one or more of these questions, it is quite likely that your symptoms are thyroid-related. You don't have to suffer any longer. The Thyroid Solution will show you how you can work with your physician to heal these lingering symptoms.

The Thyroid and the Mind

At any given time in the United States, more than 20 million people suffer from a thyroid disorder, more than 10 million women have low-grade thyroid imbalance, and nearly 8 million people with thyroid imbalance remain undiagnosed. Some 500,000 new cases of thyroid imbalance occur each year. All of these people are vulnerable to mental and emotional effects for a long time even after being diagnosed. Incorrect or inadequate treatment leads to unnecessary suffering for millions of these people. But these are numbers. Behind the numbers are the symptoms and ravaging mental effects experienced by real human beings.

The 1990s have seen a major increase in the recognition and detection of previously unsuspected thyroid diseases among presumably healthy people. This stems in part from improved medical technology, which has led to the development of sensitive methods of screening and diagnosing thyroid disease. It also stems from the increased public awareness that thyroid disease may remain undiagnosed for a long time and that even mild thyroid dysfunction may affect your health. Recently, some medical associations such as the American Association of Clinical Endocrinologists have initiated public screenings for thyroid disease, much as cholesterol testing has become available in shopping malls and other public places. At any given time, more than half the patients in our population with low-grade hypothyroidism remain undiagnosed. In a recent thyroid-screening program involving nearly two thousand people that I directed in the Houston area, 8 percent of those tested had an underactive thyroid. Many people screened had nev
er heard of the thyroid gland but rushed to be tested when they recognized that they were suffering many of the symptoms listed in the announcement of the screening. The public's awareness of thyroid disease was boosted by press reports about former president George Bush and his wife Barbara, Russian president Boris Yeltsin, and Olympic track champion Gail Devers when they were diagnosed with thyroid disease. Thanks to these factors, people with nonspecific, undiagnosed complaints are becoming increasingly likely to ask their physicians whether their symptoms might be related to an undiagnosed thyroid disorder.

As an endocrinologist who has focused his research, teaching, and patient care on thyroid conditions, I realized early on in my practice that taking care of thyroid patients was not as easy as I had expected. Treating and correcting a thyroid condition with medication may not always make the patient feel entirely better. I discovered that to care fully for my patients, to help them heal completely, I had to treat their feelings as well as their bodies. If they didn't feel better even though their lab tests said they were cured, I learned to listen to them, believe them, and work with them to help them become wholly cured. In taking care of thyroid patients, the physician's role is not merely to address physical discomfort, test the thyroid, and make sure blood test results are normal (indicating that the right amounts of the various thyroid hormones are circulating in the body). Addressing the effects of thyroid disorders on the mind, helping patients cope with their condition, and counseling them sympathetic ally are equally important.

Many physicians treat dysfunctioning thyroids, but few of them listen to the person attached to the gland. They concentrate on the blood levels. For these physicians, once the lab results say that a patient appears stabilized, the case is closed. Yet many patients go on to suffer for years from a variety of symptoms left over from the thyroid imbalance. A recent survey conducted in our outpatient endocrine clinic revealed that nearly a third of patients with underactive thyroid glands continue to have symptoms after their thyroid hormone blood levels are normal. Physicians should be treating the still-suffering patients with new protocols for as long as it takes for the mental effects to subside. The reality today, however, is that millions of patients suffer needlessly while their doctors continue to treat thyroid dysfunction as a simple physical disorder rather than what it is: a complex blow to the body and brain.

In general, primary care physicians have not been adequately trained to detect and manage thyroid disease and may lack the expertise needed to diagnose and treat a wide range of thyroid disorders. They also receive little teaching on the effects of thyroid disease on mental health or on understanding the interplay between the mind and the thyroid.

The majority of practitioners of internal medicine and family medicine complete their residency without having had a rotation (or semester) in endocrinology. Many physicians leave their training programs with inadequate knowledge of thyroid disorders and inadequate experience in diagnosing and treating these disorders. Physicians who do receive training in endocrinology realize that thyroid conditions are more widespread than most people think and are also some of the more complex problems in medicine.

Recently I talked with several residents who were about to complete their training in internal medicine. They had also just finished a two-month rotation in endocrinology (including attendance at outpatient clinics). One outstanding resident, who was about to start a primary care practice, pointed out the inadequate training for primary care physicians in diagnosing and treating thyroid conditions. He confessed:

I didn't see many thyroid patients during my three years of training prior to attending your outpatient clinics. The patients I recall were those who came into the hospital with acute thyroid conditions or patients with medical conditions known to be related to thyroid disease. In these cases, the diagnosis was easy to make based on obvious signs and symptoms. But even in the outpatient setting, we residents seldom look for subtle indications of thyroid disease.

Because both the physical and mental symptoms of thyroid disease masquerade as signs of many other illnesses, getting the proper diagnosis can sometimes take a long time. Often symptoms are misdiagnosed and mistreated. Until patients find the right doctor, they are left alone to deal with devastating effects, which may include depression or even upsetting changes in personal behavior. Inexperienced and poorly trained physicians sometimes make their patients feel crazy or hypochondriacal when they report their symptoms. The doctors may give them antidepressants and a pep talk instead of blood tests, proper medication, and counseling on how to cope with their problems. Female hypothyroid patients may be given estrogen replacement therapy instead of thyroid hormone. Yet what male and female patients really need is a program of medication and counseling. Thyroid imbalance can quickly escalate into a destructive brain chemistry disorder--as powerful and pervasive as major depression, an anxiety disorder, or manic-

Once the brain has been denied thyroid hormone or oversupplied with it because of thyroid disease, it takes a long time to recover. If the symptoms are ignored, they can intensify. A vicious cycle occurs wherein the patient gets depressed, the thyroid disease worsens, physical and emotional effects multiply, and mental health suffers further. This cycle is not widely understood or recognized, and many physicians do not know how important it is to halt the cycle--or indeed how to halt it.

To understand how we got to this sad state of affairs, it is instructive to take a look at how perceptions of the thyroid and knowledge of its functions have evolved over the past century.

Changing Views of the Thyroid

The Swiss artist Arnold Böcklin (1827-1901) painted a portrait of a woman who appeared quite depressed. Her unsmiling face was sad and lifeless, and her eyes had a detached look. The most striking thing about her appearance, however, was that the front of her neck was swollen. The swelling was so evident that Böcklin drew attention to it with his use of color and lighting. As a layman, he recognized that she had a physical illness and that she was depressed, but it is doubtful that he made a connection between her physical and mental states because even physicians and psychiatrists did not begin to understand the true reason for this connection until the late nineteenth century. In fact, the chicken-or-the-egg riddle was at work: health care professionals did not know whether mood disorders and emotional problems were the result of thyroid disease or the cause of thyroid disease.

Even before the thyroid gland was shown to play a role in regulating metabolism, it was recognized as "the gland of the emotions." In fact, the relationship between the thyroid gland and the mind was thought for years to have merely an anatomical basis: the thyroid is physically close to the brain. The thyroid was believed to protect the brain from overheating, which could result from increased blood flow to the brain when a person was upset. Dr. Robert Graves was the first to provide the classic description of what is now known as Graves' disease. In his description of this "newly observed affection of the thyroid gland in females," he highlighted symptoms of the nervous system and used the term globus hystericus because of the many psychiatric manifestations exhibited by his patients. Dr. Caleb Parry, who had recognized the condition before Graves but expired before his observations were published, wrote: "In more than one of these [patients], the affliction of the head has amounted almost to madness."

For decades, in fact, Graves' disease was considered to be a mental illness rather than a true thyroid disorder. The early label "crystallized fright" illustrates that this condition was seen as some kind of mental illness that follows a psychological trauma. Among the first physicians to focus on the physical symptoms of the condition was Baron Carl Adolph von Basedow. In 1840, he described four patients with protruding eyes, goiter, and rapid heartbeat. He was also the first to describe pretibial myxedema, a brownish swelling over the legs that occurs in a small number of patients with Graves' disease. Whereas the term Graves' disease has prevailed in the English-speaking world, von Basedow's disease is the term used in Germany and some other European and African countries.

Nearly half a century after Graves' observations, the British physician Dr. William Gull described for the first time the physical and mental consequences of an underactive thyroid. His writings suggested that some of the effects of hypothyroidism were significant mental changes leading to a severe slowing of the mind. Since then it has become clear that the main function of the thyroid gland is to produce thyroid hormone, which regulates the functioning of our body and at the same time is a bona fide brain chemical that regulates mood, emotions, and many other brain functions. Doctors now have come to understand that the basis of the thyroid-mind connection, which was, for a long time, a mystery, is at least in part related to too little or too much thyroid hormone circulating in the body. A patient with a thyroid imbalance may experience physical effects such as skin problems, irregular heartbeat, congestive heart failure, high blood pressure, muscle dysfunction, and gastrointestinal disturbances. Thyroid h
ormones regulate the metabolic rate, a concept so well popularized that most people associate thyroid imbalance with metabolism and weight problems. And yet, for many people, the emotional and mood-related consequences of a thyroid imbalance are more drastic than the physical ones.

Paradoxically, whereas nineteenth-century physicians first described and demonstrated the significance of such mental symptoms, many modern-day physicians who treat thyroid patients tend to view thyroid disease only as a glandular disorder with physical symptoms.

Why Thyroid Imbalances Are Frequently Unsuspected

Patients with dysfunctional thyroid glands often go to their primary care physicians and describe an array of symptoms, both physical and emotional. Physicians are expected to find the root of the suffering and alleviate the symptoms with treatment. Primary care physicians, however, may have neither the time nor the expertise to deal with conditions involving a combination of physical and emotional symptoms. When patients describe symptoms such as fatigue and anger, many doctors fall back on the catchall diagnoses of stress, anxiety, or depression.

Even when doctors correctly diagnose their thyroid patients, they often fail to give the patients adequate information about their condition and symptoms. Patients may continue to suffer mental anguish because many physicians minimize the seriousness of the physical and mental consequences of thyroid imbalance. Patients may be infantilized or made to feel foolish for asking "too many questions" about "minor considerations" such as forgetfulness or mood swings. As a result, many patients find themselves isolated and misunderstood.

Some physicians may perceive important symptoms of hypothyroidism as trivial, primarily because a large percentage of the population complains of varying degrees of tiredness, lack of interest in life, and weight problems. Not only do symptoms of hypothyroidism and hyperthyroidism begin in an insidious fashion, but they can also involve different bodily organs. When physical symptoms of thyroid disease are prominent, the physician may focus on the specific organ or organs involved instead of searching for a general body imbalance and an underlying condition. The primary care physician may order tests only if he or she feels that the symptoms strongly indicate a thyroid disorder.

Let's take a look at the main reasons why doctors misdiagnose thyroid imbalances.

Stress, depression, anxiety, tiredness, and other emotional or mental states can mask a thyroid imbalance. The doctor on whom you rely to detect and treat your thyroid condition is usually the same doctor responsible for detecting and even treating most mood disorders. Depression is the most common condition seen in general medical practice. Researchers estimate that, at any given time, 10 percent of the population suffers from depression; over a lifetime, the prevalence may be as high as 17 percent. Most patients with mental health problems seek help from primary care physicians rather than psychiatrists. Quite often these physicians have received no training or inadequate training in assessing, detecting, and managing subtle mental disorders. Doctors in health maintenance organizations accurately diagnose fewer than 50 percent of those patients with unequivocal depression. Even among those who are correctly diagnosed with depression, only a small portion receives adequate treatment for a sufficient time.

During physicians' training, their exposure to psychiatric problems takes place primarily in emergency rooms and less frequently in hospital wards. But they receive virtually no formal training in outpatient psychiatry. Quite often, patients with thyroid disease will describe symptoms that may indicate depression but without recognizing that they are depressed. Some doctors may dismiss these symptoms as unimportant. Under some managed care systems, doctors cannot spend additional time talking to patients who may be depressed because they do not have time or do not get reimbursed for that time. Getting into the emotional aspects of somebody's life can be a drain on physicians' energy, so many will actually avoid trying to understand the roots of a patient's anxiety or depression. Internists and family practitioners may feel uncomfortable dealing with mental anguish and may stick to the familiar territory of performing a physical examination, obtaining laboratory test results, and prescribing medications.

Some doctors may tell their patients "You're doing too much" if they complain about tiredness, depression, and weight gain. One patient of mine, Margaret, a twenty-seven-year-old financial broker, told me of her experience with a previous physician. At the time, Margaret had become continually exhausted and moody and had gained twenty pounds. At first, she felt embarrassed to go see her doctor, thinking, "Who goes to the doctor because they're tired?" After three months of suffering, however, she did go to see her physician. He examined her and advised, "Exercise more and don't eat so much." According to Margaret, "I told him I was exercising more than anyone I know. He probably didn't believe me. The second time that I told him about my tiredness, he was flippant and said, 'I don't think you're sick.'"

Margaret was frustrated, angry, and depressed for months. Thankfully, her stepmother suggested that Margaret get a thyroid test. Margaret was finally diagnosed with an underactive thyroid.

When obvious precipitating reasons for depression are present--such as a difficult divorce, a stressful job, or other personal problems--a doctor is unlikely to consider a thyroid dysfunction as a possible cause or a contributing factor to the depression. The patient, family members, and the doctor become convinced that the overwhelming stress and life situations are responsible for the symptoms. Yet, as we'll see in Chapter 2, stress itself can trigger a thyroid imbalance and contribute to depression. Stress generated by the effects of thyroid hormone imbalance can lead to an escalating cycle of stress/illness/stress. Stressful life events may then be blamed for what are really thyroid-related symptoms, allowing these symptoms to linger and intensify. I recommend that everyone who has experienced a major stressful event, such as a difficult divorce or the death of a loved one, and has ongoing anxiety symptoms have his or her thyroid tested.

Doctors are even more likely to miss a thyroid problem and misdiagnose you if you have previously suffered from depression, panic attacks, or any other mood disorder. Symptoms of a thyroid imbalance are then likely to be attributed to the mood disorder, and the physician searches no further. One patient told me, "I learned quickly after I had been in the psychiatric hospital the first time what not to tell doctors, because once they hear that you had a mental condition, they disregard everything else you say."

Depression and anxiety disorders are the most common psychiatric conditions in the general population as well as the most common mental effects of thyroid disease. Therefore, patients with thyroid imbalance may see a psychiatrist rather than a medical practitioner. Because depression and anxiety disorders can cause the same physical symptoms as thyroid imbalance (such as a rapid heartbeat, increased sweating, and lack of sleep), psychiatrists are likely to come up with a psychiatric diagnosis when they see a thyroid patient. Often psychiatrists do not perform physical examinations that could lead them to detect physical causes for mental symptoms. One study showed that when psychiatrists use conventional psychiatric criteria to assess hyperthyroid patients, they diagnose nearly half of the patients as depressed or suffering from an anxiety disorder. Unfortunately, some psychiatrists do not always assess their patients for an underlying thyroid condition that might explain their fatigue, lack of interest in life, and inability to function as before.

The apparently close link between depression and thyroid imbalance has wide-ranging consequences. For a person like Rachel, a young wife and real estate agent I treated recently, uncovering that link was crucial for overall health and happiness. Before her true, thyroid-related condition was identified and treated, Rachel showed many of the signs of clinical depression. "I was always tired," she related.

I couldn't exercise anymore, and that was very frustrating. I would come home and fall asleep. If I wasn't sleeping, I was doing nothing more than watching TV. I didn't cook. I didn't clean. I didn't even let the dog out. I also put on twenty pounds in one month and lost a lot of hair, which was terrible for my looks and my self-esteem. I became cold and was constantly turning up the thermostat. Jimmy, my husband, couldn't believe I was so cold. I just had no willpower. I had to take a broker's license test, which cost my firm $2,000, but I couldn't even get motivated to study for it. I just wanted to go home and put on my nightgown and sit there on the couch. I lost interest in having any social life with my husband. I didn't want to see anyone. We quit going out. Our sexual relationship went to zero, too.

Given Rachel's symptoms, it is not surprising that for a long time she was diagnosed as depressed. Yet many of these same symptoms are associated with an underactive thyroid, and when Rachel was treated for her thyroid imbalance, she began to improve. "I gradually woke up and began to feel good," she said. "I didn't feel groggy or rushed anymore. I started eating right. I was more active and doing moderate exercise, and I lost thirty pounds. My husband and I went dancing, and I reunited with my friends again. They all asked, 'Where were you?'" For Rachel to fully answer that question, she would need to understand more about the interplay of thyroid, mind, and mood. Clearly, an underactive thyroid frequently causes depression, and an overactive thyroid tends to result in an anxiety disorder. Nevertheless, anxiety is also common in hypothyroid patients, and some patients with an overactive thyroid suffer from depression. Although when hyperthyroid patients suffer from depression, the bouts of depression tend to be short-lived, some of these patients may have persistent, lingering depression that fulfills the psychiatric criteria for depression.

Patients aren't totally aware of the full range of their symptoms or don't communicate them to their doctors. Patients themselves sometimes unintentionally hinder a proper diagnosis by failing to volunteer all of their complaints to their doctors. The statement "I'm tired and exhausted" usually reflects only surface symptoms. The symptom of fatigue may hide a multitude of feelings and emotional problems that patients may be reluctant to reveal. Most people have difficulty analyzing and clearly expressing how they feel or how their mind has been affected. Often we are not taught to recognize how our hearts feel, and many of us are taught to ignore or discount our emotions. We frequently lump all discomfort and mental suffering into "I'm tired, I'm exhausted, and I can't function the way I used to." Also, we tend to dismiss any mental or physical dysfunction as temporary.

Many people experiencing fatigue, lack of interest in life, and an inability to function as they once did suffer for years. They adjust to these feelings and are able to work and take care of responsibilities at home. But inside they are hurting. They have to struggle to appear normal to those around them. They live in a state of denial or self-dismissal and may not seek help or treatment for their symptoms.

Some of this self-dismissal stems from the stigma our culture puts on any and all mental conditions. The prevailing view that mental suffering is less serious than physical suffering may cause some persons with a thyroid imbalance to hide their anxiety, depression, or pain and not seek medical help. Others may fear ridicule from friends and relatives if they do seek treatment.

One patient who was suffering from lingering depression due to hypothyroidism told me, "I knew I was depressed and something was inadequate within me. I didn't want my family to know. I didn't want my company to know. I didn't have health insurance coverage for depression treatment, so I couldn't afford proper help." Many patients who seek psychiatric care may encounter significant difficulties in obtaining life and disability insurance. Many people with depression choose not to be diagnosed and treated because they know they will be discriminated against when they change jobs.

A second-year law student whom I evaluated for a possible thyroid disorder had suffered from a severe anxiety disorder for two years. He had correctly diagnosed his anxiety disorder a year earlier but had not reached out for help. "I could not go see a psychiatrist because later on, when I sit for my bar exams, just having a record saying I saw a psychiatrist will affect my entire career." This patient turned out to have an overactive thyroid due to Graves' disease.

I cannot emphasize enough how important it is for you to seek help as soon as possible after the onset of your symptoms rather than accepting them and doing nothing about them.

The wide range of physical symptoms can mask a thyroid imbalance. Another reason why doctors may miss a diagnosis of thyroid disease is that thyroid patients' mental suffering may be buried amid the multiple physical effects of thyroid disease. When physical symptoms of thyroid disease are quite prominent, doctors may treat patients for those specific symptoms and fail to diagnose the thyroid condition that is causing the symptoms. For instance, rapid heartbeat is a common symptom of an overactive thyroid that often leads physicians to consider heart disease. But if the heart evaluation is normal, doctors often dismiss the patient as anxious.

Excerpted from

The Thyroid Solution: A Mind-Body Program for Beating Depression and Regaining Your Emotional and Physical Health
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