See introduction
ANTIDEPRESSANTS
SSRI’s, or Selective Serotonin Reuptake Inhibitors, modulate the serotonin system. They keep serotonin in the synapses between cells longer, which increases serotonin activity. This happens within 12 hours and some conditions like Premenstrual Dysphoric Disorder and premature ejaculation respond very quickly to these medications. It takes 2-3 weeks for SSRI’s to start helping anxiety and depression. This is because it’s not the direct effect of serotonin but how it effects the receiving cells and the sending cells. I call SSRI’s modulators because they increase serotonin activity if it’s too low (as in depression) and decrease it if it’s too high (as in anxiety). Sometimes serotonin is high in some brain areas and low in others.
SSRI’s started with Prozac in 1987 and now include Zoloft, Paxil, Luvox, Celexa, and Lexapro. I include Effexor XR 37.5 to 75mg in this group because at these doses its primary effect is on serotonin. At higher doses (150-225mg) it is an SNRI. SSRI’s, including low doses of Effexor XR are better for anxiety disorders than depression. All SSRI’s have potential side-effect issues in the short term and long term.
The biggest problem with the SSRI’s is in the long term. This is what matters the most to patients because they usually need these medications long term. Over several weeks to months there is frequently a “poop out” effect associated with some decrease in energy/motivation. Sexual dysfunction, especially loss of libido, and weight gain are common. Sometimes these can be improved by lowering the dose or adding another medication (like Wellbutrin XL), or in the case of Effexor XR, either increasing or decreasing the dose. But sometimes patients prefer to stop the medication or change to something else.
Protein binding is an important factor with the SSRI’s because it’s only the percentage of the medication that is free (not protein bound) that interacts with the receptors on the cells. Medications are like keys, and receptors are like locks. Medication can either turn on the receptors or plug them up and prevent them from being turned on.
BEST SSRI’s

1. EFFEXOR XR
Effexor XR is my first choice for an SSRI mainly because it is the one that in my experience patients are most likely to be happy with long term. It is the quickest to work probably because it has the lowest protein binding (27%). I expect some benefit for anxiety/depression by 7 days. Effexor XR doesn’t have any significant drug-drug interactions. It has the flexibility of being increased to higher doses if/when needed, so that it becomes also a norepinephrine reuptake inhibitor. (see SNRI’s below) Effexor XR comes in capsules that can be opened and sprinkled on food to take partial doses or for people who have trouble swallowing.
Of the SSRI’s it is one of the least likely to have drug-drug interactions. It is well tolerated. Occasionally it causes initial jitteriness or nausea, but these side effects go away quickly. In general, long term side effects are the lowest of this group, except for delayed orgasm – sometimes a benefit for men. If it occurs in women, taking it after sex sometimes solves the problem.
Because Effexor XR clears the system in 3 days, it can cause rebound symptoms if stopped abruptly. It needs to be gradually tapered. On the other hand, for women who may get pregnant unexpectedly they can stop taking it and have it out of the system before maternal blood mixes with the embryo. Also, when used for Premenstrual Dysphoric Disorder, it is out of the system more quickly once stopped. With this type of very short term use, there are no rebound concerns.
2. LEXAPRO
Lexapro is my 2nd choice in this category. It has the most pure effect on serotonin, and this is an advantage for patients who don’t tolerate any norepinephrine effect. (see SNRI’s below) Because it is 56% protein bound, it is fairly rapid in onset of benefit – I expect improvement beginning in 10 days.
It has flexible dosing since it comes in tablets that can be cut. Like Effexor XR, it has minimal drug-drug interactions. Rebound is not a significant issue at least in adults.
CELEXAis 1/2 Lexapro and 1/2 relatively inactive. It acts much in the same way as Lexapro.
PROZAC
Prozac (fluoxetine) is my 3rd choice because of my long term success with many patients, especially with Obsessive Compulsive Disorder. It may be the safest in kids and young teenagers, probably because it has such a long duration of action. It takes 6 weeks to clear the body, and therefore, rebound symptoms are not an issue. Weight gain and sexual dysfunction aren’t as bad as with some of the other SSRI’s. It has 96% protein binding so onset of action usually takes at least 2 weeks.
A major problem with Prozac is that it blocks a certain enzyme system that will increase other medications. These include tricyclics, Risperdal, Dextromorphan, Strattera, and others, and decreased benefit of pain medications.

PAXIL CR
Paxil CR is a controlled release form of Paxil. 25mg of CR is equal to 20mg of the regular Paxil. It is the only SSRI that has a formal approval for all five anxiety disorders. It may be the most effective SSRI for Social Anxiety Disorder possibly because it has blocking action on the parasympathetic nervous system – which is frequently overactive with social anxiety. This blocking effect may also contribute to a sedative effect that it sometimes has – which may help with sleep even when first starting it. But the blocking effect may also contribute to side effects like constipation and sexual dysfunction.
In my experience Paxil has the worst rebound symptoms if stopped suddenly or doses are missed. It may also be more likely to cause agitation in kids and young teens. It is probably the worst SSRI for weight gain and sexual dysfunction. It also is the strongest blocker of one of the liver enzyme systems – blocking benefit from pain pills related to codeine or hydrocodone and also increasing levels of other meds like TCA’s, Strattera, Risperdal, and others. This can potentially cause toxic levels of these other meds. Because of the side effects and drug-drug interactions, I only prescribe it when other medications have not worked well. I do have many patients who have done well on it especially for Social Anxiety Disorder.
ZOLOFT
Zoloft was the 2nd SSRI available, so I had a lot of experience with it early on. It was also one of the first to be formally approved for many of the anxiety disorders. It has some effects on dopamine, and one study showed that at doses of 150mg, it had comparable benefits to Effexor. Unfortunately the dopamine effect may cause anxiety or restlessness that is sometimes severe. One 10 year old girl I had on it described her side effects as there was something inside of her that she wanted cut out because she couldn’t stand it (severe inner restlessness). It is the least likely to cause drowsiness or sluggishness and drug-drug interactions are mild (except at higher doses).
Mainly, I rank it low because over the years in my experience the percent of people who do real well on it long term is very low.
LUVOX
Luvox is now only in generic and is only formally approved for OCD but is not necessarily better for OCD than any other SSRI (several are also formally approved for OCD). I have a couple of patients on it – mostly because they were on it when I first saw them, and it seems to work o.k. So “if it ain’t broke, don’t fix it”.
The reason I rank it last is that it has a lot of side effects and the most drug-drug interactions. It’s the most likely to cause drowsiness and the most likely to cause insomnia. It prolongs the effect of caffeine by several hours, which may also contribute to a feeling of anxiousness. For these reasons I rank it last.
One indication may be for people who take Zyprexa – especially if they smoke. Luvox will decrease their daily dose requirement – which could save several hundred dollars per month. How esoteric is that?
SNRI’s
Serotonin Norepinephrine Reuptake Inhibitors are serotonin modulators (SSRI’s), and norephinephrine modulators (NRI’s).
By blocking the reuptake of norepinephrine SNRI’s modulate this system just as SSRI’s modulate serotonin. Adding the norepinephrine effect increases benefit for generalized anxiety and especially increases the benefit for depression. In multiple studies antidepressants that modulate both serotonin and norepinephrine consistently help more patients reach full remission.
Chronic major depression is associated with low serotonin and low norepinephrine levels and this results not only in increased pain from all causes, but multiple other physical/medical problems such as urinary and sexual dysfunction.
It also seems that the norepinephrine effect reduces “poop out” seen so frequently with SSRI’s. It may also help with ADHD.
1. EFFEXOR XR 150-225mg
I rank Effexor XR as my #1 choice in this category. As the dose of Effexor XR goes up, the effect on serotonin levels off and the effect on norepinephrine increases. Effexor XR has the flexibility of being an SSRI at lower doses and an SNRI at higher doses. It works quicker (probably due to low protein binding), has no significant drug-drug interactions, and has a proven record for the full range of anxiety disorders and depression. In my experience over the long haul, it has the greatest benefit and the best tolerability of any antidepressant, and I therefore rank it my #1 antidepressant.
2. CYMBALTA
I rank Cymbalta as my #2 choice in this category, partly because it has been on the market for less than a year, so we don’t have a lot of experience with it. It works well for depression, and it may help all the anxiety disorders. But the studies haven’t been done. It may not be tolerated by panic patients. There are more controlled studies with Cymbalta showing benefit for all kinds of pain than any other antidepressant. It is especially helpful for back pain.
Some patients don’t tolerate it very well, and the dosing isn’t as flexible because it’s in capsules that can’t be sprinkled. There are issues with drug-drug interactions – it shouldn’t be mixed with Paxil or Prozac. It will weaken the effect of pain medications. 7% of Caucasians are genetically slow metabolizers and may have a significant increase in blood levels of Cymbalta and may show more side effects. Cymbalta will increase Strattera, Risperdal, Dextromorphan, and others. Having drug-drug interactions increases the complexity of prescribing any medication.
Because of its proven track record, I start with Effexor. But for those that don’t do well on Effexor for whatever reason, I have had some success with Cymbalta, especially for depression associated with chronic pain.

Other Antidepressants
WELLBUTRIN XL
Wellbutrin XL is a totally different type of antidepressant. It is not a reuptake inhibitor, so it is not a modulator like the SSRI’s and SNRI’s. Its mechanism of action is not as well understood but we know it increases norepinephrine and to a lesser degree increases dopamine. Wellbutrin’s main benefit is to increase motivation, energy and interest and to restore the capacity for pleasure and enjoyment that is often lost when someone is clinically depressed.
Sexual dysfunction, (reduced libido, arousal, orgasmic delay or absence) can be a part of clinical depression or a side effect of SSRI’s or SNRI’s. Wellbutrin frequently improves sexual functioning either given alone or with other antidepressants.
Wellbutrin may help some of the symptoms of ADHD, but like Provigil, Tenex, or Strattera it doesn’t have the level of effectiveness that the stimulants (Adderall XR, Concerta, etc.) have.
Wellbutrin is the most effective medicine currently on the U.S. market to decrease craving for smoking and to make it easier to quit or at least cut back. It was marketed for smoking cessation under a different name, Zyban, which I thought was silly and causes a lot of confusion.
The best thing about Wellbutrin is that it doesn’t cause weight gain or sexual dysfunction short term or long term. It may cause nervousness, irritability, insomnia or constipation.
Wellbutrin is not a broad spectrum antidepressant like Effexor XR or Cymbalta. It is not useful for premenstrual dysphoric disorder, anxiety disorders or the cognitive symptoms of depression. It is not as good for sadness and guilt. But overall it is probably the best tolerated antidepressant long term, and many of my patients take it.
The XL form is better tolerated than the SR (now in generic) and especially better than the short acting tablets which are much more likely to cause side effects and lower seizure threshold. Caution still is necessary even with the XL in someone with an elevated risk of seizure either because of a previous seizure or severe head injury. It is also not safe in actively purging bulimics. In over 15 years of using Wellbutrin, the only seizures I have seen have been associated with abruptly stopping Xanax – usually with excess levels of shorter acting Wellbutrin. For most patients it is a non-issue.
Wellbutrin XL is very good for motivation, interest, and pleasure, but because it doesn’t do well with the whole range of depressive symptoms nor with anxiety disorders, I rank it 2nd overall of the antidepressants.

REMERON
Now available in Sol tabs that dissolve immediately for those who have trouble swallowing like the elderly and young children. The regular tabs are now available in generic.
Remeron is a broad spectrum antidepressant that is sometimes used to immediately enhance sleep and appetite. I tell patients you’ll sleep the first night and you’ll gain weight in your sleep. For people who have lost a lot of weight due to depression or for the elderly who have no appetite with or without depression this is very helpful. It is also sometimes used to treat stimulant side effects – especially in preadolescent boys who are usually not interested in losing any weight.
I use Remeron most often to enhance other antidepressants, especially Effexor XR. In addition to helping with sleep and appetite, it accelerates the antidepressant effect of Effexor XR and blocks side effects so that I can push the dose of Effexor rapidly – this is especially important with severe melancholic depression.
I usually start at 7.5mg or less because a.m. sedation/grogginess is so common. Starting with a higher dose may be less likely to cause a.m. sedation but may actually be worse, so I prefer to start low. This effect improves in a few days.
Remeron is usually not a good long term treatment because of the carbohydrate craving and weight gain. One lady told me, “Doctor you don’t understand. I got up during the night, drove to an all night grocery store and bought a cake. Then I went home and ate the whole cake.”
Because of daytime drowsiness that is so common and major league weight gain my overall ranking for Remeron is low. But for certain situations or for short term use it is very effective, and it’s in generic so reasonably priced.

Click here to see how Dr. Jones determines “Best Meds”
I decided to discuss anxiety and depression together because they usually occur
together, have a lot of the same genetic predisposition, and respond to a lot of the same medications.
Anxiety is like spending more money than you make – depression is like being in debt. In anxiety there is excessive activity in certain brain modulators, especially serotonin and norepinephrine. There also may not be enough GABA, the brain’s natural tranquilizing system.
Anxiety symptoms (and ultimately clinical depression) are caused by stress overload and more importantly stress vulnerability (genetics and early life experience). Unfortunately, the worse your genetics the more likely you are to have early life trauma, loss, abuse, i.e. “double jeopardy”.
There are five types of anxiety disorders – mostly treated with the same medications, but each responding to different types of cognitive behavioral therapy.
They are:
• Generalized Anxiety Disorder
• Panic Disorder +/- Agoraphobia
• Social Anxiety Disorder
• Obsessive Compulsive Disorder
• Post Traumatic Stress Disorder
Treatment Options

When treating anxiety disorders, I usually start with a benzodiazepine or something that works quickly. In some cases, like panic disorder and occasionally social anxiety or GAD, this along with cognitive behavioral therapy is all that is needed. But usually for OCD and PTSD and frequently for the other anxiety disorders, an SSRI or SNRI is the more definitive treatment. The problem is they take 2-4 weeks or more to help, and in the meantime, their side-effects make things worse. So, usually I start with a benzodiazepine and add on an SSRI plus cognitive behavioral therapy. Then, as the patient gets back to normal, frequently we can taper one of the medications. Benzodiazepines, not SSRI’s, can also be taken on an as needed basis.
Generalized Anxiety Disorder combines excessive worry with hyperarousal. It responds to benzodiazepines, SSRI’s, SNRI’s, Tricyclics, some anticonvulsants (Neurontin, Gabatril), and Buspar.
Social Anxiety Disorder – the generalized type responds to SSRI’s, SNRI’s, benzodiazepines, some anticonvulsants, MAOI’s and sometimes stimulants.
For specific performance anxiety, we often use beta blockers +/- alpha blockers to prevent heart pounding, shaky voice or hands, blushing or excessive sweating. These meds are most often used situationally.
Panic Disorder – Benzodiazepines, especially Alprazolam and Clonazepam, SSRI’s, SNRI’s
Obsessive Compulsive Disorder – SSRI’s, Anafranil, Clonazepam, Atypicals
Post Traumatic Stress Disorder – SSRI’s, SNRI’s, benzodiazepines, Atypicals, sometimes Beta Blocker’s (especially the first 24 hours)
PTSD is much more than anxiety disorder and will be discussed in detail in a future article.
In clinically depressed states, there are one or more deficits in brain modulators serotonin, norepinephrine, and dopamine. Stress hormones, especially cortisol and cortisol releasing factor, are elevated. Stress hormones are bad for your physical and mental health. Modulating brain transmitters with antidepressants normalizes stress hormones and therefore protects your health.
The most prescribed antidepressants are SSRI’s and SNRI’s and Wellbutrin. If a benzodiazepine is needed for anxiety Alprazolam is preferable. Other medications, like stimulants, hormones, sleep medications, and mood stabilizers, may be used, and MAOI’s are still occasionally used.
When treating depression I start with sleep problems and anxiety, if present. Antidepressants take time to work, and people who are suffering with clinical depression need some reason to be hopeful – the sooner the better. For recurring depression “the dose that got you well keeps you well”. So, we need to choose carefully, minimizing long term side-effects.
Benzodiazepines (Bnz)
Benzodiazepines have been used since 1960. They all work by enhancing GABA, the natural tranquilizer in the brain. We have more GABA than any other neurotransmitter. Some people with anxiety disorders have been found to have a deficiency of GABA in areas of the brain that regulate emotion. Because benzo’s work indirectly, they are relatively safe (i.e., you won’t die from an accidental or intentional overdose because they don’t suppress breathing like barbiturates and alcohol do in overdose amounts).
One myth that complicates the use of BNZ by doctors and patients is that they are “highly addictive”. The fact is that if they are taken regularly, so that they are always in your system, over time you develop a physical dependence. This means that you have physiologically adapted to the medication, and if you stop it suddenly or go off it too fast you can have withdrawal symptoms. But, physical dependence has nothing to do with addiction. Addiction is compulsive behavior in spite of negative consequences. Most people take medication to feel more normal and to be able to function. Addicts aren’t interested in feeling normal. It’s either “too boring” or “too stressful” or both. They prefer to be “high” or “numb”. The small percent of patients who abuse bnz’s are usually wanting to be numb. But this is less than 5% of patients who are prescribed one of these medications. Pain meds, especially hydrocodone types, are 3x more likely to be abused.
All bnz’s multiply the effects of alcohol, and mixing them will significantly increase the effect of both. This is especially a problem with driving – if mixing alcohol and bnz’s don’t drive. This is especially a problem with longer acting benzo’s.
Best Benzodiazepines
Xanax (Alprazolam) has been available since 1980 and is my first choice. I have many patients who have taken this medication either regularly or as needed for up to 25 years. Literally hundreds of patients I have treated with Xanax will say things like “it saved my life”. It is especially good for panic attacks and anxiety and it may help depression (although it’s not an antidepressant). There are cases where it has caused hypomania in a Bipolar patient. It has very few side effects – mainly sedation if too high a dose. The regular tabs are short-acting (4-8 hours), and most people who take them for a continuous effect take 4 doses per day. There is now an XR form that can be taken once or twice daily. Xanax (Alprazolam) was the most prescribed medication in 2003 for stress disorders in the U.S.
Niravam (Alprazolam orally disintegrating tablet) is now available. It is a rapidly dissolving wafer. Many patients report that it is convenient and faster to take. Some patients prefer to dissolve it under the tongue. Wafer forms of medication are especially helpful with panic patients who frequently have difficulty swallowing pills. They usually have more confidence when they have a medication with them that doesn’t require water and can be taken inconspicuously.

Klonopin (Clonazepam) is a close 2nd to Xanax. It is now available as Klonopin wafers that dissolve immediately, and used sublingually (under the tongue), seem to work faster. This is especially useful for panic attacks and acute anxiety. Klonopin is good for racing thoughts (helps with mania) and obsessing (is often added for OCD) and social anxiety. It is not as good for general anxiety. It is twice as strong as Xanax for panic attacks so 1mg Xanax = .5mg Klonopin. Klonopin lasts for 6-12 hours. It has more potential side-effects, probably because it seems to be the only bnz to decrease release of serotonin. It can worsen depression especially at doses above 2mg/day, and it can cause significant sexual dysfunction. It’s because of the potential side-effects of Klonopin and the greater benefit in general for anxiety and depression that I rank Xanax 1st and Klonopin 2nd.
Ativan (lorazepam) is relatively short acting like Xanax and is only 1/2 as strong for panic (1mg Xanax = 2mg Ativan). It is relatively effective for anxiety and is also a good muscle relaxant. It is one of the milder medications in this class. Abuse potential is similar to Xanax. It doesn’t go through normal liver metabolism, so it is safer in patients with liver problems.
Tranxene (clorazepate) and longer acting Tranxene 50 are long acting and mild. They have a relatively low abuse potential and can be taken once daily. They provide help with anxiety for 24 hours. They are not helpful for panic disorder because it would require very high doses.
Valium (diazepam) has been around for over 40 years. Of the bnz’s it is the most likely to be abused because it is highly fat soluble and has the quickest onset of action that might provide a euphoric feeling. It is also long acting, so that it may take 2-3 days or longer to be completely out of the system. It is good for anxiety and muscle relaxation, but not panic attacks. I have a few patients that have been on it for years and do well on it, but I very seldom put new patients on it.
Serax (oxazepam) is not used much anymore. The main reason that it use to be prescribed is that it is the least likely to lead to disinhibition, anger, and aggression in impulsive type people. I use it very seldom now. Like Ativan, it doesn’t go through normal liver metabolism.

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More on antidepressants
Read Dr. Jones’ response to email on benzo’s

HORMONE TREATMENTS FOR MOOD DISORDERS
Strictly speaking, hormones (especially thyroid and estrogen) are not mood stabilizers, but, in my experience, need to be addressed first in all mood disorders.
THYROID
The thyroid hormone T4 (Synthroid) helps to stabilize mood, but needs to be in the upper 1/4th of the normal range. Another thyroid hormone, T3 (Cytomel), acts more like an antidepressant. Thyrolar and Armour thyroid provide T4 + T3.
TESTOSTERONE
In men with depression and low testosterone – supplemental replacement hormone has anti-depressant effects. Unfortunately, oral testosterone is not effective in men. Injections are a hassle. Patches and gels are expensive and frequently not covered by insurance.
DHEA
A recent study found that supplemental DHEA, which is an inexpensive over-the-counter, may help depression. It is a normal hormone that slowly declines in both men and women. It turns into partly estrogen, partly testosterone.
ESTROGEN & PROGESTRONE
I have treated many women over the years that were perimenopausal or menopausal in whom I was not able to control their depression or mood swings without supplemental estrogen. There is confusion and controversy regarding the use of hormone replacement therapy (HRT) in menopausal women. Each study seems to contradict the one before.
The confusion is due to multiple factors – usually not addressed in the studies. The simplest factor is dosage – lower doses are probably effective and don’t have significant risk issues. Menopausal women who still have their uterus have to take progesterone if they take estrogen. Progesterone takes away from the estrogen benefits in the brain (mood, memory, verbal, fluency). It also makes a difference what kind of progesterone is taken – synthetics (Provera and others) or natural (prometrium and others). More important is how progesterone is provided. Intra-uterine or intra-vaginal probably does not interfere with brain benefits of estrogen.
Another factor is what type of estrogen and how it’s taken. Conjugated estrogens (Premarin and Cenestin), containing many of the different types of estrogen, can probably be taken by mouth without causing possible reductions of many hormones.
Taking Estradiol (the most active form of estrogen) by mouth (Estrace, Estradiol, most birth control pills) causes the liver to make more binding proteins for thyroid, testosterone and the Estradiol itself. This reduces the effect of each of these unless the woman compensates by making a lot more of this hormone. Each woman is different, but I have seen many patients where the oral Estradiol causes low effective hormone levels.
Then there are the studies that scare women away from HRT. These studies usually focus on a small subgroup of women and aren’t relevant to the average woman.

Mood stabilizers are the most powerful and most important medications that physicians/psychiatrists have to treat the most severe stress disorders, including bipolar disorder, schizophrenia, agitation and/or psychosis associated with many disorders, even Alzheimer’s and other dementias. They are the most effective treatment for all forms of excess anger/aggression. More recently, we have learned that they are effective in highly recurrent clinical depression or depression that doesn’t fully respond to antidepressants. They include all the "atypicals," some anticonvulsants and Lithium. They can be used alone or added to other meds. Atypicals are sometimes added to an SSRI for treatment resistant OCD.
The goal in treating any stress disorder is complete resolution of all symptoms allowing for optimal functioning and quality of life. We first maximize any particular medication – best dose, best time(s) of day. If not helping significantly or not well tolerated, we stop it. After maximizing the benefit of a particular med, if we still have significant symptoms remaining, we will carefully add another med.
In bipolar disorder, multiple meds are the rule not the exception. In one study, less than 20% of bipolar patients needed only 1 med and 35% needed 4 or more.

All of these medical treatments are in the context of counseling about important aspects of lifestyle, especially sleep, physical activity, and general health habits. Addiction counseling or psychotherapy is often but not always needed.
The average person with a stress disorder has an average of 3 different conditions, each of which needs to be considered. Since there’s so much overlap, sometimes we can choose one medication that treats 2 or 3 concurrent conditions. Implicit in all this is that a complete evaluation needs to be done before a decision can be made for what treatment is most likely to work best.
Unfortunately, at our current stage of neuroscience, there is no way to determine with certainty which treatment will be best in any individual. Soon, we will be able to make better choices because we will be able to look at each person’s genetic profile and do brain imaging to show which areas are over or under active. We will also have many new treatment options.
For now, we combine the best current science with the art of medicine to make the best educated guesses. We will use trial and error. We will always start with a complete evaluation and also monitor outcome in a comprehensive manner. If what we are doing isn’t working, we will do something else. We will think systematically, but also listen to our intuition, which is smarter than we are. We will work as a team, and we will not settle for less than the optimal quality of life.

• Take responsibility for your health and well-being.
• Develop good health habits and a lifestyle that fosters vitality and fulfillment.
• Continually educate yourself about health issues and research advances through reading, internet, discussions, etc.
• And find a good doctor!

What does it mean to find a good doctor?

Find a physician that you feel good rapport with and that you have confidence in.  You need to feel like you can comfortably discuss any health related issues with your doctor. You need to trust that your confidentiality will be respected. You should feel a mutual respectfulness that your concerns and needs and time are just as important as your physician’s. You get the feeling that your doctor genuinely cares about your well being. You are confident that your doctor keeps current and you should appreciate that your physician has confidence in their knowledge and skills, but is not arrogant.

A good doctor admits there are a lot of things we don’t know and every patient is unique and no treatment works for everyone. A good doctor is open to a variety of approaches and welcomes your questions or information that you bring in – not just about yourself but general information like an article you read about a new study. A good doctor doesn’t get defensive. You never feel that any of your concerns are discounted.

So what if you don’t have this kind of relationship with your doctor? It may be that by being open and honest with them you can gradually build this ideal partnership. So for example, you might say, “Doctor, I sometimes feel rushed – that I don’t have enough time to discuss all of my concerns with you.”   Your physician may say, “I’m sorry, take whatever time you need. My patients understand that I frequently run late because I’m willing to give my patients extra time when they need it.” Or they may say, “I’m sorry but we only have 15-20 minutes scheduled and I really need to stay on time today – but let’s reschedule as soon as possible so that we can address all your questions,” or there may be other considerate responses.

But if the doctor got annoyed or defensive such as “I’m behind, there are other patients to see and besides your insurance doesn’t pay well and you already got your money’s worth.” Or, “you have me confused with somebody who cares.” I hope it goes without saying – unless your doctor is just having a bad day you need to find another doctor.

Your relationship with your primary physician is so important that you have to make the time and take the trouble to find the right doctor for you. Ask your friends, ask your pharmacist, ask other health care professionals, but keep looking until you are satisfied. Your primary physician may be a family doctor, internist, OB-gyn, psychiatrist, or other specialist. If you need more than one doctor you can frequently get a referral from your primary physician and increase your chances. Although preferable, it is not essential that you feel as comfortable with every physician you see – as long as you can check things out with your primary physician.

In order to have complete confidence in your physician, you have to believe that they are thorough. My patients usually see my clinical assistant before they see me and they always fill out forms and symptom checklists. I also require that they check in with us at least every six months (3 months if they are on any controlled substances like stimulants or benzodiazepines). Sometimes we do “med checks” by phone. Every patient has to be seen in the office for a more comprehensive review of their status and treatment at least once a year, even if they are doing well – which fortunately most of my patients are. For new patients and patients not doing well, follow-ups are more frequent and are determined according to each individual situation.

There are a lot of good doctors that don’t use clinical assistants or don’t use many (or any) forms, and that’s fine. But, it will require more time with them to cover everything that needs to be covered.

Change starts with awareness. You can’t fix a problem you don’t know you have. A comprehensive evaluation is essential.

Certain problems like lung cancer and colon cancer have to be diagnosed before they cause symptoms or “you are toast!” So, you have a lot of headaches but Advil takes care of them, “it must be stress.” But what if it’s because you have high blood pressure. The Advil is not protecting your arteries (kidneys, heart, brain). The first symptom of heart disease in a significant percent of cases is sudden death. “Oops!” You are tired a lot, your concentration is not very good – maybe it’s ADHD. But what if it is sleep apnea? Eventually sleep apnea raises blood pressure and may cause a significantly shorter life span if not treated.

You have to have a complete evaluation before treating symptoms. Borrow some forceps if necessary, but get your head out of your sigmoid colon.

Being proactive means thinking about and preferably writing down your medical history and family history (at least to include all 1st degree relatives, parents, siblings, and children). Include all medical and psychiatric disorders. Also include any history of recreational drug use, especially any bad reactions you had.

 

Click here to see how Dr. Jones determines “Best Meds”
In my clinical experience mood disorders are the most challenging and in many ways the most difficult to treat. Frequently mood problems lead to substance abuse, which makes them worse. Lifetime suicide risk for Bipolar Disorder is 15%. Only 1% of the population has classic Bipolar I disorder (the old term – manic depressive.) Frequently, they’re psychotic; usually, they require hospitalization.

Much more common is what is now being called Bipolar spectrum disorders. This includes lesser degrees of mania and episodic rage attacks. Antidepressants tend to aggravate Bipolar symptoms, or at least increase the frequency of abnormal mood cycles. Bipolar disorder means that in addition to symptoms of depression, there are symptoms of mania or hypomania (see newsletter on Bipolar Disorder).

Mood stabilizers by definition ideally help depression and/or manic symptoms – but at least help one without making the other worse.  Antidepressants and stimulants aren’t mood stabilizers because they usually aggravate manic symptoms.  Klonopin and the old-fashioned antipsychotics like Haldol and Navane don’t count because they can aggravate depression.

The 1st mood stabilizer available in the U.S. was Lithium Carbonate in 1970.  In the late 70’s, Tegretol (now Carbatrol), an anticonvulsant, was added.  In the early 80’s, Depakote was found to help especially manic symptoms.  Then in the 90’s, we started getting the 2nd generation antipsychotics, “Atypicals”: first Clozaril, then Risperdal, Seroquel, Zyprexa and Geodon, and most recently, the 1st of the 3rd generation, Abilify.  Also in the 90’s we found that an anticonvulsant, Lamictal was especially good for Bipolar Depression.  It reduces manic episodes.  It is not useful in treating acute mania.
What makes these medications so important is that it is estimated that 1/3 of clinical depression is really part of a Biploar Spectrum.  This means 8% of the population could be effected.  Many alcoholics and drug abusers are self-treating a bipolar mood disorder.
Most recently, highly recurrent unipolar depression (NO manic symptoms) may respond better to mood stabilizers than antidepressants, especially if early onset (20’s or younger) plus family history of Bipolar Disorder, frequent or severe episodes, history of less than optimal response or poor tolerance to antidepressants or stimulants.

My ranking of these medications is based on my clinical experience plus my knowledge of the research as well as experience of experts in the field.  The factors I considered were: the range of symptoms treated, the degree of benefit for these symptoms, and relative lack of side-effects, especially in the long term.

To maintain stable mood, before considering formal mood stabilizers address life-style factors:

1. Sleep (ideally 7 hours normal sleep every night) is the single most important.
2. Regular aerobic activity – 30 minutes daily preferable.
3. Maintain good levels of estrogen/testosterone.
4. Keep thyroid level in the high average range.

Hormone Treatments for Mood Disorders

There are 3 categories of mood stabilizers. (The majority of bipolar patients require more than one medication).
They are:

All Atypicals:
Abilify
Seroquel
Symbyax (Zyprexa plus Prozac)
Zyprexa
Risperdal
Geodon
Clozaril

Some Anticonvulsants

Lamictal
Depakote
Carbatrol (Tegretol)

Lithium Carbonate

Click Here to See the Rankings Mood Stabilizers vs. Antidepressants

Citing 20 cases of sudden death of patients taking Adderall XR, the Canadian equivalent of our FDA suspended sales of this popular ADHD medication. The FDA in the U.S. has reports of 12 sudden deaths in children over a 5-year period where 30 million prescriptions for Adderall were written. It is the current opinion of our FDA that this rate of sudden death is not higher than would be expected in the general population if not on Adderall. Half of the deaths were in patients that had heart defects; one heat exhaustion/heat stroke and most of the others had either other serious health problems or were on other concomitant medications. At this time the FDA does not believe there is any significant risk except possibly in patents with congenital heart defects or other serious compromising medical conditions, such as uncontrolled high blood pressure. The Canadian number of 20 deaths apparently includes some adults, but most, if not all, had multiple complicating factors. It is my opinion that with the few exceptions mentioned above, the benefits of Adderall XR far outweigh any potential risk, and I am advising my patients that there�s no need to discontinue the med or have undue concern. If you want additional information go to FDA.gov or Shire.com
Related Article: Best Meds – Stimulants

RANKING THE MOOD STABILIZERS
(Intro to Mood Stabilizers)

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1. ABILIFY
Abilify is an atypical, and is my top ranked mood stabilizer. It helps with agitation, irritability, mania and depression. It usually starts helping the first day taken. It comes in multiple size tablets, 5, 10, 15, 20 and 30mg. Because the tablets can be cut in half it makes for easy titration of dose. Abilify also has a long duration of action so it doesn’t hurt to be late or miss a dose. It also doesn’t matter whether you have eaten before taking.
Side-effects are mild. Occasionally there is restlessness in the first few days but that usually goes away. If restlessness is a significant concern, it is easily managed with Clonazepine, Ativan, or Propranolol. If sedation occurs it can be taken in the evening. There usually is no weight gain or sexual dysfunction.
Many of my patients feel that this medication more than any other mood stabilizer has significantly changed their life for the better. Even after 1 year or more it continues to work well and have negligible side-effects.

2. SEROQUEL
Seroquel is an “atypical” and ranks second. Like Abilify, it helps agitation, irritability, mania, and depression. It also helps sleep and may be better for anxiety.
It tends to cause daytime sedation but this usually goes away in 10-14 days. It may also cause dizziness upon standing. With long term use it can result in moderate weight gain. It is fairly short acting so it may need to be given twice a day and missed doses can be more problematic. Because many patients can’t tolerate higher doses it is probably not as good for depression as Abilify.
Overall it is effective, especially good for sleep and well tolerated. It is sometimes combined with Abilify.

3. LAMICTAL
Lamictal is an anticonvulsant and is my third ranked drug. It is especially good for Bipolar depression. Although it doesn’t help reduce manic symptoms, it does reduce manic episodes and was actually approved by the FDA for Bipolar maintenance. It is one of the most useful for rapid cycling (four or more episodes of depression or mania per year).

The only significant side effect concern is a rare serious rash that may require medical treatment. It only occurs in 1 per 1000 patients. To minimize any rash, the dose has to be very slowly increased, taking 6 weeks to reach the usual effective dose.
It is taken once a day in the morning. It has a very favorable side effect profile with no weight gain, sexual dysfunctioning, or sedation. I have many patients whose quality of life has been enhanced by Lamictal over the past few years.
It mainly treats depression and doesn’t help mania or agitation. It probably doesn’t help irritability and takes a few weeks to titrate. I rank it below Abilify and Seroquel.

4. LITHIUM CARBONATE
Lithium Carbonate is a salt that we all have in our system as a trace mineral. It was discovered in 1949 to help treat mania and to a lesser extent Bipolar depression. It effectively reduces episodes of both. It also reduces volatile temper outbursts and most strikingly reduces suicide risk by 800% by reducing impulsivity.
It is relatively inexpensive even in its more commonly prescribed longer acting forms, Eskalith 450 and Lithobid 300.
In spite of 35 years experience in the U.S. and 45 years in England it is much less prescribed in this country partly because there are no pharmaceutical companies really promoting it – there’s no money in it.
It has to be titrated carefully and occasionally blood levels are required. It tends to lower thyroid so thyroid levels have to be monitored more closely than usual.
Lithium does have some significant side effects, such as weight gain in many patients. Side effects like tremor, nausea, diarrhea, urinary frequency and excessive thirst can be managed by adjusting dose or other techniques.
It works for classic Bipolar I with manic episodes and depressed phases alternating with completely normal periods of time. It may work well as a stand alone medication. This is what Jane Pauley and the psychologist/author Kay Jamison take. I have patients who have done well on Lithium for literally decades.
There is an occasional patient that develops complications of kidney inflammation which can be a serious problem if its not stopped.
There is also a relatively low therapeutic index, meaning the difference between optimal dose and toxic dose is not very great. Blood levels can also be effected by extremes of diet and hydration. Because it competes with salt (sodium) in the body, high salt intake will decrease Lithium levels and it may lose its effect. No sodium intake (not eating) or high losses of sodium with extreme sweating, vomiting, or diarrhea, causes the person to save Lithium and possibly become toxic.
In spite of these side effect issues and potential risks there are more studies supporting its effectiveness in reducing major mood episodes than for any other medication. For someone frequently or chronically suicidal, or impulsive behavior, it appears to be more protective than anything else. I rank it as my 4th mood stabilizer.

5. ZYPREXA & 6. SYMBYAX
Zyprexa is an atypical that works very well for agitation, mania, depression, and sleep. It seems to work quickly. Symbyax is a combination of Zyprexa and Prozac. This combination is very effective for Bipolar depression. It is the only medication that has a formal FDA approval specifically for this diagnosis. I have had several patients whose depression was severe and a range of multiple antidepressants didn’t help. They had an excellent response to Symbyax.
I rank Symbyax (5th) above Zyprexa (6th) because of the frequent dramatic benefit for this group of desperately depressed patients. Unfortunately, the majority of patients on this medication gain a tremendous amount of weight, may have increases in cholesterol, triglycerides and adult onset Diabetes. I had one lady that gained 100 pounds in one year on Zyprexa. Thinner patients gain more than patients who are already obese-but thinner patients object to weight gain even more. With the exception of patients with anorexia nervosa, weight gain is a serious side effect. Another problem is cost. All of the “atypicals” are expensive, but these two are almost twice as much as the others.
Because Zyprexa takes 5 hours to reach maximum blood level, it is best taken around 6pm to induce sleep at normal bedtime, and then be worn off enough in the am-although morning grogginess is sometimes a problem.
In spite of the side effects (especially weight gain) I still use this medication in some patients but will usually shift to Abilify or Lamictal after they are stabilized.
One additional issue is that smoking may decrease blood levels of Zyprexa by 30%, requiring an increased dose and therefore an increase in price. Since almost all Schizophrenics smoke, this has major budget implications for government sponsored clinics, Medicaid, and insurance carriers-who of course pass on the cost.

7. RISPERDAL
Risperdal was the first “atypical” to be used in general clinical practice in the U.S. and therefore we have the most experience with it. It works well for agitation, mania, irritability, and also helps depression. It is not particularly good for sleep.
Risperdal comes in multiple sizes that are easily broken into 1/2 or 1/4′s, making for maximum flexibility of dose. This also helps with cost by buying the larger sizes.

Unfortunately, it has a lot of side effect issues-mostly in the long term. It causes moderate weight gain and frequently increases the hormone prolactin. This may cause breast enlargement (not popular with men), and sometimes lactation (not popular with men or women). There may be no obvious clinical effects of increased prolactin but since it lowers testosterone and estrogen it is frequently
associated with decreased libido. It may also increase risk of future osteoporosis in women. In addition, it is the most likely of the “atypicals” to cause movement disorders and has a risk of Tardive Dyskinesia. Taking it with Paxil or Prozac or being a genetically slow metabolizer may increase this risk by increasing blood levels. It is believed to be relatively safe in most people at doses less than 6mg per day. Because of its benefits and general tolerability, I rank it #7.

8. GEODON
Geodon is one of the newer “atypicals”. It is weight friendly and non-sedating and generally works for the full range of mood symptoms. Like Abilify, it may have more cognitive benefits. At lower doses it has antidepressant effects that predominate and this can be a problem, especially for manic or hypomanic patients.
It has to be pushed to higher doses to function well as a mood stabilizer and generally has to be taken twice daily. A big problem with it is that if you don’t take it with food the effect is cut in half. I haven’t seen many great responses.
It comes in capsules that are hard to titrate. It doesn’t help sleep (at least initially) and the food issue puts it further down on my list. It is effective and it is weight friendly. I rank it #8.

9. DEPAKOTE
I have twenty years of experience with this anticonvulsant type of mood stabilizer. Because of aggressive marketing and because using Lithium is more complicated, Depakote replaced Lithium as the top selling mood stabilizer. It was later replaced by the “atypicals” and Lamictal as most prescribed.
For a hospitalized acute manic Depakote has the advantage of being sedating and the full dose can be given on day one. But I can’t remember any patient saying, “Depakote is great.”
It causes weight gain, frequently daytime sluggishness and may cause hair loss (not popular). It also increases risk of polycystic ovaries in young girls which is a big problem.
Depakote does help mania and agitation. It also helps prevent migraine and it is still frequently prescribed. It can raise blood levels of many other medications by inhibiting metabolism and this can create confusion.
I don’t prescribe it much because the downside is as great as the benefits. I rank it 9th.

10. CARBATROL
Carbatrol is an anticonvulsant that has been used as a mood stabilizer since the late 70′s although formal FDA approval is still pending. It is used frequently by neurologists for seizure disorders, but use in psychiatry has been more limited, most especially because of its drug drug interactions.
It is a potent inducer of a liver enzyme (3A4) that metabolizes 2/3′s of all medications that we use. This means that it will lower levels of other medications so that doses of the other meds have to be adjusted. Lamictal doses, for example, have to be doubled if given with Carbatrol. Since Carbatrol also lowers estrogen and testosterone levels this can cause problems. The strength of birth control pills frequently has to be increased or unwanted pregnancies can result. Otherwise, it is fairly well tolerated and is especially useful in controlling symptoms of aggression. I rank it 10th.

11. CLOZARIL
Clozaril was the first “atypical” to be approved for schizophrenia. Because it can occasionally cause bone marrow suppression blood levels have to be done weekly initially and then every 2 weeks. It has other possible serious side effects such as seizures and other undesirable effects like drooling. It also causes substantial weight gain.
Because I knew I would never use it enough to really learn all its nuances I have never prescribed it even though it has been available for several years. The one patient I referred to the medical school to take it as a part of a study was accepted into the study. He then changed his mind. When I asked “how come?” he said, “they told me one of the side effects was death!” Hard to sell.
Having said all that, there are reports of patients with severe Bipolar disorder or Schizophrenia who do well with this drug and not on anything else. I rank it last.

Recently it was reported that a common anti-inflammatory medication (Aleve) caused an increase in heart problems or stroke in patients being studied to see if it helped Alzheimer’s risk. Another common medication, Vioxx, was taken off the market after studies showed that long term use increased risk of heart problems. A major problem is that the FDA over emphasizes short term studies and the wealth of clinical experience is not systematically monitored. The media contributes to the problem. Medications that help people feel better or raise their quality of life don’t make news. That wouldn’t increase ratings. It’s the juicy stories that get the press.

Last year, a report on a study of hormone treatment in menopausal women claimed that hormone therapy causes increased heart problems, strokes, and cancer. On the Today Show an author was interviewed saying basically that pharmaceutical companies have misled doctors and the public. The author further stated that they have profited by misrepresenting the benefits of hormones and failed to report dangerous complications. The interviewer’s response was "a lot of us women are mad that we have been so deceived." The truth of the matter is that less than half of menopausal women were on hormones at the time and up to half of the ones that were on hormones stopped them after the report came out. Insurance companies fearing an avalanche of law suits, put pressure on physicians. Some insurance companies told gynecologists they wouldn’t cover complications of hormone treatment other than short term use. For this and other reasons many doctors advise their patients to get off hormones. My knowledge of the limitations of studies and more importantly my clinical experience all lead me to believe at this time the benefits both short term and long term (especially for the brain) outweigh the risks for most menopausal women taking hormones.

Another example of media impact is that of Michael Moore. He is currently working on an expose of the pharmaceutical industry. He is allegedly paying physicians, pharmaceutical reps and others to provide the "inside scoop" on the workings of the pharmaceutical industry. On a recent Today Show he described the pharmaceutical industry as evil. Katie Couric’s attempt to get him to admit that the industry does provide us with new and better treatment was met with sarcasm and contempt. He gave an example that Eli Lilly had known for years but kept secret that Prozac, a popular treatment for depression and anxiety, increased the risk of suicide 12 times. My reply to this is, "do you think it would still be on the market if it was that dangerous?" He made his statement as if it were fact. A lot of people see him as a folk hero. I like that in America we are free to say what we believe. I’m exercising the right of free speech now. What I don’t believe in is the right to present opinions and distorted information out of context, and quote uninformed sources as though they are well researched fact. Satire should not be presented as a documentary. It does a lot of harm. But it gets the ratings and makes the money, and after all this is America.

What role has managed care (more honestly, managed cost), played in changing the way medical care is provided? The idea of a system that improves the quality of medical care is a good one. But over the past two decades I believe the result has been more the opposite. When I first started treating patients in the private sector, (early 70′s), decisions about medical tests, hospitalization, and treatment were made between the patient and doctor. Insurance would help with the cost depending upon the specifics of the policy or health care program. Medications were mostly generic. As health care costs escalated, insurance company profits began to shrink and the cost to employers was increasing at an alarming rate. Thus, the managed care system was born.

Managed care now monitors care and has the right to approve or not approve tests, hospitalization, or treatment. The decisions about care were gradually taken away from the patient and the doctor. Of course, the patient is always free to pay for healthcare themselves, but the costs are usually prohibitive.

The managed care companies became a fourth player in this process. They justified their existence by reducing the amount of dollars insurance companies had to pay – the managed care company would then get part of the savings for their profit and cost of doing business. So, in effect, the insurance companies would sometimes save 30% (20% of which would go to the management company). The insurance companies were happy, the employers were happier because they had more cost containment, the management companies were happy they had a job, BUT the poor patient now has about 30% less help with care and mainly has been out of the loop. In addition, the management companies contract with certain physicians who help "contain costs". This would insure that the physician gets a certain volume of patients with guaranteed but reduced payment for their services.

So how does this change the way physicians provide care? Almost always it means less time for the patient. The visit is shorter, and maybe less frequent, and tests are harder to get approved. Certain medications (cheaper generics) are more likely to get approved. Although I stopped accepting insurance (control) for my services a few years ago, I must still get involved frequently with having to request approval for medications that I feel are the best for the patient. Recently, I asked an insurance company to approve Provigil, a medication that increases alertness, and is also used for narcolepsy, shift work, and many other causes of excessive sleepiness. This was the only medication that I could find that one of my patients could take that would allow her to stay awake at work and not cause any side effects. After two letters pleading our case we were still denied. Why? COST. The insurance company felt that the drug was too expensive so the patient was "out of luck".

I am a bibliophile, or a person who loves books. My friends and family would probably say I am more a hoarder of books, journals, magazines and notes. (More about what causes hoarding later) I love going to book stores and I always see what they have on medicine and neuroscience. I don’t think it’s a coincidence that there are more books on thyroid than any other subject. I believe the reason is low thyroid is an extremely common, fixable problem that may be more frequently mismanaged than any other medical condition. Proper treatment improves fitness and quality of life but most doctors don’t get it. There are two maladies that I have noted in some physicians, PRE EXTRACTION DISORDER and MILK OF MAGNESIA DEFICIENCY. In the first condition they lack important information or don’t understand key principles because their head is somewhere in their sigmoid colon. In milk of magnesia deficiency, they believe things that are sometimes creative or at one time believed, but unfortunately not true – ergo they are full of crap. You may think this point of view is unkind, and you’re right. I believe that as an ADHD person I was put on earth to stir things up and challenge the system, so I won’t apologize for being at times “tacky”.

Why are there so many books about thyroid? I believe when a doctor “gets it” and starts treating low thyroid effectively, they realize how often it is mistreated and how many patients suffer the consequences. I could regale you with case after case of examples, but suffice it to say, I too feel compelled to try and educate the public and my physician peers about the physiology of thyroid hormones.

The thyroid gland in the neck secretes two primary hormones, the more abundant T4 and the more active T3. Most of our T3 is made in other parts of the body by converting T4 to T3. I am working on a thyroid article that will go into detail about all the important nuances, but the key points are:

• Thyroid regulates the activity of every cell in the body.
• Many people, for various reasons, are low in T4 and/or T3.
• Most doctors will order only part of the tests needed for accurate diagnosis (the TSH).
• Total T4 and T3 uptake and a multiple called T7 or free thyroid index (FTI).

The FTI is preferred by insurance companies because it’s cheap, not because it’s adequate. This test is unreliable according to many reputable texts, so I consider it to be useless. The most important test is the Free T4 and sometimes the Free T3. Even when the Free T4 is within normal range, it may be too low for the individual. It would be analogous to giving you an IQ test in which you scored 90, and I told you this range was normal. The normal average range of IQ is 90-110, but what if you said “my IQ used to be 130”? … Something’s wrong. That may be the case with your thyroid.

One reason that this is missed is that most doctors don’t ask about thyroid symptoms (or a lot of other symptoms for that matter). But if you have fatigue or easy fatigueability you need to review all the possible symptoms:

Dry skin, hair loss, sensitivity to cold, constipation, swelling, decreased memory, depression, or mood sensitivity, weight gain, difficulty losing weight, and infertility.

Even when low thyroid is treated, it usually is undertreated. The main medication used is Synthroid (the generic is especially unreliable). Many patients also need T3, either Cytomel, or in combination Armour or Thyrolar.

In the past 2 years I have attended two lectures by different Endocrinologists who talked about treating low thyroid. They talked about TSH, estimated Free T4 and treatment with Synthroid. No discussion of secondary hypothyroidism (low thyroid) which means due to causes other than an underfunctioning of the thyroid gland. Neither presenter talked about the role of T3 or use of T3 in treatment.
The books on medicine and endocrinology all say that for secondary hypothyroidism the TSH is useless, and yet, that is frequently the only test they get. At the second talk I asked if they believed that the soul was in the pituitary. This is the gland that helps regulate thyroid by monitoring levels and secreting TSH. But the problem is the pituitary (the master gland just outside the brain) is regulated by the hypothalamus in the brain.

Years ago a study found that if post menopausal women not on estrogen were treated with too much thyroid it could worsen osteoporosis. Ever since there is a fear of causing bone loss, and the result has been a lot of undertreatment. The problem is over reliance on the TSH and fear of osteoporosis, “osteophobia.”

In secondary hypothyroidism the thermostat for body temperature and the set point for basal metabolic rate is set too low. I believe a common cause is “hibernation”. Many of us are mostly indoors and some are mostly sedentary. But we adapted over 1000′s of years to being outside all day and physically active. Our energy and sleep were regulated by the bright outside light. Even on a cloudy day it is 10x’s brighter outside than inside. If our brain thinks we are hibernating, and especially if we have cultural heritage from the northern countries, then we compensate by reducing our metabolism until the weather permits productive outside activity. By reducing our temperature and metabolism we conserve energy (stored as fat). This is also why it’s very difficult to lose weight.

If our hypothalamus is set too low the pituitary will read our level as too high when we take an adequate healthy amount of thyroid medicine. The TSH will then be below the normal range – this is fine. But most doctors overreact and lower the thyroid medicine. Now the patient feels terrible, but their TSH comes up and the doctor is happy – pre-extraction disorder. Most doctors are conscientious. They want to do what’s best for their patients, but in the case of thyroid, they mostly don’t get it.

Low thyroid can cause or worsen depression. In women it is:

It’s like for your car you have to have gas, oil, and water. You can’t compensate for no gas with more water. You can’t compensate for low thyroid with an SSRI (antidepressant such as Lexapro). In men testosterone is more important than estrogen. The brain converts testosterone to estrogen in men and women. Older men have more brain estrogen than older women (who are not taking estrogen). Older men have half as much Alzheimers – the only common cause of premature death more common in women.

In bipolar disorder Synthroid or T4 needs to be in the upper part of normal range to help stabilize mood. T3 is more of an antidepressant but obsession by “osteophobic” physicians results in inadequate treatment doses to help with mood. “The operation was a success (we kept the TSH up) but the patient died.”

I will cover osteoporosis n detail later but just a note – adequate estrogen/testosterone/DHEA, weight bearing exercise, and adequate calcium is the prevention/treatment.

Other than that I have no opinions.