Psychiatric complications - thyroid involvement?

[debbie0413]

My 20 year old daughter was diagnosed and treated by radioiodine ablation for Grave's disease 3 years ago.  Within the last 6 weeks she has been in a psychiatric hospital twice, has shown some thyroid fluctuation in blood tests, and has been diagnosed with major depression, eating disorder, and borderline personalilty disorder.  The first hospitalization was involuntary in Philadelphia (where she attends college) due to her taking a non-toxic dose of Motrin, but she checked herself into a local psychiatric hospital once she got home here in Milwaukee, WI.

My husband and I agree with the depression and eating disorder labels, but we have doubts about the borderline diagnosis.  To make matters more complicated, our daughter reacted a bit when my husband and I expressed some doubts about the borderline finding, and she withdrew her permission for us to be involved with her health information and treatment decisions.  Now the docs want to use electroshock therapy on our daughter!  I have read that this treatment has had a comeback in the last 25 years, but it still carries some risks.  The treatment forces your body into a grand mal seizure and can affect memory, cognitive function, and learning in the short term.

Our daughter has displayed symptoms of both mild hyperthyroid and extreme hypothyroid states over the past several months, sometimes even fluctuating over a few hours or days.  This fluctuation has also shown up on thyroid blood tests both in Philadelphia and Milwaukee, but so far she has not had a full thyroid panel done.  I wish I had numbers to share, but I did not write them down when we had a meeting because I thought I would be allowed to get copies.  When our daughter got a blood test in early April in Philly, her doc commented to her that she was "hyperthyroid again" and lowered her levothyroxine from .150 mg. to .125 mg.  I am wondering if this was what triggered her big emotional reaction that landed her in the first psychiatric hospital.  The current psychiatric hospital has an endocrine doc on staff who has done SOME thyroid blood tests and is trying to stablize our daughter's correct thyroid dosage, but they have commented that it would be best if an endocrine specialist direct the correct tests (which might mean more than just tests for the thyroid).

Here is my question: does it make good medical sense for us to continue to strongly encourage our daughter to seek a second opinion with an endocrine physician who specializes in thyroid disorders (or better yet, a neuroendocrinologist if we can find one in our area), or should we just go along with the electroshock treatments our daughter's docs are recommending?  I am guessing that they are looking at this treatment because the depression symptoms continue to fluctuate in and out, even after about 5 weeks on Celexa.  Of course, these symptoms may be fluctuating precisely BECAUSE there is a thyroid imbalance (perhaps hashitoxicosis?)!  We DO have the names of a couple of endocrine docs in the area who do a lot of work with thyroid issues.  I really appreciate any comments you could give us on this.  

[Smilerdeb]

Abnormal Bleeding

SSRIs and SNRIs, including duloxetine, may increase the risk of bleeding events. Concomitant use of aspirin, nonsteroidal anti-inflammatory drugs, warfarin, and other anti-coagulants may add to this risk. Case reports and epidemiological studies (case-control and cohort design) have demonstrated an association between use of drugs that interfere with serotonin reuptake and the occurrence of gastrointestinal bleeding. Bleeding events related to SSRIs and SNRIs use have ranged from ecchymoses, hematomas, epistaxis, and petechiae to life-threatening hemorrhages.

Patients should be cautioned about the risk of bleeding associated with the concomitant use of duloxetine and NSAIDs, aspirin, or other drugs that affect coagulation.

Activation of Mania/Hypomania

In placebo-controlled trials in patients with major depressive disorder, activation of mania or hypomania was reported in 0.1% (2/2,489) of duloxetine-treated patients and 0.1% (1/1,625) of placebo-treated patients. No activation of mania or hypomania was reported in DPNP, GAD, or fibromyalgia placebo-controlled trials. Activation of mania or hypomania has been reported in a small proportion of patients with mood disorders who were treated with other marketed drugs effective in the treatment of major depressive disorder. As with these other agents, Cymbalta should be used cautiously in patients with a history of mania.

Hyponatremia

Hyponatremia may occur as a result of treatment with SSRIs and SNRIs, including Cymbalta. In many cases, this hyponatremia appears to be the result of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Cases with serum sodium lower than 110 mmol/L have been reported and appeared to be reversible when Cymbalta was discontinued. Elderly patients may be at greater risk of developing hyponatremia with SSRIs and SNRIs. Also, patients taking diuretics or who are otherwise volume depleted may be at greater risk [see Use in Specific Populations]. Discontinuation of Cymbalta should be considered in patients with symptomatic hyponatremia and appropriate medical intervention should be instituted.

Signs and symptoms of hyponatremia include headache, difficulty concentrating, memory impairment, confusion, weakness, and unsteadiness, which may lead to falls. More severe and/or acute cases have been associated with hallucination, syncope, seizure, coma, respiratory arrest, and death.
Use in Patients with Concomitant Illness

Clinical experience with Cymbalta in patients with concomitant systemic illnesses is limited. There is no information on the effect that alterations in gastric motility may have on the stability of Cymbalta's enteric coating. In extremely acidic conditions, Cymbalta, unprotected by the enteric coating, may undergo hydrolysis to form naphthol. Caution is advised in using Cymbalta in patients with conditions that may slow gastric emptying (e.g., some diabetics).

Cymbalta has not been systematically evaluated in patients with a recent history of myocardial infarction or unstable coronary artery disease. Patients with these diagnoses were generally excluded from clinical studies during the product's premarketing testing.

Clinical Worsening and Suicide Risk

Patients, their families, and their caregivers should be encouraged to be alert to the emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania, other unusual changes in behavior, worsening of depression, and suicidal ideation, especially early during antidepressant treatment and when the dose is adjusted up or down. Families and caregivers of patients should be advised to observe for the emergence of such symptoms on a day-to-day basis, since changes may be abrupt. Such symptoms should be reported to the patient's prescriber or health professional, especially if they are severe, abrupt in onset, or were not part of the patient's presenting symptoms. Symptoms such as these may be associated with an increased risk for suicidal thinking and behavior and indicate a need for very close monitoring and possibly changes in the medication.

Signs and Symptoms

In postmarketing experience, fatal outcomes have been reported for acute overdoses, primarily with mixed overdoses, but also with duloxetine only, at doses as low as 1000 mg. Signs and symptoms of overdose (duloxetine alone or with mixed drugs) included somnolence, coma, serotonin syndrome, seizures, syncope, tachycardia, hypotension, hypertension, and vomiting.

[Smilerdeb]

Families and caregivers of patients being treated with antidepressants for major depressive disorder or other indications, both psychiatric and nonpsychiatric, should be alerted about the need to monitor patients for the emergence of agitation, irritability, unusual changes in behavior, and the other symptoms described above, as well as the emergence of suicidality, and to report such symptoms immediately to health care providers. Such monitoring should include daily observation by families and caregivers. Prescriptions for Cymbalta should be written for the smallest quantity of capsules consistent with good patient management, in order to reduce the risk of overdose.

Hepatotoxicity

There have been reports of hepatic failure, sometimes fatal, in patients treated with Cymbalta. These cases have presented as hepatitis with abdominal pain, hepatomegaly, and elevation of transaminase levels to more than twenty times the upper limit of normal with or without jaundice, reflecting a mixed or hepatocellular pattern of liver injury. Cymbalta should be discontinued in patients who develop jaundice or other evidence of clinically significant liver dysfunction and should not be resumed unless another cause can be established.

Cases of cholestatic jaundice with minimal elevation of transaminase levels have also been reported. Other postmarketing reports indicate that elevated transaminases, bilirubin, and alkaline phosphatase have occurred in patients with chronic liver disease or cirrhosis.

Cymbalta increased the risk of elevation of serum transaminase levels in development program clinical trials. Liver transaminase elevations resulted in the discontinuation of 0.3% (82/27,229) of Cymbalta-treated patients. In these patients, the median time to detection of the transaminase elevation was about two months. In placebo-controlled trials in any indication, elevation of ALT > 3 times the upper limit of normal occurred in 1.1% (85/7,632) of Cymbalta-treated patients compared to 0.2% (13/5,578) of placebo-treated patients. In placebo-controlled studies using a fixed dose design, there was evidence of a dose response relationship for ALT and AST elevation of > 3 times the upper limit of normal and > 5 times the upper limit of normal, respectively.

Because it is possible that duloxetine and alcohol may interact to cause liver injury or that duloxetine may aggravate pre-existing liver disease, Cymbalta should ordinarily not be prescribed to patients with substantial alcohol use or evidence of chronic liver disease.

Serotonin Syndrome or Neuroleptic Malignant Syndrome (NMS)-like Reactions

The development of a potentially life-threatening serotonin syndrome or Neuroleptic Malignant Syndrome (NMS)-like reactions have been reported with SNRIs and SSRIs alone, including Cymbalta treatment, but particularly with concomitant use of serotonergic drugs (including triptans) with drugs which impair metabolism of serotonin (including MAOIs), or with antipsychotics or other dopamine antagonists. Serotonin syndrome symptoms may include mental status changes (e.g., agitation, hallucinations, coma), autonomic instability (e.g., tachycardia, labile blood pressure, hyperthermia), neuromuscular aberrations (e.g., hyperreflexia, incoordination) and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). Serotonin syndrome, in its most severe form can resemble neuroleptic malignant syndrome, which includes hyperthermia, muscle rigidity, autonomic instability with possible rapid fluctuation of vital signs, and mental status changes. Patients should be monitored for the emergence of serotonin syndrome or NMS-like signs and symptoms.

[Smilerdeb]

Bumping this up for others to see...........

[debbie0413]

Scratch out the part above about Kalina possibly transferring to another local hospital.  I just reviewed the info., and I made a mistake.  That hospital does NOT have an eating disorder unit.  There is one other possible hospital.  I have to talk to Kalina and the social worker and see what she wants to do.

[debbie0413]

Well, we got through the meeting.  The social worker is sympathetic to Kalina's plight and even shared his own medical history of having thyroid surgery for his own depression.  However, a couple of important things came out of the meeting: Kalina needs continuing treatment for an eating disorder (which her insurance will not pay for within an affiliation of this psych. hospital) as well as for her depression.  The social worker will see if she can be transfered to another local hospital that has an eating disorder unit (one which is in the hospital system where her new doctor has privleges).  Also, it is apparent that Kalina's doctor (both a psychiatrist and a family medicine doc) did NOTHING in terms of follow up RE: her thyroid problems.  There are no transferred medical records in the file, there is no evidence of any thyroid testing at all, and I heard through the grapevine that Kalina's psychiatrist made a statement like, "I've never known a patient to die of low magnesium."  So, it is probably just as well that she goes to another facility.  I'll let everyone on the forum know what happens in the next couple of days.

[debbie0413]

I just wanted to thank everyone and ask one question.  Your support and prayers have been SO helpful to me.  I try to protect my daughter's privacy, so I haven't told poeple in our church (except for a few) about the hospitalizations.  It's a bit hard when the pastor asked my husband, "Is she in sin?"  Felt like asking him if HIS elderly father was "in sin" because he was recently diagnosed with Parkinson's!  Anyway, I got over being hot about that one, and we are working hard to EDUCATE folks about how complex these endocrine disorders are and how they mask as mental illness.

Here is my question: the psych. docs just put Kalina on Cymbalta (don't know what dosage) about last Wednesday.  Has anyone heard of any interaction issues with Cymbalta and Armour thyroid?  Just on Tuesday it seemed to me that the brain fog was lifing and Kalina was starting to actively plan about getting discharged.  Now she is reporting to her dad that she is having trouble sleeping, her anxiety is increasing, and she is trying to make fine cuts on her arms (with the plastic wrist band that she pried off).  Sounds like bad side effects to me!

Right now I am going to check out 2 other hospitals that have mental health inpatient units.  This currentl hospital is not only NOT helping her, it seems to be making things worse.  One of the hospitals I will check out is a hospital where the new doc she has an appt. for tomorrow morning has privleges.  Since it doesn't look like she will be ready to be discharged today, maybe this will be a way to finally get her thyroid treatment pushed into first priority.  I would appreciate your thoughts and prayers!!!