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T3 Augmentation in Treatment of Major Depressive Disorder
In Session With Lisa J. Rosenthal, MD:
T3 Augmentation in Treatment of Major Depressive Disorder
Assistant Professor of Psychiatry; Director, Consultation Liaison Service; Director, Psychosomatic Fellowship, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago
First published in Psychiatry Weekly, Volume 7, Issue
2, on January 23, 2012
Q: When might T3 be considered as an augmentation treatment for MDD?
A: T3 augmentation can be considered for all patients with treatment-resistant depression (TRD), and especially in patients who may be particularly affected by the potential metabolic side effects of other FDA-approved augmentation agents. Patients with apathy, who are having trouble getting out and about, or those with neurovegetative symptoms would, I believe, be good candidates for T3. Many people who come to see psychiatrists have already tried and failed many antidepressants; if that were the case, or if there were a case of severe depression, I would immediately think of T3 augmentation.
Q: T3 augmentation is well tested with tricyclic antidepressants, but what about the literature regarding the SSRI class?
A: That literature is still growing. In a recent review, we noted that there are 2 meta-analyses on the effectiveness of T3 augmentation in SSRIs, one of which reported that there is not enough evidence to make a statistically significant conclusion but that the evidence is promising. The other analysis had a negative outcome, perhaps owing in part to its very strict inclusion criteria, which excluded some of the studies that seemed to show a benefit. The real-world STAR*D trial did show a significant benefit in terms of the effectiveness of T3.
Q: What are some of the primary safety considerations to weigh when considering T3 augmentation?
A: Cardiovascular effects need to be considered, as well as the potential for osteopenia and osteoporosis, especially in postmenopausal women. Women taking T3 augmentation need to maintain adequate levels of Vitamin D and calcium, and a bone density scan may be necessary during long-term use. Keeping thyroid levels within normal limits may help minimize these risks. On the other hand, new findings suggest that people on thyroid replacement with normal replacement levels had a higher risk of hip fractures. T3 augmentation is not prevalent enough—especially long-term use—for us to say definitively what the potential outcomes are, but it is generally considered fairly safe.
Most people in studies of T3 who withdrew because of side effects reported feeling jittery and anxious, or having a tremor. In the STAR*D trial, people seemed to prefer T3 to lithium, and, in studies from the endocrine literature using a combination of T3 and T4, people seemed to prefer T3 alone over T4 alone. It’s not clear why that is, but T3 is overall well tolerated.
The treatment of depression is still inadequate. We manage to cure very few depression patients with medication. There are risks to many treatments, and our medications are scrutinized very carefully because the morbidity and mortality of depression and other mental illnesses is underestimated. Therefore, I believe that risk-benefit analysis of our medications needs to consider the risk of untreated or undertreated depression.
Disclosure: Dr. Rosenthal reports no affiliations with, or financial interests in, any organization that may pose a conflict of interest.
References:
1. Rosenthal LJ, Goldner WS, O’Reardon JP. T3 augmentation in major depressive disorder: safety considerations. Am J Psychiatry. 2011;168(10):1035-1040.