CASE REPORT

A 54-year-old man presented to the emergency room with suicidal ideation 5 years ago. Additionally, patient had severe depression and an immense desire to surf the internet, generally prohibited sites. He also noted a 12-pound weight gain, dry skin, and cold intolerance. Family history was significant for Hashimoto’s thyroiditis in one daughter. Physical examination showed HR 64 bpm, BP 140/90 mm Hg. Thyroid was diffusely enlarged, approximately 40 grams without palpable nodules. Rest of the examination was normal, except for delayed deep tendon reflexes. Laboratory values at admission: normal CBC, CMP, and serum B12 level. Thyroid functions: serum TSH 560 µIU/mL (normal 0.41–4.2), FT4 0.20 ng/dL (normal 0.90-2.18), total T3 38 ng/dL (normal 59-174), TPO antibody 278 IU/mL (normal 0-34), TG antibody 9.8 ng/dL (normal 0.0-0.9). Ultrasound confirmed a heterogeneously enlarged thyroid consistent with Hashimoto’s thyroiditis. Diagnoses of major depressive disorder and primary hypothyroidism were made. GHQ, TSQ and BDI-II scores obtained 2 days after admission were markedly abnormal (during the 8 week basal period, the symptom scores and thyroid functions were measured at 2 to 3 week intervals (n=4) and these functions were GHQ, 26.0 ± 8.49, TSQ 28.5 ± 7.77, BDI-II 45.0 ± 6.18, TSH 165 ± 133 µIU/mL, Free T4 0.79 ± 0.25 ng/dL, and total T3 60.5 ± 7.89 ng/dL) . Patient was treated with levothyroxine (LT4) 175mcg daily and citalopram 20mg daily. The dose of citalopram was gradually increased to 40mg daily and amitriptyline 50mg at bedtime was added along with twice weekly psychotherapy sessions. After 8 weeks of treatment there was modest improvement in GHQ, TSQ, and BDI-II despite normal serum TSH 1.34 µIU/mL (Table 1, Figures 1, 2). Three months later, because of the poor response to antidepressant drugs aripiprazole and buspirone were added. After 9 months, LT3 5 mcg once daily was added. Patient continued LT4 + LT3 5mcg combination for another 13 months and at this time the treatment was changed to LT4 only. Despite being on 4 antidepressant drugs and LT4, his depression scores and internet addiction did not improve significantly (Table 1). Approximately 2 ½ years after the initial visit, patient was placed on LT3 5mcg thrice daily with reduced dose of LT4. Within 4 weeks of starting LT4 + LT3 TID dosing, patient noted remarkable improvement in depression, suicidal ideation, and internet addiction. It was possible to gradually discontinue all the antidepressant drugs over the next 9 months (Table 1). However, the psychiatrist prescribed over the counter antidepressant drugs, S-adenosylmethionine (SAMe), (Pure Encapsulations TM, Sudbury MA) 1600 mg/day, and Rhodiola rosea (rosavins > 3.0%, salidroside > 0.8% at a ratio of 3:1, Pure Encapsulations TM, Sudbury MA) 200mg twice daily. The serum total T3 levels remained in the upper normal range while the patient was taking LT4 +LT3 5mcg TID dosing and the serum TSH levels remained in the lower normal range. A follow up cardiac evaluation was completely normal. He presently continues psychotherapy visits only every 3 months. Additionally, he is gainfully employed and also continues a happy married life. A genetic screen performed for DIO2 polymorphism confirmed that the patient carries one allele of Thr92 Ala-DIO2 polymorphism. The GHQ, TSQ and BDI-II scores correlated well with serum TSH and T3 levels (Figures 1,2), but less significant with serum free T4 levels (correlation coefficient (r) for GHQ: 0.52, r for TSQ: 0.62, r for BDI-II 0.66, Figure 3)