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Levothyroxine for Hypothyroidism and Bipolar Disorder

Can treatment with the T4 thyroid drug levothyroxine help bipolar disorder, in addition to hypothyroidism?
Levothyroxine for Hypothyroidism and Bipolar Disorder
Last updated:
8/8/2023
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We know that the thyroid gland plays a significant role in nearly every function and system of the body, including the digestive, cardiovascular, musculoskeletal, and nervous systems. Studies have shown that thyroid hormone levels can also affect behavior, mood, and mental health. For example, hyperthyroidism -- an overactive thyroid -- is associated with symptoms of anxiety and panic disorder, while hypothyroidism -- an underactive thyroid -- can cause symptoms of depression and bipolar disorder.

How are hypothyroidism and bipolar disorder treated? Are they treated in tandem or as two separate disorders? Let’s dive in.

What is bipolar disorder?

Formerly called manic depressive illness or bipolar depression, bipolar disorder is a mental illness that causes shifts in mood, energy, weight, activity levels, concentration, and the ability to handle daily tasks. It affects men and women equally; 2.8% of the U.S. population is diagnosed with bipolar disorder, and nearly 83% of those cases are classified as severe.

The key types of bipolar disorder include the following:

Bipolar I Disorder: this type of disorder involves manic episodes that can last up to a week, and in some cases, it requires hospitalization to help minimize symptoms

Bipolar II Disorder: less severe than type 1, this is defined as having a unique pattern of depressive episodes and hypomanic episodes

Cyclothymic disorder: the least severe form, which involves recurrent hypomanic and depressive symptoms that are neither long-lasting nor highly intense. These symptoms do not qualify this disorder type to be considered as hypomanic or depressive episodes, compared to type 2

Treating bipolar disorder

The most common drug used for bipolar disorder, especially for the past 70 years, is lithium. Lithium treatment aims to prevent relapses and treat related conditions such as mania and depression. The efficacy of lithium as a treatment for bipolar has been shown, including groups such as pediatric patients, geriatric patients, and pregnant and postpartum patients. A subset of patients has lithium-resistant bipolar illness. In those cases, other pharmacologic treatments, including antidepressant therapy and antipsychotic medications, have been shown to have beneficial effects in regulating mood and reducing the frequency and severity of manic and depressive episodes.

Hypothyroidism and bipolar disorder

Having bipolar disorder, and treating it with lithium, are both associated with thyroid disorders. A study from 2021 reported that people with bipolar disorder experience significant changes in their thyroid hormone levels during a depressive or hypomanic episode. Each patient in the study had blood samples collected to measure thyroid hormone levels and depressive and manic symptoms, assessed by two different scales (MADRS & YMRS). The study found that Free T3 (free triiodothyronine) levels (T3 is the active form of thyroid hormone) were significantly different in patients experiencing manic episodes and those experiencing depressive episodes. The thyroid axis dysfunction was also far more severe for people experiencing manic episodes.

Lithium therapy is a well-known trigger of autoimmunity, leading to the onset of drug-induced hypothyroidism. In fact, some studies show that up to 50% of patients treated with therapeutic doses of lithium will develop an underactive thyroid. Lithium-induced hyperthyroidism and Graves’ disease are less common but can also occur.

In addition to the use of lithium, other antipsychotic drugs and tricyclic antidepressant medication can interfere with both thyroid hormone production and TSH levels.

Experts recommend that patients with bipolar disorder being treated with lithium, antipsychotic drugs, or tricyclic antidepressants should have frequent thyroid blood testing done to monitor for any thyroid changes. This is in addition to monitoring for common symptoms of hypothyroidism.

It can be confusing, however, as some symptoms of hypothyroidism cross over to symptoms of bipolar disorder, including weight changes, fatigue, difficulty concentrating, and mood changes.

Can levothyroxine help bipolar disorder?

In some situations, lithium or antidepressants aren’t an option or effective enough at resolving bipolar depression. Studies have shown success in using levothyroxine thyroid hormone treatment to manage both treatment resistant bipolar disorder and hypothyroidism concurrently.

There is also some evidence favoring the use of thyroid hormone replacement therapy as an adjunctive treatment to help stabilize mood in patients with more chronic and severe bipolar disorder.

A note from Paloma

There’s no reason you can’t live a healthy and vital life with bipolar disorder and hypothyroidism. The keys are knowledge, careful management, and the right treatments.

If you have bipolar disorder, it’s crucial to test your thyroid levels frequently. The convenient Paloma Complete Thyroid Test Kit can make it easy, private, and affordable to test your Thyroid Stimulating Hormone (TSH), Free Thyroxine (Free T4), Free Triiodothyronine (Free T3), and Thyroid Peroxidase Antibodies (TPOAb). To diagnose, treat, and manage your hypothyroidism, you can schedule a virtual visit with one of our thyroid-savvy Paloma doctors. Paloma’s practitioners can work with you to monitor your thyroid levels regularly, assess any symptoms and clinical manifestations of hypothyroidism, and prescribe appropriate treatment for your underactive thyroid condition as necessary.

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References:

National Institute of Mental Health. Bipolar disorder. National Institute of Mental Health. Published January 2020. https://www.nimh.nih.gov/health/topics/bipolar-disorder

Zhao S, Zhang X, Zhou Y, et al. Comparison of thyroid function in different emotional states of drug-naïve patients with bipolar disorder. BMC Endocrine Disorders. 2021;21(1). doi:10.1186/s12902-021-00869-5

Joffe RT. How should lithium-induced thyroid dysfunction be managed in patients with bipolar disorder? Journal of Psychiatry and Neuroscience. 2002;27(5):392. Accessed May 4, 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC161685/

‌Bauer M, Priebe S, Berghöfer A, Bschor T, Kiesslinger U, Whybrow PC. Subjective response to and tolerability of long-term supraphysiological doses of levothyroxine in refractory mood disorders. Journal of Affective Disorders. 2001;64(1):35-42. doi:10.1016/s0165-0327(00)00215-9

‌Chakrabarti S. Thyroid Functions and Bipolar Affective Disorder. Journal of Thyroid Research. 2011;2011:1-13. doi:10.4061/2011/306367

Thomsen AF, Kvist TK, Andersen PK, Kessing LV. Increased Risk of Developing Affective Disorder in Patients with Hypothyroidism: A Register-Based Study. Thyroid. 2005;15(7):700-707. doi:10.1089/thy.2005.15.700

Khalil RB, Richa S. Thyroid Adverse Effects of Psychotropic Drugs. Clinical Neuropharmacology. 2011;34(6):248-255. doi:10.1097/wnf.0b013e31823429a7

Malhi GS, Gessler D, Outhred T. The use of lithium for the treatment of bipolar disorder: Recommendations from clinical practice guidelines. Journal of Affective Disorders. 2017;217:266-280. doi:10.1016/j.jad.2017.03.052

Chakrabarti S. Thyroid Functions and Bipolar Affective Disorder. Journal of Thyroid Research. 2011;2011:1-13. doi:10.4061/2011/306367

‌Miller KK, Daniels GH. Association between lithium use and thyrotoxicosis caused by silent thyroiditis. Clinical Endocrinology. 2001;55(4):501-508. doi:10.1046/j.1365-2265.2001.01381.x

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Neeyaz Zolfaghari

Holistic Nutritionist and Nourishment Coach

Neeyaz Zolfaghari is the founder of Unspoken Nutrition, a nutrition and lifestyle brand dedicated to helping others find and create harmony with their daily habits to support their wellbeing and ‘health’. Her journey began over a decade ago, when she was diagnosed with two autoimmune diseases. Knowing what she learned from her upbringing, Neeyaz turned to nutrition as the first pillar of her healing. As her body began to heal on a physical level, she began to learn how our minds, bodies and souls are all innately connected.  

Now as an Integrative Nutritionist and Patient Advocate, Neeyaz offers the people she works with the support, guidance, and tools they need in order to live a fulfilled life. While Neeyaz initially endeavored to make a difference at the individual level, her vision grew to embrace broader community impacts. She is currently pursuing her Masters in Public Health, serving as a testament to her unwavering commitment to instigate change on a grander scale.

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