Section - Expert Consultations

01. Recognizing Thyroid Dysfunction in Psychiatry: What to Order and How to Interpret Tests

Published on August 28, 2026 Certification expiration date: August 28, 2029

James K. Rustad, M.D.

Professor & Psychiatrist in the Mental Health and Behavioral Sciences Service - Geisel School of Medicine at Dartmouth

Key Points

Consider checking a baseline TSH in patients diagnosed with mood disorders. An elevated TSH warrants free T4 and TPO antibodies to clarify extent and etiology.
Euthyroid sick syndrome means abnormal thyroid labs without true thyroid disease. It affects up to a third of psychiatric patients, often reverses on its own, and levothyroxine can worsen symptoms.
In anxious patients, check for fine tremor with arms extended and ask about weight loss despite increased appetite. These free bedside findings can unmask hyperthyroidism masquerading as anxiety.

To unlock this audio you need to become a Silver, Gold, Silver extended or Gold extended Member.

Check Our CME Program

Downloads for Offline Access

Download Audio File (MP3)

Text Version

How Thyroid Dysfunction Shows Up in Psychiatric Patients

Flavio Guzman, M.D.: Let’s start with the bigger picture. How often is thyroid dysfunction part of a psychiatric presentation, and what does it look like?

James K. Rustad, M.D.: Clinical hypothyroidism is frequently associated with depressive symptoms. Subclinical hypothyroidism, defined as an elevated serum TSH with normal serum T3 and T4 levels, is commonly reported in treatment-resistant depression.¹

However, most patients with depression do not have biochemical evidence of thyroid dysfunction.

Some older individuals have fewer adrenergic symptoms and instead present with so-called apathetic thyrotoxicosis, which looks like depression, lethargy, and weight loss. That is one of the rarer clinical manifestations of hyperthyroidism.

Who to Test and What to Order: A TSH-First Protocol

Flavio Guzman, M.D.: It would be useful if you could help us conceptualize thyroid testing. What do you order first, and how do you act on the results you

Unlock this Expert Consultation and earn 0.50 CMEs
Become a Silver, Gold, Silver extended or Gold extended Member.

Get Instant Access

Already have an account? Sign in

Table of Contents

Next Section

02. Thyroid Psychopharmacology: T3 Augmentation, Levothyroxine Dosing, and Lithium-Induced Hypothyroidism

Learning Objectives:
After completing this activity, participants should be able to:

Apply a TSH-first testing protocol in patients with mood, anxiety, and psychotic disorders, and interpret free T4 and anti-thyroid antibody results to identify clinical and subclinical thyroid dysfunction.
Assess whether a thyroid abnormality is contributory or comorbid, distinguishing euthyroid sick syndrome from true hypothyroidism and recognizing hyperthyroid presentations that may be mistaken for anxiety or mania.
Integrate T3 and T4 augmentation into the care of treatment-resistant depression and rapid cycling bipolar disorder, applying dosing, titration, and monitoring parameters, including thyroid replacement in lithium-induced hypothyroidism.

Original Release Date: August 28, 2026
Expiration Date: August 28, 2029

Expert: James K. Rustad, M.D.
Medical Editors: Flavio Guzmán, M.D.

Relevant Financial Disclosures:
James K. Rustad, declares the following interest:

United States Department of Veterans Affairs: Employed

All the relevant financial relationships listed above have been mitigated by Medical Academy and the Psychopharmacology Institute.

None of the other faculty, planners, and reviewers for this educational activity has relevant financial relationships to disclose during the last 24 months with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Contact Information: For questions regarding the content or access to this activity, contact us at support@psychopharmacologyinstitute.com

Instructions for Participation and Credit:
Participants must complete the activity online within the valid credit period noted above.

Follow these steps to earn CME credit:

View the required educational content provided on this course page.
Complete the Post-Activity Evaluation to provide the necessary feedback for continuing accreditation purposes and for the development of future activities. NOTE: Completing the Post Activity Evaluation after the quiz is required to receive the earned credit.
Download your certificate.

Please note that CME and SA CME certificates completion dates are recorded using UTC. Depending on your local time zone, activities completed later in the day may appear on your certificate with the following calendar date.

Accreditation Statement
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the joint providership of Medical Academy LLC and the Psychopharmacology Institute. Medical Academy is accredited by the ACCME to provide continuing medical education for physicians.

Credit Designation Statement
Medical Academy designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Artificial Intelligence (AI) Use DisclosureArtificial intelligence (AI) tools may have been used in limited stages of developing this activity (e.g., drafting or language refinement). The specific tool, version, and date of use are documented internally.AI does not determine clinical recommendations. All content is reviewed, verified, and approved by the listed faculty and medical editors, and reflects independent human clinical judgment consistent with ACCME Standards for Integrity and Independence in Accredited Continuing Education.