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 21, 2029 DOI: 10.64239/PI-EC08201

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Key Points

1. 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.
2. 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.
3. 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.

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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

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

Learning Objectives

After completing this activity, the learner will 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.

Activity

Original Release Date: August 28, 2026
Expiration Date: August 21, 2029
Expert: James K. Rustad, M.D.
Medical Editor: Flavio Guzmán, M.D.

Relevant Financial Disclosures:

James K. Rustad, M.D. 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.

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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.

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Artificial Intelligence (AI) Use Disclosure

Artificial 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 is used solely as an editorial support mechanism and does not replace human expertise. AI does not determine clinical recommendations. All content is reviewed, verified, and approved by the listed experts and medical editors, and reflects independent human clinical judgment consistent with ACCME Standards for Integrity and Independence in Accredited Continuing Education.