Q:  T3/T4 Appropriate for a Child...?

Dear Dr. Phelps,

My 10-year-old son has been diagnosed with bipolar disorder.  We have had some limited success with bipolar medications but with many side effects.  I am intrigued by your t3/t4 treatment results.  My son has subclinical hypothyroidism and is currently being treated with 25 mcg synthroid.  He has been on the synthroid about a month and I see some improvement in energy levels and sleep patterns but he has had other medication changes during this time so it’s difficult to sort out cause and effect.

My son’s psychiatrist didn’t feel qualified to treat a child with thyroid medications and it wasn’t easy finding and convincing a pediatric endocrinologist that thyroid treatment would potentially improve my son’s cycling. I’m sure I’ll never find anyone to prescribe t3 but I’d like to know if you think t3/t4 treatment is appropriate for a child and if it’s worth pursuing.  What do endos worry about when treating a child?  Do you think the following is significant?

1.  My son had an elevated TSH level before he took any meds so the problem is not med related.  His first test showed TSH = 6.9.  He then started taking depakote and needed monthly blood tests so the pediatrician added TSH to the tests for the months he was on depakote.  Subsequent levels were: 8.6, 7.9, 3.9, 6.2.  These levels
increased after lithium was added and went as high as 10.2.

2.  We have significant family history of thyroid problems and autoimmune disease.  My son's father, paternal uncle and two paternal aunts have hypothyroidism (out of 7 children.)  His maternal grandfather and great-grandfather have/had hypothyroidism.  His maternal aunt had hyperthyroidism as a teenager and his maternal uncle showed thyroid nodules on autopsy.  He has a male cousin on his father's side with autoimmune hepatitis.  There are other more distant relatives with thyroid disorder.   There are many family members on both sides with eczema.

3.  The people on my side of the family who have or have had thyroid disease are the ones most often described as "interesting", "eccentric", and "difficult."  No relatives have been diagnosed with bipolar disorder although there is lots of anxiety and depression.

Thank you,


Dear Ms. M' -- 
I have just finished writing a letter to a Ms. J' on the subject of thyroid treatment approaches.  I am going to refer you to that letter as I think all of it applies, unfortunately probably most of all the warnings about "I don't know much about this!"

However, on the basis of what I've learned so far and what I see in the literature (e.g. try a search on Pub Med and enter just thyroid bipolar and look at all the articles you find that target the emergingly obvious connection; just look at stuff since 2000, because before that the notion was less strongly recognized), I'm pretty sure you're onto something very important.  For example, at minimum we know so far that people with bipolar depression symptoms are more likely to get better in response to their treatment, whatever it is, if their TSH is closer to 1 than it is to 4 -- even though both values are in the "normal range"!  (Cole et al: Slower treatment response in bipolar depression predicted by lower pretreatment thyroid function). 

Stay with your inquiry.  Good luck to you. 

Dr. Phelps


Published September, 2002