This is the second of five lectures given by Dr. Cady in Santa Fe, NM for the 2012 IMMH conference. It covers the need to identify the hormonal deficiencies of a patient, and ways to remediate them.

1. Mental Health and
Hormones: What in the
World do Hormones Have
to Do with Current
Allopathic Psychiatry?
Louis B. Cady, MD – CEO &
Founder – Cady Wellness Institute
Adjunct Assoc. Prof. - Indiana
University School of Medicine
Department of Psychiatry
Child, Adolescent, Adult & Forensic
For IMMH – Santa Fe, New Mexico Psychiatry – Evansville, Indiana
September 22, 2012
(c) 2012 Louis B. Cady, M.D. - all rights reserved

2. “The mind, once
expanded to the
dimensions of larger
ideas, never returns to
its original size.”
- Oliver Wendell Holmes

3. Rationale for this lecture:
• Many “mental health” issues are actually
“hormone health issues.”
• Contemporary medical practice is not equipped
to handle OPTIMIZATION of these hormones
• The literature is CLEAR; conventional practice
is frequently the OPPOSITE.
• If you don’t go back with this to your town,
nobody else will know it either.
• You will have to decide how you will cope.

4. What our patients are telling us:

5. A Shrink meets the “anti-aging” crowd
• Patient “complaints” • Personal experience
• Loss of energy • Previous state:
• Loss of stamina “energy to burn”
• Loss of libido • “Snooze bar
• Weight gain syndrome”
• Loss of zest for life • “Piles syndrome”
• Loss of interest in career • “Why can’t I make
myself exercise?”
• “I’ve felt like I’ve been
aging since I was 35.” • Car wash MSE!

7. Interesting lab values – Cady – 3/11/03:
Lab Value Cenegenics Normal
a.m.glucose 87 mg/dl 65 – 85 65 – 109
Fasting insulin 3 u U/ml <5 <20
HgB A1C 4.9 % <5.1% < 6.0 %
Cholesterol 241 mg/dl <200 <200
Triglycerides 42 mg/dl <120 <150
Cor. Risk ratio 3.3 <4.0 Av = 5 – 6
Homocysteine 7.9 <8.0 5.4-11.4
DHEA-S 148 350 – 500 59 – 452

8. 4

9. Useful Target Symptoms in MDD
♦ Depressed mood 100%
♦ Reduced energy: 97%3
♦ Fatigue or loss of energy: 94%2
♦ Impaired concentration: 84%3
♦ Tiredness: 73%1
♦ Hypersomnia: 10%–16%4 (Insomnia)
1. Tylee et al. Int Clin Psychopharmacol 1999;14:139-151. 2. Maurice-Tison et al. Br J Gen
Pract 1998;48:1245-1246. 3. Baker et al. Comp Psychiatry 1971;12:354-65. 4. Horwath et
al. J Affect Disord 1992;26:117-25. 5. Reynolds and Kupfer. Sleep 1987;10:199-215.

10. “But the doctor told me my thyroid
was fine.”
• Can be “wnl” but suboptimal.
• TSH frequently only thing checked.
• Nothing known about Free T4 or Free T3.
• Free T4 can be converted to Reverse T3 under
stress (cortisol)
• Free T4 can be underconverted to T3.
• Can have normal levels (or slightly elevated
levels) of everything and have auto-immune
thyroid disease.

11. THYROID – this one is kind of
important, gang!
• Regulates:
– Temperature
– Metabolism – increases fat breakdown
– BRAIN FUNCTION
– ENERGY
• Protects against:
– Cardiovascular disease
– Fatigue and weight gain
– MEMORY LOSS
– COGNITIVE IMPAIRMENT

12. FEEDBACK
INHIBITION
Selenium CORTISOL
required!
“the foot soldier” “the evil twin”

13. Progress – sort of
Graphic from January 2003 AACE pres release accessed here:
http://thyroid.about.com/od/gettestedanddiagnosed/ss/normaltsh_5.htm

14. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS
MEDICAL GUIDELINES FOR CLINICAL PRACTICE
FOR THE EVALUATION AND TREATMENT OF
HYPERTHYROIDISM AND HYPOTHYROIDISM
AACE Thyroid Task Force
Chairman
H. Jack Baskin, MD, MACE
Committee Members
Rhoda H. Cobin, MD, FACE
Daniel S. Duick, MD, FACE
Hossein Gharib, MD, FACE
Richard B. Guttler, MD, FACE
Michael M. Kaplan, MD, FACE
Robert L. Segal, MD, FACE
Reviewers
Jeffrey R. Garber, MD, FACE
Carlos R. Hamilton, Jr., MD, FACE
Yehuda Handelsman, MD, FACP, FACE
Richard Hellman, MD, FACP, FACE
John S. Kukora, MD, FACS, FACE
Philip Levy, MD, FACE
Pasquale J. Palumbo, MD, MACE
Steven M. Petak, MD, JD, FACE
Herbert I. Rettinger, MD, MBA, FACE
Helena W. Rodbard, MD, FACE
F. John Service, MD, PhD, FACE, FACP, FRCPC
Talla P. Shankar, MD, FACE
Sheldon S. Stoffer, MD, FACE
John B. Tourtelot, MD, FACE, CDR, USN
2006 AMENDED VERSION
This amended version reflects a clarification to specify pertechnetate as the
compound attached to 99mTc.
ENDOCRINE PRACTICE V ol 8 No. 6 November/December 2002 457

16. “Thyrotropin (Thyroid-Stimulating
Hormone or TSH). Measuring TSH is the
most sensitive indicator of
hypothyroidism.” (hunh?!)
http://www.umm.edu/patiented/articles/how_serious_hypothyroidism
Accessed: 9/5/2011

19. Se
CORTISOL
“the foot soldier” “the evil twin”

20. Modern Medicine’s Paradigm:
Two Standard Deviations – “if you are not
sick, then you must be well.”
“NORMAL”
OPTIMAL?
OPTIMAL

21. Definition of “normal labs”:
“When your lab
values are as
crappy as
everyone else’s.”
- Neal Rouzier,
MD (World Link Medical Seminar II
– Spring 2011)

22. Yes, T-3 DOES get into the brain
(Transthyretin = carrier protein)
Or: The idiocy of T4 only thyroid treatment…
• Terasaki, T. and Pardridge, W.M.: Stereospecificity of triiodothyronine
transport into brain, liver, and salivary gland: role of carrier- and
plasma protein-mediated transport. Endocrinology, 121(3):1185-1191,
1987.
• http://www.kingpharm.com/uploads/pdf_inserts/Cytomel_PI.pdf.
• Mooradian, A.D.: Blood-brain transport of triiodothyronine is reduced in
aged rats. Mech. Ageing Dev., 52(2-3):141-147, 1990.
• Cheng, L.Y., Outterbridge, L.V., Covatta, N.D., et al.: Film
autoradiography identifies unique features of [125I]3,3'5'-(reverse)
triiodothyronine transport from blood to brain. J. Neurophysiol.,
72(1):380-391, 1994.
• Rudas, P. and Bartha, T.: Thyroxine and triiodothyronine uptake by the
brain of chickens. Acta Vet. Hung, 41(3-4):395-408, 1993.

23. Transthyretin (a systemic amyloid precursor)
may be protective for Alzheimer’s (Why?)
Li X et al. J Neurosci 2011 Aug 31;31(55):12483-90

24. LEVEL III RESULTS:
Per HDRS – 17, remission in:
15.9% on Li
24.7% on T3
Per QIDS-SR16, remission in:
13.2% on Li
24.7% for T3 *
* Fava & Covino: Augmentation/Combination Therapy in STAR*D Trial,
Medscape Psychiatry

27. • Early 20’s college student
• Weight gain, fatigue, brain fog
• Saw “numerous” MD’s asking for help
• Told “nothing is wrong with your thyroid;
your labs are fine.”

28. Don’t forget DELAYED deep tendon
reflexes – delayed relaxation.

29. The glycemic controlling hormones
CORTISOL
-Gets glucose INSULIN:
INTO the blood -Gets glucose
from stored OUT of the blood
glycogen -Too little = DM
-Good news – & complications
keeps you from -Too much
dying causes:
-Bad news – * Weight
goes up with gain
stress * “Crashes”

30. W. Wheat Rice Big Mac, Ice cream;
Toast, OJ, cakes, Fries, Shake Coke & chips
coffee coffee
H - 30

31. Blood sugar goes up due
to cortisol for rescue
W. Wheat
Toast, OJ,
Cortisol
coffee secreted by
adrenals
H - 31

32. Benefits of low-glycemic eating
H - 32

33. Glycemic index
• A measure of how fast a
carbohydrate triggers a rise in
circulating blood sugar.
• The higher the number, the greater
the blood sugar response.

34. “The Twinkie Defense”
• “A derisive lable for an improbable legal defense.”
[Wikipedia]
• Defendant Dan White for San Francisco murders of
Harvey Milk and mayor George Moscone
• Actually, “Twinkies” were used as a symptom of
underlying depression, not the cause.
• White – found guilty on voluntary manslaughter

35. Fatigue from Adrenal Dysfunction - The
Worst Case Scensario:
Addison’s Disease

36. “Hypoadrenia”: The Adrenal Problem that most
conventionally trained physicians don’t know about.
• Non-Addison’s hypoadrenia
• Subclinical hypoadrenia
• Neurasthenia
• Adrenal neurasthenia
• Adrenal apathy
• Adrenal fatigue
• “Adrenal burnout”
• “Chronic fatigue syndrome”?!!

37. The state of adrenal exhaustion can
be determined
• 21 yo female
college student
• Exceptionally
tired in the a.m.
• Not following
IgG food diet

38. DHEA – the critical hormone most
doctors never check
• Produced in the adrenal cortex
– Humans and primates are unique in secreting large
amounts
• Immune system booster
• Insulin regulator
• Energy increase – remarkable
• Boosts growth hormone
– 20% in men; 30% in women in one study
• [Yen, Morales Khorram – one year double-blind placebo
controlled crossover experiment – with 100mg DHEA]
• Antidepressant

39. 348 citations on “DHEA with energy” – as of
of 8/17/2012

40. The two “new ones” – 8/17/2012
- Opioid use has
increased.
- Concomitantly OPIAD
has increased.
- Testosterone and DHEA
are recommended.
-Corticotroph def = crucial
element of ant. Pituitary failure
-Dx with a.m. cortisol w/ stim
-TX with HC 20 mg per day,
divided doses.
-Tx determined by fatigue, BP,
BW, skin trophicity

41. Why isn’t adrenal fatigue diagnosed?
• Not severe enough to be an
emergency
• Symptoms can be attributed to other
things, including “just neurotic” or
“avoidant”
• “Functional medicine” testing not
typically done (& rarely is DHEA-S
checked)
• Modern medicine focuses on the
treatment of sickness, not “less than
optimal” function.
• “Bell Curve” paradigm

42. Neurobiological & neuropsychiatric effects
of DHEA & DHEAS [Maninger N et al. Front
Neuroendocrinology 2009]
• DHEA & DHEAS synthesized in adrenals
AND BRAIN.
• Biological actions of DHEA/DHEA-S:
– Neuroprotection
– Neurite growth
– Antagonistic effects on oxidants & glucocorticoids
• “accumulating data suggest abnormal DHEA
(S) concentrations in several neuropsychiatric
conditions.”

43. “Women’s issues”

44. The Glamorous Grandmother
• 4/8/11 – 80 yo returned to practice. No real
complaints. History of depression. On Pristiq.
– Daughter “handling her finances”
• 5/2/11 – “doing terrible.”
– TSH 3.84, Free T3 2.8 – on 50 MICROgrams T4
– Fasting BS 120; HgBA1C 6.5%
– Fasting insulin 36 (!!!) {3 – 25}
– Progesterone – 0.2 {0.2 – 1.4 follicular}
– Total testosterone 11
– DHEA-S = 25 MICROgrams/dL (!!)
• Age adjusted {10 – 90} . Cenegenics = {c. 500}
• Rouzier = {300 –females, 600 males}

45. G.G. - interventions 5/2/11 & Follow-up
• Interventions:
– DHEA – 25 mg SR q a.m.
– Progesterone 200 mg/cc, Topiclick – ¼ cc at
HS, then increase to ½ cc
– Testosterone – 8mg/cc Topiclick – 1/4cc
topically for one week, then ½ cc
– Referred to better MD for intervention with
AODM.
• 6/13/2011 – improvement in fatigue. Labs
rechecked.
• 7/11/2011 – “feeling wonderful”

46. G.G. – labs before and after
4/11/11 interventions 7/11/11 changes
TSH 3.84 Raise T4 from 0.01 (L) none
50 – 75 ug
FT4 1.16 “ 1.24 “
FT3 2.8 “ 3.3 “
Progesterone <0.2 100mg topical 0.9 None
HS
Testosterone 11 4mg topical 15 4 mg LABIAL
DHEA-S 25 25 mg SR n/a continue

47. The glamorous grandmother – post tune-up
Two pictures, after “tine-up” – removed from
presentation posted on internet
9/28/2011 (permission granted to use photos & data) 01/26/2012

48. One destigmatizing notion:
Estrogen as MAOI
• Estrogen & Testosterone (!) decrease
MAO
– Luin, VN. Brain Res. 1975;86:273-306
• Platelet MAO levels inversely
correlated to estradiol levels
– Klaiber EL et al. Psychoneuroendo-
crinology. 1997 Oct;22(7):549-58.
• Estrogen decreases MAO-A & MAO-B
– Holschneider DP et al. Life Sci. 1998;63(3):155-60

49. Estrogen-related mood disorders –
reproductive life cycle factors.
Douma SL et al. Adv. Nursing Sci. 2005. 28 (4):364-375
• “Clinical recovery from depression
postpartum, perimenopause, and
postmenopause through
restoration of stable/optimal
levels of estrogen has been
noted.”

50. Symptoms of estrogen imbalances*:
 Hot flushes or flashes; night sweats
 Mood swings
 DEPRESSION, and/or anxiety, panic attacks
 “Concentration” issues: Memory, communication,
and attention span loss, “brain fog.” (Think:
“MORE MAO.”)
 Insomnia
 Weight gain – “appetite changes”
 SOMATIC symptoms : aches and pain
 General deterioration: Incontinence, digestive
disturbances, sensory function loss, aging skin . . .
thinning, wrinkles, sagging* Adapted from Whitney Gabhart, N.D.

51. The Case of the Crying Cleaner
• 1/11/12 - Symptoms:
– Crying/depressed = on
Citalopram
– Hot flashes
– Night sweats
• RX:
– Estradiol – 2 mg @HS
– Prometrium – 100 mg
@HS
– (continue citalopram)
• 1/15/12 – RESOLVED
• In 4 days!

52. Psychoactive Progesterone*
 Increases energy and libido
 Has a calming effect, acting like a
benzodiazepine to the brain (HS dosing)
 Enhances mood
 Balances blood sugar (appetite)
 Regulates fluid balance, sodium mineral balance
 Necessary for fertility
 Helps relieve menopausal symptoms
 Decreases risk of endometrial cancer and may help protect
against breast cancer, fibrocystic breasts, and
osteoporosis * Adapted from Whitney Gabhart, N.D.

53. Testosterone: The “sexist” bias against women
(e.g., “your loss of sex drive is just natural for
your age.”)
• Fall in the circulating testosterone and the adrenal
preandrogens most closely parallel increasing
age.
• Accelerated decrease occurs in the years
preceding menopause (like estrogen).
• Their loss affects: libido, vasomotor symptoms
(hot flashes), mood, well-being, bone structure,
and muscle mass.
– Burd, Bachmann. Androgen replacement in
menopause. Curr Womens Health Rep. 2001 Dec;
1(3):202-5.

54. The Case of “Pajama Mama”
• 41 yo MWF, mother of three, ref by therapist for worsening depression.
History of chronic headaches. Mild dep symptoms x 16 years.
• CC: “I think I need a good medication, and I need to stay on it.”
• In normal mood state until after birth of second child 14 years prior (@
age 27)
– Recalls “calling the doctor all the time” and ego-dystonic worries of
dropping her baby over a railing ACCIDENTALLY on the stairway
at home
• RX tried
– fluoxetine– “worked reasonably well”
– Amitryptline for headaches – “knocked me out”
– Alprazolam – had her first panic attack ON IT.
– Tried on duloxetine – no relief.
• Rx at presentation – fluoxetine 20 mg; topirimate 100 mg, sumitriptatn
as needed

55. The Case of “Pajama Mama” - treatment
• Fluoxetine gave sexual side effects. Stopped.
Escitalopram now at 15 mg. Trazodone 25 mg HS..
– Topirimate continued for migraines.
• Psychotherapy: focused on significant dependent
personality disorder and on controlling, overbearing, free-
spending, financially irresponsible husband.
– Increasing limit setting noted. Patient reading her bibliotherapy
assignments
• Escitalopram didn’t work. Back to fluoxetine. IgG Food
sensitivities found; diet restrictions instituted.
• 11/15/2011 – working professionally in her field, has gotten
graduate degree, but tired and wrung out. Exhausted at
end of day. Was tired on a cruise vacation almost all the
time. Went back to room to sleep. Forcing self to
exercise.

56. The Case of “Pajama Mama” – lab review
• TFT’S
– TSH 0.38 (L) {0.55 – 4.78}
– Free T4 1.05 {0.80 – 1.76}
– Free T3 2.9 {2.3 – 4.2}
– Reverse T3 199 {90 – 350}
• SEX HORMONES
– Total testosterone 11 {9 – 55}
– Free testosterone 1.3 {1.1 – 5.8}
– SHBG 60 {30 – 155}
– Progesterone 1.0 {0.2 – 1.4}
– Estradiol 67 {24 – 284}
• DHEA-Sulfate 55 {32 – 240}

57. This is what those labs “sound like”
• “I must be worse than I think I am, because my daughter made a comment about the members of her family. ‘Mom
likes her pajamas.’”
• “I’m frustated that I’m not doing great – I don’t know why. There should be no reason why I should think about the
way I feel, or wonder, ‘why don’t I want to get up?’ or ‘Why do I feel anxiety?’ I don’t have to give a speech. I don’t
have to do anything.”
• “I’ve done a lot of right things… I’ve done so many right things. I’ve taken my medicine like I’m supposed to. I’ve
tried to change my life and my thinking. I’ve done physical things [exercise] to try to help me.”

58. Pajama Mama – treatment and follow-up
• All psychotropics kept same
• Hormones added (11/15/2011):
– Testosterone – 10/mg/cc – ¼ cc labially daily -
increased to ½ cc (5 mg) labially per day.
– Amour thyroid – ¼ grain x 1 week, then ½ grain
– DHEA – 25 mg SR micronized daily in a.m.
• Still tired – 12/13/2011 –
– New RX: Hydrocortisone – 5 mg twice daily
added (a.m. and lunch)

59. PJ Mama – STABLE – 1/17/2012
• “I don’t have a hyperactive sense of energy, [but]
I’m no longer pajama mama [sic]. I just have the
energy to do what I’m supposed be doing, and
more, sometimes. But it’s not an odd, hyperactive
type thing.”
• Household budget now fixed and stable.
Increased limit setting with husband.
• “He has used anger to shut me down and shut me
out from day 1. He still uses anger, but instead of
me going away, he goes away. I don’t back
down.”

61. Testosterone (Men)
• Decline in male sex steroids not as
abrupt as menopause, but equally
debilitating
–Between 40 – 70, average male
loses:
• Nearly 2" of height
• 15% of bone density
• 10 – 20 pounds of muscle
• At 70 yoa, 15% completely
impotent

62. T vs Cognitive Function
Rosario ER. JAMA. 292(2004):1431-2

63. T vs Cognitive Function
• 400 independently living men, 40-80yo
– 100 in each age decade
– MMSE 21-30, average 28
– TT: 208-1141ng/dL; Bio-avail T 78-470ng/dL
• HIGHER T = better cognitive performance in
OLDEST AGE category
• Men with lowest 1/5 T = worse than men with
highest 1/5 T
• Highest Bio-available T more significant
than TT, age, intelligence level, mood,
smoking, and alcohol.
Muller M. Neurology. 64(2005):866-71

64. T vs Mood in men
• Study: 278 men, >45yo, followed 2 years
• Compared to eugonadal patients,
hypogonadal men w/TT <200ng/dL had
– 4-fold increase risk of depression
– Significantly shorter time to depression
diagnosis
• Depression risk inversely related to TT
w/statistical significance <280ng/dL
Shores MM, Arch Gen Psychiatry. 61(2004):162-7

65. Testosterone and “Prostate Cancer risk”
• Prostate CA found 2.15 & 2.26 times more
likely in lowest compared to highest tertile
of total and free testosterone
• “. . . there are several papers showing a
relationship between LOW testosterone
and prostate cancer. Specifically, low
testosterone has been associated with
high-grade tumors, advanced stage of
presentation, and worse prognosis.”
Morgentaler A. Eur Urol. 50(2006):935-9
Morgentaler A. Urology. 68(2006):1263-7

66. Treatment options – not just
“the needle”

67. State of the art compounding devices

68. The Case of the Mismanaged
Executive - summary
• 42 year old male ADHD CEO. Background in
psychology. Now EXTREMELY stressed.
• “So tired I feel like I’m dying.” “Depressed.”
• Lab findings – low testosterone, despite multiple
pumps of Androgel per day managed by
endocrinologist (!). Low thyroid. Low DHEA.
• RX: Testosterone cypionate IM – 60 mg twice
weekly. DHEA – 50 mg SR. Armour thyroid – ½
grain.
• Clinical status: total resolution of symptoms in 3- 4
weeks. No antidepressant used.

69. Holistic Fun with Hormones
A synthesis…

70. Key points
• A predominantly psychiatric view with
psychiatric interventions…
– Will not fix all symptoms
– Unlikely to get anybody else to do it for you,
either.
• STABILIZING THE BIOLOGICAL is critical
for full remission and total wellness when
hormones are not optimal.
• Holistic and integrated tx required.
• Yoking of thyroid, adrenal & sex steroids

71. HOW OBVIOUS DOES IT HAVE TO BE?
The Challenge of Empathic Listening
& CREATIVE THINKING
Ron Hunt lost an eye but suffered
no brain damage after a freak
accident with a large drill bit.
(ABCNEWS.com)

72. “Sit down before fact as
a little child,
be prepared to give up
every preconceived
notion,
follow humbly wherever
… nature leads,
or you shall learn
nothing.”
- Thomas H. Huxley