How to manage mood disturbances in patients with Graves' disease?

Management of Mood Disturbances in Graves' Disease

Beta-blockers should be used as first-line treatment for mood disturbances in Graves' disease, particularly for symptoms of anxiety, irritability, and emotional lability, while simultaneously treating the underlying hyperthyroidism with antithyroid medications. 1, 2

Pathophysiology and Presentation

• Graves' disease commonly presents with psychiatric manifestations including mood disorders, anxiety disorders, and sometimes cognitive dysfunction, primarily due to hyperactivity of the adrenergic nervous system caused by hyperthyroidism 2
• Common mood symptoms include:
  • Anxiety, irritability, and emotional lability 2, 3
  • Difficulty concentrating and memory impairment 2
  • Depression (which may persist even after treatment of hyperthyroidism) 2

Treatment Algorithm

Step 1: Treat Underlying Hyperthyroidism

• Methimazole is the preferred first-line antithyroid medication for most patients 1, 4
  • Standard protocol: 12-18 months of therapy
  • Initial monitoring: Every 4-6 weeks, then every 2-3 months once stable
  • Goal: Maintain free T4 in high-normal range using lowest possible dose

Step 2: Immediate Symptomatic Relief of Mood Symptoms

• Beta-blockers (such as propranolol) for symptomatic relief of:
  • Anxiety and emotional lability 1, 2
  • Tachycardia and tremor (which can exacerbate anxiety) 1
  • Monitor closely every 2-3 weeks initially to catch transition to hypothyroidism 1

Step 3: Assess Response After Achieving Euthyroidism

• If mood symptoms persist despite normalization of thyroid function and beta-blocker therapy:
  • Consider specific psychiatric evaluation and treatment 2
  • Psychotropic medications may be needed for persistent psychiatric symptoms 2
  • Consider that the autoimmune process itself or ophthalmopathy may contribute to mood disturbances independent of thyroid hormone levels 2

Special Considerations

• A substantial proportion of patients may have persistent altered mental state even after successful treatment of hyperthyroidism 2
• Mechanisms other than hyperthyroidism that may contribute to mood disturbances:
  • The Graves' autoimmune process itself 2
  • Ophthalmopathy (present in 25% of patients) 5
  • Pre-existing psychiatric conditions exacerbated by Graves' disease 2

Monitoring Recommendations

• Monitor thyroid function every 2-3 weeks initially, then every 4-6 weeks once stable 1
• Assess mood symptoms at each follow-up visit 1
• Watch for transition from hyperthyroidism to hypothyroidism, which can also cause mood disturbances 1

Common Pitfalls to Avoid

• Failing to recognize that mood symptoms may persist despite normalization of thyroid function 2
• Overlooking ophthalmopathy, which can independently contribute to psychological distress 1
• Attributing all psychiatric symptoms to hyperthyroidism without considering other causes 2
• Inadequate beta-blocker dosing for symptomatic relief of adrenergic symptoms 3