How should I manage an 18-year-old patient with a history of Grave's disease presenting with symptoms of anxiety and depression, who is likely not currently being treated for their hyperthyroidism?

SOAP Template for 18-Year-Old with Untreated Graves' Disease Presenting with Anxiety and Depression

Immediately assess thyroid status and initiate antithyroid treatment, as untreated hyperthyroidism directly causes anxiety and depression through adrenergic hyperactivity, and these psychiatric symptoms will not fully resolve without achieving euthyroidism.

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SUBJECTIVE

Chief Complaint

• Document specific anxiety symptoms: palpitations, tremor, restlessness, panic attacks, sleep disturbances 1
• Document specific depressive symptoms: fatigue, poor concentration, anhedonia, suicidal ideation 2
• Critical screening question: Assess for suicidal ideation immediately, as severe depression can provoke suicide attempts 2

Graves' Disease History

• When was Graves' disease diagnosed and what was the initial treatment plan? 3, 4
• Current medication adherence (methimazole or propylthiouracil) 3, 4
• Last thyroid function tests (TSH, free T4, free T3) and dates 5, 6
• Symptoms of hyperthyroidism: heat intolerance, weight loss, increased appetite, diarrhea, tremor 1
• Ophthalmopathy symptoms: eye pain, diplopia, proptosis 1

Psychiatric History

• Past history of depression or anxiety BEFORE Graves' diagnosis (critical to distinguish primary psychiatric disorder from thyroid-induced symptoms) 2
• Previous psychiatric medications or therapy 2
• Family history of psychiatric disorders 2

Psychosocial Stressors

• Major life events and daily hassles, as stress exacerbates both hyperthyroidism and psychiatric symptoms in Graves' disease 7, 8
• Work/school functioning and cognitive complaints (difficulty concentrating, memory problems) 9
• Social support system 7

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OBJECTIVE

Vital Signs

• Heart rate and blood pressure (tachycardia and hypertension indicate uncontrolled hyperthyroidism) 1
• Weight and recent weight changes 1
• Temperature 3, 4

Physical Examination

• Thyroid examination: size, nodularity, bruit 1
• Ophthalmologic examination: proptosis, lid lag, extraocular movements 1
• Cardiovascular: tachycardia, irregular rhythm (atrial fibrillation risk) 1
• Neurologic: tremor (fine resting tremor of hands), hyperreflexia, proximal muscle weakness 1
• Dermatologic: warm, moist skin; pretibial myxedema 1
• Mental status: affect, psychomotor agitation or retardation, thought content 2

Laboratory Tests (Order Immediately)

• TSH, free T4, free T3 to assess current thyroid status 5, 6
• TSH receptor antibodies (if not previously documented) 8
• Complete blood count with differential (baseline before antithyroid drugs; assess for agranulocytosis if already on treatment) 3, 4
• Comprehensive metabolic panel (liver function tests critical, especially if considering propylthiouracil) 4
• Prothrombin time/INR (antithyroid drugs can cause hypoprothrombinemia) 3, 4

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ASSESSMENT

Primary Diagnosis

Anxiety and depression secondary to untreated Graves' hyperthyroidism 9, 1

• Up to 89% of hyperthyroid Graves' patients experience mental fatigue, and psychiatric manifestations result from adrenergic nervous system hyperactivity 9, 1

Differential Considerations

• Primary psychiatric disorder (less likely if symptoms began after Graves' diagnosis) 1, 7
• Residual psychiatric symptoms from Graves' disease (38% have persistent mental fatigue even after achieving euthyroidism) 9
• Medication-induced symptoms (if on levothyroxine for hypothyroidism, excessive dosing causes anxiety) 5

Risk Stratification

• High risk if suicidal ideation present 2
• Moderate risk if TSH suppressed/undetectable (indicates severe hyperthyroidism) 5
• Increased relapse risk if high psychological distress (GSI >60 on SCL-90-R correlates with higher relapse rates) 10

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PLAN

1. Immediate Thyroid Management

If TSH is suppressed and free T4/T3 are elevated (confirming active hyperthyroidism):

• Initiate methimazole 15-30 mg daily (preferred first-line antithyroid drug in non-pregnant patients) 3

  • Methimazole is preferred over propylthiouracil due to lower hepatotoxicity risk 3, 4
  • Counsel patient to report immediately: sore throat, fever, rash, jaundice, right upper quadrant pain (signs of agranulocytosis or hepatotoxicity) 3, 4

• Add propranolol 20-40 mg three times daily (or other beta-blocker) to rapidly control adrenergic symptoms including anxiety, tremor, and palpitations 1

  • Beta-blockers are first-line for psychiatric symptoms in hyperthyroidism 1
  • Adjust dose when euthyroid (hyperthyroidism increases beta-blocker clearance) 3, 4

If already on antithyroid medication but non-adherent:

• Assess barriers to adherence and reinforce importance 8
• Consider supervised administration or simplified regimen 8

2. Psychiatric Symptom Management

During the hyperthyroid phase (first 4-8 weeks):

• Do NOT initiate antidepressants immediately 1
• Prioritize achieving euthyroidism with antithyroid drugs plus beta-blockers, as most psychiatric symptoms will improve with thyroid normalization 1
• Monitor psychiatric symptoms weekly during initial treatment phase 5

After achieving euthyroidism (if psychiatric symptoms persist):

• If depression persists after 2-3 months of stable euthyroidism, initiate SSRI (selective serotonin reuptake inhibitors are safest in thyroid disease) 2

  • Avoid tricyclic antidepressants (can cause orthostatic hypotension and arrhythmias) 2
  • Monitor for hypertension with SSRIs 2

• Consider cognitive behavioral therapy for residual anxiety and depression 2

3. Monitoring Schedule

First month:

• Thyroid function tests (TSH, free T4, free T3) every 2-4 weeks 2, 5
• CBC with differential every 2 weeks (agranulocytosis risk highest in first 3 months) 3, 4
• Psychiatric symptom assessment weekly (use standardized tools like HADS or PHQ-9) 10

After achieving euthyroidism:

• Thyroid function tests every 2-3 months 2
• Psychiatric symptom assessment monthly for first 6 months 9, 10
• Monitor for residual mental fatigue distinct from depression (present in 23% of treated patients) 9

4. Patient Education and Counseling

• Explain that anxiety and depression are direct physiological consequences of untreated hyperthyroidism, not personal weakness 1, 7
• Set realistic expectations: psychiatric symptoms improve significantly with treatment but may take 2-3 months to fully resolve 9, 1
• Warn that 38% of patients have residual mental fatigue even after successful treatment, which may require rehabilitation support 9
• Discuss that psychosocial stress can exacerbate hyperthyroidism and increase relapse risk 7, 8

5. Referrals

Immediate referrals:

• Psychiatry or emergency department if suicidal ideation present 2
• Endocrinology for co-management of Graves' disease (especially if severe hyperthyroidism or ophthalmopathy) 1

Delayed referrals (after 2-3 months of euthyroidism):

• Psychiatry if depression/anxiety persists despite euthyroidism 1, 7
• Psychology for cognitive behavioral therapy 2
• Occupational therapy if cognitive complaints affect work/school function 9

6. Safety Monitoring

• Prothrombin time before any surgical procedures (antithyroid drugs cause hypoprothrombinemia) 3, 4
• Liver function tests at baseline and if symptoms of hepatotoxicity develop (especially with propylthiouracil) 4
• Screen for vasculitis symptoms: new rash, hematuria, decreased urine output, dyspnea, hemoptysis 3, 4

7. Follow-Up

• Return in 1 week for thyroid function test results and psychiatric symptom reassessment 5
• Return in 2 weeks for CBC results (agranulocytosis screening) 3, 4
• Establish long-term follow-up every 2-3 months once stable 2, 5

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Critical Pitfalls to Avoid

• Do not treat psychiatric symptoms with antidepressants alone without addressing hyperthyroidism (the underlying cause must be corrected first) 1, 7
• Do not assume all psychiatric symptoms will resolve with euthyroidism (46% have persistent depressive personality traits requiring specific psychiatric treatment) 8
• Do not overlook suicidal ideation (severe depression in hyperthyroidism can provoke suicide attempts) 2
• Do not use propylthiouracil as first-line in young patients (hepatotoxicity risk, especially in pediatric/young adult populations) 4
• Do not dismiss cognitive complaints (95.6% of patients report cognitive difficulties even when objective testing is normal) 9, 10
• Do not ignore psychosocial stressors (stress directly worsens thyroid function and increases relapse risk in Graves' disease) 7, 8