Is Low T Contributing to Your Patient’s Depression?

Although the symptoms of low testosterone frequently overlap with psychiatric symptoms, routine screening for low testosterone is rare in psychiatric settings (1).

Several studies point to an association between low testosterone levels and depression in men. A 2017 study comparing testosterone levels in men with and without depression found that men with major depressive disorder had lower average testosterone levels than non-depressed controls. This difference was not seen when the researchers compared hormone levels in women with and without depression (2). Although only a small percentage of men (5.4 percent) in the study had a total testosterone level lower than 230 ng/dL (considered below the normal range of testosterone for men), 90 percent of them met the criteria for major depressive disorder.

Another study tracked older men over a nine-year period. The researchers found that the risk of developing depression over the course of the study was nearly double in men with lower baseline testosterone levels even after adjusting for age, lifestyle factors, and medical comorbidities (3).

What options do you have if you suspect low testosterone (low T) may be contributing to mood symptoms in your patient?

To screen for testosterone deficiency, most clinicians rely on a 10-item questionnaire known as ADAM (Androgen Deficiency in Aging Males), which assesses energy, mood, and sexual performance. It is a good test in the general population, but in psychiatric settings, questions such as “Do you feel sad and/or grumpy?” or “Have you noticed a deterioration in your work performance?” may be less effective.

A better approach might be to ask your male patients with depression if they have had any problems with low libido, reduced frequency of morning erections, or other erectile dysfunction. If they answer yes to any of these questions, recommend a morning testosterone blood test. If the levels are below 300 ng/dL, you can consider the following treatment options:

• Consider alternatives to current medications. Selective serotonin reuptake inhibitors (SSRIs) might contribute to testosterone loss, as laboratory studies have shown they can convert testosterone to estradiol (6). The antidepressants bupropion or mirtazapine might be better for patients experiencing low testosterone. The antidepressants bupropion or mirtazapine might be better for patients experiencing low testosterone. Studies also show that the long-term use of opioids is associated with testosterone loss, so taper patients off opioids, or use buprenorphine, if necessary (7). The antipsychotic risperidone is also known to suppress testosterone by raising prolactin levels in the body; in place of risperidone, you may want to prescribe aripiprazole.

• Encourage weight loss if appropriate. Studies have suggested that just a 10 percent loss in body weight can boost testosterone by about 80 ng/dL (8). Such a jump in testosterone levels could be enough to take someone with significant deficiency back above 300 ng/dL.

• Consider referring the patient to a urologist for testosterone replacement therapy. If your patient tests low for total testosterone levels, you may want to refer him to a urologist for testosterone replacement therapy (TRT). In 2015, the Food and Drug Administration issued a black box warning about TRT, stating it should only be used in people with testosterone deficiency due to pituitary, testicular, or brain problems. Because the studies used in the FDA’s decision had some statistical problems and used poor comparison groups, several medical groups including the American Urological Association have said they believe TRT remains appropriate for men with demonstrated low T and significant hypogonadism-related symptoms, absent contraindications such as male breast cancer. Testosterone replacement has a contraceptive effect, so ensure patients have no concerns about preserving fertility.