Thyroid disorders - Unstable Thyroid
By Dr. Alan Rind, M.D. on Unstable Thyroid Disease
Dr. Rind is a board certified
Endocrinologist/Psychiatrist in private practice for 16 years. He was trained at
In our profession we are taught to treat the patient and the family. All too often we forget how the suffering of the patient is transferred to the family as well. We forget that we are suppose to bring them relief and comfort. Instead too many patients are treated as a number, even put aside when they become too much trouble to deal with. In my private practice I have had the opportunity to treat many patients who came to me from other Doctors with thyroid conditions and were told that their symptoms were just in their heads. These individuals suffer every day from improperly treated thyroid conditions as well as the other disorders that were unleashed. It is my intent with the experience and knowledge I have gathered over the years and witnessing countless conditions, to bring to the public information that can help them in the discovery and recovery process of an unstable thyroid. Let’s begin by explaining the Thyroid and its function and we will go from there.
If My Thyroid Labs Are
When is the last time
you went to the doctor and gave some kind of sample that was then sent to a lab? Chances are that lab result came back 'normal'.
However, all too often when interpreting lab values one looks for normal rather than optimal. The frequently used term
of ‘normal’ refers to a mathematical or statistical situation. Thus, a ‘normal’ state of health probably
means you have some medical problems. It may be normal to die at 76 yrs of age, but at 75 years old, you may decide that what
you really want is ‘optimal’ health as opposed to ‘normal’.
TSH: Thyroid Stimulating Hormone (TSH) represents the pituitary's need
or ‘desire’ for more thyroid hormone (T4 or T3) relative to the body’s ability to utilize energy.
Thus a ‘high TSH level’ is like the pituitary saying it has a ‘high need for thyroid hormone’. A low
TSH reflects a low need or ‘desire’ for thyroid hormone. An optimal value of TSH means the thyroid hormone levels
match the body’s energy needs and/or ability to utilize the energy.
Thyroid Function Tests
Hormones (T4, T3, and RT3), once released into the bloodstream, exist either as protein bound or in a free form. Protein acts as a sponge or reservoir to which hormones bind and then can be freed. Hormone in free form is then available to interact with a cell’s receptor site to produce its hormonal effect. It is only the free form hormone that is biologically available or active. When the hormone is bound to a protein it is restrained from interacting with a cell’s receptor site. Below is a brief explanation of commonly used hormone level tests.
Which test to use? If no estrogen elevation is present (i.e. no
birth control pills or pregnancy), I test for Total T4, Total T3, and TSH levels because they most closely reflect
the patient’s clinical condition. If there is estrogen elevation, I test for Free T4, Free T3 and TSH levels.
Defining the Thyroid Scale
The Thyroid Scale is a powerful tool. It is a relative (to optimal) scale that converts different thyroid hormone values to a common unit of measurement. By looking at values relative to optimal (and each other) on a common scale, one can obtain a clearer picture of what is going on.
Using a fairly proportional distribution between Low and High lab values relative to Optimal, the relative scale lab value ranges are as follows:
Simply plot the different hormone lab values on the relative scale using the provided lab value ranges. Remember that this is not an exact science and that the purpose of the relative scale is to help us understand where lab values sit relative to optimal and then each other. There needs to be sufficient detail to do this but not so much detail that the scale becomes too cumbersome. The below diagram shows an example of a completed Thyroid Scale™ diagram for what may be a metabolically healthy individual -- the T3, T4, and TSH are all in the optimal zone.
The reason why we go through all this effort is because there is great diagnostic value in how the different lab values line up on the Thyroid Scale™.
If you have a "normal" TSH level but you still think you have hypothyroidism, ask for more thyroid testing. TRH stimulation test might produce more conclusive test results. Note that hyperthyroidism can also be missed by relying too much on the TSH test; some people get symptoms of hyperthyroidism when their TSH level is within the lab reference range, but at the low end of the range. If you think you are under treated, you can use these compilations to ask your doctor about a dose increase.
What about low or suppressed TSH levels?
A lot of hypothyroid patients need to have a very low TSH level to be symptom-free.
Some doctors believe that too little thyroid medication is preferable to the possibility of temporarily overdosing, and won't increase the dose once the TSH level is within the wide reference range. While it's commonly taught that too much thyroid hormone causes health and functioning problems, it's not as well known that so does even a slight deficiency of thyroid hormone. Under medicating a patient is like stopping a diet too soon, or driving a car too slowly for traffic conditions.
If you take a little too much thyroid medication, you can reduce your dose and still reach your target. You'll never get there, however, if you don't have enough thyroid hormone. Cars have speedometers, which are usually reliable, but the TSH test has been proven to be an unreliable indicator of adequate thyroid hormone levels due to the wide range. As a side note, if you have been diagnosed with Hashimotos, you should never skip a dose! If you feel you are taking too much, you may simply be taking too much at once. Split your dose and take it twice during the day. If you feel it is still too much then reduce your dose by half until you feel better and contact your doctor to have your blood levels checked and dosage adjusted. To skip a dose will merely cause your thyroid to go into a crisis state and your symptoms can easily be magnified and it could days for your thyroid to recover. Remember your thyroid needs to be supplemented and starving it from your prescribed medication will only shock this now delicate organ and could potentially lead to coronary disorders and high cholesterol as well.
What about disorders from an unstable Thyroid?
Using the TSH (thyroid stimulating hormone) level as a diagnostic and assessment tool for hypothyroidism is inadequate because this test often fails to identify hypothyroidism. In addition, conditions such as depression, heart disease, and high cholesterol may develop as a result of untreated hypothyroidism, but not be identified as such because the TSH level can remain in the reference range.
1. Subtle thyroid underfunction may be contributing to depression in some patients with TSH in the upper half of the range usually considered normal.
2. "Thyroid hormone levels before unsuccessful antidepressant therapy are associated with later response to T3 augmentation"
While all measures of thyroid function were within the euthyroid range, eventual T3 augmentation responders were found to have, prior to any antidepressant treatment, lower levels of TSH and higher levels of thyroxine (T4) and free thyroxine index (FTI) than non-responders.
3. "Thyroid hormone concentrations in depressed and nondepressed adolescents: group differences and behavioral relations" (US, 1996)
The sample included 21 depressed adolescents and 20 matched control adolescents. Blood was drawn to measure thyroid-stimulating hormone (TSH), free thyroxine (FT4), thyroxine (T4), and triiodothyronine (T3)....Paired analysis revealed there were no significant group or gender differences or group by gender interactions for TSH, T4, or T3. For FT4, however, there were significant group differences (p = .008) showing lower concentrations in depressed adolescents than control subjects, suggesting that the former might be functionally hypothyroid. Although there were no significant correlations of TSH with any of the psychological measures obtained, in the depressed group correlations were negative (although not always significant) with FT4 and total behavior problems...as well as with symptom scores....Higher numbers of symptom scores of Obsessive compulsive and Attention deficit were related to lower concentrations of FT4.
4. Depressions resistant to tricyclic antidepressive treatment and hypothyroidism: The relationship between thyroid disorders and depression is well known [including] the finding of slight thyroid dysfunction (increased TSH response after injection of TRH) in a patient with depression. The frequency of the association of hypothyroidism and resistant depression underlines the need to perform thyroid function tests in all depressed patients who do not respond normally to appropriate antidepressor therapy.
5. Hypothyroidism and depression. Evidence from complete thyroid function evaluation.
These results suggest that a significant proportion of patients with depression and anergia may have early hypothyroidism, the cases of about half of which are detected only by thyrotropin-releasing hormone (TRH) testing. Because hypothyroidism can produce signs and symptoms of depression and can coexist as a second illness in depressed patients, patients with early hypothyroidism may be candidates for thyroid replacement therapy. In patients who already have a thyroid condition and are depressed as well may struggle with depression through the course of their lives. Effects of a poor diet or a diet high in carbohydrates, sugars and alcohol also seem to produce an instability in the adrenal and thyroid levels leaving the patient in a state of chronic depression and in some exhaustion.
1. Risk factors for cardiovascular disease in women with subclinical hypothyroidism. SH [subclinical hypothyroidism] was defined as an elevated thyrotropin (TSH) (>4.5 mU/L) and normal free thyroxine (FT4) level (8.7-22.6 nmol/L)....the percentage of patients with SH having hypertension (20%), hypertriglyceridemia (26.9%), elevated TC/HDL-C (11.5%), and LDL-C/HDL-C (4%) ratios were higher than the percentages in controls.
2. Subclinical hypothyroidism is an independent risk factor for atherosclerosis and hyocardial infarction in elderly women:
Conclusion: Subclinical hypothyroidism is a strong indicator of risk for atherosclerosis and myocardial infarction in elderly women.
3. Borderline low thyroid function and thyroid autoimmunity. Risk factors for coronary heart disease?
Men and women with a thyroid stimulating hormone of 4.0 mU/l or over had a higher prevalence of coronary heart disease than did age-matched controls, and this difference was significant in women....Women with thyroid antibodies had a slightly higher prevalence of coronary heart disease despite the unexpected finding of a lower serum cholesterol. The data point to an association between borderline thyroid function and autoimmunity and coronary heart disease which is not mediated through a raised serum cholesterol.
"High serum cholesterol levels in persons with 'high-normal' TSH levels: should one extend the definition of subclinical
Subjects with high-normal TSH levels [2.0-4.0 ľU/ml] combined with ThAabs [thyroid autoantibodies] may, in fact, have subclinical hypothyroidism presenting with elevated cholesterol levels. It is possible that these patients might benefit from thyroxine administration.
Unstable Thyroid and Goiters
More serious symptoms of a Goiter coupled with an unstable Thyroid.
Other symptoms of a goiter can be varied. Some people have hyperthyroidism symptoms -- such as palpitations, insomnia, weight loss, anxiety, OCD, Manic Depression, sexual misbehavior, delusions, and tremors -- and others have hypothyroidism symptoms -- weight gain, fatigue, loss of libido, depression even severe depression. Some will cycle back and forth between hyperthyroid and hypothyroid symptoms. The people who cycle back and forth are the ones who feel loss of control of their lives and therefore can become unstable themselves even suicidal.
Where to go from here?
As mentioned in my opening statement, far too many who suffer from this condition are either misdiagnosed or improperly treated. I will say that this is a very difficult condition to diagnose and many Doctors, although well intended, are not qualified to treat accordingly. I feel that it has become the patient's responsibility to inform themselves and help guide your physician in your treatment. I hope to have informed the reader with enough information to help them in their discovery and recovery. Treatment isn’t only for the patient, but for the family and loved ones as well. All too often they are overlooked and may even seek help of their own. When I have treated someone with an unstable thyroid, I always bring in the spouse, parents and siblings and recruit their help in the recovery of the suffering patient. You will have to tailor your treatment according to your resources available to you.
Once an individual has been diagnosed with an unstable Thyroid and should there be a complication of Hashimoto’s and/or a goiter the first step is to accept your condition. The person whether they are male or female, young or old have done nothing wrong to acquire this condition. It also should not be taken lightly it can be become very serious and even life threatening. At this point I begin counseling in order to help them understand what is wrong and how they will have to manage their thyroid as well as the symptoms it may or may not produce. From a medical standpoint the first issue I convey is the importance of medication prescribed to support the Thyroid. It may take time, weeks even months to find the right amount to help you feel yourself again. The biggest problem I am faced with is once the patient begins to feel better, they believe they are healed and no longer need to take medication. This is absolutely wrong! They feel better because they are on medication and must continue to do so perhaps for the remainder of their lives. The second problem I face is all too often they give up and don’t want to face it. These patients are the ones who need the family unit and loved ones to support them.
B. Dealing with the symptoms
Symptoms can vary from one individual to another. Depending on which end of the scale you are located, some can be severe and some mild, but they are influenced by the severity of your condition. Women are more likely to have more severe symptoms than men due to the female hormone’s dependence on Thyroid function. Neurotransmitters from the brain can be become unbalanced even non functioning causing problems like depression, severe depression, manic depression better known as Bipolar Disorder, anxiety, OCD – Obsessive Compulsive Disorders, and loss of sexual desire or uncontrollable sexual misbehavior. Psychiatric medicine and Psychological therapy are usually required to aid in the individual’s recovery and control. Once you have been diagnosed and you have accepted your condition, the next step is usually to find a good Psychiatrist and or Psychologist. These caregivers must be people you can trust and feel comfortable with, after all they will help you through some of your darkest times. I usually will treat my patients with both Thyroid medication along with antidepressants and mood stabilizers if needed.
A person who is depressed may appear sluggish and sad or irritable and anxious. He or she may be withdrawn, speaks little, stops eating, and sleeps little, is experiencing what doctors call vegetative symptoms. In contrast, a person who appears anxious and fearful (especially in the evening), has an increased appetite resulting in weight gain, and, although initially unable to sleep, sleeps for increasingly longer periods is experiencing depression with atypical symptoms. Many people with depression cannot experience emotions—including grief, joy, and pleasure—in a normal way; in the extreme, the world appears to have become colorless and lifeless. Thinking, speech, and general activity may slow down so much that all voluntary activities stop. Depressed people may be preoccupied with intense feelings of guilt, self-denigration, pessimistic, humorless, or incapable of having fun; passive and lethargic; introverted; skeptical, hypercritical, or constantly complaining; self-critical and full of self-reproach. They are preoccupied with inadequacy, failure, and negative events, sometimes to the point of morbid enjoyment of their own failures. They may experience feelings of despair, loneliness, and low self-esteem. They are often indecisive and withdrawn, feel progressively helpless and hopeless, severe depression can lead to thoughts of death and suicide. Sleep problems are common, most depressed people have difficulty falling asleep and awaken repeatedly, particularly early in the morning. A loss of sexual desire or pleasure is common. Times of stress can exacerbate these symptoms. Poor appetite and weight loss sometimes lead to emaciation, and in women, menstrual periods may stop. There are many good antidepressants to relieve the symptoms of depression. Several types of drugs—tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), psychostimulants, and other antidepressants—are available. Most must be taken regularly for at least several weeks before they begin to work. The chances that any given antidepressant will work for a particular person are about 65%. Side effects vary with each type of drug. Sometimes when treatment with one drug fails to relieve depression, another must be tried until you find one that works best for you. A side note: for some people it may be necessary to take antidepressants for many years or even a lifetime as the Thyroid will continue to wreak havoc on your neurological system, again this is an issue you need to discuss with your caregiver. The family and loved ones are recruited at this point to watch over the depressed individual and guard against any possible attempt to hurt themselves or even attempt suicide. If the person becomes too much to handle, he/she may be placed in a hospital where they can be watched around the clock. Diet can also affect the symptoms of depression. A poor diet one rich in sugar, carbohydrates and alcohols can put undue stress on the adrenal glands resulting in a domino effect of stress on all internal organs. The thyroid in its weakened or unstable condition may not be able to function or adapt to this fluctuation. The thyroid and pituitary gland can be directly affected by the highs and lows leaving them either overworking or shutting down. Depression is usually the end result and therefore a proper diet should be taken into consideration. Aside from depression, Manic-Depression(Bipolar Disorder) is one of the most difficult times for the family. Also from watching the suffering and not usually knowing exactly what to do, this can put a tremendous amount of stress on them. This issue has been a thorn in my side regarding health care. Both sides must be addressed, although the individual is suffering they may not understand that they are, however the family unit knows that both parties are and at times it can take a toll on them more than the patient. Doctors and caregivers must take into account the whole family when treating.
D. Manic-Depression or Bipolar Disorder
When diagnosed with an unstable thyroid, a person at any given time can swing from a state of Hypothyroidism to Hyperthyroidism. This usually occurs when there is a goiter present. Treatment of the goiter is critical when these symptoms occur and I have even gone so far as to have the goiter removed. Failure to treat a goiter when the thyroid is fluctuating can leave a person experiencing a manic depressive state. A person who is manic may be irritable, cantankerous, or hostile. He/she typically believes he/she is quite well. A lack of insight into his condition, along with a huge capacity for activity, can make the person impatient, intrusive, meddlesome, irrational and aggressively irritable when crossed. Mental activity speeds up (a condition called flight of ideas). The person is easily distracted and constantly shifts from one theme or endeavor to another. The person may have false convictions of personal wealth, power, inventiveness, and genius and may temporarily become delusional or assume a grandiose identity, sometimes believing that he/she is God, even drug or alcohol abuse. The person may believe he/she is being assisted or persecuted by others or have hallucinations, hearing and seeing things that are not there. The need for sleep decreases. A manic person is inexhaustibly, excessively, and impulsively involved in various activities such as risky business endeavors. If they are in a position of power in a company, they may cause great financial disaster leading to their dismissal. Gambling, this can lead to great personal financial ruin or even permanent indebtedness. Perilous sexual behavior without recognizing the inherent social dangers and the potential for acquiring STDs or pregnancy. In extreme cases, mental and physical activity is so frenzied that any clear link between mood and behavior is lost in a kind of senseless agitation (delirious mania). Immediate treatment is then required, because the person may die of sheer physical exhaustion. In less severe mania, hospitalization may be needed during periods of overactivity to protect the person and his family from ruinous financial or sexual behavior. Mania is diagnosed by its symptoms. However, because people with mania are notorious for denying that there is anything wrong with them, doctors usually have to obtain information from family members. Because mania is a medical and social emergency, a doctor must make all attempts to treat the person. Manic-depressive illness can recur in nearly all cases. Episodes may sometimes switch from depression to mania, or vice versa, without any period of normal mood in between. Some people cycle more rapidly through episodes than do others. These are known as rapid cyclers in which their moods can swing in a matter of hours rather than days and are more difficult to treat. Up to 15% of people with manic-depressive illness are male, while women make up the balance. Optimally, most people with manic-depressive illness should be given mood-stabilizing drugs, such as Lor an anticonvulsant, such as Depakote when they are treated with antidepressants. Here once again it is up to the family to decide what to do. A person in the manic state may be too difficult to manage or control. They are usually committed or hospitalized for their own safety as well as for the safety of others. Once the person has been treated they begin to recover and become stable the next step is a long road to repairing any psychological damage caused by the illness. It is imperative that the person does not place the blame on themselves and try to carry the burden of fault. Whether you are the spouse, parent or sibling, you simply cannot lose touch with the ones that love you the most. Now comes the time to repair the damage if any through Marriage Counseling, Family Counseling, Psychotherapy or even through your preferred religious group or Church. The point is to get the help you may need to recover your relationships and to move on in life.
Anxiety can arise suddenly, as in panic, or gradually over minutes, hours, or days. Anxiety induces the fight-or-flight response. The anxiety itself can last for any length of time, from a few seconds to years. Anxiety ranges in intensity from barely noticeable qualms to full-blown panic attack, during which a person may experience shortness of breath, dizziness, and increased heart rate. Anxiety disorders can be so distressing and interfere so much with a person's life. A doctor should aim to treat the primary cause, in this case the Thyroid, rather than the secondary anxiety symptoms. The anxiety should subside after the Thyroid disorder is treated and becomes stable. A doctor can treat any remaining anxiety with appropriate anti-anxiety drugs or psychotherapy (such as behavior therapy). During these episodes, the family can comfort the individual and reassure them that they are ok until the attack subsides. Anxiety attacks are usually not life threatening, but also should not be taken lightly.
F. OCD – Obsessive Compulsive Disorder
Another troublesome disorder is OCD or Obsessive Compulsive Disorder. Worries, doubts, superstitious beliefs all are common in our everyday life. However, when they become so excessive such as hours of hand washing or things that make no sense at all such as driving around and around the block to check that an accident didn't occur then a diagnosis of OCD is made. In OCD, it is as though the brain gets stuck on a particular thought or urge and just can't let go. These brain structures use the chemical messenger serotonin. It is believed that insufficient levels of serotonin are prominently involved in OCD. Drugs that increase the brain concentration of serotonin often help improve OCD symptoms. Although it seems clear that reduced levels of serotonin play a role in OCD, there is no laboratory test for OCD. Rather, the diagnosis is made based on an assessment of the person's symptoms. People with OCD often say the symptoms feel like a case of mental hiccups that won't go away. OCD is a brain disorder that causes problems in information processing. It is not your fault or the result of a "weak" or unstable personality. OCD usually involves having both obsessions and compulsions, though a person with OCD may sometimes switch from one to the other. Times of stress can exacerbate these symptoms as well.
Obsessions are thoughts, images, or impulses that occur over and over again and you feel out of control. The person does not want to have these ideas, finds them disturbing and intrusive, and usually recognizes that they don't really make sense. People with OCD may worry excessively about dirt and germs and be obsessed with the idea that they are contaminated or may contaminate others. Or they may have obsessive fears of having inadvertently harmed someone else (perhaps while pulling the car out of the driveway), even though they usually know this is not realistic. Obsessions are accompanied by uncomfortable feelings, such as fear, disgust, doubt, or a sensation that things have to be done in a way that is "just so." I treated a woman who had her entire family put out there clothes the night before so she could approve what they are wearing. She performed an inspection each morning making sure the clothes were ironed without flaw, that there were no stains or threads hanging. Each individual had to have there hair combed “Just so” and without flaw. The family was patient during this activity until her disorder was brought under control.
People with OCD typically try to make their obsessions go away by
performing compulsions. Compulsions are acts the person performs over and
over again, often according to certain "rules." People with an obsession about
contamination may wash constantly to the point that their hands become raw
and inflamed. A person may repeatedly check that she has turned off the
stove or iron because of an obsessive fear of burning the house down. She
may have to count certain objects over and over because of an obsession
about losing them. Unlike compulsive drinking or gambling, OCD
compulsions do not give the person pleasure. Rather, the rituals are
performed to obtain relief from the discomfort caused by the obsessions.
Below are some symptoms of Obsessive-Compulsive Disorder:
1. Contamination fears of germs, dirt, etc.
The constant need to clean and scrub to the point of exhaustion.
2. Imagining having harmed self or others.
Thoughts of inflicting pain on yourself or others.
3. Imagining losing control or aggressive urges
Fear of not being in control of everything in your daily life to the point of anger with outbursts or irrationality. Intolerance of mistakes by yourself and others.
4. Excessive religious or moral doubt
The belief that your religion or God has abandoned you. Difficulty with right and wrong.
5. A need to have things "just so"
The need to have things in an exact order exactly the way you see it needs to be.
6. A need to confess
Constant praying and confessing of what you consider to be your sins. This prayer can last for hours and can be repeated over and over.
OCD symptoms cause distress, take up a lot of time, or significantly interfere with the person's work, social life, or relationships. Most individuals with OCD recognize at some point that their obsessions are coming from within their own minds and are not just excessive worries about real problems, and that the compulsions they perform are excessive or unreasonable. OCD symptoms tend to wax and wane over time. Again we go back to the unstable thyroid and it’s inability to control the neurotransmitters that allow serotonin to function as it should. Proper function of the thyroid is critical in relieving the symptoms. Until it is functioning in a stable manner conditions like Depression, Mania and OCD become a revolving door of problems that even the best of medicine will have a difficult time providing relief. Families and loved one must practice patience and understanding. You the patient can not fight this on your own, it requires help from medication and family. Be patient with them as they learn your needs, they are in effect your best support system during your recovery time.
On to the road of Recovery
In my practice I have been fortunate enough to bring people back to health. Although the road can be long and arduous, it can be done and you can regain control of your life. Your first priority is to take your medication, I simply cannot stress this enough. Stay focused. Next, keep your family and loved ones close to your side. I have had family members set up a shiftclock so someone is always available 24 hours a day when needed. Get your blood work checked often especially in the beginning when your physician is trying to find your optimal levels. If your condition has lead you mental/emotional dysfunctions, do not be afraid to get Psychological/Psychiatric care. Diet and exercise can be a big part of your recovery as well. Eating well balanced foods and avoid those that are high in carbohydrates and reduce or eliminate your sugar intake. Alcohol can also have a detrimental effect on your thyroid’s stability it is best to greatly limit or even avoid it whenever possible. Begin a regular exercise program and focus on reducing stress perhaps through Yoga or just spending quiet time with your family. Controlling stress is necessary simply because the brain releases chemicals under stress that modifies your mood and in essence simply causes you more grief. Getting a good night of sleep is very crucial during your recovery period. Most people require a minimum of 6 to 8 hours of sleep daily. Get as much sleep as your body tells you to, you should wake up feeling refreshed. All too many do not take this seriously, while sleep is necessary for the mind and body to repair itself. At first onlook this may seem to be a lot to do, but once you realize the alternative I believe anyone would agree this is your best solution. Therefore in conclusion: you are not at fault if you have this disorder. Seek proper medical help, get blood levels tested often in the beginning and regularly afterwards. TAKE YOUR MEDICATION, adjust it if need be, but do take it daily. Keep a positive attitude and do not give up, recruit your spouse, parents and other loved ones to help you through. Be patient with them as they are patient with you, a stronger family bond is inevitable after an event such as this. Seek psychological help if needed or if your depression or other disorders are unmanageable. Diet and exercise, stay focused and I can almost guarantee you without fail that you will come back to the world of good health and living.
Dr. Alan Rind M.D.