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Thread: Convincing a psychiatrist to prescribe TRT

  1. #11
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    Louisiana does. You may not prescribe for non legitimate conditions. Prescribing test for someone 400-500 at 50 is a good way to be reprimanded, and continued you can end up losing your license.

  2. #12
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    Quote Originally Posted by Soule View Post
    He never had it checked to his recollection. I recommended he get it checked at a t-clinic years ago, as it has been proven to help treat depression. He then mentioned this to his psychiatrist, who said it wasn’t a good idea at the time because they were trying to get his meds right. He was then hard to convince otherwise.

    Recently he had to get off a med that had been linked to alzheimer’s and he sunk into a pretty bad depression. He stopped training, got out of town for two months and was almost hospitalized twice. He’s back now and wants to get his life in order.

    Seems to me they’re always trying to get his meds right, because he gets depressive, lethargic episodes, at least partly, from having low T. But I’m not a doctor...
    Isn't it interesting that the only "med" he may need to get right is testosterone, but the sillyass psychiatrist won't even try it until she gets through playing with his brain.

    Quote Originally Posted by Bbinck1 View Post
    Louisiana does. You may not prescribe for non legitimate conditions. Prescribing test for someone 400-500 at 50 is a good way to be reprimanded, and continued you can end up losing your license.
    That leaves 49.

  3. #13
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    Quote Originally Posted by Mark Rippetoe View Post
    Isn't it interesting that the only "med" he may need to get right is testosterone, but the sillyass psychiatrist won't even try it until she gets through playing with his brain.



    That leaves 49.
    Yep. I may have talked him into just going to the T clinic now that he’s at the point of “it can’t get worse than this.”

  4. #14
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    Quote Originally Posted by Soule View Post
    Hey Coach,

    I have a friend and trainee who is in his early 60s and is clearly dealing with low T problems: trouble sleeping, stiff and sore all of the time, poor recovery from relatively low stress training days and major depressive disorder. He’s also bipolar and is uncertain that his psychiatrist would be on board for prescribing or recommending TRT.
    The list of conditions that cause these problems is surprisingly long. Before assuming it’s low testosterone, it would be worth checking it.

    Few psychiatrists will manage testosterone replacement therapy, although you might get one to order a test.

    The best thing would be to have the GP/urologist/endocrinologist, or whoever is going to manage T replacement, communicate with the psychiatrist.

    Low T can cause depression, but would not cause bipolar disorder. If that is your friend’s actual diagnosis (you also mention “major depressive disorder,” which is not diagnosed simultaneously with bipolar), he should not forego psychiatric treatment once starting testosterone, even if it helps with his depression.

  5. #15
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    And even if the testosterone level is not "low", if TRT improves the patient's symptoms, we have permission to use it anyway, right? Would it be okay to at least try it, given that the reference range is very seldom predictive of symptoms, and that response is usually noted in 48-72 hours, so we'll know pretty quick if it helped? And what exactly is the downside of trying it? More importantly, why has the T level not been checked already? Had he presented with lethargy/tiredness, he would probably have been checked for thyroid hormone levels immediately, if he hasn't been already. But not testosterone. Testosterone is an important hormone, low levels of which cause profound problems, but because Mark McGwire had to talk to the Senate about STEROIDS, we can't even consider it? Is it a bias against the idea that "enhancing masculinity" might be a good thing for some men?

    I think part of your friend's problem is that he is perfectly happy with letting other people decide what he should do. Test might help with that too.

  6. #16
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    Quote Originally Posted by jfsully View Post
    The list of conditions that cause these problems is surprisingly long. Before assuming itÂ’s low testosterone, it would be worth checking
    Sully,

    There is something I don’t understand about the medical community and I sincerely hope you can shed some light on this for me. I’ve seen it happen with COVID, repeatedly, and it grinds my gears.

    Let’s say the guy does have bipolar disorder. In fact, let’s say he is a complete basket case. Nuttier than squirrel turds. Let’s also say that he’s in the lower part of the reference range, but not considered “Low.” In fact, he's just on the low side of dead middle. Not what the medical community would deem in need of TRT by any stretch.

    Despite this, he finds a shady low T clinic where “everyone is low,” and he manages to get his hands on TRT. They administer a therapeutic dose of 150mg week (don’t hang me for dosing levels, I’m guessing). A few weeks later, he’s still batshit crazy, but his quality of life has improved. Maybe he’s got a little more lead in the pencil, a little more confidence, and he has the energy to do some training, or exercising, or just something at all to get his dead ass off the couch. In return, his mental state improves (maybe even slightly) because he’s at least experiencing life a little better nowadays. It’s not perfect, but there is a quality of life improvement.

    I often feel like the objection to this from many doctors is that using TRT, when not in the low reference range, carries a risk of too many ill side effects. Let’s say our protagonist will develop heart disease 5 years earlier, and will die because he’s taking TRT when he’s not technically “low.” Why is THIS the focal point of the medical community when his next 15, 20, or 25 years will be miserable? They’re looking to give him 5 more miserable years, not 15-25 decent ones.

    If you bring this up to your PCP, they’ll say pretty much what you said. The continued conversation, from my experience goes something like, “There’s no evidence that TRT will fix your bipolar disorder and there’s probably another reason for your depression. Here is a prescription for depression. By the way, it makes it impossible for you to orgasm. Here is a bipolar medicine that is so powerful you might develop a deadly rash, and I’ll sweeten the pot by prescribing 20mg of Tadalifil to help you stay erect for the rest of the night, even though you can’t finish the job.”

    I haven’t met a man yet who felt worse in the presence of more testosterone. Why not be a little more liberal with it, especially in hard cases like this one?

  7. #17
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    Quote Originally Posted by Mark Rippetoe View Post
    ?
    I think part of your friend's problem is that he is perfectly happy with letting other people decide what he should do. Test might help with that too.
    He’s actually quite the free thinker. He just doesn’t know much about TRT and is worried about “roid rage” interacting with his manic episodes. We both know that roid rage isn’t a thing when your hormones are properly managed, but testosterone still has that stigma in many circles. He’s had some pretty aggressive manic episodes in the past and unfortunately he has been advised that test might enhance that.


    And don’t worry, Sully. The guy has been in treatment for most of his life and he knows it’s always going to be necessary. He just feels stuck in a pretty low spot right now and having known and trained him for about 5 years I can say with confidence that he has low testosterone.

    Quote Originally Posted by Frank_B View Post
    Sully,

    There is something I don’t understand about the medical community and I sincerely hope you can shed some light on this for me. I’ve seen it happen with COVID, repeatedly, and it grinds my gears.

    Let’s say the guy does have bipolar disorder. In fact, let’s say he is a complete basket case. Nuttier than squirrel turds. Let’s also say that he’s in the lower part of the reference range, but not considered “Low.” In fact, he's just on the low side of dead middle. Not what the medical community would deem in need of TRT by any stretch.

    Despite this, he finds a shady low T clinic where “everyone is low,” and he manages to get his hands on TRT. They administer a therapeutic dose of 150mg week (don’t hang me for dosing levels, I’m guessing). A few weeks later, he’s still batshit crazy, but his quality of life has improved. Maybe he’s got a little more lead in the pencil, a little more confidence, and he has the energy to do some training, or exercising, or just something at all to get his dead ass off the couch. In return, his mental state improves (maybe even slightly) because he’s at least experiencing life a little better nowadays. It’s not perfect, but there is a quality of life improvement.

    I often feel like the objection to this from many doctors is that using TRT, when not in the low reference range, carries a risk of too many ill side effects. Let’s say our protagonist will develop heart disease 5 years earlier, and will die because he’s taking TRT when he’s not technically “low.” Why is THIS the focal point of the medical community when his next 15, 20, or 25 years will be miserable? They’re looking to give him 5 more miserable years, not 15-25 decent ones.

    If you bring this up to your PCP, they’ll say pretty much what you said. The continued conversation, from my experience goes something like, “There’s no evidence that TRT will fix your bipolar disorder and there’s probably another reason for your depression. Here is a prescription for depression. By the way, it makes it impossible for you to orgasm. Here is a bipolar medicine that is so powerful you might develop a deadly rash, and I’ll sweeten the pot by prescribing 20mg of Tadalifil to help you stay erect for the rest of the night, even though you can’t finish the job.”

    I haven’t met a man yet who felt worse in the presence of more testosterone. Why not be a little more liberal with it, especially in hard cases like this one?
    Nailed it.

  8. #18
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    Unfortunately I think part of the reluctance in the medical community stems from fear of litigation. Prescribing testosterone to a person with “normal” levels (and I understand all of the nebulousness of references) that has a heart attack or whatnot later can turn into a lawsuit that can take literally years of your time. You have to go explain to a jury why you were prescribing a medicine to a guy that had normal levels. And there will be a expert witness that will say it is inappropriate and certainly contributed to his horrible outcome etc etc etc. Finally you will be asked if you are a board certified endocrinologist and when you say no I’m a plastic surgeon that runs a testosterone clinic you will be labeled a shady steroid pusher that prescribes on demand and were it not for scum like you Dad would still be alive. Or something along those lines. So yeah a lot of docs want nothing to do with it. Same goes for diet pills.

  9. #19
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    Quote Originally Posted by Bbinck1 View Post
    Unfortunately I think part of the reluctance in the medical community stems from fear of litigation. Prescribing testosterone to a person with “normal” levels (and I understand all of the nebulousness of references) that has a heart attack or whatnot later can turn into a lawsuit that can take literally years of your time. You have to go explain to a jury why you were prescribing a medicine to a guy that had normal levels. And there will be a expert witness that will say it is inappropriate and certainly contributed to his horrible outcome etc etc etc. Finally you will be asked if you are a board certified endocrinologist and when you say no I’m a plastic surgeon that runs a testosterone clinic you will be labeled a shady steroid pusher that prescribes on demand and were it not for scum like you Dad would still be alive. Or something along those lines. So yeah a lot of docs want nothing to do with it. Same goes for diet pills.
    This doesn’t align with what we currently know about TRT and i doubt it would hold up in court.

  10. #20
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    Quote Originally Posted by Soule View Post
    This doesn’t align with what we currently know about TRT and i doubt it would hold up in court.
    Agreed. Plus it’s not like the medical community had a problem shoving opioids down people’s throats for decades. Maybe if pharmaceutical companies had better gift baskets for doctors prescribing TRT...

    My personal opinion is that any doctor who takes any gift, payment, etc., from a pharmaceutical company is an unethical asshole who should lose their license, but that discussion should probably take place in the COVID thread.

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