Professor David Nutt
University of Bristol

Professor Nutt is a psychiatrist who, from time to time, sees patients with pituitary disorders referred by endocrinologists. Most of these people are aware of their altered psychological state and wish to know whether it is due to their illness or their treatment. The answers to these questions are complex and were discussed.

A broad classification of psychiatric illnesses divides them into: neurotic - which may present as anxiety or depression (or both) or psychotic - in which the subject loses touch with reality. Neurotic patients know that they are ill, psychotic ones do not. Neurotic subjects with anxiety have symptoms either of constant worry over everything, or panic attacks, in which worry is periodic but very intense. Neurotic depression may involve many symptoms, including loss of enjoyment of activities previously enjoyed (hobbies, food, sex), sleep disturbances, loss of self worth or apathy.

It has been known for some time that people with Cushing's are unusually prone to depression. Recent studies have shown that, in groups of healthy people, those that have a high serum level of Hydrocortisone are more likely to become depressed. It is thought that the raised hydrocortisone produces changes in the brain, which lead to the psychological changes. Interestingly, reduced thyroid hormone may also lead to depression.

The production of pituitary hormones is controlled by hormones produced in a specialised area of the brain just above the pituitary called the Hypothalamus. For example, corticotrophin releasing hormone (CRF) produced in the hypothalamus stimulates the production of Adrenocorticotrophic Hormone (ACTH) in the pituitary which, when released into the blood, reaches the Adrenal glands and stimulates them to produce hydrocortisone. CRF and other release hormones are not confined to the hypothalamus and Pituitary gland, but are found in other parts of the brain, particularly the limbic system, which controls behaviour, mood and stress protection. In animal experiments, CRF injected into the brain produces depression, sleep disturbance and loss of appetite. Blood tests which show normal hormone levels for the body may not reflect the needs of the brain. As an example, Professor Nutt described a case in which a subject who had had a thyroid deficiency which was controlled and appeared well, but was found to have abnormal sleep cycles suggesting that the brain's needs were not being met.

Patients with pituitary dysfunction who become depressed should be treated in the same way as other depressed persons. Antidepressive drugs are the treatment of choice. Patients with sleep disturbances can be helped by practising 'good sleep hygiene'. Go to bed at the same time each day and get up at the same time. Do not alter this. No day-time naps. No alcohol just before bed time. No caffeine after 6pm. If you do not sleep, get up. Short-acting hypnotic drugs may be useful if routines have to be changed.

Coping with the psychological effects of illness requires a coping strategy. Understand what is going on and involve others. Talk to fellow sufferers and your family. Some people benefit from behavioural or cognitive therapy. Psychotherapy is not useful for subjects with endocrine problems.