TESTOSTERONE REPLACEMENT FOR OLDER MEN WITH DEPRESSION

Older men undergoing treatment for depression who are not improving should have their testosterone level checked. Low testosterone levels cause, or contribute to, depression in some men, and sometimes explain why treatment fails to help. Depressed men with low testosterone levels should talk with their healthcare professionals about whether testosterone replacement therapy might be right for them.

Most men’s testosterone levels decline with age. Often the testosterone level remains normal, just lower than before. The normal range for testosterone is between around 300 nanograms per deciliter (ng/dL) and 1000 ng/dL.  If your testosterone level was 800 ng/dL when you were 40 years old, it might be only 400 ng/dL when you are 75 years old.   But it should remain above 300 ng/dL.   Some men maintain levels as high as younger men, but abnormally low levels are seen in 30 percent of men over age 70 and 50 percent over age 80.

Low testosterone causes various symptoms including decreased muscle size and strength, weakening of the bones, decreased sexual performance, increased fat, fatigue, poor concentration, and loss of sexual interest. Such symptoms are often viewed as inevitable signs of aging, and left at that. They are neither treated nor even looked into. Some healthcare professionals do check testosterone levels in older men with these symptoms, and they prescribe testosterone replacement. But should they? The practice has been controversial.

What’s the fuss about? A recent study1 shows that the benefits of testosterone replacement are, for the most part, minimal. In this study of nearly 800 men with testosterone levels below 275 ng/dl, most symptoms failed to improve. The small improvements that occurred were not enough to justify the risks (below) of testosterone therapy. However, both sexual interest and mood did get significantly better.  And this was seen among men who did not enter the study for depression. What about men with low testosterone who do have severe depression?

Other research studies show that giving testosterone replacement to depressed older men with low testosterone results in good rates of improvement of depression.   Patients selected to participate in such studies typically have testosterone levels of less than 280 ng/dL.  Testosterone therapy is more likely to help older men with depression who get depression for the first time in old age than those who first developed depression when they were younger.2,3,4

It is not surprising that low testosterone is a factor in depression because testosterone has important actions in the brain affecting emotions.   Testosterone helps regulate serotonin, a chemical crucial to many brain circuits involved in mood, and it increases blood flow to the front of the brain, an area involved in emotions and behavior.

There are a few different ways of taking testosterone replacement.   Oral replacement is available, but almost never used, because testosterone is not absorbed well by mouth and causes a high rate of liver toxicity when taken this way. Long-acting injections are a good option for some men.   These injections are given every two or three weeks. The problem with this approach, in addition to the need for regular shots, is uneven testosterone levels. After each shot, the testosterone level builds up quickly for several days. Peak, high levels can cause more side effects and pose greater risks. Levels then gradually subside, often becoming too low before the next shot, resulting in a return of symptoms.

Topical application, applied to the skin daily, is the best approach for most men.   Topical testosterone comes in patches, gels, and solutions. There also is a tablet that is applied in the mouth, to the gums, every 12 hours.   Topical approaches provide steady, daily levels.

So what are the risks of testosterone replacement therapy? Men receiving testosterone replacement therapy have an increased rate of heart attacks. Use of testosterone replacements also can worsen benign prostatic enlargement, a common condition among older men.   This may lead to increased urinary symptoms.   And testosterone therapy raises some men’s risk of prostate cancer.

Some doctors believe that testosterone replacement therapy is not safe.   But older men must weigh the risks of testosterone replacement against the risks of depression.   Depression also increases the risk for heart attack, and it also increases the risk of stroke, some forms of cancer, and premature death, not to mention the emotional pain and anguish depression causes. On balance, testosterone replacement may be a good treatment for many older men with depression.

Low testosterone is just one among many possible medical causes of depression. In my book, Beat Depression to Stay Healthier and Live Longer: A Guide for Older Adults and Their Families, I discuss the importance of having a thorough medical evaluation before starting any treatment for depression. It’s now available in bookstores or from your favorite online bookseller. Check it out.

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  1. New England Journal of Medicine 2016; 374:611-624
  1. Journal of Clinical Psychiatry 2009; 70: 1009-1016.   A Randomized, Double-Blind, Placebo-Controlled Study of Testosterone Treatment in Hypogonadal Older Men With Subthreshold Depression (Dysthymia and Minor Depression).
  1. Testosterone Therapy in Late-Life major Depression in Males.   Journal of Clinical Psychiatry 2002; 63: 1096-1101.
  1. Testosterone and Depression in Aging Men. American Journal of Psychiatry 1999; 7:18-33.

Updated April 2016

Moak Center for Healthy Aging