Hormonal and thyroid augmentation

1. Introduction

Version followed: NICE NG222 Depression in adults: treatment and management (2022; NICE reviewed it on 30 January 2026 and said it will not update the recommendations), NICE NG23 Menopause (updated November 2024; public information and update notes), the 2018 NAMS / National Network of Depression Centers Guidelines for the Evaluation and Treatment of Perimenopausal Depression (Maki, Kornstein et al.), and the US Cytomel (liothyronine sodium tablets) full prescribing information (revised 4/2025). Sources also include Pfizer's full prescribing information (Cytomel indications, boxed warning, contraindication, warnings, monitoring, adverse reactions and drug interactions), NICE's update-information page (scope of the NG23 2024 update) and a report of the Walther et al. meta-analysis (testosterone evidence). Where CANMAT 2023 places thyroid hormone and lithium is taken from a secondary report by two of its authors and remains [uncertain]; the final NG23 2024 recommendation wording and NG222's collaborative-care recommendations are not reproduced here [uncertain].

"Hormonal and thyroid augmentation" is not a psychotherapy. It is a group of prescriber-delivered medical strategies: adding a thyroid hormone (liothyronine) to an antidepressant when depression has not responded, and using hormonal treatments (mainly oestrogen-based therapy) where depression or low mood arises around the perimenopause. Decisions about these medicines belong to the prescriber (GP, psychiatrist, menopause specialist or endocrinologist). This guide is written for the psychotherapist working alongside them. The core idea, as the sources frame it, is biological: some depressions respond when an antidepressant is supplemented by another agent (NICE lists liothyronine among specialist combination or augmentation options), and in the perimenopause, hormonal change is a window of vulnerability in which oestrogen therapy may have antidepressant effects. The therapist's contribution to change is to notice when hormonal or thyroid factors may be part of the picture, help the client get a medical review, support informed and shared decisions, keep psychological treatment going alongside, and pass on observations to the prescriber. [source: NICE NG222 full guideline PDF, recs 1.9.9, 1.4.1; Maki et al. 2018; NICE UK Government Web Archive copy of NG222 overview]

Nothing in this guide is advice on whether a client should take, start, stop or change any medicine. Those questions always go to the prescriber.

2. Framework

This is not a phased therapy; the framework below describes the medical pathway as the guidelines set it out and where the therapist fits at each point. [source: NICE NG222 recs 1.9.1–1.9.9; Maki et al. 2018] Session counts are not defined by any source; the psychotherapy runs on its own schedule. [synthesis]

Stage A. Recognising non-response or a possible hormonal/thyroid contribution.

Goal: notice that depression is not improving, or that its timing or features suggest perimenopause, thyroid symptoms or another medical factor.
NICE NG222: if there is no response after an adequate trial of antidepressant, psychological therapy or combined treatment, clinicians first discuss personal, social, environmental, physical and mental health factors and any adherence problems, then review the diagnosis and consider alternative or comorbid conditions, and reassure the person that other treatments can be tried. [source: NG222 recs 1.9.1–1.9.3]
The NAMS/NNDC guideline describes the perimenopause as "a window of vulnerability" for depressive symptoms and major depressive episodes, even in women without prior depression; most perimenopausal major depressive episodes are recurrences. [source: Maki et al. 2018]
Move on when: the therapist has concerns that warrant a medical review and the client agrees to raise them. [synthesis]

Stage B. Medical review and assessment (prescriber-led).

Goal: the prescriber reviews diagnosis, physical health, adherence and options.
For perimenopausal depression, assessment covers identifying menopause stage, co-occurring and overlapping menopause and psychiatric symptoms, psychosocial risk factors and differential diagnosis (including bipolar depression and general medical causes). The guideline names screening tools such as the PHQ-9 and notes that menopause rating scales contain mood items that can help clarify what is menopause-related. [source: Maki et al. 2018] The guideline does not specifically name thyroid disease in its differential [source: Maki et al. 2018]; thyroid testing as part of medical review is a prescriber decision [synthesis].
NICE NG222 refers readers to NICE's separate menopause guideline for people who are menopausal. [source: NG222 rec 1.4.1]
Move on when: the prescriber and client have reached a shared decision. [source: NG222 recs 1.6.1, 1.9.4–1.9.6]

Stage C. Shared decision on further-line options.

NICE NG222 lists further-line options to be discussed and decided jointly, including adding or switching to psychological therapy, changing antidepressant, adding group exercise, or combining therapy with medication. For combination treatments it advises considering referral to, or consultation with, specialist services, and lists options including adding a second-generation antipsychotic or lithium, and augmenting with ECT, lamotrigine or liothyronine. NICE notes some of these uses were off-label (as of June 2022) and that medication combinations are likely to increase side effects. [source: NG222 recs 1.9.4–1.9.9]
For perimenopausal major depression, the NAMS/NNDC guideline keeps proven antidepressants as front-line treatment, calls CBT "a reasonable option" on preliminary evidence, and says oestrogen therapy has antidepressant effects in perimenopausal (not postmenopausal) women, while noting estrogen "is not FDA approved to treat mood disturbance" and that using it to augment antidepressants should be considered with caution, preferably when also indicated for other symptoms such as vasomotor symptoms. [source: Maki et al. 2018]
NICE menopause information for the public: HRT may be offered if menopause is causing low mood; CBT may be offered for menopause-related low mood or anxiety; antidepressants have not been shown to help low mood during menopause in people not diagnosed with depression. [source: NICE NG23 information for the public]

Stage D. Treatment and monitoring (prescriber-led), psychotherapy continuing.

The prescriber carries out the monitoring that the labelling and guidelines require (Section 4). The therapist keeps the psychological work going, tracks mood and side effects the client reports, and passes concerns on. [source: NG222 recs 1.4.25–1.4.37; synthesis for therapist role]

Stage E. Review, continuation and ending.

Continuing, changing or stopping any augmenting medicine is decided with the prescriber; NICE says lithium and antipsychotics should be stopped only in, or with advice from, specialist services. [source: NG222 recs 1.4.32, 1.4.37] The therapist supports relapse prevention and adjustment after the medical treatment changes. [synthesis]

3. Guiding principles

The prescriber decides about medicines. Practical meaning: you never recommend, discourage or comment on whether to start, stop or change a medicine; you help the client take questions to the prescriber. [source: NG222 rec 1.4.12 (people who want to stop should talk with the prescriber); synthesis]
Rule out the basics before escalating. Practical meaning: when depression is not lifting, explore life circumstances, adherence and physical health with the client, mirroring what NICE asks clinicians to review first. [source: NG222 recs 1.9.1–1.9.2]
Low mood in menopause is not the same as depression. Practical meaning: use a careful mood assessment rather than assuming either; NICE public information states low mood in menopause "is different from depression". [source: NICE NG23 information for the public]
Prior depression matters. Practical meaning: women with past major depression, severe symptoms or suicidal thoughts in the perimenopause should always be evaluated for a mood disorder. [source: Maki et al. 2018]
Shared decision-making. Practical meaning: help the client understand options, preferences and trade-offs so they can take part in the decision; NICE asks clinicians to "reach a shared decision" on treatment. [source: NG222 rec 1.6.1; CANMAT 2023 summaries describe a personalised, shared decision-making approach [source: Medthority CANMAT 2023 summary]]
Continuity and liaison. Practical meaning: with consent, keep regular contact with the prescriber; NICE asks for liaison between specialist and non-specialist settings and for people to see the same professional where possible. [source: NG222 recs 1.3.2, 1.4.1]
Measurement-based care. Practical meaning: use a validated scale regularly and review scores with the client; CANMAT speakers stressed scales "do not replace clinical assessment". [source: Progress in Mind summary of CANMAT 2023 session]
Off-label and regulatory status is part of informed consent. Practical meaning: clients may need to know that liothyronine for depression, and oestrogen for mood, are not licensed or approved indications; the prescriber explains this. [source: NG222 rec 1.9.9; Maki et al. 2018]
Psychotherapy remains active treatment. Practical meaning: augmentation does not replace therapy; NICE lists combined psychological and medical treatment among further-line options and NAMS/NNDC notes CBT plus antidepressant may be more effective than medication alone. [source: NG222 recs 1.9.4–1.9.6; Maki et al. 2018]
Stay within competence. Practical meaning: you can notice and describe symptoms (heat intolerance, palpitations, hot flushes, cycle changes) but do not interpret blood tests or diagnose thyroid or menopausal disorders. [synthesis]

4. Intervention inventory

Part A describes how the medical treatments are delivered, at a descriptive level only and as the cited sources state it. Part B gives the psychotherapist's own interventions.

A1. Liothyronine (thyroid hormone, T3) augmentation in depression (prescriber-delivered)

Purpose: an add-on option when depression has not responded to antidepressant treatment. [source: NG222 rec 1.9.9]
How it is delivered (descriptive): NICE NG222 lists augmenting an antidepressant with liothyronine among combination options for which referral to, or consultation with, specialist mental health services should be considered; NICE notes some of these uses were off-label as of June 2022. It is given as a tablet. [source: NG222 rec 1.9.9] A secondary clinical summary also describes its use for depression as off-label with "less extensive and heterogeneous" evidence. [source: iatroX TRD augmentation page; secondary]
Who delivers: the prescriber, with specialist involvement as NICE advises; in the UK, a GP may continue prescribing under shared care [uncertain: shared-care arrangements vary locally].
Regulatory status: liothyronine is licensed for thyroid conditions, not for depression; use in depression is off-label. [source: NG222 rec 1.9.9] The US prescribing information for Cytomel (liothyronine sodium tablets; revised 4/2025) lists its indications as hypothyroidism, TSH suppression alongside surgery and radioiodine in well-differentiated thyroid cancer, and thyroid suppression tests; it contains no psychiatric indication and no statement about depression. Its boxed warning is that it is not for obesity or weight loss: the label states thyroid hormones should not be used to treat obesity or for weight loss, that amounts within the body's daily hormonal requirement do not reduce weight in people with normal thyroid function, and that larger amounts can cause serious or life-threatening toxicity, especially together with sympathomimetic amines such as appetite suppressants. [source: Cytomel full prescribing information, Pfizer, rev. 4/2025] (This is US labelling; UK product information is not covered here [uncertain].)
CANMAT 2023: published summaries describe earlier use of adjunctive treatment rather than cycling through monotherapies. [source: Progress in Mind summary of CANMAT 2023 session] A Psychopharmacology Institute lecture on the guideline lists aripiprazole and brexpiprazole as first-line adjuncts, several other atypical antipsychotics and ketamine forms as second-line, and lamotrigine and stimulants as third-line. [source: Psychopharmacology Institute, CANMAT 2023 adjunct options; secondary] An industry-supported expert report written by two CANMAT 2023 authors (Kennedy and Tourjman, The Medical Xchange, 2024) reproduces the guideline's adjunctive-agent table for difficult-to-treat depression, and lithium and triiodothyronine appear there in the second-line group. [source: Medical Xchange CANMAT MDD expert report; secondary] The line labels in that report's table are misaligned, so the exact line and evidence level CANMAT 2023 gives to thyroid hormone and lithium remain [uncertain: secondary, unverified].
Monitoring and warning signs as the US label states them (for its thyroid indications; the label sets out no depression-specific monitoring): whether treatment is adequate is judged by periodic laboratory tests (TSH and T3) together with clinical evaluation; liothyronine has a narrow therapeutic index, so the label calls for careful adjustment and monitoring to avoid over- or under-treatment; thyroid hormone may worsen diabetes control, so glycaemic control is monitored when it is started, changed or stopped. Labelled warnings and precautions: cardiac adverse reactions from over-treatment (raised heart rate, angina or arrhythmias), especially in older people and in those with heart disease; acute adrenal crisis in people with adrenal insufficiency (uncorrected adrenal insufficiency is a contraindication); oral thyroid hormone is not recommended for myxoedema coma; and reduced bone mineral density with over-replacement, particularly after menopause. Listed adverse reactions include nervousness, anxiety, emotional lability and insomnia, which can overlap with the symptoms the therapy is tracking. Labelled interactions relevant to mental health care: tricyclic and tetracyclic antidepressants may have increased therapeutic and toxic effects (including arrhythmia risk and central nervous system stimulation); sertraline may raise thyroid hormone requirements; sympathomimetics may increase effects and coronary risk; and ketamine used at the same time may cause marked rises in blood pressure and heart rate. [source: Cytomel full prescribing information, Pfizer, rev. 4/2025, sections 4–7] Which tests are done during off-label augmentation is the prescriber's decision [synthesis]; the therapist's role is to pass on new physical or emotional symptoms the client reports, such as palpitations, an irregular heartbeat, new restlessness or sleeplessness (see B5).
Watch for: the client describing the medicine as a "weight" or "energy" pill, or obtaining thyroid hormone without a prescriber; the label's boxed warning states thyroid hormones are not for obesity or weight loss [source: Cytomel prescribing information]. Pass this on to the prescriber. [synthesis]

A2. Lithium augmentation and its thyroid link (prescriber-delivered; brief)

Purpose: NICE lists combining an antidepressant with lithium among specialist further-line options. [source: NG222 rec 1.9.9]
Monitoring as NICE states it (no numbers given here): before treatment, weight, renal and thyroid function and calcium are assessed, and they are monitored at least every six months; serum lithium levels are checked regularly, especially after starting and after any change; ECG monitoring is considered in people with cardiovascular disease or high cardiovascular risk. [source: NG222 recs 1.4.25–1.4.30]
Warning signs named by NICE: signs of lithium toxicity such as "coarse tremor, ataxia, confusion and convulsions"; concerns about toxicity or side effects are managed with specialist secondary care, and lithium is stopped only in, or with advice from, specialist services. [source: NG222 recs 1.4.28–1.4.32]
Therapist relevance: thyroid function is part of lithium monitoring; a client on lithium who reports new slowing, weight change or feeling cold, or any toxicity signs, needs prompt contact with the prescriber (toxicity signs: same day or urgent care). [source: NG222 for toxicity signs; synthesis for routing] Full lithium content belongs to the lithium entry. [synthesis]

A3. Oestrogen-based therapy and HRT in perimenopausal depression and menopausal low mood (prescriber-delivered)

Purpose: treating menopause-related low mood (NICE public information) and, as a guideline-discussed option, perimenopausal depression. [source: NICE NG23 information for the public; Maki et al. 2018]
NICE menopause public information: HRT may be offered if menopause is causing low mood; CBT may be offered for menopause-related low mood or anxiety; SSRIs and SNRIs have not been shown to help low mood during menopause in people who have not been diagnosed with depression; benefits and risks of HRT are discussed with the GP before starting; people with a womb are offered combined oestrogen and progestogen HRT because oestrogen alone can harm the womb lining. [source: NICE NG23 information for the public] The public page reflects the 2015 guideline. NICE updated NG23 in November 2024 with new [2024] recommendations on CBT for menopause-associated symptoms, genitourinary symptoms and the effects of HRT on specific health outcomes, and [2015, amended 2024] changes on when to refer to a professional with menopause expertise and how to address possible effects of menopause on mental health. [source: NICE NG23 update information] NICE's announcement of the draft update (November 2023) said CBT can help reduce hot flushes and night sweats, depressive symptoms and sleep problems, and should be considered alongside or as an alternative to HRT for hot flushes and night sweats. [source: NICE news on the draft updated guideline] The final 2024 recommendation wording is not reproduced here [uncertain].
NAMS/NNDC 2018 positions: proven antidepressants remain front-line treatment for major depressive episodes in the perimenopause; oestrogen therapy shows antidepressant effects in perimenopausal women of similar size to antidepressants, but "is ineffective as a treatment for depressive disorders in postmenopausal women"; evidence is not sufficient to recommend oestrogen-based therapy to prevent depression; data on combined oestrogen plus progestogen for mood are "sparse and inconclusive"; there are no randomised trials of hormonal contraceptives in clinically depressed women; "Estrogen is not FDA approved to treat mood disturbance". [source: Maki et al. 2018]
Formulation types named in the source: transdermal estradiol and oral micronised progesterone appear in prevention research. [source: Maki et al. 2018] No regimens are given here.
Who delivers: GP, gynaecologist or menopause specialist. [source: NICE NG23 information for the public names the GP and menopause specialists]

A4. Testosterone (prescriber-delivered; where sources discuss it)

NICE menopause public information: if HRT does not help low sexual interest, testosterone may be offered; at publication testosterone supplements "were not licensed for use in women". [source: NICE NG23 information for the public]
Testosterone for depression: none of the guidelines cited here recommends testosterone as a treatment or augmentation for depression in women or men. A JAMA Psychiatry meta-analysis (Walther et al., online November 2018; 27 placebo-controlled trials in men) found a modest pooled reduction in depressive symptoms, but the authors noted testosterone is not recommended in national or international guidelines because of uncertainty about efficacy, age criteria, duration and method of application; few trials studied otherwise healthy depressed men, no adequately powered long-term safety studies exist, and they called for large preregistered trials with depression as the primary outcome. [source: MDedge report of Walther et al.; secondary] If a client raises testosterone for mood, route the question to the prescriber or relevant specialist (GP, endocrinologist, menopause service). [synthesis]

A5. Antipsychotic augmentation (pointer)

NICE lists second-generation antipsychotics among specialist combination options and asks for baseline and regular physical monitoring and review of whether to continue; see the antipsychotic entries for detail. [source: NG222 recs 1.9.9, 1.4.33–1.4.37]

B1. Recognising when hormonal or thyroid factors warrant a medical review

Purpose: spot presentations where a medical review could change the picture. Use when depression is not responding, or when the timing or symptoms suggest perimenopause, a thyroid problem or another physical factor. [source: NG222 recs 1.9.1–1.9.2; Maki et al. 2018]
Steps: (1) Track progress on a validated measure and note when there is little change despite an adequate trial of therapy, medication or both. [source: NG222 rec 1.9.1; Progress in Mind CANMAT summary] (2) Ask about menstrual changes, hot flushes, night sweats, sleep disturbance and anxiety in midlife women, and about past depression, since these are listed risk factors and features. [source: Maki et al. 2018] (3) Ask in general terms about physical symptoms and recent health checks; note symptoms the client describes (for example feeling cold or hot all the time, palpitations, changes in weight or energy, tremor) without interpreting them. [synthesis] (4) Ask whether the client takes thyroid medicine, lithium, hormones or contraception, and who prescribes them. [synthesis] (5) If concerns remain, suggest the client books a review with the prescriber or GP and agree what they will raise.
Example language (illustrative): "Some of what you're describing, the night sweats and the change in your cycle alongside the low mood, is worth talking through with your GP. Would you be willing to book a review and mention these?"
Watch for: attributing everything to hormones (missing depression or risk) or to psychology (missing a medical cause); both errors are avoided by referral plus ongoing assessment. [synthesis]

B2. Referral and collaborative care

Purpose: coordinated care between therapist, GP, psychiatrist and menopause or endocrine services. [source: NG222 recs 1.3.2, 1.4.1] NG222's own collaborative-care recommendations are not reproduced here [uncertain]. For context only: a 2017 NIHR evidence alert described the earlier NICE position (CG91, depression with a chronic physical health problem) that collaborative care, in which a non-specialist case manager such as a practice nurse keeps regular contact and organises care with the GP and a mental health specialist, should be considered when depression has not responded to initial psychological or drug treatment. [source: NIHR Evidence alert, 2017; secondary, may be outdated]
Steps: (1) Get the client's written consent to share information. (2) Write a brief, factual letter: presenting problem, measure scores over time, symptoms the client reported, current psychological treatment, and the specific question (for example, "review of possible perimenopausal contribution"). (3) Agree with the prescriber who monitors what and how you will share concerns. (4) Record the plan and review it at set points. [synthesis]
Example language (illustrative): "I'll write a short note to your GP describing what we've noticed. You can read it before it goes. Is that OK?"
Watch for: letters that recommend a specific medicine; keep to observations and questions. [synthesis]

B3. Psychoeducation

Purpose: help the client understand the options and their status so they can take part in decisions.
Content the sources support: low mood in menopause differs from depression [source: NICE NG23 information for the public]; the perimenopause is a period of raised vulnerability, often a recurrence of earlier depression [source: Maki et al. 2018]; HRT may be offered for menopausal low mood and CBT for low mood or anxiety [source: NICE NG23 information for the public]; oestrogen is not FDA-approved for mood and is ineffective for depression after menopause per NAMS/NNDC [source: Maki et al. 2018]; liothyronine augmentation is a specialist, off-label option [source: NG222 rec 1.9.9]; combinations usually bring more side effects [source: NG222 rec 1.9.8].
Steps: (1) Ask what the client already knows or has read. (2) Give one or two points at a time. (3) Check understanding. (4) Write down questions for the prescriber. [synthesis]
Example language (illustrative): "The guidelines treat this as something your doctor would weigh up with you. I can help you think through your questions, but the decision about medicines is between you and them."
Watch for: misinformation from social media or private clinics (for example, hormones as a cure-all); correct gently with sources and route to the prescriber. [synthesis]

B4. Supporting informed consent and shared decision-making

Purpose: help the client reach the shared decision NICE describes. [source: NG222 recs 1.6.1, 1.9.4]
Steps: (1) Clarify the client's values and priorities (for example, fewer side effects vs faster change, preference for therapy). (2) Help list questions: why this option, what it is licensed for, what monitoring it needs, what side effects to report, what happens if it does not help. (3) Role-play the appointment if anxious. (4) Debrief afterwards. [synthesis]
Example language (illustrative): "What matters most to you in choosing what comes next? Let's write that down so you can tell your psychiatrist."
Watch for: the client deferring entirely or feeling pressured; return to values. [synthesis]

B5. Monitoring and passing on side effects and warning signs

Purpose: an extra pair of eyes between prescriber appointments.
Steps: (1) At each session briefly ask about mood, sleep, physical changes and new symptoms since starting or changing any medicine. (2) Note the client's own words. (3) For routine concerns, encourage the client to contact the prescriber and, with consent, inform them. (4) For signs NICE lists as lithium toxicity (coarse tremor, unsteadiness, confusion, fits), or chest pain, fainting or severe palpitations, advise urgent medical care the same day. [source: NG222 rec 1.4.28 for toxicity signs; synthesis for other urgent signs and routing] (5) For a client taking liothyronine, pass on new palpitations, an irregular heartbeat or chest symptoms promptly, since the label lists cardiac adverse reactions such as atrial fibrillation, especially in older people and those with heart disease. [source: Cytomel prescribing information; synthesis for routing]
Example language (illustrative): "That shakiness sounds new. Please call your prescriber today about it; I can wait while you do."
Watch for: the client minimising symptoms to avoid a change; normalise reporting. [synthesis]

B6. Conversations about adherence and ambivalence (never advising a change)

Purpose: explore mixed feelings about a medicine without steering the decision; NICE asks clinicians to review adherence when there is no response, and people who want to stop antidepressants to talk with the prescriber. [source: NG222 recs 1.9.1, 1.4.12]
Steps: (1) Ask open questions about how taking the medicine is going. (2) Reflect both sides of ambivalence. (3) Avoid opinions about the medicine itself. (4) Encourage taking the concerns to the prescriber; offer to help prepare. [synthesis, using standard motivational-interviewing stance]
Example language (illustrative): "Part of you is worried about taking hormones, and part of you wants to feel like yourself again. Those are both important to bring to your doctor before anything changes."
Watch for: a client who has already stopped; do not judge; encourage prompt contact with the prescriber, as NICE says lithium and antipsychotics should be stopped only with specialist advice. [source: NG222 recs 1.4.32, 1.4.37]

B7. Crisis and safety planning

Purpose: manage risk during non-response or treatment changes. NICE advises urgent referral to specialist services for considerable immediate risk and considering specialist referral for suicide risk. [source: NG222 recs 1.2.9, 1.2.12] Women with suicidal ideation in the perimenopause should always be evaluated for a mood disorder. [source: Maki et al. 2018]
Steps: (1) Ask directly about suicidal thoughts at each review. (2) Build or update a written safety plan with warning signs, coping steps, contacts and crisis numbers. (3) Include lethal-means counselling about safe storage of medicines. (4) Escalate urgently per local pathways. [synthesis following standard risk practice]
Example language (illustrative): "When things are this hard, some people think about ending their life. Has that been on your mind?"
Watch for: rising hopelessness when an option "fails"; reassure, as NICE does, that other treatments can be tried. [source: NG222 rec 1.9.3]

B8. Integrating psychotherapy before, during and after augmentation

Purpose: psychotherapy continues as an active treatment; NICE lists combined therapy and medication among further-line options and NAMS/NNDC notes CBT plus antidepressant may outperform medication alone and calls CBT a reasonable option for menopause-transition depression. [source: NG222 recs 1.9.4–1.9.6; Maki et al. 2018] NAMS/NNDC also considers it reasonable to recommend exercise, especially alongside therapy or medication. [source: Maki et al. 2018]
Steps: (1) Before: formulate the role of life stage, sleep, relationships and identity. (2) During: continue the agreed therapy; target sleep disruption, anxiety and behavioural activation. (3) After: relapse-prevention planning. [synthesis]
Example language (illustrative): "Whatever your doctor decides about medication, we can keep working on sleep and the things that lift your mood."
Watch for: attributing all improvement or setbacks to the medicine; review both. [synthesis]

B9. Support after treatment ends or changes

Purpose: steady the client through any prescriber-led change. [synthesis]
Steps: (1) Check in more often around changes. (2) Monitor for return of symptoms and pass on concerns. (3) Consolidate relapse-prevention skills. [synthesis]
Example language (illustrative): "Let's agree what early warning signs you'd want us to notice, and who you'd call."
Watch for: early relapse signs; route to the prescriber.

5. Handling problems

Most of this section is [synthesis]; the sources address the medical decisions, not the therapist's difficulties.

Client asks you whether they should take HRT, thyroid hormone or testosterone. Say plainly that this is the prescriber's decision, offer to help them prepare questions, and give the guideline facts in B3 if useful. (illustrative) "I can't advise on that, but I can help you get the most out of your appointment." [synthesis]
Client wants to stop, or has stopped, a medicine. Do not endorse or argue; explore reasons; encourage prompt contact with the prescriber. NICE says people wanting to stop antidepressants should talk with the prescriber, and lithium and antipsychotics should be stopped only in, or with advice from, specialist services. [source: NG222 recs 1.4.12, 1.4.32, 1.4.37]
Client is sourcing hormones or thyroid medicine without a prescriber (online, a friend, a private clinic without oversight). Express concern, explain why medical monitoring matters, and encourage them to tell a prescriber; consider risk. [synthesis]
Stuck: no response to several options. Review with the client what NICE asks clinicians to check (life factors, adherence, diagnosis, comorbidity); reassure that other treatments can be tried; revisit the psychological formulation and the therapy approach. [source: NG222 recs 1.9.1–1.9.3; synthesis for therapy review]
Client dismissed by a clinician ("it's just your age" or "it's just hormones"). Validate; help the client describe symptoms and impact concretely, consider measure scores in a letter (with consent), and if needed support seeking a second opinion or specialist menopause service. [synthesis]
Overwhelm with information or conflicting advice. Reduce to a few questions; point to official sources (NICE public information); use one written plan. [synthesis]
Rupture: client feels you are "pushing medication" or "blaming hormones". Acknowledge, clarify your role (observations and referral, not prescribing), and repair. [synthesis]
Bipolar features emerge (for example elevated mood or reduced need for sleep after a treatment change). Pass on promptly to the prescriber; NAMS/NNDC lists bipolar depression in the differential diagnosis. [source: Maki et al. 2018 for differential; synthesis for action]
Physical warning signs during augmentation (signs NICE lists for lithium toxicity, or chest pain, fainting, severe palpitations). Advise urgent same-day medical care; inform the prescriber with consent or per safeguarding duties. [source: NG222 rec 1.4.28; synthesis]
Postmenopausal client hoping oestrogen will treat depression. Share, as information only, that NAMS/NNDC found oestrogen ineffective for depressive disorders after menopause, and that this is for the prescriber to discuss. [source: Maki et al. 2018]
Questions about testosterone for mood. Explain that NICE menopause public information discusses testosterone only for low sexual interest when HRT has not helped, that a meta-analysis in men found a modest effect on depressive symptoms but guidelines do not recommend testosterone for depression, and refer the question to the prescriber. [source: NICE NG23 information for the public; MDedge report of Walther et al.]
Confidentiality tension (client does not want the GP told). Respect consent except where risk requires disclosure under your professional code; explain limits early. [synthesis]
Out of competence. If you notice yourself interpreting blood results or suggesting regimens, stop, seek supervision and refocus on referral. [synthesis]

Sources

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