Association of Hypothyroidism and Clinical Depression: A Systematic Review and Meta-analysis

Association between different triglyceride glucose index-related indicators and depression in premenopausal and postmenopausal women: NHANES, 2013-2016

BACKGROUND AND AIM

The association between the Triglyceride-glucose (TyG) index and depression has been observed, yet its confirmation within peri- and postmenopausal demographics remains elusive. Consequently, the principal aim of this investigation is to explore the nexus between TyG-related indicators and depressive symptoms among pre- and postmenopausal women.

METHODS

The data utilized in this study were obtained from the National Health and Nutrition Examination Survey (NHANES) conducted from 2013 to 2016. The patients were divided into three groups based on TyG, Triglyceride-Glucose-Body Mass Index (TyG-BMI), Triglyceride-Glucose-Waist Circumference (TyG-WC), and Triglyceride-Glucose-Waist-to-Height Ratio (TyG-WHtR): Q1 (1st quintile), Q2 (2nd quintile), and Q3 (3rd quintile). Further exploration of the differences between these groups was conducted. Employing logistic regression, stratified analysis, restricted cubic splines, and subgroup analyses, we scrutinized the correlation between TyG-related indicators and depressive symptoms in both premenopausal and postmenopausal women. Furthermore, sensitivity analyses were conducted to assess the durability and uniformity of this relationship.

RESULTS

In premenopausal women, there was a consistent independent positive correlation between TyG-BMI, TyG-WC, and TyG-WHtR with depressive symptoms across all three models, while TyG itself did not show a significant association. In Models 1 and 2, TyG-BMI exhibited a higher odds ratio (OR) value than the other two indicators [Model 1, Q3 OR (95 % confidence interval, CI) = 3.37 (1.91-5.94); Model 2, Q3 OR (95 % CI) = 3.03 (1.67-5.52)]. In Models 3, TyG-WHtR demonstrates a more significant association with depressive symptoms [Model 3, Q3 OR (95 % CI) = 2.85 (1.55-5.27)]. This correlation does not manifest in menopausal women.

CONCLUSIONS

In premenopausal women, TyG-BMI, TyG-WC, and TyG-WHtR exhibited a positive and linear relationship with depressive symptoms. Furthermore, the analysis revealed that the combined measures of TyG-BMI, TyG-WC, and TyG-WHtR offered greater precision and sensitivity in assessing this association compared to TyG alone.

Total testosterone plays a crucial role in the pathway from hypothyroidism to broad depression in women

BACKGROUND

Depression tends to develop in correlation with hypothyroidism, however it's unclear how testosterone traits contribute to this association. We examined the causal association between depression, testosterone traits, and hypothyroidism using Mendelian randomization (MR).

METHOD

We conducted univariable and multivariable MR studies using summary-level statistics from genome-wide association studies (GWAS) of Hypothyroidism (n = 213,990), broad depression (n = 322,580), probable major depressive disorder (probable MDD) (n = 174,519), and International Classification of Diseases (ICD)-9 or ICD-10-coded MDD (n = 217,584) from European ancestry. The inverse variance weighted (IVW) method was used as the main MR analysis.

RESULTS

In univariate MR analysis, there is a positive causal relationship between hypothyroidism and broad depression (P = 0.0074; OR = 1.0066; 95%CI: 1.0018-1.0114) and probable MDD (P = 0.0242; OR = 1.0056; 95%CI: 1.0007-1.0105). In females, there is a causal relationship between hypothyroidism and decreased total testosterone (P < 0.001; OR = 0.9747; 95%CI: 0.9612-0.9885) and sex hormone binding globulin (SHBG) levels (P = 0.0418; OR = 0.9858; 95%CI: 0.9723-0.9995). In females, there is an inverse causal relationship between total testosterone and broad depression (P = 0.0349; OR = 0.9898; 95%CI: 0.9804-0.9993). Furthermore, in multivariate MR analysis, after adjusting for total testosterone in females, hypothyroidism only has a positive causal relationship with probable MDD, and the relationship with broad depression is no longer significant. Most notably, after adjusting for hypothyroidism, the inverse causal effect of female total testosterone levels on broad depression becomes more significant (P = 0.0154; OR = 0.9878; 95%CI: 0.9780-0.9977).

CONCLUSION

Hypothyroidism increases the risk of broad depression and probable MDD development. Total Testosterone appears to play an important role in the relationship between hypothyroidism and broad depression in female.

Protective role of the ginsenoside Rg1 against methimazole-induced gestational hypothyroidism on reflexive behaviors, conditioned fear and cortical antioxidant levels in mice offspring

Ginsenoside Rg1(Rg1), a monomer of a tetracyclic triterpenoid derivative, possesses diverse medicinal properties attributed to its unique chemical structure and may have beneficial effects on fetal development. This study aimed to investigate the protective effects of prenatal exposure to Rg1 against Methimazole-induced gestational hypothyroidism on reflexive behaviors, conditioned fear, and cortical antioxidant levels in mouse offspring.40 female virgin mice and 12 male NMRI mice were assigned to four groups: group 1 served as the control, group 2 received Methimazole(MMI) at a concentration of 0.02% in their drinking water, group 3 received Rg1(150 mg/kg), and group 4 received both MMI and Rg1.Groups of 2-4 were administered the substances from days 1-9 of gestation. After delivery, pups were selected, and reflexive motor behaviors and conditioned fear were assessed. Additionally, levels of brain tissue catalase(CAT), malondialdehyde(MDA), superoxide dismutase(SOD), and glutathione peroxidase(GPx) levels were measured. Furthermore, postpartum immobility time in the forced swimming test (FST), tail suspension test (TST), and the number of squares crossed in the open field test (OFT)were determined. The results demonstrated that maternal exposure to Rg1 improved ambulation score, hind-limb suspension score, grip strength, front-limb suspension, hind-limb foot angle, negative geotaxis, surface righting, and conditioned fear in hypothyroidism-induced offspring(P<0.05). Rg1 decreased immobility time in the FST, and TST, and increased the number of squares crossed in the OFT in postpartum hypothyroidism-induced mice(P<0.05). Moreover, Rg1 reduced brain tissue MDA levels and increased brain tissue CAT, SOD, and GPx levels in mice and their offspring(P<0.05). These findings indicate that Rg1 mitigated postpartum depression in mice and improved reflexive motor behaviors in their pups.

Sex differences in correlates of suicide attempts in Chinese Han first-episode and drug-naïve major depressive disorder with comorbid subclinical hypothyroidism: A cross-sectional study

BACKGROUND

This study aimed to investigate sex differences in risk factors for suicide attempts in first-episode and drug naive (FEDN) major depressive disorder (MDD) with comorbid subclinical hypothyroidism (SCH).

METHODS

A total of 1034 FEDN MDD patients with comorbid SCH were enrolled. The Hamilton Depression Scale (HAMD), Hamilton Anxiety Scale (HAMA), and Positive and Negative Syndrome Scale (PANSS) positive subscale were used to assess patients' symptoms. Thyroid hormone levels and metabolic parameters were measured.

RESULTS

MDD patients with SCH had a significantly higher risk of suicide attempts than those without SCH (25.4% vs. 12.2%). Logistic regression showed that HAMA score, thyroid stimulating hormone (TSH) levels, and thyroid peroxidase antibody (TPOAb) levels were significantly associated with an increased risk for suicide attempts in both male and female MDD patients comorbid SCH, while low-density lipoprotein cholesterol (LDL-C) was significantly associated with an increased risk for suicide attempts only in male patients, HAMD score and systolic blood pressure were significantly associated with an increased risk for suicide attempts only in female patients.

CONCLUSION

SCH comorbidities may increase suicide attempts in MDD patients. Our results showed significant sex differences in clinical and metabolic factors associated with suicide attempts among FEDN MDD patients with comorbid SCH, highlighting appropriate sex-based preventive interventions are needed.

Drug-induced hypothyroidism in tuberculosis

INTRODUCTION

Adverse reactions to tuberculosis treatment can impact patient adherence and prognosis. Hypothyroidism is a frequent adverse reaction caused using ethionamide, prothionamide, and para-aminosalicylic acid and is often underdiagnosed.

AREAS COVERED

We searched Scielo, Scopus, and EMBASE databases, including 67 articles. Antitubercular drug-induced hypothyroidism has a prevalence of 17%. It occurs after 2 to 3 months of treatment and resolves within 4 to 6 weeks after discontinuation. It is postulated to result from the inhibition of thyroperoxidase function, blocking thyroid hormone synthesis. Symptoms are nonspecific, necessitating individualized thyroid-stimulating hormone measurement for detection. Specific guidelines for management are lacking, but initiation of treatment with levothyroxine, as is customary for primary hypothyroidism, is recommended. Discontinuation of antitubercular drugs is discouraged, as it may lead to unfavorable consequences.

EXPERT OPINION

Antitubercular drug-induced hypothyroidism is more common than previously thought, affecting one in six MDR-TB patients. Despite diagnostic and treatment recommendations, implementation is hindered in low-income countries due to the lack of certified laboratories. New drugs for tuberculosis treatment may affect thyroid function, requiring vigilant monitoring for complications, including hypothyroidism.

Investigating the association of anticholinergic burden with depression in older adults: a cross-sectional study

BACKGROUND

Although depression and anticholinergic drug use are common comorbidities that impair health status in later life, there are insufficient data on their relationship. This study aimed to investigate the relationship between depressive symptoms and anticholinergic use in older individuals.

METHODS

Community-dwelling older adults (≥65 years) admitted to the tertiary referral geriatric outpatient clinic were included. Participants were evaluated for depressive symptoms using the Geriatric Depression Scale (GDS) with a cut-off score of ≥6 for depression. Exposure to anticholinergic drugs was assessed using the anticholinergic cognitive burden (ACB) scale and three subgroups were created: ACB = 0, ACB = 1, and ACB ≥ 2. The relationship between these two parameters was assessed using multivariate logistic regression analysis considering other potential variables.

RESULTS

The study included 1232 participants (mean age 78.4 ± 7.2 years and 65.2% female) and the prevalence of depression was 24%. After adjusting for potential confounders, compared to ACB = 0, having ACB ≥ 2 was related to depression symptoms (odds ratio (OR): 1.56, 95% CI: 1.04-2.35, P = 0.034), whereas having ACB = 1 did not increase the risk (OR: 1.27, 95% CI: 0.88-1.83, P = 0.205).

CONCLUSION

Our findings indicate that special attention should be paid to drug therapy in preventing depression in older adults, as exposure to a high anticholinergic load is negatively associated with psychological status.

Prevalence and clinical correlates of suicide attempts in patients with first-episode drug-naïve major depressive disorder and comorbid autoimmune thyroiditis

BACKGROUND

Autoimmune thyroiditis is closely associated with major depressive disorder (MDD) and suicide attempts. However, few studies have examined this relationship.

AIMS

The study aimed to assess the prevalence and correlates of suicide attempts in patients with first-episode drug-naïve (FEDN) MDD and autoimmune thyroiditis.

METHOD

We recruited 1718 out-patients with FEDN MDD and assessed depressive, anxiety and psychotic symptoms with the Hamilton Rating Scale for Depression, Hamilton Rating Scale for Anxiety (HRSA) and Positive and Negative Syndrome Subscale positive subscale, respectively. The serum levels of free triiodothyronine, free thyroxine, thyroid stimulating hormone (TSH), antithyroglobulin, thyroid peroxidase antibody (TPOAb) and several other metabolic parameters were assessed. Patients were divided into non-autoimmune thyroiditis, autoimmune thyroiditis only and autoimmune thyroiditis with abnormal TSH groups, based on autoimmune thyroiditis severity. Multiple logistic regression model was applied to identify the correlates of suicide attempts in patients with MDD and autoimmune thyroiditis with abnormal TSH.

RESULTS

Compared with the non-autoimmune thyroiditis group, the autoimmune thyroiditis with abnormal TSH group had a nearly fourfold higher likelihood of reporting a suicide attempt, whereas no difference was found between the non-autoimmune thyroiditis and autoimmune thyroiditis only groups. HRSA score, lnTPOAb and lnTSH were independently associated with suicide attempts in patients with autoimmune thyroiditis with abnormal TSH.

CONCLUSIONS

Patients with MDD and autoimmune thyroiditis with abnormal TSH are at higher risk for suicide attempt. TPOAb, TSH and anxiety are all independently associated with suicide attempts in this population, and regular thyroid checks are warranted.

The association between plasma thyroxine levels and neurocognitive impairment in early-onset schizophrenia and other psychosis spectrum disorders

BACKGROUND/AIM

Limited studies have delved into the association between thyroid hormones and neurocognition in schizophrenia. We aimed to evaluate the relationship between thyroid hormone levels and neurocognitive functions in patients with schizophrenia and other psychosis spectrum disorders (SSD).

METHOD

A total of 135 patients with early-onset SSD were included in the study. The participants underwent a cognitive assessment. Blood samples were collected to measure serum levels of thyroid-stimulating hormone (TSH), free thyroxine (fT4), and free triiodothyronine (fT3). Subgroup analyses were conducted based on the severity of the psychosis.

FINDINGS

The results revealed a significant association between fT4 levels and various cognitive domains, including processing speed, verbal fluency, working memory, verbal learning, verbal memory, and visual memory. However, serum TSH and fT3 levels exhibited no significant association with neurocognitive impairment in adjusted linear regression models. Specifically, the correlation between fT4 levels and global cognition was more pronounced in patients with higher scores.

CONCLUSIONS

Serum fT4 levels were associated with the performance across various cognitive domains in cases of early-onset psychotic disorders. This correlation was accentuated among patients with higher illness severity. Future studies could focus on the effects of specific pathways that can affect the course and progression of psychosis.

The Cross-sectional and Longitudinal Association Between Thyroid Function and Depression: A Population-Based Study

CONTEXT

An association of thyroid function with mood disorders has been widely suggested, but very few studies have examined this association longitudinally.

OBJECTIVE

We assessed the cross-sectional and longitudinal association between thyroid function and depression in a population-based cohort.

METHODS

A total of 9471 individuals were included in cross-sectional analyses, of whom 8366 had longitudinal data. At baseline, we assessed thyroid function using serum samples (thyrotropin [TSH], free thyroxine (FT4), and thyroid peroxidase antibodies) and depressive symptoms using the Centre for Epidemiologic Studies Depression (CES-D) scale. Incident depressive events (n = 1366) were continuously followed up with the CES-D and clinical interviews. We analyzed the cross-sectional association of thyroid function and thyroid disease with depressive symptoms using linear and logistic regression, and the longitudinal association with Cox proportional hazard models for depressive events.

RESULTS

Lower TSH levels and lower and higher FT4 levels were cross-sectionally associated with more depressive symptoms with a B value of -0.07 per 1 unit increase of natural log-transformed TSH (95% CI -0.11; -0.04). Furthermore, hypothyroidism was cross-sectionally associated with less depressive symptoms and hyperthyroidism with more depressive symptoms. Longitudinally, there was a U-shaped association between FT4 and incident depressive events but only in euthyroid participants.

CONCLUSION

We show a cross-sectional association between thyroid (dys)function with depressive symptoms, and a U-shaped association between FT4 and incident depressive events in euthyroid individuals. Our findings suggest an association of thyroid function with the risk of developing depression, albeit small. Reverse causation and additional underlying factors may also contribute to the association.

Association between hypothyroidism subtypes and major depression: A two-sample Mendelian randomization study

BACKGROUND

The causal relationship between different hypothyroidism subtypes and the risk of major depression (MD) is yet to be fully elucidated. This study aimed to determine if there's a causal relationship between various hypothyroidism subtypes (and related factors) and the risk of MD.

METHODS

This genetic association study utilized a two-sample Mendelian Randomization (MR) approach to explore the causal relationships between various hypothyroidism subtypes and MD risk. Genome-Wide Association Study (GWAS) summary statistics were obtained from the FinnGen and the UK Biobank. Instrumental variables (IVs) were chosen based on single nucleotide polymorphisms (SNPs).

RESULTS

Among the analyzed hypothyroidism subtypes and related factors, "Hypothyroidism, strict autoimmune" (HTCBSA) and "Hypothyroidism, levothyroxin purchases" (HT/LP) demonstrated a statistically significant positive causal relationship with MD, with odds ratios of 1.020 (95 % CI: 1.004-1.037) and 1.022 (95 % CI: 1.005-1.040), respectively. The sensitivity analysis supported the robustness of these findings, showing no significant horizontal pleiotropy and confirming the stability of results when individual SNPs were removed. "Congenital iodine-deficiency syndrome/hypothyroidism" (CIDS/HT), "Postinfectious hypothyroidism" (PHT), "Hypothyroidism due to medicaments and other exogenous substances" (HDTDM and OES), "Thyroid Stimulating Hormone" (TSH), "Thyrotropin-releasing hormone" (THRH), and "Hypothyroidism, strict autoimmune, 3 medication purchases required" (HTCBSA/3MPR) showed no significant causal relationship with MD.

LIMITATIONS

The study population was limited to individuals of European ancestry, and there may be certain genetic differences between different ethnic groups.

CONCLUSIONS

This MR study suggests a potential causal relationship between certain hypothyroidism subtypes (specifically HTCBSA and HT/LP) and an increased risk of MD.

Low and very low lithium levels: Thyroid effects are small but still require monitoring

AIM

Low doses of lithium, as might be used for mood or dementia prevention, do not carry the same renal, toxicity, and tolerability problems of doses used for prophylaxis or treatment of mania. However, thyroid effects of low doses have not been investigated. Our goal in this study was to assess the changes in thyroid-stimulating hormone (TSH) associated with a broad range of lithium levels, including those well below the therapeutic range for bipolar disorders.

METHODS

This study was conducted in a small healthcare system with 19 associated primary care clinics served by a Collaborative Care program of psychiatric consultation. In this retrospective review of electronic records, we searched for patients who had received a lithium prescription and both pre- and post-lithium thyroid-stimulating hormone (TSH) levels.

RESULTS

Patients with low lithium levels (<0.5 mEq/L, N = 197) had a mean thyroid-stimulating hormone (TSH) increase of 0.52 mIU/L. Patients with maintenance lithium levels (0.5-0.8 mEq/L; N = 123) had a mean TSH increase of 1.01 mIU/L; and patients with antimanic lithium levels (>0.8 mEq/L; N = 79) had a mean TSH increase of 2.16 mIU/L. The probability of TSH exceeding the upper limit of normal in our laboratory (>4.2 mIU/L) was positively associated with pre-lithium TSH.

CONCLUSION

These results suggest that the risk of lithium-induced hypothyroidism is dose-related, and relatively small with very low doses, but thyroid monitoring, including a pre-lithium TSH, is still warranted.

Prenatal exposure to poly- and perfluoroalkyl substances and postpartum depression in women with twin pregnancies

BACKGROUND

Women with multiple pregnancies are vulnerable to experience postpartum depression (PPD). Emerging evidence indicates an association between poly- and perfluoroalkyl substances (PFAS) exposure and PPD in women delivering singletons. The health risks of PFAS may also be present in women delivering twins.

OBJECTIVE

To estimate the impacts of prenatal PFAS exposure on the risk of PPD in women with twin pregnancies.

METHODS

Our study included 150 mothers who gave birth to twins and were enrolled in the Wuhan Twin Birth Cohort. The concentrations of maternal plasma PFAS were measured in each trimester and averaged. Eight individual PFAS were included in analyses. We used Edinburgh Postnatal Depression Scale to evaluate maternal depression at early pregnancy and 1 and 6 months after childbirth. The outcome was dichotomized using a cutoff value of ≥10 for main analyses. Associations were examined using multiple informant models and modified Poisson regressions. PFAS mixture effects were estimated using quantile g-computation.

RESULTS

Using quantile g-computation models, a quartile increase in the PFAS mixture during the first, second, third, and average pregnancy was significantly associated with a relative risk (RR) of 1.73 (95% CI: 1.42, 2.12), 1.54 (95% CI: 1.27, 1.84), 1.75 (95% CI: 1.49, 2.08), and 1.63 (95% CI: 1.35, 1.97) for PPD at 6 months after childbirth, respectively. The results of the single-PFAS models also indicated significant positive associations between individual PFAS and PPD at both 1 and 6 months.

CONCLUSIONS

The first study of women with twin pregnancies suggests that prenatal exposure to PFAS increases PPD risk up to 6 months postpartum. Twin pregnant women should receive long-term follow-up after delivery and extensive social support.

Heartache and Heartbreak: An Observational and Mendelian Randomization Study

Background

Depression has a significant effect on cardiovascular disease (CVD), but uncertainties persist regarding which modifiable risk factors mediate the causal effects. We aim to determine whether depression is causally linked to CVD and which modifiable risk factors play potential mediating roles.

Methods

We used a two-sample Mendelian randomization (MR) approach and NHANES 2007-2018 data to estimate the effects of depression on various CVD cases and investigated 28 potential mediators of the association between depression and CVD.

Results

The results of our MR analysis indicated that genetically determined depression was associated with increased risk of several CVD, including coronary heart disease (odds ratio (OR) = 1.14; 95% confidence interval (CI): 1.05,1.22), myocardial infarction (OR = 1.19; 95% CI, 1.09,1.31), atrial fibrillation (OR = 1.14; 95% CI, 1.06,1.22), and stroke (OR = 1.13; 95% CI, 1.05,1.22). However, there was no causal association between depression and heart failure. Four out of 28 cardiometabolic risk factors, including hyperlipidemia, hypertension, diabetes, and prescription opioid use, were identified as mediators of the association between depression and various CVDs. Observational association analyses from NHANES data yielded consistent results.

Conclusion

Our findings demonstrated that depression has a causal detrimental effect on various CVDs. Four causal mediators (hyperlipidemia, hypertension, diabetes, and prescription opioid use) were screened to explain the causal effect. Implementing targeted management strategies for these risk factors may be warranted to mitigate the public health burden of CVD among individuals with depression.

Somatic disease burden and depression risk in late life: a community-based study

AIMS

Co-occurring somatic diseases exhibit complex clinical profiles, which can differentially impact the development of late-life depression. Within a community-based cohort, we aimed to explore the association between somatic disease burden, both in terms of the number of diseases and their patterns, and the incidence of depression in older people.

METHODS

We analysed longitudinal data of depression- and dementia-free individuals aged 60+ years from the population-based Swedish National Study on Aging and Care in Kungsholmen. Depression diagnoses were clinically ascertained following the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision over a 15-year follow-up. Somatic disease burden was assessed at baseline through a comprehensive list of chronic diseases obtained by combining information from clinical examinations, medication reviews and national registers and operationalized as (i) disease count and (ii) patterns of co-occurring diseases from latent class analysis. The association of somatic disease burden with depression incidence was investigated using Cox models, accounting for sociodemographic, lifestyle and clinical factors.

RESULTS

The analytical sample comprised 2904 people (mean age, 73.2 [standard deviation (SD), 10.5]; female, 63.1%). Over the follow-up (mean length, 9.6 years [SD, 4 years]), 225 depression cases were detected. Each additional disease was associated with the occurrence of any depression in a dose-response manner (hazard ratio [HR], 1.16; 95% confidence interval [CI]: 1.08, 1.24). As for disease patterns, individuals presenting with sensory/anaemia (HR, 1.91; 95% CI: 1.03, 3.53), thyroid/musculoskeletal (HR, 1.90; 95% CI: 1.06, 3.39) and cardiometabolic (HR, 2.77; 95% CI: 1.40, 5.46) patterns exhibited with higher depression hazards, compared to those without 2+ diseases (multimorbidity). In the subsample of multimorbid individuals (85%), only the cardiometabolic pattern remained associated with a higher depression hazard compared to the unspecific pattern (HR, 1.71; 95% CI: 1.02, 2.84).

CONCLUSIONS

Both number and patterns of co-occurring somatic diseases are associated with an increased risk of late-life depression. Mental health should be closely monitored among older adults with high somatic burden, especially if affected by cardiometabolic multimorbidity.

Emotional and behavioral features associated with subclinical hypothyroidism in children and adolescents with Down syndrome

Background

Subclinical hypothyroidism (SH) is particularly frequent in individuals with Down syndrome (DS). Despite the amount of evidence suggesting SH is associated with psychopathological symptoms and sleep problems in general population, poor is known about the emotional and behavioral features associated with SH in children with DS.

Objective

The first aim of the current study was to investigate differences in emotional and behavioral profiles between a group of children with DS exhibiting co-occurring SH and a group of age and BMI-matched children with DS without co-occurring SH. The second aim of the present study was to investigate differences in sleep disturbances between these groups.

Methods

We included in this retrospective study 98 participants with DS aged 3-18 years with the aim to explore differences in emotional/behavioral problems as well as in sleep difficulties between children with DS with or without co-occurring SH.

Results

Participants with co-occurring SH exhibited significantly higher scores at several scales of the Conners' Parent Rating Scales Long Version - Revised. However, they did not exhibit more sleep problems than control group.

Conclusion

These results provide specific indications for psychological and neuropsychiatric evaluation of children with DS with suspected or diagnosed SH, highlighting the importance of a multidisciplinary approach in clinical care for children and adolescents with DS.

Impact of Adjunctive VNS on Drug Load, Depression Severity, and Number of Neuromodulatory Maintenance Treatments

Vagus nerve stimulation (VNS) is a long-term adjunctive treatment option in patients with difficult-to-treat depression (DTD). A total of n = 20 patients (mean age 52.6 years) were included in the multicenter, prospective, observational, naturalistic RESTORE-LIFE study and were treated with adjunctive VNS as an add-on to treatment as usual. Exploratory and secondary outcome parameters from a single center were investigated for this present analysis. The overall mean drug load slightly decreased from 4.5 at baseline to 4.4 at 12 months (Z = -0.534, p = 0.594). The drug load was lower in previous electroconvulsive therapy (ECT) responders than in non-responders. There was a reduction in the mean number of hospitalizations per month after VNS implantation (Z = 1.975, p = 0.048) and a significant decrease in the mean Montgomery Åsberg Depression Rating Scale (MADRS) score from 27.3 at baseline to 15.3 at 12 months (T = 4.230, degree of freedom (df) = 19, p = 0.001). A history of ECT response at baseline was associated with greater improvement in the MADRS score after 12 months of VNS (F = 8.171, p = 0.013). The number of neuromodulatory maintenance treatments decreased during the follow-up period. In summary, there was an alleviation in the burden of illness among DTD patients treated with VNS.

[Depressive symptoms in a sample of women with subclinical hypothyroidism and their relationship to chlorates in tap water]

INTRODUCTION

depressive symptoms may develop in subclinical hypothyroidism and their presence usually facilitates recognition and the establishment of replacement treatment; however, recent studies have found no association between the two. Be-sides, thyroid function can be affected by endocrine disruptors and some of them, such as chlorates, can be found in the water we drink.

OBJECTIVES

to know if the type of water consumed may influence the development of depressive symptoms in patients with subclinical hypothyroidism.

METHODS

96 women with subclinical hypothyroidism, without thyroid treatment, par-ticipated from a health area in Spain. We studied, among other variables, the presence of depressive symptoms, type of water consumption (tap, bottled or spring) and the level of chlorates in the tap water.

RESULTS

41.7 % (40) of women presented depressive symptoms and these were related to the consumption of tap water (p = 0.001), resulting in a reliable predictor (OR, 27.79; p = 0.007). Chlorate level in the tap water was 250 µg/L, a value within the maximum limit allowed by law.

CONCLUSIONS

chronic exposure to chlorates in water, in women with subclinical hypo-thyroidism, at levels authorized by law, could favor the inhibition of iodine transport and the appearance of depressive symptoms. It would be interesting to test this hy-pothesis as well as its possible effect on other population profiles.

Lack of Association Between Depression and Subclinical Hypothyroidism in Adolescents Presenting for Routine Physical Examinations

Background

There are conflicting results in the existing studies regarding the association between depression and subclinical hypothyroidism in adolescents. Subclinical hypothyroidism is defined as elevated thyroid stimulating hormone (TSH) levels above the reference range without signs or symptoms of hypothyroidism.

Objectives

The focus of this study is to determine whether there is any association between depression and subclinical hypothyroidism, (as defined by the serum TSH levels) in a population of healthy adolescents.

Design

Quantitative-based cross-sectional study of a representative subset of the adolescent population.

Methods

We carried out a cross-sectional study to determine the association between major depressive disorder (MDD) and subclinical hypothyroidism, in adolescents presenting for annual physical examinations during the peak period of the COVID-19 pandemic in the USA, a period deemed high for adolescent depression. All the adolescents were screened for depression by the PHQ-9 screening tool and had their TSH measured.

Results

Of the 304 subjects analyzed, 179 (58.88%) were minimally or not depressed according to the Patient Health Questionnaire (PHQ-9) screening tool (mean PHQ 1.80 ± 1.49). 70 (23.03%) had mild depression (mean PHQ 6.59 ± 1.46), 50 (16.45%) had moderate depression (mean PHQ 13.70 ± 2.75), and 5 (1.64%) had severe depression (mean PHQ 21.40 ± 1.67). Mean TSH values were 1.93 ± 0.99, 1.77 ± 1.05, 2.10 ± 0.98, and 1.57 ± 0.32 mIU/L, respectively in the four groups. All values were within the recommended range of 0.50 to 4.30 mIU/L, without statistically significant inter-group differences.

Conclusion

We conclude that there is no statistically significant association between depression and subclinical hypothyroidism, in a population of adolescents presenting for physical examinations, and if the screening for depression by the PHQ-9 tool indicates depression, a screening TSH test for subclinical hypothyroidism is not justified.

TCF4 and RBFOX1 as peripheral biomarkers for the differential diagnosis and treatment of major depressive disorder

BACKGROUND

Recent genome-wide association studies on major depressive disorder (MDD) have indicated the involvement of LRFN5 and OLFM4; however, the expression levels and roles of these molecules in MDD remain unclear. The present study aimed to determine the serum levels of TCF4 and RBFOX1 in patients with MDD and to investigate whether these molecules could be used as biomarkers for MDD diagnosis.

METHODS

The study included 99 drug-naïve MDD patients, 90 drug-treated MDD patients, and 81 healthy controls (HCs). Serum TCF4 and RBFOX1 levels were measured by ELISA. Pearson's correlation analysis was conducted to determine the association between TCF4/RBFOX1 and clinical variables. Linear support vector machine classifier was used to evaluate the diagnostic capabilities of TCF4 and RBFOX1.

RESULTS

Serum TCF4 and RBFOX1 levels were substantially higher in MDD patients than in HCs and significantly lower in drug-treated MDD patients than in drug-naïve MDD patients. Moreover, serum TCF4 and RBFOX1 levels were associated with the Hamilton Depression Scale score, duration of illness, serum lipids levels, and hepatic function. Thus, both these molecules showed potential as biomarkers for MDD. TCF4 and RBFOX1 combination exhibited a higher diagnostic performance, with the mean area under the curve values of 0.9861 and 0.9936 in the training and testing sets, respectively.

LIMITATIONS

Small sample size and investigation of only the peripheral nervous system.

CONCLUSIONS

TCF4 and RBFOX1 may be involved in the pathogenesis of MDD, and their combination may serve as a diagnostic biomarker panel for MDD.

Screening of Geriatric Depression in Makkah, Saudi Arabia: A Pilot Study

OBJECTIVE

There is currently limited evidence about the prevalence of depression among elderly people residing in Makkah, Saudi Arabia. This study aims to report the magnitude of depression among the older population in Makkah, Saudi Arabia, and the related risk factors.

METHODS

An online cross-sectional pilot survey was carried out in Makkah City, Saudi Arabia. Data were collected using an online self-administered questionnaire.

RESULTS

The study questionnaire was completed by 191 older people. The participants' ages varied from 60 to 88 years. 55.5% were women, 47.9% were married, and 21.5% were divorced/widowed. 46.6% had hypertension, 42.4% had diabetes, 17.3% had hypothyroidism, 7.9% had cardiovascular diseases (CVDs), and 6.3% reported psychiatric problems. 44.5% of the subjects had no depression, 23.5% had mild, 15.2% had moderate, and 16.8% had severe depression. The sample included 32% who had been classified as having major depression. Elderly participants with insomnia, cognitive diseases, and chronic diseases showed a high risk for experiencing severe depression (OR=2.74; 95% CI: 1.42-5.28),(OR=2.63; 95% CI: 1.29-5.40), and (OR=2.62; 95% CI: 1.11-6.14) respectively.

CONCLUSION

Depression was common among the elderly population in Makkah, particularly among those with a documented history of insomnia, cognitive diseases, and chronic diseases. Depression screening and treatment for old people in medical settings is recommended.

Endocrinological Treatment Targets for Depressive Disorder

Depressive disorder exhibits heterogeneity in clinical presentation, progression, and treatment outcomes. While conventional antidepressants based on the monoamine hypothesis benefit many patients, a significant proportion remains unresponsive or fails to fully recover. An individualized integrative treatment approach, considering diverse pathophysiologies, holds promise for these individuals. The endocrine system, governing physiological regulation and organ homeostasis, plays a pivotal role in central nervous system functions. Dysregulations in endocrine system are major cause of depressive disorder due to other medical conditions. Subtle endocrine abnormalities, such as subclinical hypothyroidism, are associated with depression. Conversely, depressive disorder correlates with endocrine-related biomarkers. Fluctuations in sex hormone levels related to female reproduction, elevate depression risk in susceptible subjects. Consequently, extensive research has explored treatment strategies involving the endocrine system. Treatment guidelines recommend tri-iodothyronine augmentation for resistant depression, while allopregnanolone analogs have gained approval for postpartum depression, with ongoing investigations for broader depressive disorders. This book chapter will introduce the relationship between the endocrine system and depressive disorders, presenting clinical findings on neuroendocrinological treatments for depression.

Prevalence of Mental Disorders Among Patients with Multimorbidity Visiting Primary Care Settings in Slums of Karachi, Pakistan

BACKGROUND

Anxiety and depression often exacerbate multimorbidity conditions, leading to increased disability rates among affected individuals.

OBJECTIVE

The study aimed to assess the mental health status of individuals with multimorbidity belonging to the marginalized population of Karachi, Pakistan. Specifically, the prevalence of anxiety and depression was investigated.

METHODS

A multicenter cross-sectional study was conducted between July 2022 and June 2023 in 10 primary healthcare clinics located in 4 peri-urban areas of Karachi. A total of 9331 participants were included in the study. The Patient Health Questionnaire 4 (PHQ-4), Generalized Anxiety Disorder 7 (GAD-7), and Patient Health Questionnaire 9 (PHQ-9) were used to assess symptoms of anxiety and depression. The data collected were analyzed using the statistical analysis system (SAS) version 9.4.

RESULTS

Among the study participants, 2894 (31%) were men and 5534 (59.3%) were women. The prevalence of moderate to severe anxiety was 31% among men and 59.3% among women. The age group between 41 and 60 years exhibited the highest rates of moderate to severe anxiety, 19.3% as evaluated by GAD-7 and 34.6% by PHQ-9. The Pathan ethnic group had the highest prevalence of anxiety (11%) and depression (28.3%) in the neighborhoods. Unemployed participants showed moderate to severe anxiety in 21.3% of the cases and moderate to severe depression in 25.5% of the cases.

CONCLUSION

The study revealed a significant cooccurrence of anxiety and depression among individuals with multimorbidity in the marginalized population of Karachi, Pakistan. Furthermore, the presence of anxiety symptoms in multimorbidity patients with depression indicates a more unfavorable health state. It is essential to explore the implementation of screening measures and therapeutic interventions for comorbid anxiety and depression in this population to improve clinical outcomes.

Association between ambient air pollution and thyroid hormones levels: A systematic review and meta-analysis

BACKGROUND

Growing studies have focused on the effects of ambient air pollution on thyroid hormones (THs), but the results were controversial. Therefore, a systematic review and meta-analysis was conducted by pooling current evidence on this association.

METHODS

Four databases were searched for studies examining the associations of particulate matter [diameter ≤10 μm (PM10) or ≤2.5 μm (PM2.5)] and gaseous [sulfur dioxide (SO2), nitrogen dioxide (NO2), ozone (O3), carbon monoxide (CO)] pollutants with THs levels. Random effects models were used to pool the changes in THs levels with increasing air pollutant concentrations. Subgroup analyses were constructed by region, design, sample size, pollutant concentrations, evaluated methods, and potential risk exposure windows.

RESULTS

A total of 14 studies covering 357,226 participants were included in this meta-analysis. The pooled results showed significant associations of exposure to PM2.5, PM10, NO2, SO2, and CO with decreases in free thyroxine (FT4) with percent changes (PC) ranging from -0.593 % to -3.925 %. PM2.5, NO2, and CO were negatively associated with levels of FT4/FT3 (PC: from -0.604 % to -2.975 %). In addition, results showed significant associations of PM2.5 with hypothyroxinemia and high thyroid-stimulating hormone (TSH). Subgroup analyses indicated that PM2.5 and NO2 were significantly associated with FT4 in studies of Chinese, and similar significant findings were found in studies of PM2.5 and FT4/FT3 in areas with higher concentrations of air pollutants and larger samples. PM2.5 exposure in the first trimester was found to be associated with lower FT4 levels in pregnant women.

CONCLUSION

Our findings suggest that exposure to air pollution is associated with changes in THs levels. Enhanced management of highly polluted areas, identification of harmful components and sources of PM, and protection from harmful exposures in early pregnancy may be of great public health importance for the population's thyroid function.

National trends and resource associated with recurrent penetrating injury

BACKGROUND

While recurrent penetrating trauma has been associated with long-term mortality and disability, national data on factors associated with reinjury remain limited. We examined temporal trends, patient characteristics, and resource utilization associated with repeat firearm-related or stab injuries across the US.

METHODS

This was a retrospective study using 2010-2019 Nationwide Readmissions Database (NRD). NRD was queried to identify all hospitalizations for penetrating trauma. Recurrent penetrating injury (RPI) was defined as those returned for a subsequent penetrating injury within 60 days. We quantified injury severity using the International Classification of Diseases Trauma Mortality Prediction model. Trends in RPI, length of stay (LOS), hospitalization costs, and rate of non-home discharge were then analyzed. Multivariable regression models were developed to assess the association of RPI with outcomes of interest.

RESULTS

Of an estimated 968,717 patients (28.4% Gunshot, 71.6% Stab), 2.1% experienced RPI within 60 days of the initial injury. From 2010 to 2019, recurrent gunshot wounds increased in annual incidence while that of stab cohort remained stable. Patients experiencing recurrent gunshot wounds were more often male (88.9 vs 87.0%, P<0.001), younger (30 [23-40] vs 32 [24-44] years, P<0.001), and less commonly insured by Medicare (6.5 vs 11.2%, P<0.001) compared to others. Those with recurrent stab wounds were younger (36 [27-49] vs 44 [30-57] years, P<0.001), less commonly insured by Medicare (21.3 vs 29.3%, P<0.001), and had lower Elixhauser Index Comorbidities score (2 [1-3] vs 3 [1-4], P<0.001) compared to others. After risk adjustment, RPI of both gunshot and stab was associated with significantly higher hospitalization costs, a shorter time before readmission, and increased odds of non-home discharge.

CONCLUSION

The trend in RPI has been on the rise for the past decade. National efforts to improve post-discharge prevention and social support services for patients with penetrating trauma are warranted and may reduce the burden of RPI.

Depression and atrial fibrillation in a reciprocal liaison: a neuro-cardiac link

OBJECTIVE

To explore the reciprocal relationship of depression and atrial fibrillation (AF).

METHODS

A literature search was conducted in Pub Med, Scopus, and Google Scholar using relevant terms for depression and AF and respective therapies.

RESULTS

There is evidence that depression is involved in the aetiology and prognosis of AF. AF, independently of its type, incurs a risk of depression in 20-40% of patients. Also, depression significantly increases cumulative incidence of AF (from 1.92% to 4.44% at 10 years); 25% increased risk of new-onset AF is reported in patients with depression, reaching 32% in recurrent depression. Hence, emphasis is put on the importance of assessing depression in the evaluation of AF and vice versa. Persistent vs paroxysmal AF patients may suffer from more severe depression. Furthermore, depression can impact the effectiveness of AF treatments, including pharmacotherapy, anticoagulation, cardioversion and catheter ablation.

CONCLUSIONS

A reciprocal association of depression and AF, a neurocardiac link, has been suggested. Thus, strategies which can reduce depression may improve AF patients' course and treatment outcomes. Also, AF has a significant impact on risk of depression and quality of life. Hence, effective antiarrhythmic therapies may alleviate patients' depressive symptoms. KEY POINTSAF, independently of its type of paroxysmal, permanent or chronic, appears to have mental besides physical consequences, including depression and anxietyA reciprocal influence or bidirectional association of depression and AF, a neurocardiac link, has been suggestedAF has considerable impact on the risk of depression occurrence with 20-40% of patients with AF found to have high levels of depressionAlso, depression significantly increases 10-year cumulative incidence and risk of AF from 1.92% to 4.44% in people without depression, and the risk of new-onset AF by 25-32%Emphasis should be placed on the importance of assessing depression in the evaluation of AF and vice versaPersistent/chronic AF patients may suffer from more severe depressed mood than paroxysmal AF patients with similar symptom burdenDepression and anxiety can impact the effectiveness of certain AF treatments, including pharmacotherapy, anticoagulation treatment, cardioversion and catheter ablationThus, strategies which can reduce anxiety and depression may improve AF patients' course and treatment outcomesAlso, effective antiarrhythmic therapies to control AF may alleviate patients' depressive mood.

Prevalence and correlates of suicide attempts in young patients with first-episode and drug-naïve major depressive disorder: A large cross-sectional study

BACKGROUND

Few studies in China have reported factors influencing suicide attempt in young first-episode drug-free (FEDN) MDD patients. This study aimed to investigate the incidence and potential relevant factors of suicide attempt among young Chinese patients with FEDN MDD to prevent suicidal behavior in this population.

METHODS

We recruited 1076 FEDN MDD outpatients aged 18-45 years. Patients' mental states were measured by the Hamilton Anxiety Scale (HAMA), Hamilton Depression Scale (HAMD), Positive and Negative Syndrome Scale (PANSS) positive subscale, and Clinical Global Impression Severity Scale (CGIS). Fasting blood glucose, lipid levels, and thyroid function parameters were also measured.

RESULTS

The prevalence of suicide attempt for FEDN MDD patients was 18.31 %. Compared to patients without suicide attempt, patients with suicide attempt had an older age of onset, higher HAMA, HAMD, PANSS-positive subscale and CGI-S scores, higher blood pressure, fasting blood glucose, thyroid peroxidases antibody (A-TPO), anti-thyroglobulin (A-TG), thyroid stimulating hormone (TSH), low-density lipoprotein cholesterol (LDL-C), and total cholesterol (TC), but lower high-density lipoprotein cholesterol (HDLC) (all p < 0.05). Logistic regression analysis showed that duration of illness, hypertension, PANSS-positive subscale, HAMA and CGI-S scores, and A-TPO, LDL-C, TC, and HDL-C were associated with suicide attempt in patients with MDD.

LIMITATIONS

The main limitations are cross-sectional design and inability to control selection bias.

CONCLUSIONS

This study suggests that young patients with FEDN MDD have a high rate of suicide attempts. Several clinical and metabolic indicators related to lipids and thyroid function may be involved in suicide attempts in FEDN MDD patients.

Thyroid Predictors of Postpartum Mood Disorders

Postpartum mood disorders (PMD) are currently among the leading causes of maternal postpartum morbidity and mortality. PMD include the conditions of postpartum blues (PB), postpartum depression (PPD), and postpartum psychosis. The pathogenesis of PMDs are ambiguous, and there are no reliable prenatal predictive markers despite current research efforts. Even though reliable indicators have not been found, leading ideas suggest an etiology of hormonal fluctuations. Although thyroid markers have long been linked to psychiatric disorders such as major depressive disorder (MDD), how they correlate with PMDs is still unclear. This study aimed to evaluate the pathophysiological link between thyroid function, PMDs, and the usefulness of thyroid markers as indicators of their occurrence and severity. The methodology consisted of a narrative literature review. Several inclusion and exclusion criteria were used to filter the results of literature searches in PubMed. Studies were included if they discussed any marker related to thyroid endocrinology in relation to the incidence or pathophysiology of any PMD. Both primary and secondary analyses were included. The permissive inclusion criteria were used due to the relative scarcity of research on the topic and the ambiguous pathophysiology of PMD. The results demonstrated the potential utility of thyroid autoimmunity as a predictor of late-onset PPD. Hypothyroidism, low euthyroid hormone levels, and the presence of thyroid autoantibodies were correlated with increased incidence of PPD and late postpartum depressive symptoms, past the timeline of PB. Most notably a rapid postpartum drop in cortisol level may precipitate thyroid autoimmunity in anti-thyroid peroxidase (TPO) antibody positive women, which could eventually produce a hypothyroid phase associated with depressive symptoms. There was insufficient evidence to suggest a relationship with postpartum psychosis. In conclusion, the exact pathophysiological mechanisms of PMDs remain ambiguous, but TPO-antibodies in the third trimester may be a predictor of late PPD.

Insights Into the Association Between Myasthenia Gravis and Depression: A Clinical Case Study

Myasthenia gravis (MG) is a serious and debilitating autoimmune disease characterized by muscle weakness, shortness of breath, and issues affecting the eyes, limbs, throat, and speech. Given the intense physical toll of the disease, it is unsurprising that higher rates of depression are observed among MG patients. We present a case involving a 30-year-old female patient who was admitted to the hospital for MG exacerbation and had a psychiatric consultation for worsening depression symptoms. The patient acknowledged symptoms of sad mood, crying spells, anhedonia, fatigue, insomnia, and inappropriate guilt. She admits to psychosocial stressors of her declining health, recent job loss, and low self-esteem due to weight gain. Past medical history includes a thymectomy and a total thyroidectomy that caused postsurgical-acquired hypothyroidism. She is currently on prednisone and pyridostigmine for her MG. The patient has many potential causes of her increased depressive symptoms, including her medications, psychosocial stressors, and her past medical history, in addition to her MG. However, the literature shows higher incidence rates of depression in MG patients compared to both healthy controls and controls with other comparable chronic conditions, as well as shows a positive association between increased depressive symptoms and MG severity. Thus, these findings prompt the consideration of possible physiological interplay between the two diseases and encourage further research into the association between MG and depression.

Association of Low-Normal Free T4 Levels With Future Major Depression Development

Context

Hyperthyroidism and overt and subclinical hypothyroidism are associated with major depression; however, the association of major depression across the spectrum of thyroid function within the normal range is unknown.

Objective

We investigated whether higher or lower levels of free thyroxine (T4) and thyrotropin (TSH) within the normal range are associated with major depression.

Methods

This was a retrospective cohort study of 66 960 participants with normal thyroid function who visited for health checkups (St. Luke's International Hospital, 2005-2018). The primary outcome was the development of major depression during the follow-up period. Participants were divided into 3 equal groups based on baseline free T4 or TSH values (low-, middle-, or high-normal), and the incidence of major depression was compared using the Cox proportional hazard model after adjusting for potential covariates.

Results

During the median follow-up of 1883 days, 1363 (2.0%) patients developed major depression. The low-normal free T4 group had a significantly higher risk of major depression (adjusted HR 1.15; 95% CI, 1.01-1.31), but not the high-normal free T4 group or TSH groups. The association between low-normal free T4 and the development of major depression was maintained, rather more obvious, upon exclusion of participants whose thyroid hormone levels became abnormal during follow-up compared with data from all participants (adjusted HR 1.24; 95% CI, 1.07-1.43).

Conclusion

In this cohort, low-normal free T4 was associated with an increased risk of future major depression, even if subsequent hormone levels were maintained within the normal range. The magnitude of the impact of low-normal free T4 was relatively mild.

Levothyroxine Monotherapy: What Works Better for the Individual With Hypothyroidism?

OBJECTIVE

I explore objective data not supporting the addition of liothyronine (medication) (LT3) to levothyroxine (medication) (LT4) in patients with hypothyroidism. Accurate identification of patients with symptomatic (almost exclusively overt) hypothyroidism is important in evaluating clinical outcomes of therapies. Recent studies have documented that nearly a third of individuals who are offered thyroid hormone are euthyroid at the time of initiation. Additionally, others are clinically diagnosed without biochemical confirmation, so a sizable proportion of those started on LT4 are not hypothyroid. The assumption that nonhypothyroid symptoms will resolve with LT4 is problematic. The true underlying cause of these symptoms remains unidentified and untreated.

METHODS

In a narrative fashion I will review the positive predictive value of and correlation of symptoms consistent with hypothyroidism and confirmed hypothyroidism likely to favorably respond to thyroid hormone replacement.

RESULTS

Following a review of the reliability of thyroid-stimulating hormone (TSH) in predicting a euthyroid state, the correlation of circulating triiodothyronine (serum measurement) (T3) levels with symptoms and predictive value of T3 to forecast the outcome of adding LT3 to LT4 will be reviewed. The utility of striving for high, middle, or low TSH set points within the expected range to predict changes in clinical quality of life and the ability of blinded patients to sense subtle differences along this spectrum will be documented. In addition, the clinical impact of single nucleotide polymorphisms in the type 2 deiodinase gene will be reviewed. Finally, the overall satisfaction of selected patients with their thyroid hormone treatments will be outlined and preferences for T3-containing treatments from blinded studies will be summarized.

CONCLUSION

Basing thyroid hormone treatment decisions on patient symptoms likely results in missed diagnoses We should encourage primary care physicians to assess a differential diagnosis, exclude other diagnoses, and not assume a thyroid etiology when TSH is normal. Modifying treatment to a particular TSH target or adjusting based on a low T3 level does not seem to enhance patient outcomes. Finally, pending further trials of "symptomatic" participants, using sustained release LT3 to mimic normal physiology, and including monocarboxylate 10 transporter and Type 2 deiodinase polymorphisms and objective outcomes, I will continue to depend on therapy with LT4 monotherapy and seek alternative explanations for my patients' nonspecific symptoms.

Subclinical hypothyroidism, outcomes and management guidelines: a narrative review and update of recent literature

Subclinical hypothyroidism (SCH) is diagnosed when serum thyroid stimulation hormone (thyrotropin; TSH) levels are above the reference range, accompanied by levels of free thyroxine within its reference range. The management of SCH remains a diagnostic and therapeutic challenge despite many years of research relating to its epidemiology, aetiology, effectiveness of treatment and safety. European Thyroid Association (ETA) guidelines for the management of SCH were published almost a decade ago. This narrative review summarizes the clinical literature relating to SCH and outcomes since the publication of these guidelines. Clinical evidence emerging during the previous decade generally supports the view that SCH is associated with adverse outcomes to an extent that is intermediate between euthyroidism and overt hypothyroidism although evidence that treatment with thyroid hormone replacement is beneficial is lacking. Accordingly, the rationale for the recommendations for intervention in the ETA guidelines based on the age of the patient, level of serum TSH, symptoms and comorbidities remains valid today.

Exploring the Genetic Link Between Thyroid Dysfunction and Common Psychiatric Disorders: A Specific Hormonal or a General Autoimmune Comorbidity

Background: The hypothalamus-pituitary-thyroid axis coordinates brain development and postdevelopmental function. Thyroid hormone (TH) variations, even within the normal range, have been associated with the risk of developing common psychiatric disorders, although the underlying mechanisms remain poorly understood. Methods: To get new insight into the potentially shared mechanisms underlying thyroid dysfunction and psychiatric disorders, we performed a comprehensive analysis of multiple phenotypic and genotypic databases. We investigated the relationship of thyroid disorders with depression, bipolar disorder (BIP), and anxiety disorders (ANXs) in 497,726 subjects from U.K. Biobank. We subsequently investigated genetic correlations between thyroid disorders, thyrotropin (TSH), and free thyroxine (fT4) levels, with the genome-wide factors that predispose to psychiatric disorders. Finally, the observed global genetic correlations were furthermore pinpointed to specific local genomic regions. Results: Hypothyroidism was positively associated with an increased risk of major depressive disorder (MDD; OR = 1.31, p = 5.29 × 10-89), BIP (OR = 1.55, p = 0.0038), and ANX (OR = 1.16, p = 6.22 × 10-8). Hyperthyroidism was associated with MDD (OR = 1.11, p = 0.0034) and ANX (OR = 1.34, p = 5.99 × 10-⁶). Genetically, strong coheritability was observed between thyroid disease and both major depressive (rg = 0.17, p = 2.7 × 10-⁴) and ANXs (rg = 0.17, p = 6.7 × 10-⁶). This genetic correlation was particularly strong at the major histocompatibility complex locus on chromosome 6 (p < 10-⁵), but further analysis showed that other parts of the genome also contributed to this global effect. Importantly, neither TSH nor fT4 levels were genetically correlated with mood disorders. Conclusions: Our findings highlight an underlying association between autoimmune hypothyroidism and mood disorders, which is not mediated through THs and in which autoimmunity plays a prominent role. While these findings could shed new light on the potential ineffectiveness of treating (minor) variations in thyroid function in psychiatric disorders, further research is needed to identify the exact underlying molecular mechanisms.

Clinical symptoms, thyroid dysfunction, and metabolic disturbances in first-episode drug-naïve major depressive disorder patients with suicide attempts: A network perspective

BACKGROUNDS

Co-occurrence of thyroid dysfunction, metabolic disturbances, and worsening clinical symptoms in major depressive disorder (MDD) patients with suicidal attempts (SA) are common. However, their relationship in SA patients remains unexplored. We aimed to (1) determine the independent association of thyroid dysfunction, clinical symptoms, and metabolic disturbances with SA; and (2) identify their interactions in SA patients via the network approach.

METHODS

1718 FEDN MDD patients were recruited. Depressive, anxiety, and psychotic symptoms were assessed by the Hamilton Rating Scale for Depression (HAMD), the Hamilton Rating Scale for Anxiety (HAMA), and the Positive and Negative Syndrome Subscale positive subscale, respectively. The serum levels of thyroid hormones and other metabolic parameters were assessed. Logistic regression model was applied to determine the correlates of SA. Network analysis was applied to determine the interaction between thyroid dysfunction, clinical symptoms, and metabolic disturbances.

RESULTS

SA patients had significant worse metabolic disturbances, thyroid dysfunction, and clinical symptoms than non-SA patients. Thyroid peroxidases antibody, thyroid stimulating hormone (TSH), HAMD scores, HAMA scores, and systolic blood pressure was independently associated with SA. Network analysis suggested that TSH was the hub of the network, exhibiting substantial associations with metabolic disturbances, anxiety, and psychotic symptoms in SA patients.

CONCLUSIONS

Our work highlights the predominant role of serum TSH levels in the pathophysiology of SA. Regular thyroid function tests might help early detect SA. Targeting increased TSH levels may help reduce metabolic disturbances and clinical symptoms in SA patients.

Association of thyroid function with abnormal lipid metabolism in young patients with first-episode and drug naïve major depressive disorder

INTRODUCTION

Abnormal lipid metabolism in patients with major depressive disorder (MDD) has received increasing attention. The coexistence of MDD and abnormal thyroid function has been intensively studied. Moreover, thyroid function is closely related to lipid metabolism. The aim of this study was to investigate the relationship between thyroid function and abnormal lipid metabolism in young patients with first-episode and drug naïve (FEDN) MDD.

METHODS

A total of 1,251 outpatients aged 18-44 years with FEDN MDD were enrolled. Demographic data were collected, and lipid and thyroid function levels were measured, including total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), thyroid stimulating hormone (TSH), free triiodothyronine (FT3), free tetraiodothyronine (FT4), anti-thyroglobulin antibody (TG-Ab), and anti-thyroid peroxidase antibody (TPO-Ab). The Hamilton Rating Scale for Depression (HAMD), Hamilton Anxiety Rating Scale (HAMA), and Positive and Negative Syndrome Scale (PANSS) positive subscale were also assessed for each patient.

RESULTS

Compared with young MDD patients without comorbid lipid metabolism abnormalities, patients with comorbid lipid metabolism abnormalities had higher body mass index (BMI) values, HAMD score, HAMA score, PANSS positive subscale score, TSH levels, TG-Ab levels, and TPO-Ab levels. Binary logistic regression analysis showed that TSH level, HAMD score and BMI were risk factors for abnormal lipid metabolism. TSH levels were an independent risk factor for abnormal lipid metabolism in young MDD patients. Stepwise multiple linear regression showed that both TC and LDL-C levels were positively correlated with TSH levels, HAMD and PANSS positive subscale scores, respectively. HDL-C levels were negatively correlated with TSH levels. TG levels were positively correlated with TSH and TG-Ab levels and HAMD score.

DISCUSSION

Our results show that thyroid function parameters, especially TSH levels, are implicated in abnormal lipid metabolism in young patients with FEDN MDD.

From hormone replacement therapy to regenerative scaffolds: A review of current and novel primary hypothyroidism therapeutics

Primary hypothyroidism severely impacts the quality of life of patients through a decrease in the production of the thyroid hormones T3 and T4, leading to symptoms affecting cardiovascular, neurological, cognitive, and metabolic function. The incidence rate of primary hypothyroidism is expected to increase in the near future, partially due to increasing survival of patients that have undergone radiotherapy for head and neck cancer, which induces this disease in over half of those treated. The current standard of care encompasses thyroid hormone replacement therapy, traditionally in the form of synthetic T4. However, there is mounting evidence that this is unable to restore thyroid hormone signaling in all tissues due to often persistent symptoms. Additional complications are also present in the form of dosage difficulties, extensive drug interactions and poor patience compliance. The alternative therapeutic approach employed in the past is combination therapy, which consists of administration of both T3 and T4, either synthetic or in the form of desiccated thyroid extract. Here, issues are present regarding the lack of regulation concerning formulation and lack of data regarding safety and efficacy of these treatment methods. Tissue engineering and regenerative medicine have been applied in conjunction with each other to restore function of various tissues. Recently, these techniques have been adapted for thyroid tissue, primarily through the fabrication of regenerative scaffolds. Those currently under investigation are composed of either biopolymers or native decellularized extracellular matrix (dECM) in conjunction with either primary thyrocytes or stem cells which have undergone directed thyroid differentiation. Multiple of these scaffolds have successfully restored an athyroid phenotype in vivo. However, further work is needed until clinical translation can be achieved. This is proposed in the form of exploration and combination of materials used to fabricate these scaffolds, the addition of peptides which can aid restoration of tissue homeostasis and additional in vivo experimentation providing data on safety and efficacy of these implants.

Subclinical Hypothyroidism and Incident Depression in Adolescents and Young Adults: Results from a Nationwide Representative Prospective Study

Background: Although the relationship between subclinical hypothyroidism and major depressive disorder (MDD) has been studied in adults in cross-sectional and prospective population-based studies, this has not yet been done in adolescents. However, since thyroid function and MDD risk are subjected to maturational processes and ramifications of illness duration over the life span, these findings may not readily transfer to adolescents. Methods: The relationship between subclinical hypothyroidism and MDD was studied in a representative subsample of the nationwide KIGGS ("The German Health Interview and Examination Survey for Children and Adolescents") survey. A total of 4118 adolescents were examined over a median period of 6 years, and data were analyzed by a logistic regression approach accounting for important covariates related to thyroid function and/or MDD risk. The same approach was chosen to investigate the relationship between quartiles of thyrotropin (TSH) and free thyroxine (fT4) levels and incident MDD in euthyroid participants to broaden the focus on the relationship between thyroid hormone levels and MDD in a dose-response manner. Results: During the observation period, 121 cases of MDD were reported. There was no association between subclinical hypothyroidism and MDD when comparing 111 adolescents with subclinical hypothyroidism with 4007 euthyroid adolescents, representative of ∼106,000 and 3,610,000 adolescents from the general pediatric population, respectively. This also applied when studying the relationship between quartiles of TSH and fT4 levels and MDD in euthyroid participants. All results were confirmed by sensitivity analyses accounting for thyroid autoimmunity. Conclusions: Consistent with findings in adults, there is no association between subclinical hypothyroidism or quartiles of TSH and fT4 levels in the normal range and MDD in adolescents, despite potential age-related differences regarding thyroid function and MDD risk.

Pathophysiology and Management Possibilities of Thyroid-Associated Depression

Thyroid hormones and the hypothalamic-pituitary-thyroid (HPA) axis are responsible for multiple metabolic processes and psychological well-being. Hypothyroidism can induce mood changes, depressive symptoms and even major depressive disorder. This review is focused on the pathophysiology and mechanisms through which the low level of thyroid hormones may affect the brain function, causing the characteristic symptoms of depression. Key pathways of hypothyroid-associated depressive states include: morphological changes in some brain areas (mainly in the hippocampus – a reduction in its volume); a significant reduction of the cerebral blood flow (incl. hippocampus), and lowered levels of neurotrophic factors (e. g. BDNF – brain-derived neurotrophic factor), which are regulated by the thyroid hormones. An adequate and timely thyroid hormone replacement and treatment with conventional antidepressants often can reverse the psychological symptoms.

Hyperthyroidism and clinical depression: a systematic review and meta-analysis

Hyperthyroidism and clinical depression are common, and there is preliminary evidence of substantial comorbidity. The extent of the association in the general population, however, has not yet been estimated meta-analytically. Therefore we conducted this systematic review and meta-analysis (registered in PROSPERO: CRD42020164791). Until May 2020, Medline (via PubMed), PsycINFO, and Embase databases were systematically searched for studies on the association of hyperthyroidism and clinical depression, without language or date restrictions. Two reviewers independently selected epidemiological studies providing laboratory or ICD-based diagnoses of hyperthyroidism and diagnoses of depression according to operationalized criteria (e.g. DSM) or to cut-offs in established rating scales. All data, including study quality based on the Newcastle-Ottawa Scale, were independently extracted by two authors. Odds ratios for the association of clinical depression and hyperthyroidism were calculated in a DerSimonian-Laird random-effects meta-analysis. Out of 3372 papers screened we selected 15 studies on 239 608 subjects, with 61% women and a mean age of 50. Relative to euthyroid individuals, patients with hyperthyroidism had a higher chance of being diagnosed with clinical depression: OR 1.67 ([95% CI: 1.49; 1.87], I²: 6%; prediction interval: 1.40 to 1.99), a result supported in a number of sensitivity and subgroup analyses. The OR was slightly less pronounced for subclinical as opposed to overt hyperthyroidism (1.36 [1.06; 1.74] vs. 1.70 [1.49; 1.93]). This comorbidity calls for clinical awareness and its reasons need investigation and may include neurobiological mechanisms, common genetic vulnerability and a generally heightened risk for clinical depression in patients with chronic somatic disorders.

COVID-19 and Thyroid Function: A Bi-Directional Two-Sample Mendelian Randomization Study

Background: Thyroid dysfunction has been observed among some patients with coronavirus disease (COVID-19). It is unclear whether severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (or its severity) leads to the development of thyroid dysfunction, or vice versa. In this study, we examined the bi-directional causal relationship between host genetic liability to three COVID-19 phenotypes (including SARS-CoV-2 infection, hospitalized and severe COVID-19) and three thyroid dysfunction traits (including hyperthyroidism, hypothyroidism, and autoimmune thyroid disease [AITD]) and three continuous traits of thyroid hormones (including thyrotropin [TSH] and free thyroxine [fT4] within reference range, and TSH in full range). Methods: Summary statistics from the largest available meta-analyses of human genome-wide association studies were retrieved for the following variables: SARS-CoV-2 infection (n = 1,348,701), COVID-19 hospitalization (n = 1,557,411), severe COVID-19 (n = 1,059,456), hyperthyroidism (n = 51,823), hypothyroidism (n = 53,423), AITD (n = 755,406), TSH within reference range (n = 54,288), fT4 within reference range (n = 49,269), and TSH in full range (n = 119,715). Using a two-sample Mendelian randomization (MR) approach, the inverse-variance weighted (IVW) method was adopted as the main MR analysis. Weighted median, contamination mixture, MR-Egger, and MR pleiotropy residual sum and outlier (MR-PRESSO) methods were applied as sensitivity analyses. Results: Host genetic susceptibility to SARS-CoV-2 infection was causally associated with hypothyroidism in the main IVW analysis (per doubling in prevalence of SARS-CoV-2 infection, odds ratio [OR] = 1.335; 95% confidence interval [CI]: 1.167-1.526; p = 2.4 × 10^-5, surpassing the Bonferroni multiple-testing threshold). Similar causal estimates were observed in the sensitivity analyses (weighted median: OR = 1.296; CI: 1.066-1.575; p = 9 × 10^-3; contamination mixture: OR = 1.356; CI: 1.095-1.818; p = 0.013; MR-Egger: OR = 1.712; CI: 1.202-2.439; p = 2.92 × 10^-3, and MR-PRESSO: OR = 1.335; CI: 1.156-1.542; p = 5.73 × 10^-4). Host genetic liability to hospitalized or severe COVID-19 was not associated with thyroid dysfunction or thyroid hormone levels. In the reverse direction, there was no evidence to suggest that genetic predisposition to thyroid dysfunction or genetically determined thyroid hormone levels altered the risk of the COVID-19 outcomes. Conclusions: This bi-directional MR study supports that host response to SARS-CoV-2 viral infection plays a role in the causal association with increased risk of hypothyroidism. Long-term follow-up studies are needed to confirm the expected increased hypothyroidism risk.

The prevalence and clinical correlates of suicide attempts in comorbid subclinical hypothyroidism in patients with never-treated major depressive disorder in China

BACKGROUND

Previous studies have emphasized the possible association between subclinical hypothyroidism (SCH) and major depressive disorder (MDD). This study aimed to further investigate suicide attempts and their clinical correlates in MDD patients with comorbid SCH.

METHODS

This cross-sectional study recruited 1706 eligible MDD outpatients. The Hamilton Depression Rating Scale (HAMD), Hamilton Anxiety Rating Scale (HAMA), Positive and Negative Syndrome Scale (PANSS) and Clinical Global Impression of Severity Scale (CGI-S) were applied to evaluate mental status. Fasting blood samples were collected to examine thyroid function. SCH was defined as thyroid stimulating hormone (TSH) > 8 mIU/L with normal free thyroxine levels.

RESULTS

The prevalence of suicide attempts in the SCH group (51.7 %) was significantly higher than that in the non-SCH group (15.4 %; p < 0.001). Logistic regression showed that patients with comorbid SCH were 1.81 times more likely to have attempted suicide as compared with those without (p = 0.001). Among those with TSH > 8 mIU/L, patients with severe anxiety were 3.57 times more likely to attempt suicide compared with those without (p < 0.01). Logistic regression also showed that the CGI-S score (p < 0.001) was independently associated with suicide attempts, while TSH level was not.

CONCLUSIONS

SCH comorbidity may pose a specific hazard in MDD patients due to increased suicide attempts. Exhibiting severe anxiety, overall severity of depressive and psychotic symptoms, but not TSH levels, may be independently correlated with suicide attempts in MDD patients with TSH > 8 mIU/L.

Using the Biopsychosocial Approach to Identify Factors Associated with Major Depressive Disorder for Individuals with Hypothyroidism

Previous research has found that major depressive disorder (MDD) commonly occurs in hypothyroid populations. The purpose of this study was to use the biopsychosocial model to investigate factors associated with MDD and hypothyroidism by comparing hypothyroid patients with MDD and without MDD. A sample of 386 participants with hypothyroidism completed both cognitive and psychosocial self-reported assessments along with a questionnaire rating the severity of common hypothyroid symptoms. Participants were divided into two groups (MDD and no MDD) using the diagnostic criteria of the Patient Health Questionnaire. Univariate comparisons were used to assess differences in the severity of physical, psychological, and social correlates in participants with and without MDD. Participants with MDD reported significantly worse symptom severity, increased stress, and disruptions of cognitive functioning. Compared to individuals without MDD, they also indicated poorer quality of life, doctor-patient relationships, and treatment adherence. Individuals with comorbid depression and hypothyroidism reported worse outcomes across physical symptoms, social factors, and psychological and cognitive states than individuals without MDD. Integrating depression screeners and independent treatment for MDD, in addition to the patient's hypothyroid treatment plan, may result in hypothyroid symptom relief and greater quality of life.

Mining comorbidities of opioid use disorder from FDA adverse event reporting system and patient electronic health records

BACKGROUND

Opioid use disorder (OUD) has become an urgent health problem. People with OUD often experience comorbid medical conditions. Systematical approaches to identifying co-occurring conditions of OUD can facilitate a deeper understanding of OUD mechanisms and drug discovery. This study presents an integrated approach combining data mining, network construction and ranking, and hypothesis-driven case-control studies using patient electronic health records (EHRs).

METHODS

First, we mined comorbidities from the US Food and Drug Administration Adverse Event Reporting System (FAERS) of 12 million unique case reports using frequent pattern-growth algorithm. The performance of OUD comorbidity mining was measured by precision and recall using manually curated known OUD comorbidities. We then constructed a disease comorbidity network using mined association rules and further prioritized OUD comorbidities. Last, novel OUD comorbidities were independently tested using EHRs of 75 million unique patients.

RESULTS

The OUD comorbidities from association rules mining achieves a precision of 38.7% and a recall of 78.2 Based on the mined rules, the global DCN was constructed with 1916 nodes and 32,175 edges. The network-based OUD ranking result shows that 43 of 55 known OUD comorbidities were in the first decile with a precision of 78.2%. Hypothyroidism and type 2 diabetes were two top-ranked novel OUD comorbidities identified by data mining and network ranking algorithms. Based on EHR-based case-control studies, we showed that patients with OUD had significantly increased risk for hyperthyroidism (AOR = 1.46, 95% CI 1.43-1.49, p value < 0.001), hypothyroidism (AOR = 1.45, 95% CI 1.42-1.48, p value < 0.001), type 2-diabetes (AOR = 1.28, 95% CI 1.26-1.29, p value < 0.001), compared with individuals without OUD.

CONCLUSION

Our study developed an integrated approach for identifying and validating novel OUD comorbidities from health records of 87 million unique patients (12 million for discovery and 75 million for validation), which can offer new opportunities for OUD mechanism understanding, drug discovery, and multi-component service delivery for co-occurring medical conditions among patients with OUD.

Depression and Autoimmune Hypothyroidism—Their Relationship and the Effects of Treating Psychiatric and Thyroid Disorders on Changes in Clinical and Biochemical Parameters Including BDNF and Other Cytokines—A Systematic Review

Various autoimmune diseases, including autoimmune hypothyroidism (AHT), are associated with a higher risk of developing mood disorders throughout life. Depression is accompanied by the changes in the levels of inflammatory and trophic factors, including interleukins (IL-1beta, IL-2, IL-6), interferon alpha (IFN-alpha), tumor necrosis factor alpha (TNF-alpha), C-reactive protein (CRP), and brain derived neurotrophic factor (BDNF). Disclosure of the relationship between the coexistence of depression and AHT indicates that the pathomechanism of depression may be related to the changes in the immune system, it is also possible that both conditions may be caused by the same immune processes. The above hypothesis is indirectly supported by the observations that the treatment with both antidepressants and levothyroxine leads to a decrease in the levels of proinflammatory cytokines with an increase in BDNF concentrations, simultaneously correlating with an improvement in the clinical parameters. However, so far there are no long-term studies determining the causal relationship between depression, thyroid autoantibodies, and cytokine profile, which could bring us closer to understanding the interrelationships between them and facilitate the use of an adequate pharmacotherapy, not necessarily psychiatric. We consider the above issues to be insufficiently investigated but of great importance. This article is an overview of the available literature as well as an introduction to our research project.