High prevalence of thyroid abnormalities in a Chilean psychiatric outpatient population

Gender differences in the association between anxiety symptoms and thyroid hormones in young patients with first-episode and drug naïve major depressive disorder

Objective

Gender differences are prevalent in major depressive disorder (MDD), but the gender differences in the relationship between comorbid anxiety and thyroid hormones in young first-episode and drug-naive (FEND) MDD patients are unknown.

Methods

A total of 1,289 young outpatients with FEDN MDD were recruited. Demographic and clinical data were collected for each patient. The patient's blood glucose, blood pressure, thyroid hormone, and thyroid antibody levels were measured. The Hamilton depression scale (HAMD), Hamilton anxiety scale (HAMA), and Positive and Negative Syndrome Scale (PANSS) were used to assess patients' depression, anxiety, and positive symptoms, respectively.

Results

The prevalence of comorbid anxiety disorders was 80.4 and 79.4% in male and female MDD patients, respectively. Patients with anxiety had higher HAMD and PANSS scores, higher serum thyroid stimulating hormone (TSH), anti-thyroglobulin antibody (A-TG), and thyroid peroxidase antibody (A-TPO) levels, higher blood glucose and blood pressure levels, and more patients with psychotic symptoms and suicide attempts. Male patients were younger and had a younger age of onset. Logistic regression analysis showed that HAMD score and comorbid suicide attempts were significant predictors of anxiety symptoms in both males and females, whereas A-TG predicted anxiety symptoms in female patients only. Limitations: No causal relationship could be drawn due to the cross-sectional design.

Conclusion

This study showed gender differences in factors associated with anxiety symptoms in patients with MDD. Some factors were associated with anxiety symptoms in both male and female patients, while A-TG was only associated with anxiety symptoms in female patients.

Climacteric symptoms are related to thyroid status in euthyroid menopausal women

BACKGROUND

Climacteric symptoms are a variety of disturbing complaints occurring during menopausal transition, many of which may be influenced by hormonal abnormalities other than related to sex steroids.

AIM OF THE STUDY

In this study, we investigated the association between the intensity of climacteric symptoms measured with the Kupperman index and a thyroid status.

MATERIAL AND METHODS

We evaluated by measuring serum thyrotropin (TSH), and free thyroxine (fT4) 202 euthyroid women admitted to the Department of Gynecological Endocrinology, Poznan University of Medical Sciences because of climacteric symptoms. Patients were both in perimenopause (n = 74) and postmenopause (n = 128), with no history of thyroid disorders.

RESULTS

Results presented as the mean value and standard deviation were as follows: age 54.2 ± 4.9 years, BMI 26.8 ± 4.6 kg/m², Kupperman index 26 ± 13.1 points, TSH 2.4 ± 2.6 mU/l, fT4 1.2 ± 0.37 ng/dl. We observed a negative correlation between fT4 and the time since the last menses (R = - 0.38; p = 0.02) as well as between serum TSH concentration and sweating (R = - 0.18; p = 0.03), general weakness (R = - 0.17; p = 0.03), and palpitation (R = - 0.18; p = 0.02) and a positive correlation between fT4 and nervousness (R = 0.34; p = 0.007) and palpitations (R = 0.25; p = 0.04). In the perimenopausal subgroup, there was a positive correlation between fT4 and general weakness (R = 0.42; p = 0.03), palpitations (R = 0.50; p = 0.009), and paresthesia (R = 0.46; p = 0.01). In the postmenopausal subgroup, there was a negative correlation between TSH and sweating (R = - 0.21; p = 0.03).

CONCLUSIONS

Menopausal symptoms are related to thyroid status in euthyroid menopausal women.

FT4 and TSH, relation to diagnoses in an unselected psychiatric acute-ward population, and change during acute psychiatric admission

BACKGROUND

Alteration in thyroid activity is a well-known cause of symptoms mimicking psychiatric disorders. There are reports on altered levels of thyroid hormones in patients with certain psychiatric disorders compared to healthy controls; still, the magnitude and importance of the phenomenon is not known. We wanted to explore the level of thyroid hormones in different diagnostic groups in an acute-psychiatric population. We also wanted to follow any change during their stay.

METHODS

Patients aged 18 years and older admitted to a closed, psychiatric inpatient ward were eligible if giving informed consent. For 539 patients representing all main psychiatric diagnostic groups and with equal gender distribution, data for FT4 were available for 539 patients, and data for TSH were available from 538 patients at admittance. For 239 patients, data for FT4 were available at both admittance and discharge, and the corresponding number for TSH was 236 patients.

RESULTS

A significantly higher share of patients had higher levels of FT4 and TSH at admittance than expected for healthy individuals. No significant effect of gender or most diagnostic groups was seen. For female patients with substance-use disorder (SUD), the level of TSH was significantly lower than that for all other diagnostic groups. No other difference in the levels of FT4 and TSH was seen between the main diagnostic groups, and the effect in SUD was not seen in males. For the population with available markers at both admittance and discharge, in total, there was a significant reduction of FT4 from admittance to discharge, not followed by any change in TSH.

CONCLUSIONS

In acutely admitted psychiatric patients there seems to be an increased FT4 and TSH. FT4 is normalized during the inpatient stay independently of TSH. This indicates somatic effects of psychiatric stress that may be of clinical importance and the phenomenon should be further explored. Mainly different diagnostic groups did not differ in level of FT4 and TSH. Thus future studies on thyroid activity in psychiatric patients should focus on function and level of stress and suffering rather than diagnostic groups.

Hypothalamic-pituitary-thyroid (HPT) axis functioning in anxiety disorders. A systematic review

Depression has repeatedly been linked to subclinical hypothyroidism, and thyroid hormones have successfully been used to augment antidepressant treatment. By contrast, the extent of thyroid dysfunction in anxiety disorders remains less clear. This is surprising, given that anxiety-related symptoms (e.g., nervousness, palpitations, increased perspiration) are highly prevalent in hyperthyroidism. The present study was undertaken to synthesize the literature on hypothalamic-pituitary-thyroid (HPT) axis functioning in anxiety disorders. The PubMed and PsycINFO databases were systematically searched. Three types of studies were included: (1) "comorbidity studies" assessing the prevalence of thyroid disorders in individuals with anxiety disorders, (2) "case-control studies" comparing HPT parameters between patients and controls, and (3) "correlational studies" assessing self-reported anxiety levels and HPT parameters. Risk of bias was assessed via a standardized quality rating. Twenty studies were eligible. Nearly all found the comorbidity between anxiety and thyroid disorders was significant. Half of the studies additionally supported the notion of subtle thyroid dysfunction in that thyroid-stimulating hormone (TSH) responses to the administration of thyrotropin-releasing hormone (TRH) were blunted and an inverse relationship was observed between self-reported anxiety levels and TSH. Overall, HPT assessments were well conducted, but several studies failed to adjust their analyses for smoking, body mass index (BMI), and depression. The findings resonate well with clinical recommendations to routinely screen for thyroid disorders in patients with anxiety disorders, and with what is known from basic research about thyroid-brain interactions. The results of the risk of bias assessment underscore the importance of further high-quality experimental and longitudinal epidemiological research.

Subclinical thyroid dysfunction and psychiatric disorders: cross-sectional results from the Brazilian Study of Adult Health (ELSA-Brasil)

OBJECTIVE

To evaluate the association between subclinical thyroid dysfunction and psychiatric disorders using baseline data from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

DESIGN

Cross-sectional study.

PATIENTS

The study included 12 437 participants from the ELSA-Brasil with normal thyroid function (92·8%), 193 (1·4%) with subclinical hyperthyroidism and 784 (5·8%) with subclinical hypothyroidism, totalling 13 414 participants (50·6% of women).

MEASUREMENTS

The mental health diagnoses of participants were assessed by trained raters using the Clinical Interview Schedule - Revised (CIS-R) and grouped according to the International Classification of Diseases 10 (ICD-10). Thyroid dysfunction was assessed using TSH and FT4 as well as routine use of thyroid hormones or antithyroid medications. Logistic models were presented using psychiatric disorders as the dependent variable and subclinical thyroid disorders as the independent variable. All logistic models were corrected for multiple comparisons using Bonferroni correction.

RESULTS

After multivariate adjustment for possible confounders, we found a direct association between subclinical hyperthyroidism and panic disorder odds ratio [OR], 2·55; 95% confidence Interval (95% CI), 1·09-5·94; and an inverse association between subclinical hypothyroidism and generalized anxiety disorder (OR, 0·75; 95% CI, 0·59-0·96). However, both lost significance after correction for multiple comparisons.

CONCLUSION

Subclinical hyperthyroidism was positively associated with panic disorder and negatively associated with anxiety disorder, although not significant after adjustment for multiple comparisons.

Lack of confirmation of thyroid endophenotype in Bipolar Disorder Type I and their first-degree relatives

BACKGROUND

Among the biological factors associated with the development and outcomes in Bipolar Disorder Type I (BD-I), previous studies have highlighted the involvement of both thyroid function and/or auto-immunity, proposing a thyroid endophenotype. The objective of this study was to determine the presence of thyroid alterations in BD-I and their first-degree relatives (FDR).

METHODOLOGY

Unselected, cross-sectional case-control study with parallel analysis of individuals affected by BD-I (239), their FD-R (131), and 108 healthy controls. Thyroidal functional abnormalities (TSH and free T4) and thyroidal antibodies (thyroglobulin and thyroperoxidase antibodies) were studied. Assessments were carried out in parallel. The sample was described using arithmetic means, standard deviations, percentages and ranges. Chi-square, Student-t tests, ANOVA and Pearson correlation coefficients were used when indicated.

RESULTS

BD-I on actual and/or ever treated with lithium showed significant thyroidal functional abnormalities as compared to their FD-R and healthy controls. This BD-I subgroup showed a significant greater proportion of subjects suffering from subclinical hypothyroidism (22%). The role of gender/lithium interactions was relevant. The groups did not show differences in terms of positivization of thyroidal antibodies.

LIMITATIONS

The crosssectional design and the lack of determination of dietary iodine deficiencies and/or thyroidal ecographical controls may be a drawback.

CONCLUSIONS

The present study supports previous findings on the effect of lithium treatment on thyroidal functional, but did not support previous findings related to a familial association or endophenotype. In addition, the present study did not support a familial aggregation of thyroidal antibodies positivization in pedegrees of BD-I.

Relationship of cortisol levels and genetic polymorphisms to antidepressant response to placebo and fluoxetine in patients with major depressive disorder: a prospective study

BACKGROUND

Increased cortisol levels and genetic polymorphisms have been related to both major depressive disorder and antidepressant treatment outcome. The aim of this study is to evaluate the relationship between circadian salivary cortisol levels, cortisol suppression by dexamethasone and genetic polymorphisms in some HPA axis-related genes to the response to placebo and fluoxetine in depressed patients.

METHODS

The diagnosis and severity of depression were performed using the Mini International Neuropsychiatric Interview (M.I.N.I.) and Hamilton depression scale (HAM-D17), respectively. Euthyroid patients were treated with placebo (one week) followed by fluoxetine (20 mg) (two months). Severity of depression was re-evaluated after placebo, three weeks and two months of fluoxetine treatments. Placebo response was defined as HAM-D17 score reductions of at least 25% and to < 15. Early response and response were reductions of at least 50% after three weeks and two months, and remission with ≤ 7 after two months. Plasma TSH, free-T4, circadian salivary cortisol levels and cortisol suppression by dexamethasone were evaluated. Seven genetic polymorphisms located in the Corticotrophin-releasing-hormone-receptor-1 (rs242939, rs242941, rs1876828), Corticotrophin-releasing-hormone-receptor-2 (rs2270007), Glucocorticoid-receptor (rs41423247), FK506-binding-protein-5 (rs1360780), and Arginine-vasopressin (rs3729965) genes were determined. Association analyses between response to placebo/fluoxetine and polymorphism were performed by chi-square or Fisher exact test. Cortisol levels were compared by t-test, ANOVA and the general linear model for repeated measures.

RESULTS

208 depressed patients were recruited, 187 of whom were euthyroid. Placebo responders, fluoxetine responders and remitters exhibited significantly lower circadian cortisol levels than those who did not respond (p-values of 0.014, 0.008 and 0.021 respectively). Patients who abandoned treatment before the third week also exhibited a trend to low cortisol levels (p = 0.057). The polymorphisms rs242939 (CRHR1) and rs2270007 (CRHR2) were not in Hardy-Weinberg equilibrium. Only the rs242939 polymorphism (CRHR1) exhibited association with early response (three weeks) to fluoxetine (p-value = 0.043). No other association between outcomes and polymorphisms was observed.

CONCLUSIONS

These results support the clinical relevance of low salivary cortisol levels as a predictor of antidepressant response, either to placebo or to fluoxetine. Only one polymorphism in the CRHR1 gene was associated with the early response. Other factors may be involved in antidepressant response, although further studies are needed to identify them.

Drug prescriptions of adults with adolescent depression in a community sample

PURPOSE

The prescription drugs have, to our knowledge, not been much studied in epidemiological samples with long-term follow-up. Accordingly, our purpose was to analyze the use of prescription drugs in adults with adolescent depression.

METHODS

A population-based cohort of adolescents (n = 2465) was screened for the presence of depressive symptoms and diagnosed according to a structured interview. Totally, 362 individuals were identified as depressed and compared with 250 non-depressed controls. The prescription drugs were evaluated at the age of 29-31 years from a register kept by the National Health and Welfare Board.

RESULTS

The formerly depressed females received significantly more prescription drugs, such as antidepressants, antiepileptics, antibacterials, antimycotics, and antihistamines for systemic use as well as other drugs, compared with controls (15.6 ± 27.4 vs 8.2 ± 7.4 recipes, p < 0.001). Formerly depressed males did not differ from controls regarding prescription drugs.

CONCLUSIONS

The females but not males with adolescent depression subsequently received more prescription drugs than non-depressed peers. Depressed female adolescents received more psychotropic and non-psychotropic drugs later in life compared to the non-depressed. This might be as a result of physical illnesses, different treatment-seeking behaviors, or somatizing reactions.

Diagnosis of co-morbid axis-I psychiatric disorders among women with newly diagnosed, untreated endocrine disorders

OBJECTIVES

To determine the prevalence of major depressive disorder (MDD) and other selected axis-I disorders among women with newly diagnosed, untreated endocrine disorders.

METHODS

Two hundred and eighteen consecutive women, aged 18-65, with newly diagnosed, untreated endocrine disorders were referred for potential diagnosis of co-morbid axis-I disorders with the use of the Structured Clinical Interview for Axis I-Patient Edition (SCID-P). The SCID-P was re-administered after 12 weeks.

RESULTS

At baseline, 64 (29.3%) women met criteria for at least one axis-I disorder. Women who were diagnosed with hyperthyroidism were more likely to meet criteria for generalized anxiety disorder and panic disorder than women without hyperthyroidism. Nine of 154 (5.8 %) women who did not meet criteria for an axis-I disorder at baseline met criteria for at least one axis-I disorder during follow-up. Among them, the presence of diabetes mellitus was statistically correlated with a higher probability of developing major depressive disorder at follow-up.

CONCLUSIONS

Although preliminary, our findings are consistent with previous studies and suggest an increased prevalence of MDD and other axis-I disorders among women with newly diagnosed endocrine disorders, providing further evidence suggesting that women with endocrine abnormalities may be at increased risk of depression and/or anxiety disorders.

Methimazole-induced hypothyroidism inhibits the panic-like behaviors produced by electrical stimulation of dorsal periaqueductal gray matter of rats

Conflicting clinical data on the relationship of panic disorder and thyroid diseases illustrate the need for a simpler approach using animal models. Defensive behaviors evoked by electrical or chemical stimulation of dorsal periaqueductal gray matter (DPAG) have been proposed as a model of panic attack. Therefore, the present study examined the effects of the anti-thyroid agent methimazole (MTZ) either on the panic-like behaviors induced by electrical stimulation of DPAG or the anxiety-like behaviors of rats exposed to the elevated plus-maze (EPM). Male Wistar rats bearing electrodes in the DPAG were stimulated with stepwise increased currents. Rats which displayed galloping at intensities below 60muA were retested following 5- and 10-day treatments with MTZ (0.6mg/kg/day, i.p.) or 10- and 15-day washout periods. MTZ effects on EPM performance were assessed in separate groups. MTZ-treated groups were compared to saline-treated controls. In other experiments, rats were similarly treated with MTZ and the blood was collected for hormone assays. The 10-day treatment with MTZ produced marked increases in the thresholds of exophthalmus (65%), immobility (75%), trotting (63%), galloping (56%), jumping (47%), defecation (114%) and micturition (85%). Effects outlasted the drug discontinuation. In contrast, MTZ had variable effects in the EPM, significantly increasing the open-arm exploration in 5-day treated and 10-day washout groups. Biochemical data revealed a small but significant decrease (13%) in free thyroxine in MTZ-treated groups. Although not significant, thyrotrophin levels showed a 111% increase following the 10-day treatment with MTZ. Selective attenuation by MTZ of DPAG-evoked defensive behaviors supports attenuation of panic attacks in hypothyroidism.

Refractory depression in a patient with peripheral resistance to thyroid hormone (RTH) and the effect of triiodothyronine treatment

We here described a 39-year-old woman with a severe chronic mood disorder, refractory to antidepressive therapy who showed a significant improvement after a self-prescription of high doses of liothyronine (T(3)). A modified Refetoff protocol was carried out to study the role of thyroid hormones on her clinical and biochemical responses. Depression severity was assessed by the HAM-D and MADRS Depression Rating Scales. Sequencing of Thyroid Receptors (TR) alpha1 and beta1 genes was done. At the final stage of the study, plasma T3 and free T3 were >800 ng/dl (80-180) and 1409 pg/dl (230-420), respectively. No changes in the cardiovascular parameters, alkaline phosphatase isoenzymes, creatinine kinase, or ferritin were observed. However, an improvement in mood was detected by specific scores (HAM-D 24 to 8; MADRS 40 to 11). No mutations in DNA- and hormone-binding-domains of TRbeta1 and TRalpha1 genes were found in proband, suggesting that the defect could be due to an unknown mutation in either the TR gene or a post receptor abnormality. These results support the existence of a peripheral RTH manifestation as a refractory chronic depression reverted by high doses of T(3). Screening for RTH in refractory chronic depression may provide an alternative treatment for this psychiatric condition.

Depression, anxiety, health-related quality of life, and disability in patients with overt and subclinical thyroid dysfunction

BACKGROUND

Thyroid dysfunction may impair the quality of life (QoL) and may cause psychological symptoms. The aim of this study is to investigate prospectively the effects of thyroid dysfunction on quality of life, levels of depression/anxiety and the changes in these variables after treatment.

METHODS

A total of 160 subjects, consisting of an overt hypothyroidism group (n = 33), a subclinical hypothyroidism group (n = 43), an overt hyperthyroidism group (n = 51), a subclinical hyperthyroidism group (n = 13), and a healthy control group (n = 20) were included in the study. All groups were evaluated with the Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Rating Scale (HARS), Short Form-36 (SF-36), and Brief Disability Questionnaire (BDQ). Health-related quality of life (HRQL) was measured by SF-36.

RESULTS

Anxiety and depressive symptoms were more severe in patients with overt hypo- and hyperthyroidism (p <0.001). The QoL was worse in overt or subclinical hyper- and hypothyroidism groups than in the control group [p = 0.013 for physical composite score (PCS); p = 0.002 for mental composite score (MCS)]. Psychological symptoms and QoL were improved in overt and subclinical hypothyroidism and overt hyperthyroidism groups as a result of the treatment. The overt hyper- and hypothyroidism groups showed more improvement than the subclinical groups.

CONCLUSIONS

This study suggests that restoration of euthyroidism is accompanied by improvement on QoL and psychological symptoms in all groups except the subclinical hyperthyroidism group. Controlled, randomized studies in larger groups are, however, necessary.

Increased risk of developing affective disorder in patients with hypothyroidism: a register-based study

BACKGROUND

Links between thyroid function and depression have been noted in many contexts. We assessed whether hospitalization with hypothyroidism was a risk factor for developing affective disorder.

METHODS

We conducted a prospective cohort study using historical data from Danish registers. The observational period was 1977-1999. Three study cohorts were identified: all patients with a first hospital admittance with the resulting index discharge diagnoses hypothyroidism, osteoarthritis, or nontoxic goiter. A later hospitalization with a resulting discharge diagnosis of affective disorder was used as event of interest, and rates of readmission were estimated and compared using competing risk models in survival analyses.

FINDINGS

We identified 165,307 patients discharged with an index diagnosis. In the observational period, 1041 events occurred. An index diagnosis of hypothyroidism was associated with an increased risk of hospitalization with affective disorder when compared to the control diseases. The risk of hospitalization with affective disorder was greatest in the first year after index hospitalization.

CONCLUSION

Patients hospitalized with hypothyroidism have a greater risk of readmission with depression or bipolar disorder than control patients. This renders epidemiologic support to theories linking thyroid dysfunction with mood disturbances.

Depression and anxiety in hyperthyroidism

BACKGROUND

Our objective was to determine symptomatology of depression and anxiety in patients with untreated hyperthyroidism and compare with euthyroid patients.

METHODS

Thirty-two patients with hyperthyroidism (high free T3 and free T4, and suppressed TSH) and 30 euthyroid (normal free T3, free T4, and TSH) controls attending the Endocrinology Out-Patient Department at Celal Bayar University Hospital in Manisa, Turkey were included in the study. Hormonal screening was performed by immunoassay and hemagglutination method. For psychiatric assessment, Hospital Anxiety and Depression Scale [HAD], Hamilton Depression Rating Scale [HAM-D], and Hamilton Anxiety Rating Scale [HAM-A] were used. There was no difference between the two groups in terms of demographic features.

RESULTS

Total scores obtained both from HAM-D and HAM-A were significantly greater in the hyperthyroidism group than that of the euthyroid group (p <0.05); there was no difference in terms of HAD. When compared in terms of symptomatology, early insomnia (HAM-D#6), work and activities (HAM-D#7), psychic anxiety (HAM-D#10), weight loss (HAM-D#16), insomnia (HAM-A#4), and cardiovascular symptoms (HAM-A#8) were significantly more frequent in the hyperthyroidism group. By Wilks lambda discriminant analysis, psychomotor agitation (HAM-D#9), weight loss (HAM-D#16), and insomnia (HAM-A#4) were found as the discriminating symptoms for the hyperthyroidism group, whereas somatic anxiety (HAM-A#11) and loss of interest (HAD#14) were distinguishing symptoms of the euthyroidism group.

CONCLUSIONS

Hyperthyroidism and syndromal depression-anxiety have overlapping features that can cause misdiagnosis during acute phase. For differential diagnosis, one should follow-up patients with hyperthyroidism with specific hormonal treatment and evaluate persisting symptoms thereafter. In addition to specific symptoms of hyperthyroidism, psychomotor retardation, guilt, muscle pain, energy loss, and fatigue seem to appear more frequently in patients with comorbid depression and hyperthyroidism; thus, presence of these symptoms should be a warning sign to nonpsychiatric professionals for the need for psychiatric consultation.