The presence of antithyroid antibodies in patients with affective and nonaffective psychiatric disorders

Is Every Thyroid Antibody a Bad Sign?: The Complex Relationship of Antithyroid Antibodies and Obsessive-compulsive Symptoms

Objective

: Several immunological factors are emphasized in the etiology of autoimmune thyroid diseases and obsessivecompulsive disorder. Obsessive-compulsive symptoms (OCS) are commonly seen in patients with autoimmune thyroid diseases. This study aims to evaluate the relationship between OCS and antithyroid antibodies.

Methods

: The study included 145 patients with Hashimoto thyroiditis or Graves' disease and 42 healthy controls. Thyroid function tests and serum thyroid autobody levels (anti-thyroglobulin [TG], anti-thyroid peroxidase [TPO], and anti-thyroid stimulating hormone [TSH]) of the patients were measured. The socio-demographic data and OCS of the participants were evaluated with Dimensional OCS (DOCS).

Results

: DOCS scores were higher in patients than in the control group. There was not found a significant relationship between free T3, free T4, and TSH levels and DOCS scores. Anti-TG positivity in females was associated with lower DOCS scores. Anti-TPO positivity in males had a positive correlation with DOCS scores. There was no correlation between sex and the presence of anti-TSH in terms of OCS severity. Univariate analysis found the highest OCS scores in anti-TPO positive, anti-TG, and anti-TSH negative patients. The group with the lowest OCS scores was found to be anti-TG positive, anti-TPO, and anti-TSH negative patients.

Conclusion

: OCS severity could be affected by different thyroid autoantibody profiles in patients with autoimmune thyroid diseases. While anti-TG serves a protective role against OCS in females, the presence of anti-TPO may worsen the OCS in men. Additionally, the co-existence of different antithyroid antibodies may affect the severity of OCS differently according to sex.

Association between anti-thyroid antibodies and negative symptoms in early psychosis

AIM

In the current cross-sectional study, we aimed to explore whether thyroid function or thyroid autoimmunity are associated with psychopathological symptoms and social functioning in patients with early psychosis. We hypothesized that psychopathological severity is greater in those patients with positive thyroid autoimmunity.

METHODS

We studied 70 outpatients with early psychosis (<3 years of illness) and 37 healthy subjects. Psychopathological symptoms (positive, negative, disorganized, excited and depressive) and social functioning were assessed. Thyroid autoimmunity (antibodies against thyroid peroxidase [TPO-Abs] and thyroglobulin [TG-Abs]) and thyroid function (thyroid-stimulating hormone [TSH] and free thyroxin [FT4]) were determined. Associations of thyroid variables and psychometric measures were assessed with Spearman's correlations. Logistic regression was performed to explore the association between psychopathological symptoms and positive anti-thyroidal antibodies while adjusting for covariates.

RESULTS

When compared to patients without thyroid antibodies, those with positive thyroid antibodies had more negative symptoms and poorer function (P < .05). Titres of TPO-Abs were significantly correlated with negative and depressive PANSS domains and poorer functioning. TG-Abs were also associated with poorer functioning but not with psychopathological symptoms. TSH and FT4 concentrations were not associated with clinical symptoms. In the logistic regression analysis adjusted for age, gender, antipsychotic treatment, lithium, TSH and FT4 concentrations, negative symptoms were associated with thyroid autoimmunity (OR = 1.2, P = .019).

CONCLUSIONS

Our study suggests that anti-thyroid antibodies are associated with a more severe phenotype with increased negative symptoms and poorer functioning in early psychotic patients. Since causality cannot be inferred with cross-sectional data, future longitudinal studies are needed to overcome this limitation.

Effect of Thyroxine Therapy on Depressive Symptoms Among Women With Subclinical Hypothyroidism

OBJECTIVE

To estimate the effect of antenatal treatment of subclinical hypothyroidism on maternal depressive symptoms.

METHODS

We conducted an ancillary study to a multicenter trial in women with singleton pregnancies diagnosed with subclinical hypothyroidism randomized to antenatal thyroxine therapy or placebo. Treatment was discontinued at the end of pregnancy. Women with overt thyroid disease, diabetes, autoimmune disease, and those diagnosed with depression were excluded. Participants were assessed for depressive symptoms using the Center for Epidemiological Studies-Depression scale (CES-D) before starting the study drug (between 11 and 20 weeks of gestation), between 32 and 38 weeks of gestation, and at 1 year postpartum. The primary outcome was maternal depressive symptoms score as assessed using the CES-D. Secondary outcome was the percentage of women who scored 16 or higher on the CES-D, as such a score is considered screen-positive for depression.

RESULTS

Two hundred forty-five (36.2% of parent trial) women with subclinical hypothyroidism were allocated to thyroxine (n=124) or placebo (n=121). Median CES-D scores and the proportion of participants with positive scores were similar at baseline between the two groups. Treatment with thyroxine was not associated with differences in CES-D scores (10 [5-15] vs 10 [5-17]; P=.46) or in odds of screening positive in the third trimester compared with placebo, even after adjusting for baseline scores (24.3% vs 30.1%, adjusted odds ratio 0.63, 95% CI 0.31-1.28, P=.20). At 1 year postpartum, CES-D scores were not different (6 [3-11] vs 6 [3-12]; P=.79), nor was the frequency of screen-positive CES-D scores in the treated compared with the placebo group (9.7% vs 15.8%; P=.19). Treatment with thyroxine during pregnancy was also not associated with differences in odds of screening positive at the postpartum visit compared with placebo even after adjusting for baseline scores. Sensitivity analysis including women who were diagnosed with depression by the postpartum visit did not change the results.

CONCLUSIONS

This study did not achieve its planned sample size, thus our conclusions may be limited, but in this cohort of pregnant women with subclinical hypothyroidism, antenatal thyroxine replacement did not improve maternal depressive symptoms.

The Neurobiology of Mixed States

Interest in the coexistence of manic and depressive symptoms fostered hypotheses on neurobiological underpinnings of mixed states. Neurobiological properties of mixed states, however, have not been comprehensively described. The authors searched databases for articles on neurobiological markers related to mixed states. Results showed that mixed states are characterized by elevated central and peripheral monoamine levels, greater alterations in hypothalamic-pituitary-adrenal axis, increased inflammation, and greater circadian rhythms dysfunction than nonmixed forms. Furthermore, the magnitude of pathophysiologic alterations in mixed states exceeds those associated with nonmixed mania or depression and suggest that hyperactivation and hyperarousal are core features of mixed states.

Hypothyroidism and Depression: Are Cytokines the Link?

CONTEXT

Primary hypothyroidism has been thought of as an inflammatory condition characterized by raised levels of cytokines such as C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α). Depression is also well known to occur in hypothyroidism. Depression is also characterized by elevated inflammatory cytokines. We planned to study whether cytokines play an important part in linking these two conditions.

OBJECTIVES

(1) To know the prevalence of depression in overt hypothyroidism due to autoimmune thyroid disease. (2) To correlate the levels of inflammatory markers with the occurrence of depression. (3) To study the effect of levothyroxine on inflammatory markers and depression.

MATERIALS AND METHODS

In this longitudinal, case-controlled study, 33 patients with autoimmune hypothyroidism (thyroid-stimulating hormone >10 uIU/ml) were included with 33 age-, sex-, and body max index-matched healthy controls. Individuals were tested for Serum TNF-α, IL-6, high-sensitivity-CRP (hs-CRP). They were assessed for depression using Montgomery Asberg Depression Rating Scale (MADRS) and World Health Organization Quality of Life (QOL) Scale. Patients received L Thyroxine titrated to achieve euthyroidism and were reassessed for inflammatory markers and cognitive dysfunction.

RESULTS

Nineteen patients (57%) had mild to moderate depression (MADRS >11). After 6 months of treatment, eight patients (42%) had remission of depression with significant improvement in QOL scores (P < 0.05). TNF-α, IL-6, and hs-CRP were significantly elevated in patients compared with controls and reduced with therapy but did not reach baseline as controls. The change in inflammatory markers correlated with improvement in QOL scores in social and environmental domains (P < 0.01).

CONCLUSIONS

Primary autoimmune hypothyroidism is an inflammatory state characterized by elevated cytokines which decline with LT4 therapy. It is associated with depression and poor quality of life. Treatment of hypothyroidism results in alleviation of depression in the majority of patients. Similarly, patients with mild to moderate depression should be tested for hypothyroidism as simple treatment may ameliorate their depression and improves MADRS score and QOL.

Thyroid autoimmunity in bipolar disorder: A systematic review

BACKGROUND

Accumulating evidence points to the pathophysiological relevance between immune dysfunction and mood disorders. High rates of thyroid dysfunction have been found in patients with bipolar disorder (BD), compared to the general population. A systematic review of the relationship between BD and thyroid autoimmunity was performed.

METHODS

Pubmed, EMBASE and PsycINFO databases were searched up till January 28th, 2017. This review has been conducted according to the PRISMA statements. Observational studies clearly reporting data among BD patients and the frequency of autoimmune thyroid pathologies were included.

RESULTS

11 original studies met inclusion criteria out of 340 titles first returned from the global search. There is evidence of increased prevalence of circulating thyroid autoantibodies in depressed and mixed BD patients, while there is no evidence showing a positive relationship between BD and specific autoimmune thyroid diseases. There is a controversy about the influence of lithium exposure on circulating thyroid autoantibodies, even if most of studies seem not to support this association. A study conducted on bipolar twins suggests that autoimmune thyroiditis is related to the genetic vulnerability to develop BD rather than to the disease process itself. Females are more likely to develop thyroid autoimmunity.

LIMITATIONS

The samples, study design and outcomes were heterogeneous.

CONCLUSION

Thyroid autoimmunity has been suggested to be an independent risk factor for bipolar disorder with no clear association with lithium exposure and it might serve as an endophenotype for BD.

Medical comorbidity in bipolar disorder: The link with metabolic-inflammatory systems

BACKGROUND

Bipolar disorder (BD) is associated with chronic low-grade inflammation, several medical comorbidities and a decreased life expectancy. Metabolic-inflammatory changes have been postulated as one of the main links between BD and medical comorbidity, although there are few studies exploring possible mechanisms underlying this relationship. Therefore, the aims of the current narrative review were 1) synthesize the evidence for metabolic-inflammatory changes that may facilitate the link between medical comorbidity and BD and 2) discuss therapeutic and preventive implications of these pathways.

METHODS

The PubMed and Google Scholar databases were searched for relevant studies.

RESULTS

Identified studies suggested that there is an increased risk of medical comorbidities, such as autoimmune disorders, obesity, diabetes and cardiovascular disease in patients with BD. The association between BD and general medical comorbidities seems to be bidirectional and potentially mediated by immune dysfunction. Targeting the metabolic-inflammatory-mood pathway may potential yield improved outcomes in BD; however, further study is needed to determine which specific interventions may be beneficial.

LIMITATIONS

The majority of identified studies had cross-sectional designs, small sample sizes and limited measurements of inflammation.

CONCLUSIONS

Treatment and prevention of general medical comorbidities in mood disorders should include preferential prescribing of metabolically neutral agents and adjunctive lifestyle modifications including increased physical activity, improved diet and decreased substance abuse. In addition, the use of anti-inflammatory agents could be a relevant therapeutic target in future research.

Seeking an objective diagnosis of depression

Major depressive disorder (MDD: unipolar depression) is widely distributed in the USA and world-wide populations and it is one of the leading causes of disability in both adolescents and adults. Traditional diagnostic approaches for MDD are based on patient interviews, which provide a subjective assessment of clinical symptoms which are frequently shared with other maladies. Reliance upon clinical assessments and patient interviews for diagnosing MDD is frequently associated with misdiagnosis and suboptimal treatment outcomes. As such, there is increasing interest in the identification of objective methods for the diagnosis of depression. Newer technologies from genomics, transcriptomics, proteomics, metabolomics and imaging are technically sophisticated and objective but their application to diagnostic tests in psychiatry is still emerging. This brief overview evaluates the technical basis for these technologies and discusses how the extension of their clinical performance can lead to an objective diagnosis of MDD.

Bipolar disorder and antithyroid antibodies: review and case series

Mood disorders and circulating thyroid antibodies are very prevalent in the population and their concomitant occurrence may be due to chance. However, thyroid antibodies have been repeatedly hypothesized to play a role in specific forms of mood disorders. Potentially related forms include treatment-refractory cases, severe or atypical depression, and depression at specific phases of a woman’s life (early gestation, postpartum depression, perimenopausal). With regard to bipolar disorder, studies of specific subgroups (rapid cycling, mixed, or depressive bipolar) have reported associations with thyroid antibodies. Offspring of bipolar subjects were found more vulnerable to develop thyroid antibodies independently from the vulnerability to develop psychiatric disorders. A twin study suggested thyroid antibodies among possible endophenotypes for bipolar disorder. Severe encephalopathies have been reported in association with Hashimoto’s thyroiditis. Cases with pure psychiatric presentation are being reported, the antithyroid antibodies being probably markers of some other autoimmune disorders affecting the brain. Vasculitis resulting in abnormalities in cortical perfusion is one of the possible mechanisms.

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.

Female vulnerability for thyroid function abnormality in bipolar disorder: role of lithium treatment

BACKGROUND

Previous studies have provided evidence of subtle thyroid hormone metabolism abnormalities in patients with mood disorders. Although these studies are informative, the precise role of the hypothalamic-pituitary-thyroid axis in bipolar disorder, especially in women, remains unclear. We sought to further corroborate thyroid function in patients with bipolar disorder in comparison to patients with other psychiatric, as well as non-psychiatric, diagnoses.

METHODS

In this retrospective, cross-sectional, naturalistic study, serum thyroid-stimulating hormone (TSH) levels in a total sample of 3,204 patients were compared. The study sample included patients with bipolar disorder (n = 469), unipolar depression (n = 615), and other psychiatric diagnoses (n = 999), patients from endocrinology clinics (n = 645), and patients from dermatology clinics (n = 476). Analyses were completed using two different normal ranges for TDH: a high normal range (0.4-5.0 μIU/mL) and a low normal range (0.3-3.0 μIU/mL).

RESULTS

Patients with bipolar disorder showed significantly higher serum TSH levels compared to all other groups. In women, the rate of above normal range TSH was highest in patients with bipolar disorder for both high (5.0 μIU/mL; 12.1%) and low (3.0 μIU/mL; 30.4%) upper normal limits. In patients with bipolar disorder, serum TSH levels did not differ significantly between different mood states. In the lithium-treated patients (n = 240), a significantly lower percentage of women (55.9%) compared to men (71.2%) fell within the 0.3-3.0 μIU/mL normal TSH window (p = 0.016). For the high normal range (0.4-5.0 μIU/mL), serum lithium levels above 0.8 mmol/L were associated with a significantly lower proportion of female patients (59.2%) falling within the normal range than male patients (88.9%). Non-lithium treatment was not associated with a gender difference.

CONCLUSIONS

Our findings show a higher rate of TSH abnormality in patients with bipolar disorder, particularly those taking lithium, compared to those with other psychiatric and medical conditions. Lithium-associated thyroid dysregulation occurs more frequently in female patients. Using the low normal range TSH values at follow-up can increase sensitivity in recognizing hyperthyroidism in lithium-treated female patients, and help in preventing the development of subclinical hypothyroidism and an adverse course of illness.

Immune dysregulation and autoimmunity in bipolar disorder: Synthesis of the evidence and its clinical application

OBJECTIVE

Increasing evidence suggests that inflammation and immune dysregulation play an important role in the pathogenesis of bipolar disorder. Because the brain can be affected by various autoimmune processes, it is possible that some psychiatric disorders may have an autoimmune basis.

METHOD

This article reviews the literature on peripheral and central immune dysregulation and autoimmunity in bipolar disorder. The mechanisms of the innate and adaptive immune systems in the pathophysiology of bipolar disorder are explored. The clinical features and pathogenesis of neuropsychiatric systemic lupus erythematosus, anti-NMDA encephalitis, and Hashimoto's encephalopathy are summarized.

RESULTS

Neuroinflammation and peripheral immune dysregulation may play a role in the pathophysiology of bipolar disorder. This involves a complex interaction between immune cells of the central nervous system and periphery resulting in cellular damage through mechanisms involving excitotoxicity, oxidative stress, and mitochondrial dysfunction. Neuropsychiatric systemic lupus erythematosus, anti-NMDA encephalitis, and Hashimoto's encephalopathy are important differentials for a psychiatrist to consider when suspecting autoimmune encephalopathy.

CONCLUSIONS

The link between immune dysregulation, autoimmunity, and bipolar disorder may be closer than previously thought. Psychiatrists should be vigilant for autoimmunity in presentations of bipolar disorder due to its high morbidity and therapeutic implications. Advances in neuroimaging and biomarker identification related to immune dysregulation and neuroinflammation will contribute to our knowledge of the pathophysiology of bipolar disorder.

Anti-purkinje cell and natural autoantibodies in a group of psychiatric patients. Evidences for a correlation with the psychopathological status

Phenomena of autoimmunity are frequent among psychiatric patients, but we don't know yet if they should be considered primary and linked to the pathophisiology of the disorder, or aspecific and associated to a general immune system activation. Paraneoplastic Cerebellar Degeneration (PCD) represents a well known model of specific autoimmunity. In order to better understand the abovementioned issues, we used this condition to compare a set of immune dysfunctions found in a group of psychiatric patients. For this reason we tested sera from 48 psychiatric patients (24 schizophrenics, 17 bipolars and 7 obsessive-compulsive), 22 PCD patients and 52 healthy controls for the presence of anti-Purkinje autoantibodies and of some natural autoantibodies (ANAs, AMAs, APCAs, ASMAs). Psychopatological status of the psychiatric patients was assessed with BPRS, SANS, SAPS, HAM-D, CGI-S. In the psychiatric group anti-Purkinje autoantibodies were identified in 11/48 (22,9%) patients, while they were present in 22/22 (100%) PCD patients and in 0/52 (0%) healthy controls. Among all anti-Purkinje autoantibody positive patients (in the PCD and psychiatric samples), only those belonging to the psychiatric sample, but not those with PCD, were frequently found positive also for natural autoantibodies, that are considered good markers of aspecific immune activation. In these patients, both anti-Purkinje and natural autoantibodies were found associated with acute/positive psychopathological symptoms. These results seem to point out that some phenomena of auto-immunity described in psychiatric patients could be aspecific, unrelated to the pathophysiology of the concomitant mental disorders and could be more frequent during phases of acute/positive symptoms.

The Link between Thyroid Function and Depression

The relation between thyroid function and depression has long been recognized. Patients with thyroid disorders are more prone to develop depressive symptoms and conversely depression may be accompanied by various subtle thyroid abnormalities. Traditionally, the most commonly documented abnormalities are elevated T4 levels, low T3, elevated rT3, a blunted TSH response to TRH, positive antithyroid antibodies, and elevated CSF TRH concentrations. In addition, thyroid hormone supplements appear to accelerate and enhance the clinical response to antidepressant drugs. However, the mechanisms underlying the interaction between thyroid function and depression remain to be further clarified. Recently, advances in biochemical, genetic, and neuroimaging fields have provided new insights into the thyroid-depression relationship.

Thyroid functions and bipolar affective disorder

Accumulating evidence suggests that hypothalamo-pituitary-thyroid (HPT) axis dysfunction is relevant to the pathophysiology and clinical course of bipolar affective disorder. Hypothyroidism, either overt or more commonly subclinical, appears to the commonest abnormality found in bipolar disorder. The prevalence of thyroid dysfunction is also likely to be greater among patients with rapid cycling and other refractory forms of the disorder. Lithium-treatment has potent antithyroid effects and can induce hypothyroidism or exacerbate a preexisting hypothyroid state. Even minor perturbations of the HPT axis may affect the outcome of bipolar disorder, necessitating careful monitoring of thyroid functions of patients on treatment. Supplementation with high dose thyroxine can be considered in some patients with treatment-refractory bipolar disorder. Neurotransmitter, neuroimaging, and genetic studies have begun to provide clues, which could lead to an improved understanding of the thyroid-bipolar disorder connection, and more optimal ways of managing this potentially disabling condition.

Thyroid disease and mental disorders: cause and effect or only comorbidity?

PURPOSE OF REVIEW

To discuss the effects of thyroid dysfunction and thyroid autoimmunity on mental symptoms and disorders in patients with thyroid disease with reference to recent epidemiological, clinical, and genetic findings.

RECENT FINDINGS

During brain development, iodine deficiency, maternal thyroid dysfunction, and neonatal thyroid malformations together with genetic factors contribute to neurological deficit. Most adults with thyroid dysfunction will develop mental symptoms. In hyperthyroidism, adrenergic hyperactivity is a major cause of psychiatric symptoms, and beta-adrenergic antagonists are effective treatment. Most patients with severe hypothyroidism will also demonstrate mental symptoms; however, causality is not so evident as in hyperthyroidism. Polymorphism in deiodinase genes and in transporter genes appears to make an important contribution to the presentation of mental symptoms as well as to the outcome of treatment of hypothyroidism. A thyroid autoimmunity process may by itself contribute to mental symptoms in vulnerable patients. Data from epidemiological studies provide conflicting evidence as to associations between thyroid disorders and mental symptoms.

SUMMARY

In the adult brain, compared with the developing brain, brain-thyroid relationships are less apparent but still important. Adrenergic hyperactivity is a major cause of psychiatric symptoms in hyperthyroidism. Genetic factors contribute to the development and treatment outcome of mental disorder in hypothyroidism.

Prevalence and determinants of thyroid disorders in elderly patients with affective disorders: lithium and nonlithium patients

OBJECTIVES

To determine the prevalence and determinants of thyroid dysfunction in older patients with affective disorders divided into lithium and nonlithium patients.

METHODS

This study was conducted as a retrospective cross-sectional study in patients of 65 years and older with affective disorders according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. The presence of thyroid disorders was determined on the index date defined as the date of the first available thyroid-stimulating hormone in 2005. The presence of thyroid disorder was diagnosed according to defined criteria and in case of a previous diagnosis, confirmed by researching the medical files. In a subgroup of 45 lithium patients, thyroperoxidase- and thyroglobulin antibodies were determined.

RESULTS

A total of 79 lithium patients and 85 nonlithium patients were included. The prevalence of hypothyroidism (subclinical and clinical) was 35.4% among the lithium patients, with women having a prevalence as high as 41.3% and men 12.6%. In the nonlithium patients, the prevalence was 7.1%; very close to that in the general population. No other determinant than female gender was identified. Seventeen of the 26 lithium patients were diagnosed with hypothyroidism in the first 31/2 years after the start of lithium. The prevalence of thyroid antibodies was 27% in 45 lithium patients, which was no different than the prevalence in the same age group in the general population.

CONCLUSION

The prevalence of hypothyroidism during lithium treatment was very high in the elderly, especially in women. Autoimmunity did not seem to play a major part in lithium-associated hypothyroidism in this age group. The timeframe between start of lithium and diagnosis of hypothyroidism suggests an individual susceptibility. The prevalence of hypothyroidism in nonlithium patients with affective disorders was not very different from the general population.

The prevalence of thyroid disorders among sexual and violent offenders and their co‐occurrence with psychological symptoms

The prevalence of thyroid abnormalities among 831 sexual, violent, and non‐violent non‐sex offenders was found to be greater than found in the general population. Thyroid abnormalities were most common among violent offenders and among sex offenders who victimized children. Thyroid disorders were associated with psychotic diagnoses, delusions, mania, suicidal thoughts, and showed a trend to more suicide attempts. These disorders were undiagnosed in 49.1% of the cases prior to the present clinical assessment. Of these, 59.3% faced their first criminal charges, and the undiagnosed thyroid abnormalities may be important in the offenders’ treatment and may be possible legal mitigating factors in some offenses. Results indicate that a routine endocrine evaluation with blood tests would be a valuable addition to the assessment of violent and sexual offenders.

Hashimoto's encephalopathy

Hashimoto's encephalopathy (HE) is a controversial neurological disorder that comprises a heterogenous group of neurological symptoms that manifest in patients with high titers of antithyroid antibodies. Clinical manifestations of HE may include encephalopathic features such as seizures, behavioral and psychiatric manifestations, movement disorders, and coma. Although it has been linked to cases of Hashimoto's thyroiditis or thyroid dysfunction, the most common immunological feature of HE is the presence of high titers of antithyroglobulin or anti-TPO (antimicrosomal) antibodies. At present, it is unclear whether antithyroid antibodies represent an immune epiphenomenon in a subset of patients with encephalopathic processes or they are really associated with pathogenic mechanisms of the disorder. The significance of classifying encephalopathies under the term HE will be determined in the future once the relevance of the role of antithyroid antibodies is demonstrated or dismissed by more detailed experimental and immunopathological studies. The responsiveness of HE to steroids or other therapies such as plasmapheresis supports the hypothesis that this is a disorder that involves immune pathogenic mechanisms. Further controlled studies of the use of steroids, plasmapheresis, or immunosuppressant medications are needed in the future to prove the concept of the pathogenic role of antithyroid antibodies in HE.

The thyroid-brain interaction in thyroid disorders and mood disorders

Thyroid hormones play a critical role in the metabolic activity of the adult brain, and neuropsychiatric manifestations of thyroid disease have long been recognised. However, it is only recently that methodology such as functional neuroimaging has been available to facilitate investigation of thyroid hormone metabolism. Although the role of thyroid hormones in the adult brain is not yet specified, it is clear that without optimal thyroid function, mood disturbance, cognitive impairment and other psychiatric symptoms can emerge. Additionally, laboratory measurements of peripheral thyroid function may not adequately characterise central thyroid metabolism. Here, we review the relationship between thyroid hormone and neuropsychiatric symptoms in patients with primary thyroid disease and primary mood disorders.

SNP fine mapping of chromosome 8q24 in bipolar disorder

We previously reported linkage to chromosome 8q24 in bipolar disorder (BP) with a LOD of 3.32. We fine mapped the locus with SNPs and tested for association with BP in families with evidence of linkage to the region. We genotyped 249 informative SNPs over 3.4 Mb in an initial sample of 155 nuclear families (352 affected offsprings), and followed up the best findings by genotyping six of the most significantly associated SNPs in a replication sample of 103 nuclear families (231 affected offsprings). We used FBAT and GIST for association tests. Two clusters of SNPs emerged with the strongest evidence of association. The first consisted of three SNPs, approximately 3 kb 5' from the gene ST3GAL1. These SNPs were associated with BP in the initial sample by FBAT (best P = 0.001) and GIST (best P = 0.05) and associated in the replication sample by FBAT (best P = 0.04). The second cluster consisted of four SNPs (one of which was not genotyped in the replication sample), approximately 480 kb 5' of ST3GAL1 in a relative gene desert. These SNPs were associated with BP in the initial sample by FBAT (best P = 0.007) and GIST (best P = 0.03), and marginally associated in the replication sample by FBAT (best P = 0.07) and GIST (P = 0.04). ST3GAL1 belongs to a family of glycosyltransferase proteins, several members of which are highly expressed in the brain and involved in neurogenesis. Several other interesting candidate genes are also located nearby. The congruence of findings across methods and samples suggests further investigation is warranted in these two targeted regions.

Signs of a higher prevalence of autoimmune thyroiditis in female offspring of bipolar parents

BACKGROUND

Studies are inconsistent as to whether patients with bipolar disorder are more frequently affected by autoimmune thyroiditis.

AIM

To study the prevalence of autoimmune thyroiditis in offspring of bipolar patients.

METHOD

In 1998 140 children (age 12-21 years) of bipolar parents were evaluated psychiatrically using the K-SADS-PL and blood was drawn to determine thyroperoxidase antibodies (TPO-Abs) and serum TSH. Blood samples of high school students (aged 12-19 years, n=77) and young adults (aged 20-35 years, n=52) were used as comparisons. At follow-up the offspring were psychiatrically evaluated and tested for TPO-Abs and TSH twice (14 months and 55 months after enrollment).

RESULTS

TPO-Abs were predominantly found in female bipolar offspring, who had a significantly higher prevalence of positive TPO-Ab titers (9 out of 57 female offspring subjects) as compared to the female high school and young adult comparisons (4 out of 103 female control subjects). In TPO-Ab positive offspring (n=11) a raised prevalence of 55% of thyroid failure (i.e. a raised serum TSH or l-thyroxine treatment) was evident. TPO-Ab positive offspring did not show a raised prevalence of mood disorders (or any psychopathology) as compared to the TPO-Ab negative offspring.

CONCLUSION

Our study suggests that bipolar offspring are more vulnerable to develop thyroid autoimmunity independently from the vulnerability to develop psychiatric disorders.

Peripheral thyroid dysfunction in depression

The involvement of the thyroid gland and thyroid hormones is generally believed to be important in the aetiopathogenesis of major depression. Major support comes from studies in which alterations in components of the hypothalamic-pituitary-thyroid (HPT) axis have been documented in patients with primary depression. However, screening thyroid tests are often routine and add little to the diagnostic evaluation. Overt thyroid disease is rare among depressed inpatients. The finding that depression often co-exists with autoimmune subclinical thyroiditis suggests that depression may cause alterations in the immune system, or that in fact it could be an autoimmune disorder itself. The outcome of treatment and the course of depression may be related to thyroid status as well. Augmentation of antidepressant therapy with the co-administration of thyroid hormones (mainly T3) is a well-documented treatment option for refractory depressed patients. Review of the literature suggests that there are no conclusive data on the role of thyroid function in depression. It is clear that depression is not characterised by an overt thyroid dysfunction, but it is also clear that a subgroup of depressed patients may manifest subtle thyroid abnormalities, or an activation of an autoimmune process. There is a strong possibility that the presence of a subtle thyroid dysfunction is a negative prognostic factor for depression and may demand specific therapeutic intervention.

A relative resistance of T cells to dexamethasone in bipolar disorder

OBJECTIVE

A relative resistance of immune cells to steroids has been established in patients with major depression (MD). In this study, we investigated the in vitro responsiveness of T cells to dexamethasone (DEX) of patients with bipolar disorder (BD).

METHODS

T cells of outpatients with DSM-IV BD (n = 54) and of healthy control subjects (HC; n = 29) were isolated, cultured and stimulated with phytohemagglutinin (PHA) for 72 h. The suppressive effect of graded concentrations of DEX (5 x 10(-9)-10(-5) M) on PHA-induced CD25 (IL-2R) expression was measured by fluorescence-activated cell sorting (FACS) analysis. Data were correlated to the T-cell activation status in the peripheral blood of the same patients and to their diagnosis, current mood state, ultradian cycling pattern and current use of medication, including lithium.

RESULTS

T cells of patients with BD were less sensitive to DEX-induced suppressive effects as compared with T cells of HC. These data were particularly evident at 10(-7) M DEX (mean % suppression +/- SEM BD: 18.9% +/- 3.5 versus HC: 35.8% +/- 4.7, p = 0.001). We found no correlations of this relative in vitro DEX resistance of T cells neither with the previously mentioned clinical characteristics nor with the actual activation status of the T cells in the BD patients.

CONCLUSION

A relative T-cell resistance to steroids, as has been observed in MD previously, may be a trait phenomenon of BD, independent of mood state.

Anti-heat shock protein 90 is increased in acute mania

OBJECTIVE

The aim of this work was to examine autoantibodies in patients with bipolar disorder.

METHOD

We enrolled 94 patients with acute bipolar mania, with 37 of them medicated and 57 unmedicated at the time of blood sampling. The samples also consisted of 44 patients in the remission state and another 48 normal controls. We first used human glioblastoma (U373 MG) cell lysate to screen the potential autoantibodies present in sera of bipolar mania patients, and anti-heat shock protein (anti-HSP) 60, 70 and 90 autoantibodies were identified. We then examined the serum levels of these autoantibodies by enzyme-linked immunosorbent assay.

RESULTS

The findings of this study showed that serum anti-HSP90 level was significantly higher in bipolar patients in acute mania than those in remission (p = 0.002).

CONCLUSIONS

The data of this study suggest that increased anti-HSP90 might be a state marker for acute mania in patients with bipolar disorder.

Hashimoto's encephalopathy presenting with bipolar affective disorder

OBJECTIVE

We report on a rare case of Hashimoto's encephalopathy associated with a bipolar affective disorder.

CASE REPORT

A 32-year-old woman presented with a bipolar affective disorder and Hashimoto's thyroiditis. Neurological investigations (magnetic resonance imaging of the brain and cerebrospinal fluid) did not reveal any pathological findings except for a pathological electroencephalogram (EEG). Despite consequent antidepressant treatment, the patient remitted only in conjunction with normalization of the EEG after short-term treatment with high doses of prednisolone.

CONCLUSION

In treatment resistant courses of disorders, the thorough clinical and laboratory investigation of our patient revealed a very efficient treatment strategy. Cases of Hashimoto's encephalopathy associated with the occurrence of a manic episode and hence with bipolar disorder are rare; this is the first reported case. However, clinicians should be alert to this possibility.

[Potentializing of tricyclics and serotoninergics by thyroid hormones in resistant depressive disorders]

In response to the increase of resistant depressive disorders and in spite of improved treatments, numerous studies were conducted in the last thirty Years aiming at assessing the pre-morbid thyroid state of depressed patients resistant to well conducted tricyclic treatments. "Minimal" thyroid abnormalities were evidenced as well as central thyroid disorders which may not be detected by peripheral-i.e plasmatic- dosages. Regarding the premorbid thyroid status, the hypothesis of subclinical hypothyroidism was considered by many Authors. It is marked by four grades including T3 and T4 decreased levels, basal TSH concentration abnormalities as well as increased TSH response to TRH stimulation, and the presence of antimicrosomal and antithyroglobulin antibodies. Although, there are different views on the existence or not of these abnormalities, we'll focus our attention on a metaanalysis including six studies. It shows in a population with a resistant depression, 52% of patients with subclinical hypothyroidism, against 8 to 17% in patients with simple depression and 5% in the overall population.Similarly, antithyroid antibody levels (group IV hypothyroidism) were significantly higher in depressed patients (9% to 20% against 7,5% in the overall population). For many Years, a central hypothyroidism was hypothesized on the basis of an exhausted T3-T4 transference mechanism and a lowered TRH hypothalamic biodisponibility.In the last Years, new data emerged on the role of transthyretin, a cerebral carrier T4 protein, whose concentration in the CSF was found significantly lower in depressed patients than in a control group, the lowest levels being observed in the most severely depressed. This decreased level of transthyretin would result in a lower central T4 biodisponibility-hence, in view of a T4-T3 desiodation insufficiency, a T3 deficit is observed. A low transthyretin level associated or not to subclinical hypothyroidism could be a factor of depressive vulnerability on one hand, of resistance to tricyclic treatment on the other one. Conversely, subclinical hypothyroidism could be a predictive factor of a good response to a potentializing strategy. The pharmacological mechanisms involved in this potentializing phenomenon are now well known: they consist in an interaction between depression, adrenergic receptors and thyroid hormones biodisponibility. The decreased norepinephrine level observed in depressive patients is associated, in case of increased thyroid hormones biodisponibility, with a higher sensitivity of adre-nergic receptors, mostly betaadrenergic. This seems to underly the recovery process. According to some Authors, the serotoninergic system might be involved in the potentialization of tricyclics by thyroid hormones. We know that in animals with hypothyroidism, the serotonin synthesis is decreased and that the administration of T3 increases the brain levels of serotonin and its 5HIA catabolite. In addition, T3 could correct the down-regulation induced by serotoninergics on beta-adrenergic receptors. On the basis of numerous studies carried out on the potentializing of tricyclics, we suggest practical modalities of treatment - which until today did not materialize in every day practice in the absence of a clear consensus based on statistically reliable data: after four to six weeks of inefficient tricyclic or serotoninergic treatment on a correct dosage testified by plasmatic dosages, it is recommended to initiate a T3 treatment on a effective posology (25 to 50 micrograms per day), which must be reached in 2 or 3 days, except in case of rare and transitory side effects (sweating, shaking, tachycardia, nervousness, anxiety). If the treatment is not rapidly efficient, it must be discontinued in case there is no improvement after 3 weeks. Until today, there is no consensus about the duration of a T3 treatment. It is important to take into account the predictive criteria of good or bad response to a T3 potentialization, since they have direct consequences on the management of depressed patients. For example, a high degree of chronic evolution with resistance to numerous treatments, associated disorders according to the DSM IV axis I and a comorbidity of addiction, point to a bad prognosis of a potentialization treatment. In addition, we'll examine the few recent studies on the potentializing of serotoninergic antidepressant drugs by thyroid hormones.

Thyroid function in clinical subtypes of major depression: an exploratory study

BACKGROUND

Unipolar depression might be characterized by a 'low-thyroid function syndrome'. To our knowledge, this is the first study which explores the possible relationship of DSM-IV depressive subtypes and the medium term outcome, with thyroid function.

MATERIAL

Thirty major depressive patients (DSM-IV) aged 21-60 years and 60 control subjects were included. Clinical Diagnosis: The SCAN v 2.0 and the IPDE were used. The psychometric Assessment included HDRS the HAS and the GAF scales. Free-T3, Free-T4, TSH, Thyroid Binding Inhibitory Immunoglobulins (TBII), Thyroglobulin antibodies (TA) and Thyroid Microsomal Antibodies (TMA) were measured in the serum. The Statistical analysis included 1 and 2-way MANCOVA, discriminant function analysis and Pearson Product Moment Correlation Coefficient.

RESULTS

All depressive subtypes had significantly higher TBII levels in comparison to controls. Atypical patients had significantly higher TMA in comparison to controls. No significant correlation was observed between the HDRS, HAS and GAF scales and thyroid indices. Discriminant function analysis produced functions based on thyroid indices, which could moderately discriminate between diagnostic groups, but could predict good response to treatment with 89.47% chance of success.

CONCLUSION

Although overt thyroid dysfunction is not common in depression, there is evidence suggesting the presence of an autoimmune process affecting the thyroid gland in depressive patients

No evidence for an association of the CTLA4 gene with bipolar I disorder

The purpose of the present paper was to investigate the relationship between the first exon at position +49 (A/G) polymorphism of the cytotoxic T lymphocyte antigen 4 (CTLA4) gene and bipolar disorder. Among the Korean patients diagnosed with bipolar disorder according to Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV), 90 patients without serious medical illness, neurologic illness, hormonal disorder, or concomitant mental illness were selected. The normal control group consisted of 149 age- and sex-matched subjects without current or past history of autoimmune diseases or mental disorder. DNA was extracted from peripheral blood using proteinase K; and the exon 1 region of the CTLA4 gene was amplified by polymerase chain reaction. Gene typing was performed using single strand conformation polymorphism. There were no significant differences in genotype frequencies of CTLA4*G/G, CTLA4*G/A, and CTLA4*A/A between the patients with bipolar disorder and the control group (48.9% vs 46.3%, 44.4% vs 39.6%, and 6.7% vs 14.1%, respectively). There were no significant differences in allelic frequencies of CTLA4*G and CTLA4*A between the patients with bipolar disorder and the control group (71.1% vs 66.1%; 28.9% vs 33.9%, respectively). In the present study an association was not found of exon 1 (+49) polymorphism of CTLA4 gene with bipolar disorder in the Korean population.

Linkage of bipolar affective disorder on chromosome 8q24: follow-up and parametric analysis

Our group first reported a linkage finding for bipolar (BP) disorder on chromosome 8q24 in a study of 50 multiplex pedigrees, with an HLOD score reaching 2.39. Recently, Cichon et al reported an LOD score of 3.62 in the same region using two-point parametric analysis. Subsequently, we published the results of a genome scan for linkage to BP disorder using a sample extended to 65 pedigrees in which chromosome 8q24 provided the best finding, an NPL score of 3.13, approaching the accepted score for suggestive linkage. We have now fine mapped this region of chromosome 8 in our 65 pedigrees by the addition of 19 microsatellite markers reaching a marker density of 0.8 cM and an information content of 0.84. After the addition of the new data, the original NPL score slightly increased to 3.25. Two-point parametric analysis using the model employed by Cichon et al obtained an LOD score of 3.32 for marker D8S256 at theta=0.14 exceeding the proposed threshold for genomewide significance. After adjusting the parameters in accordance with the 'common disease-common variant' hypothesis, multipoint parametric analysis resulted in an HLOD of 2.49 (alpha=0.78) between D8S529 and D8S256, and defined a 1-LOD interval corresponding to a 2.3 Mb region. No allelic association with the disease was observed for our set of microsatellite markers. Biologically, plausible candidate genes in this region include thyroglobulin, KCNQ3 coding for a voltage-gated potassium channel and the gene for brain adenyl-cyclase (ADCY8).

High rate of autoimmune thyroiditis in bipolar disorder: lack of association with lithium exposure

BACKGROUND

We assessed the prevalence of thyroperoxidase antibodies (TPO-Abs) and thyroid failure in outpatients with bipolar disorder compared with two control groups.

METHODS

The TPO-Abs of outpatients with DSM-IV bipolar disorder (n = 226), a population control group (n = 252), and psychiatric inpatients of any diagnosis (n = 3190) were measured. Thyroid failure was defined as a raised thyroid stimulating hormone level, previously diagnosed hypothyroidism, or both. Subjects were compared with attention to age, gender, and exposure to lithium.

RESULTS

The TPO-Abs were more prevalent in bipolar patients (28%) than population and psychiatric controls (3-18%). The presence of TPO-Abs in bipolar patients was associated with thyroid failure, but not with age, gender, mood state, rapid cycling, or lithium exposure. Thyroid failure was present in 17% of bipolar patients and more prevalent in women. It was associated with lithium exposure, especially in the presence of TPO-Abs, but not with current rapid cycling, although an association may have been masked by thyroid hormone replacement.

CONCLUSIONS

Thyroid autoimmunity was highly prevalent in this sample of outpatients with bipolar disorder and not associated with lithium treatment. These variables appear to be independent risk factors for the development of hypothyroidism, especially in women with bipolar disorder.

Subclinical hypothyroidism: a review of neuropsychiatric aspects

The authors review current information about the prevalence, causes, course, and consequences of subclinical hypothyroidism. There is evidence that subclinical hypothyroidism may be associated with cognitive dysfunction, mood disturbance, and diminished response to standard psychiatric treatments. Recommendations are presented for the screening, evaluation and treatment of patients in whom subclinical hypothyroidism may be contributing to neuropsychiatric dysfunction.

Immunological aspects of bipolar disorder

INTRODUCTION

Significant changes in immune function have been found in mood disorders. Controlled studies in bipolar disorder concerning cell-mediated immunity and thyroid autoimmunity are reviewed, and presented together with preliminary findings from our own ongoing study.

METHOD

Using Medline and other sources, 14 controlled studies as well as some other relevant studies were found.

RESULTS

Bipolar disorder is associated with an acute phase response and activation of the cell-mediated immune system, and with an increased prevalence of antithyroid autoantibodies.

CONCLUSION

Changes in immune function, in connection with neuroendocrine changes, may provide new hypotheses for the pathophysiology of mood disorders.

Autoantibody disturbances in affective disorders: a function of age and gender?

BACKGROUND

Numerous investigators have reported increased autoantibodies to a wide variety of native antigens in patients with affective disorders. However, association of autoimmunity with affective subtypes, mood state, psychotropic medications, age, and gender has not been extensively explored.

METHODS

The present study assessed 79 bipolar I, 24 bipolar II, and 46 unipolar major depression patients along with 22 healthy, nonpsychiatric controls for the presence of serum antinuclear (ANA), anti-double stranded DNA, antithyroid microsomal, antithyroglobulin, anticardiolipin (ACA) IgM, and ACA IgG antibodies.

RESULTS

Consistent with their higher prevalence of autoimmune disease, women exhibited increased levels of ANA and ACA IgM compared to men. ACA IgG antibody titers also increased significantly with age. Contrary to prior reports of general, overall increases in autoantibodies and specific increases in ANA and antithyroid antibodies in depressed patients, we did not see a significant association between any of the autoantibodies and affective subtype, mood state, or psychotropic medications.

LIMITATIONS

Affective subgroups were heterogeneous with respect to psychotropic medications, affective state, age, and gender in this retrospective analysis. Subgroup sample size was insufficient to determine whether interactions of these clinical variables may have influenced results.

CONCLUSION

These results suggest that gender and age may have more influence on autoantibodies than affective diagnosis, affective state, or medications.

Activation of indices of cell-mediated immunity in bipolar mania

BACKGROUND

Evidence supports that macrophages as well as lymphocytes and their products may be involved in the pathophysiology of psychiatric disorders. Whether patients with bipolar disorder have activation or reduction of immunity during a manic episode remains unclear.

METHODS

The purpose of this case-control study was to investigate the lymphocyte proliferation to phytohemagglutinin (PHA), concanavalin A, and pokeweed mitogen, and plasma levels of soluble interleukin-2 receptor (sIL-2R) and sIL-6R in patients with bipolar mania (DSM-III-R). The subjects were 23 physically healthy patients with Young Mania Rating Scale (YMRS) scores > or = 26 as well as aged < or = 45 years and 23 age- and gender-matched normal control subjects. The above immune variables were measured in acute mania and consequent remission (YMRS scores < or = 12) among bipolar patients.

RESULTS

The lymphocyte proliferation to PHA and the plasma sIL-2R levels, but not sIL-6R, of bipolar patients were significantly higher in acute mania than in consequent remission. These elevations were not due to differences in medication status. Only in acute mania were the plasma sIL-2R levels of patients significantly higher than control subjects. A positive correlation between the changes of manic severity and plasma sIL-2R levels was observed. Remitted bipolar patients and normal control subjects did not differ in any of these measures.

CONCLUSIONS

Cell-mediated immunity activation in bipolar mania was demonstrated and may be through a specifically state-dependent immune response.

Psychoneuroendocrinology of mood disorders. The hypothalamic-pituitary-thyroid axis

Abnormal thyroid functioning can affect mood and influence the course of unipolar and bipolar disorder. Even mild thyroid dysfunction has been associated with changes in mood and cognitive functioning. Thyroid hormone supplementation may have role in the treatment of certain mood disorders, particularly rapid-cycling bipolar disorder. Women are more vulnerable to thyroid dysfunction than men and also respond better to thyroid augmentation. This article reviews the relationship between thyroid function and mood, and the use of thyroid hormones in the treatment of mood disorders. The impact of gender on these issues is also discussed.

The diagnosis and treatment of subclinical hypothyroid states in depressed patients

The diagnosis and treatment of subclinical hypothyroidism in mood-disordered patients is complex and somewhat controversial. The psychiatrist must recognize that such subclinical states may contribute to depression, mood cycling, or delayed response to treatment if undetected. Autoimmune thyroiditis, which may ultimately lead to various grades of hypothyroidism, may also be seen in depressed populations, particularly in postpartum females. The author discusses these issues by means of a clinical vignette, then proposes an algorithm for the diagnosis and treatment of hypothyroid states in mood disordered populations.

Pituitary responses to thyrotropin releasing hormone stimulation in depressed women with thyroid gland disorders

From an endocrine outpatient clinic and psychiatric outpatient clinic in Kaunas, Lithuania, 41 women with major depression were selected for study. Three groups of depressed women were established: 15 with autoimmune thyroiditis (AIT); 13 with diffuse non-toxic goiter (DNG); 13 with no thyroid disease (NTD). Standard biochemical tests were used to exclude patients with overt hypothyroidism or overt hyperthyroidism. At baseline the three groups were similar in age and almost identical in severity of depression. In part because of exclusion criteria, all baseline biochemical measures were similar. However, a slight elevation of thyroid-stimulating hormone (TSH) in the AIT group was noted and considered to indicate a tendency toward subclinical hypothyroidism. After thyrotropin-releasing hormone (TRH) administration, six AIT women and six DNG women, but no NTD women, showed blunted TSH responses. As a group DNG women showed smaller TRH responses than other women. Four AIT women showed exaggerated TSH responses. In all three groups basal TSH correlated positively with TSH response to TRH. Basal prolactin (PRL) responses to TRH infusion were similar in all three groups. However, the four AIT women with enhanced TSH responses also showed enhanced PRL responses. Indeed, in the AIT group, but only in this group, PRL responses were correlated with both TSH and basal TSH. In all groups of women the PRL response was unrelated to basal PRL.

Association between chronic widespread musculoskeletal complaints and thyroid autoimmunity. Results from a community survey

OBJECTIVE

To test a hypothesis derived from observations in general practice that thyroid antibodies were associated with chronic widespread musculoskeletal complaints.

DESIGN

Cross-sectional study of 40-42 year old men and women based on a self-administered questionnaire and on results of blood tests.

SETTING

Sarpsborg municipality, Norway.

PARTICIPANTS

737 men and 771 women who attended the National Health Screening Service's mobile unit in 1989 and answered the questionnaire.

MAIN OUTCOME MEASURES

Prevalence of detectable microsomal thyroid antibodies in persons with and without chronic widespread musculoskeletal complaints.

RESULTS

The prevalence of thyroid microsomal antibodies was significantly higher in persons with than without chronic widespread musculoskeletal complaints (16.0% versus 7.3%, p < 0.01). The increase was restricted to women (20.4% versus 11.6%, p = 0.02). Thyroid function tests did not differ significantly between the two groups.

CONCLUSION

The association between chronic widespread musculoskeletal pain complaints and thyroid antibodies in women may reflect a subgroup of patients in which thyroid autoimmunity, rather than thyroid function, is important. A possible relationship to fibromyalgia is discussed as well as a hypothetical role for thyrotropin releasing hormone.

Bipolar affective disorder and autoimmune disease

In Bipolar affective disorder, the importance of genetic factors is well established through family, twin and adoption studies. However the exact mode of inheritance is not yet known. Genetic studies using DNA linkage have been attempted to identify susceptibility genes. Linkage studies of chromosome 11 and X chromosome have proved to be inconclusive. Recent studies have focused on chromosome 18 and 21, although confirmatory findings are awaited. As such, determining which part of the genome needs to be studied remains a problem. One way of overcoming this is to look for ‘candidate’ genes, ie. genes for which a priori evidence exists that a susceptibility gene may be located nearby.

Such strategies have been used for example, trying to identify genes of interest by looking at association between chromosomal aberrations and bipolar affective disorder, and the study of co-segregation of certain diseases with affective disorder. More studies are needed to provide regions of interest. I would like to report three cases of bipolar affective disorder with a rare autoimmune disorder, cryptogenic fibrosing alveolitis.

Clinical and subclinical hypothyroidism in patients with chronic and treatment-resistant depression

OBJECTIVE

To investigate the relationship between hypothyroidism and treatment-resistant depression (TRD).

METHOD

A retrospective case audit of 93 inpatients of a specialist Mood Disorders Unit. Patients referred with TRD were sub-classified into 'adequate' or 'inadequate' prior treatment groups on the basis of pre-established criteria, and compared with a 'non-TRD' control sample. Grades I (clinical) and II (subclinical) hypothyroidism were determined by review of relevant thyroid indices.

RESULTS

Patients had chronic depressive disorders (sub-group means of 57.5-82.2 weeks of illness). Of those patients referred with TRD, 22% (10/46) had evidence of clinical or subclinical hypothyroidism compared with 2% (1/47) of the non-TRD patients (p < 0.01). A gradient in the rates of grade I hypothyroidism was observed with the adequately-treated TRD patients having the highest rate (13%), the inadequately-treated TRD patients having an intermediate rate (7%), and the non-TRD patients having the lowest rate (2%). Consistent with this view, the inadequately-treated TRD group had the highest rate of grade II hypothyroidism (p = 0.01) and tended to have higher thyroid stimulating hormone (TSH) values (p = 0.06). Differences in the rates of hypothyroidism could not be accounted for by differences in age or prior exposure to lithium and/or carbamazepine. Duration of the depressive episode was negatively correlated with both the free thyroxine indices (r = -0.25, P < 0.05) and TSH levels (r = -0.32, p < 0.01).

CONCLUSIONS

This study suggests that relative hypothyroidism may play a role in the development of some treatment-resistant depressive disorders.

Borderline hypothyroidism and depression

This review defines subclinical hypothyroidism and examines its influence on the occurrence and course of major depression. Recommendations are presented for the identification and treatment of patients with coexisting mood disorders and borderline thyroid failure.

High prevalence of thyroid function test abnormalities in chronic schizophrenia

The thyroid status of 249 patients with chronic schizophrenia (males = 136, females = 113) with a median age of 36 years (range: 16 to 58 years) and a median duration of hospitalisation of 10 years (range: 1 to 30 years) was assessed. Thyroid antibodies (TAb) were found in 51 patients (20%). In female patients, 32 (28%) were TAb positive compared to 13% (n = 152, p = 0.01) in healthy female blood donors. In male patients, the prevalence of TAb was 14% compared to 7% (n = 449, p = 0.01) in healthy male blood donors. Of the 183 patients who had thyroid hormone measurements, 60% had normal test, 5% had elevated TSH and 17% had low TSH. The T4, FT41 and FT31 were significantly lower in those with low or high TSH (p < 0.001) compared to those with normal TSH. Of the 143 patients with normal TSH, 33 (23%) had low T3. In conclusion, there is a spectrum of thyroid function test abnormalities in chronic schizophrenia; this may be related to an abnormality in the central regulation of the hypothalamo-pituitary thyroid axis as well as at the peripheral level. However the association between chronic schizophrenia and the presence of thyroid antibodies, and the clinical relevance of these biochemical abnormalities, are still not clear.

Immune parameters in euthymic bipolar patients and normal volunteers

Immune system parameters were investigated in euthymic bipolar patients and matched normal volunteers. A review of the existing literature suggested that bipolar patients might be more likely to demonstrate signs of immune activation. Serum-soluble interleukin-2 receptors, circulating phenotypic lymphocyte markers, levels were measured. Euthymic bipolar patients and normal volunteers did not differ or any of these measures. Furthermore, bipolar patients could not be differentiated by medication status or gender. In conclusion, there was no evidence of immune system activation in euthymic bipolar patients.

Thyrotropin response to TRH stimulation in depressed patients with autoimmune thyroiditis

Two thyroid axis findings are often reported in depressed patients: autoimmune thyroiditis and abnormal thyrotropin (thyroid stimulating hormone, TSH) responses to thyrotropin-releasing hormone (TRH). The TSH response to TRH can be exaggerated, suggesting subclinical hypothyroidism; it can alternatively be blunted, for reasons poorly understood. We selected 28 women who had been found to have major depression for TRH testing. Fifteen patients had autoimmune thyroiditis and 13 had diffuse nontoxic goiter. The endocrinological diagnoses were verified by fine-needle aspiration biopsy and cytological assessment. Patients with overt hypothyroidism and hyperthyroidism were excluded from the study. There were no differences between the two groups in total triiodthyronine and thyroxine plasma levels or severity of depression. In the autoimmune group, basal TSH and Dmax TSH tended to be higher (p < 0.1); peak TSH was significantly higher (p < 0.05), suggesting that the prevalence of subclinical hypothyroidism was also higher. Blunted TSH responses were found about as often in one group as the other.