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

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

CONTEXT

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Serial multiple mediating roles of anxiety and thyroid-stimulating hormone in the relationship between depression and psychotic symptoms in young adults with anxious depression

BACKGROUND

Psychotic symptoms (PS) frequently occur in young adults with anxious depression (AD), yet the mediators of the associations between depression and PS remain unclear. This study aimed to investigate the prevalence and risk factors of PS in first-episode and drug-naïve (FEDN) young adults with AD and attempted to elucidate the relationship between thyroid-stimulating hormone (TSH) levels, anxiety, depression, and PS, as well as to identify potential mediating roles.

METHODS

369 FEDN young adults with AD were recruited. Clinical symptoms were assessed using the Positive and Negative Syndrome Scale's positive subscale, the Hamilton Depression Rating Scale (HAMD), and the Hamilton Anxiety Rating Scale (HAMA). Fasting glucose, lipids, and thyroid function were also collected.

RESULTS

The prevalence of PS in young adults with AD (21.68 %) was 12.24 times higher than in non-AD patients. The HAMD scores (P = 0.005, OR = 1.23), HAMA scores (P < 0.001, OR = 1.62), and TSH levels (P = 0.025, OR = 1.20) were significant predictors of PS. The combined area under the curve value for distinguishing young adults with AD with and without PS was 0.86. We also identified serial multiple mediating effects of TSH levels and anxiety on the association of depression with PS.

CONCLUSIONS

These findings emphasize the role of anxiety and TSH levels as serial mediators of the association between depression and PS. Therefore, when treating PS in young adults with AD, it is important to focus not only on depression, but also on TSH levels and anxiety to maximize benefit.

The effect of neuroendocrine abnormalities on the risk of psychiatric readmission after hospitalization for bipolar disorder: A retrospective study

BACKGROUND

The correlation between the endocrine system and bipolar disorder(BD) has been well recognized, yet the influence of neuroendocrine hormones on readmission risk post-hospitalization for BD remains largely unexplored. This retrospective cohort study was to scrutinize the impact of neuroendocrine functionality on the readmission of patients with BD post-hospitalization for mental disorders.

METHODS

The dataset was derived from the electronic medical records of the First Affiliated Hospital of Jinan University in Guangzhou, China. Both univariate and multivariate logistic regression analysis were conducted on all patients hospitalized for BD, and from 1 January 2017 to October 2022.

RESULTS

Of the 1110 eligible patients, 83 and 141 patients experienced psychiatric readmissions within 90 and 180 days post-discharge, respectively. Multivariate analysis revealed that high serum TSH levels (aOR = 1.079; 95%CI = 1.003-1.160) and thyroid disease comorbidities (aOR = 2.899; 95%CI = 1.303-6.452) were independently correlated with the risk of 90-day readmission; while increased serum TSH levels (aOR = 1.179; 95%CI = 1.081-1.287) represented a risk factor for 180-day readmission. These results indicate that high serum TSH levels and thyroid disease comorbidities may contribute to an elevated readmission risk in patients with BD following hospitalization.

CONCLUSION

Routinely evaluating and intervening in thyroid function is crucial in the treatment of BD, as it may aid in preventing re-hospitalization.

Prevalence and risk factors for metabolic syndrome in schizophrenia, schizoaffective, and bipolar disorder

BACKGROUND

Metabolic Syndrome (MetS) is a risk for developing cardiovascular diseases and its prevalence is especially high in psychiatric patients. To date, there is limited data from the United Arab Emirates (UAE) on the prevalence of MetS. Therefore, we aimed to investigate its prevalence and possible risk factors in a large sample of psychiatric patients in the UAE.

METHODS

A cross-sectional study was conducted at Al-Ain Hospital, in Al-Ain City, UAE. We collected demographic and clinical data on patients diagnosed with schizophrenia, schizoaffective, and bipolar affective disorder in the period between January 2017 and December 2020. This included their secondary diagnosis (psychiatric or medical), vital signs (heart rate, systolic and diastolic blood pressure, Body Mass Index [BMI]), metabolic parameters (fasting blood glucose, cholesterol, triglycerides, low-density lipoprotein, high-density lipoproteins), and prescribed medications. We used the American Association of Clinical Endocrinology (AACE) criteria to diagnose MetS.

RESULTS

We included 889 subjects and of these, 79.8% (N = 709) had a BMI ≥25 kg/m2 and 9.8% (N = 87) had no abnormal metabolic parameters. Overall, 28.1% (N = 250) had MetS with no statistical difference between the three groups. Fasting blood glucose levels and abnormally elevated triglycerides were significant predictors for MetS.

CONCLUSION

Our study found that around one in three patients had MetS irrespective of the three diagnoses. Some variables were significant predictors for MetS. Our findings were consistent with other studies and warrant the need for regular screening and management of abnormal metabolic parameters.

The prevalence of anxiety in adult endocrinology outpatients: A systematic review and meta-analysis

INTRODUCTION

Anxiety disorders and anxiety symptoms are common mental disorders in the medically unwell and have significant impacts on patients' quality of life and engagement with psychiatric and medical services. Several systematic reviews have examined the prevalence of anxiety in specific endocrinology settings with estimates varying significantly from study to study. No meta-analysis has examined anxiety rates across the endocrinology outpatient setting. The aim of this meta-analysis is to provide endocrinologists with a precise estimate of the prevalence of anxiety - and impacting factors - in their outpatient clinics.

METHOD

PubMed, Embase, Cochrane and PsycINFO databases and Google Scholar were searched to identify studies that assessed anxiety prevalence in endocrinology outpatients published up to 23 January 2023. This was part of a larger systematic review search of anxiety prevalence in common medical outpatient clinics. Data characteristics were extracted independently by two investigators. Studies of patients 16 years and older and representative of the clinic were included. The point prevalence of anxiety or anxiety symptoms was measured using validated self-report questionnaires or structured interviews. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklist. Pooled estimates were analysed under the random-effects model and subgroup analyses on relevant variables were conducted under a mixed-effects model. Heterogeneity was assessed using the I2 statistic.

RESULTS

Fifty-nine studies with a total of 25,176 participants across 37 countries were included in this study. The overall pooled prevalence of anxiety or anxiety symptoms was 25·1% (95%CI 21·4-29·2; 6372/25,176; n = 59). Subgroup analyses revealed no difference in prevalence between outpatients with diabetes mellitus compared to other grouped endocrine disorders. Generalized Anxiety Disorder (GAD) was the most frequent clinical diagnosis 11·7% (95%CI 8·1-16·7; I2=87·93%; 443/4604; n = 17), while panic disorder was significantly higher in the non-diabetes group 9·5% (95%CI 5·9-14·9; I2=57·28%; 56/588; n = 8), compared to the diabetes group 5·2% (95%CI 3·7-7·3; I2=32·18%; 184/3669; n = 6). Estimates of prevalence were higher when assessed with a self-report scale 32·4% (95%CI 25·6-40·0; I2=96·06%; 1565/4675; n = 21) compared to diagnostic interview 17·6% (95%CI 12·2-24·7; I2=94·39%; 636/5168; n = 21). Outpatients in developing countries had higher rates of anxiety than those in developed countries. Female diabetes patients reported higher rates of anxiety compared to males.

CONCLUSION

Our study provides evidence that anxiety occurs frequently amongst endocrinology outpatients and at a higher rate than is estimated in the general population. Given the impact anxiety has on patient outcomes, it is important that effective management strategies be developed to support endocrinologists in identifying and treating these conditions in their outpatient clinics.

Depression severity partially mediates the association between thyroid function and psychotic symptoms in first-episode, drug-naive major depressive disorder patients with comorbid anxiety at different ages of onset

BACKGROUND

Anxiety and psychotic symptoms are common in patients with major depressive disorder (MDD), with a strong association with thyroid function. Age of onset contributes to the heterogeneity of MDD patients. This study aimed to assess the prevalence of psychotic symptoms in MDD patients with comorbid anxiety and to explore the relationship between thyroid function and psychotic symptoms by ages of onset.

METHODS

A total of 894 first-episode, drug-naïve Chinese Han MDD patients with comorbid anxiety were recruited. Thyroid function and psychometric measures including Hamilton Anxiety Scale, Hamilton Depression Scale, and Positive and Negative Syndrome Scale were evaluated. Patients were divided into early adulthood onset (EAO, < 45 years old) and mid-adulthood onset (MAO, ≥ 45 years old) groups.

RESULTS

The MAO subgroup had a higher prevalence of psychotic symptoms compared to EAO subgroup. TSH and TPOAb levels were positively correlated with psychotic symptoms severity, with a more pronounced effect in MAO subgroup. Furthermore, MDD severity partially mediated the effects of TPOAb and TSH levels on psychotic symptoms in both subgroups.

LIMITATIONS

A causal relationship could not be demonstrated with this cross-sectional study, and the results should be limited to first-episode, drug-naïve MDD patients without considering more potential confounders. Moreover, the male-to-female ratio imbalance is present.

CONCLUSIONS

Our results indicated that age of onset moderated the association between thyroid function and psychotic symptom, and depression severity partially mediated the effects of thyroid function on psychotic symptoms, suggesting thyroid function may serve as a biomarker of psychotic symptoms in MDD patients with anxiety.

Impact of hyperthyroidism and its treatment on the outcome of mental health, occupational functioning, and quality of life: A naturalistic, prospective study

Context Background

Hyperthyroidism has a major impact on mental health.

Aims

We intended to determine the magnitude of the unmet need for mental health support in patients with hyperthyroidism attending an endocrinology clinic.

Settings and Design

General Hospital Endocrine Department, Prospective Study.

Methods and Material

In a naturalistic, prospective study, consecutive (n = 176) hyperthyroid patients were assessed for anxiety (generalized anxiety disorder, GAD-7), depression (Patient Health Questionnaire PHQ-9), functional impairment (work and social adjustment scale, WSAS), and quality of life (EuroQol ED5D) using standardized instruments.

Statistical Analysis Used

Percentages, mean and standard deviation (SD), Chi-square, Student's t-test, ANOVA, Spearman's correlation.

Results

A considerable proportion (40.5%) of patients had moderate and severe anxiety, around half (50.6%) had moderate or severe depression, and 20.8% had severe functional impairment at presentation. Mean EQ5D score was 59.6 ± 23.5. The scores of anxiety, depression, and functional impairment were significantly correlated with each other and negatively correlated with QOL. Following treatment of hyperthyroidism, improvement in psychiatric symptoms was noted which could be correlated with the lowering of T4. However, a significant proportion of patients continued to have psychiatric symptoms and functional impairment despite achieving euthyroidism. There was no correlation between the severity of hyperthyroidism to persistence of mental health parameters.

Conclusions

Our findings of high prevalence and persistence of impairment of mental health and functional status of patients with hyperthyroidism have highlighted the unmet needs for these patients.

Coping profiles, depression, and body image anxiety during the Covid-19 pandemic: Comparative analysis of females with thyroid diseases and a non-clinical sample

OBJECTIVES

This study aimed to compare profiles of coping among females with thyroid disorders and females from a healthy control group regarding depression levels and body image anxiety. We also wanted to check whether subjectively experienced Covid-19-related psychological distress moderated the above-mentioned association in both groups of participants.

METHOD

The study sample comprised 564 females, of which 329 were diagnosed with a thyroid disease and 235 formed the healthy control group. Participants filled out paper-and-pencil or online versions of psychometric questionnaires to assess coping strategies, depression, and body image anxiety.

RESULTS

In general, we observed higher depression intensity and a higher level of body image anxiety among females with thyroid diseases than among the healthy control group. Latent profile analysis revealed adaptive vs. maladaptive coping profiles from both study samples. Depression symptoms were significantly higher if coping was maladaptive in both the clinical and control groups. Still, there were no significant differences in body image anxiety between participants with adaptive and maladaptive coping profiles. Covid-19-related distress did not moderate the link between coping profiles, depression, and body image anxiety in either group.

CONCLUSION

Greater focus should be placed on the role of body image in females struggling with thyroid diseases. Bodily therapy may help these patients to cope better with co-occurring thyroid diseases and mental disorders, whose relationship is still not fully understood.

Graves' disease as a driver of depression: a mechanistic insight

Graves' disease (GD) is characterized by diffuse enlargement and overactivity of the thyroid gland, which may be accompanied by other physical symptoms. Among them, depression can dramatically damage patients' quality of life, yet its prevalence in GD has not received adequate attention. Some studies have established a strong correlation between GD and increased risk of depression, though the data from current study remains limited. The summary of mechanistic insights regarding GD and depression has underpinned possible pathways by which GD contributes to depression. In this review, we first summarized the clinical evidence that supported the increased prevalence of depression by GD. We then concentrated on the mechanistic findings related to the acceleration of depression in the context of GD, as mounting evidence has indicated that GD promotes the development of depression through various mechanisms, including triggering autoimmune responses, inducing hormonal disorders, and influencing the thyroid-gut-microbiome-brain axis. Finally, we briefly presented potential therapeutic approaches to decreasing the risk of depression among patients with GD.

A case of mood disorder with severe side effects of antidepressants in association with resistance to thyroid hormone beta with a THRB mutation

Background

Although resistance to thyroid hormone beta (RTHβ) is associated with attention‐deficit/hyperactivity disorder, there are few reports of other concomitant mood disorders in individuals with RTHβ.

Case presentation

A 67‐year‐old woman who had been previously diagnosed with RTHβ (Refetoff syndrome) came to our department as a depressed patient. She was hospitalized twice for depression and treated with antidepressants both times. Paroxetine (37.5 mg/day) treatment during the first hospitalization did not cause any side effects, but treatment with mirtazapine (15 mg/day) and venlafaxine (150 mg/day) during the second hospitalization caused clonus and disturbance of consciousness, and these adverse effects resulted in a prolonged period of hospitalization. Finally, the patient’s symptoms were controlled with quetiapine (75 mg/day).

Conclusion

Poor tolerability to antidepressants was observed, which may be related to thyroid hormone intolerance. Low doses of quetiapine may contribute to improvements in depression.

Management of Psychiatric Disorders in Patients with Endocrine Disorders

The neuropsychiatric symptoms and disorders among endocrine disorders are discussed in the context of current global and local epidemiological data. Neuropsychiatric symptoms, clinical differentials in hypothyroidism, hyperthyroidism, and parathyroid disorders, and relevant management protocols are described. HPT axis and its interaction with psychotropic usage are mentioned. Stress diathesis, depression, anxiety disorders, and severe mental illnesses and their respective association with diabetes, the relevant mechanisms, and management protocols are stated. The metabolic syndrome, its definition, and its relationship to psychotropic usage are laid out. Moreso, best clinical practices for scenarios such as hyperprolactinemia and psychiatric illnesses, and steroid-induced psychosis are mentioned.

Comparison of thyroid function in different emotional states of drug-naïve patients with bipolar disorder

BACKGROUND

Previous studies have shown that bipolar disorder is closely related to thyroid dysfunction. Psychiatric drugs have a large or small effect on thyroid function, and thyroid hormone levels can also affect the effect of drug treatment. Therefore, the purpose of this study is assessment the thyroid function of drug-naive bipolar disorder across different mood states, with the expectation of providing support for treatment options.

METHODS

The present study is a cross-sectional study. Patients diagnosed with bipolar disorder according to the International Classification of Diseases diagnostic Criteria, Edition 10 (ICD 10) and who had never received medication were included in the study. The Montgomery Depression Scale (MADRS) was used to assess depressive symptoms and the Young Mania Rating Scale (YMRS) for manic symptoms. Thyroid function indicators include thyroid-stimulating hormone (TSH), free triiodothyronine (FT3), total triiodothyronine (TT3), free thyroxine (FT4), and total thyroxine (TT4). Levels of TSH, TT4, FT4, TT3, and FT3 were measured within 48 h of hospitalization, between 06:00 and 08:00.

RESULTS

The data analysis finally covered the data of 291 subjects (136 in a bipolar manic group, 128 in a bipolar depressive group, and 27 in a bipolar mixed group), including 140 males and 151 females, with an average age of 27.38 ± 8.01. There was no significant difference in age, sex, marital status, work status, family history, and course of illness among the manic group, depressive group, and mixed group. The level of FT3, the rate of thyroid hormone increased secretion, and the total abnormality rate of thyroid hormone secretion in the manic group were significantly higher than those in the depressive group.

CONCLUSION

These findings indicate that thyroid functions were significantly different between depressive and manic episodes in BD patients. In clinical practice, it is necessary to take into account the differences in thyroid hormone levels in patients with BD across different emotional states in choosing drug.

Thyroid Function and Mood Disorders: A Mendelian Randomization Study

Background: Observational studies suggest that even minor variations in thyroid function are associated with the risk of mood disorders, including major depressive disorder (MDD) and bipolar disorder (BD). However, it is unknown whether these associations are causal or not. We used a Mendelian randomization (MR) approach to investigate causal effects of minor variations in thyrotropin (TSH) and free thyroxine (fT4) levels on MDD and BD risk. Materials and Methods: We performed two-sample MR analyses using data from the largest publicly available genome-wide association studies on normal-range TSH (n = 54,288) and fT4 (n = 49,269) levels, MDD (170,756 cases, 329,443 controls) and BD (20,352 cases, 31,358 controls). Secondary MR analyses investigated the effects of TSH and fT4 levels on specific MDD and BD subtypes. Reverse MR was also performed to assess the effects of MDD and BD on TSH and fT4 levels. Results: There were no associations between genetically predicted TSH and fT4 levels and MDD risk, nor MDD subtypes and minor depressive symptoms. A one standard deviation increase in fT4 levels was nominally associated with an 11% decrease in the overall BD risk (odds ratio [OR] = 0.89, 95% confidence interval [CI] = 0.80-0.98, p = 0.022) and a 13% decrease in the BD type 1 risk (OR = 0.87, CI = 0.75-1.00, p = 0.047). In the reverse direction, genetic predisposition to MDD and BD was not associated with TSH nor fT4 levels. Conclusions: Variations in normal-range TSH and fT4 levels have no effects on the risk of MDD and its subtypes, and neither on minor depressive symptoms. This indicates that depressive symptoms should not be attributed to minor variations in thyroid function. Borderline associations with BD and BD type 1 risks suggest that further clinical studies should investigate the effect of thyroid hormone treatment in BD.

A study of thyroid profile in patients suffering from the first episode of mania: A cross-sectional study

BACKGROUND

Thyroid function is commonly considered in the assessment of mood disorders. Reports of thyroid dysregulation in patients with mania are associated with several confounding factors. To eliminate confounding factors, studies of first-episode mania are desirable. This study tried to find out any relationship between thyroid disorders and mania.

AIM

The aim of this study is to assess and compare the thyroid profile between first-episode mania and healthy controls and to ascertain the correlation between severity and duration of the manic episode with FT3, FT4, and thyroid-stimulating hormone (TSH) levels.

MATERIALS AND METHODS

This was a cross-sectional study conducted in the psychiatry department of a tertiary care hospital. Forty consecutive drug-naïve patients with first-episode mania, diagnosed according to the International Classification of Disease-10 (study group), were matched with 40 healthy controls (control group). Both the groups were compared on the basis of thyroid profile and thyroid levels were correlated with duration and severity of illness in the study group.

RESULTS

Nearly 7.5% of cases in the study group had hyperthyroidism, whereas 5% had subclinical hyperthyroidism. In contrast, normal controls showed 5% and 10% prevalence of hypothyroidism and subclinical hypothyroidism, respectively. A statistically significant lower level of TSH was observed in the study group (P < 0.001), whereas the mean serum levels of FT3 and FT4 were higher in the study group, but the difference was statistically nonsignificant. No significant correlation of thyroid hormones level with duration and severity of illness was noted.

CONCLUSION

Our findings highlight a higher prevalence of hyperthyroidism in patients with mania and suggest the role of thyroid hormones in mania.

Depression and anxiety among hyperthyroid female patients and impact of treatment

Background

The aim of the present study was to compare the presence of psychiatric disorders in people with hyperthyroidism and euthyroid patients attending the Endocrinology Outpatient Department at the Shri Maharaja Hari Singh Hospital in Kashmir, India. Seventy-five patients with hyperthyroidism and an equal number of euthyroid patients participated in the study. Participants were selected using stratified random sampling. All patients were female. There was no significant difference between the two groups in terms of demographic features. Hormonal screening was performed by immunoassay and haemagglutination method. For the mental health assessment, the Mini-International Neuropsychiatric Interview (MINI), Hamilton Depression Rating Scale [HAM-D], and Hamilton Anxiety Rating Scale [HAM-A] were used.

Results

There was a higher prevalence of psychiatric disorders among the hyperthyroidism group (60% versus 34.7%). In particular, there was a higher prevalence of major depressive disorder, suicidality, generalised anxiety disorder, panic attacks, and agoraphobia. In some cases, the prevalence of a psychiatric disorder diminished after endocrinological treatment.

Conclusions

Screening patients with hyperthyroid disorders for psychiatric symptoms and disorders, and providing timely care when necessary, can go a long way in improving the quality of life of this population. It is imperative to establish routine screening and timely care of mental health symptoms and disorders in patients with hyperthyroidism.

Hypothyroidism and Complicated Sick Sinus Syndrome and Acute Severe Psychiatric Disorder: A Case Report

Background

Thyroxine is closely related to cardiovascular diseases, such as coronary heart disease, ventricular arrhythmia, atrioventricular block, myocardial systolic weakness, pericardial effusion, low cardiac output and hypertension. Previous studies have also found that hypothyroidism can also lead to mental disorders. Here, we present a rare case of severe hypothyroidism patient accompanied by sick sinus syndrome (SSS) as a cardiovascular manifestation needing cardiac pacing and severe mental disorders.

Case Presentation

A 42-year-old female patient, previously healthy, was referred to our hospital because of bradycardia complicated with sick sinus syndrome which requiring cardiac pacing and severe mental disorders. Her clinical features along with laboratory findings strongly suggested that the patient had severe hypothyroidism with sick sinus syndrome and mental disorders, both of which were reversible and successfully treated with levothyroxine.

Conclusion

This is the first reported case of hypothyroidism with sick sinus syndrome requiring pacemakers and psychiatric disorders, and the symptoms can be improved and reversed after thyroxine supplementation. This case highlights the importance of hypothyroidism screening when faced with unexplained psychosis or sick sinus syndrome, especially if combined.

A retrospective study of pituitary-thyroid interaction in patients with first-episode of bipolar disorder type I in Mania State

ABSTRACT

Bipolar disorder (BD)-mania is related to the dysfunction of anterior pituitary gland, but the pituitary-thyroid interaction on the acute stage of BD has been controversial. In order to rule out the effects of drugs, we aimed to determine the upstream interaction of first-episode of BD type I in mania state, and tried to find the relationship between thyroid-stimulating-hormone (TSH) and Prolactin (PRL)This study included 70 real-world patients diagnosed with first-episode BD-mania recuited and 70 healthy controls (HC) matched for age and sex from 2016 to 2017 in the same district of Shanghai. We compared the levels of thyroid hormones and prolactin between the two groups, and linear regression and curve estimation were used for the correlation analysis of TSH and PRLThere were differences in triiodothyronine (TT3), total thyroxin (TT4), and free thyroxine (FT4) concentrations between the groups (P's < .05). After being grouped by sex, higher PRL in the male and female BD-mania subgroup were observed compared to each isosexual HC [(P's < .01, Cohen's d = 0.82/1.08, 95%CI (0.33, 1.31)/(0.58, 1.58)]. Higher FT4 in the male BD-mania group was observed compared to the HC males [(P's  < .01, Cohen's d = 0.90, 95%CI (0.41, 1.39)] while the female BD-mania group showed lower TT3 and TT4 compared to the HC females [(P's  < .01, Cohen's d = 0.93/0.88, 95%CI (0.43, 1.42)/(0.39, 1.37)]. In the female BD-mania group, correlation analysis established an inverse relationship between PRL and TSH (r2 = 0.25, F = 11.11, P < .01).The findings demonstrate that sex impacts the concentration of hormones secreted by the anterior pituitary of patients with first-episode BD-mania. The increased PRL may be a putative mechanism that underlies the onset in female patients with a moderate inverse relationship between TSH and PRL. Thyroid hormones and prolactin levels may be developed as potential markers for identifying BD-manic.

The direct and indirect economic burden of hypothyroidism in the United States: a retrospective claims database study

OBJECTIVE

To examine direct and indirect economic burden associated with hypothyroidism in the United States.

METHODS

Medical costs attributable to hypothyroidism were estimated for patients with hypothyroidism. Non-hypothyroid (euthyroid) controls were matched to patients with hypothyroidism based upon patient characteristics and availability of productivity data. Multivariable analyses examined resource utilization, annual medical costs, comorbidities, and productivity costs.

RESULTS

Estimates of hypothyroidism-related total medical costs ranged from $460 to $2,555 per patient per year. Compared to euthyroid controls, patients with hypothyroidism had significantly higher all-cause medical costs and medical resource utilization. For the subset of patients with available productivity data, hypothyroidism was associated with significantly higher absenteeism and long- and short-term disability costs but significantly lower worker's compensation costs.

CONCLUSIONS

Hypothyroidism is associated with significant direct and indirect economic burden among employed, commercially insured patients in the US. Clinical Significance: Despite the availability of relatively inexpensive generic therapies for hypothyroidism, this study found significant direct and indirect costs associated with the condition. The large number of patients diagnosed with hypothyroidism combined with increased costs associated with hypothyroidism result in a significant burden for patients, payers, and employers.

Aggressive behavior in psychiatric patients in relation to hormonal imbalance (Review)

Aggressive behavior is one of the main characteristics of different psychiatric disorders such as: personality disorders (antisocial personality disorder, borderline personality disorder), schizophrenia, intermittent explosive disorder, post-traumatic stress disorder, bipolar disorder, depression, alcohol/substance induced psychiatric disorders. Epidemiological evidence shows that always there is a higher risk of violence and aggressivity among patients with psychiatric disorders compared with general population. Researchers have tried many times to narrow the theories that can explain such a behavior, starting from models that involve a link between illness and aggression going up to external-environmental factors including the therapeutic relation in the hospital. Even if the majority of studies are centered on intoxications (with alcohol or other substances that potentiate the aggressive behavior) we will highlight another somatic dimension linked with this behavior. In the following review we summarize the hormonal imbalances that have been noted to accompany aggressive behavior in different psychiatric disorders. Several studies have been made starting even at the age of ten corelating hormone cortisol with increase aggression, but patients with psychiatric disorders have a higher sensitivity in linking hormonal imbalance with their behavior.

The Relationship between Iodine and Selenium Levels with Anxiety and Depression in Patients with Euthyroid Nodular Goiter

OBJECTIVES

Selenium and iodine are essential microelements for normal body functions. These two elements play important roles in thyroid metabolism. The potential relationship between thyroid diseases and mental disorders have been demonstrated. We aimed to investigate the relationship between selenium and iodine levels with anxiety and depression in patients with euthyroid nodular goiter (ENG).

METHODS

In this cross-sectional study, we enrolled 102 consecutive patients with ENG who attended the endocrine outpatient clinic between January 2018 and June 2018. We noted the patient's demographics, thyroid ultrasound imaging, thyroid hormones, and urinary iodine concentration (UIC) results. We also obtained venous blood samples for serum selenium measurement. The same psychiatrist completed the Beck Anxiety Inventory (BAI) and Hamilton Depression Rating Scale (HDRS) for all participants. The study population was dichotomized according to the median values of selenium levels and UIC.

RESULTS

BAI and HDRS scores were significantly higher in the low selenium group than the high selenium group (p = 0.032 and p = 0.042, respectively). BAI scores were significantly higher in the low UIC group than the high UIC group (p = 0.007).

CONCLUSIONS

Low selenium and UIC levels may contribute to the development of anxiety and depression, independent of thyroid functions, in patients with ENG. In these patients, selenium and iodine replacement may be useful for the prevention of anxiety and depression, especially in deficient regions.

No Effect of Thyroid Dysfunction and Autoimmunity on Health-Related Quality of Life and Mental Health in Children and Adolescents: Results From a Nationwide Cross-Sectional Study

Background: In adults, a significant impact of thyroid dysfunction and autoimmunity on health-related quality of life (HRQoL) and mental health is described. However, studies in children and adolescents are sparse, underpowered, and findings are ambiguous. Methods: Data from 759 German children and adolescents affected by thyroid disease [subclinical hypothyroidism: 331; subclinical hyperthyroidism: 276; overt hypothyroidism: 20; overt hyperthyroidism: 28; Hashimoto's thyroiditis (HT): 68; thyroid-peroxidase antibody (TPO)-AB positivity without apparent thyroid dysfunction: 61] and 7,293 healthy controls from a nationwide cross-sectional study ("The German Health Interview and Examination Survey for Children and Adolescents") were available. Self-assessed HRQoL (KINDL-R) and mental health (SDQ) were compared for each subgroup with healthy controls by analysis of covariance considering questionnaire-specific confounding factors. Thyroid parameters (TSH, fT4, fT3, TPO-AB levels, thyroid volume as well as urinary iodine excretion) were correlated with KINDL-R and SDQ scores employing multiple regression, likewise accounting for confounding factors. Results: The subsample of participants affected by overt hypothyroidism evidenced impaired mental health in comparison to healthy controls, but SDQ scores were within the normal range of normative data. Moreover, in no other subgroup, HRQoL or mental health were affected by thyroid disorders. Also, there was neither a significant relationship between any single biochemical parameter of thyroid function and HRQoL or mental health, nor did the combined thyroid parameters account for a significant proportion of variance in either outcome measure. Importantly, the present study was sufficiently powered to identify even small effects in children and adolescents affected by HT, subclinical hypothyroidism, and hyperthyroidism. Conclusions: In contrast to findings in adults, and especially in HT, there was no significant impairment of HRQoL or mental health in children and adolescents from the general pediatric population affected by thyroid disease. Moreover, mechanisms proposed to explain impaired mental health in thyroid dysfunction in adults do not pertain to children and adolescents in the present study.

Rapid cycling bipolar disorder is associated with antithyroid antibodies, instead of thyroid dysfunction

BACKGROUND

Conclusions regarding the association between antithyroid antibodies or thyroid dysfunction and rapid cycling bipolar disorder (RCBD) have been conflicting. Previous studies suggest that the impact of antithyroid antibodies on mental wellbeing seems to be independent of thyroid function. Here, we investigated their independent association with RCBD in a large, well-defined population of bipolar disorder (BD).

METHODS

Fast serum levels of free thyroxine (FT4), free triiodothyronine (FT3), thyroid Stimulating Hormone (TSH), TPO-abs and Tg-abs were simultaneously measured in 352 patients with BD. Clinical features of BD were collected through semi-structural interview conducted by trained interviewers with background of psychiatric education.

RESULTS

Neither hypothyroidism nor hyperthyroidism was significantly associated with RCBD. Both TPO-abs and Tg-abs were significantly related to RCBD, even after controlling for gender, age, marriage status, education, antidepressants treatment, comorbidity of thyroid diseases, and thyroid function (serum levels of FT3, FT4 and TSH). Although TPO-abs and Tg-abs were highly correlated with each other, binary logistic regression with forward LR selected TPO-abs, instead of Tg-abs, to be associated with RCBD. TPO-abs was significantly, independently of Tg-abs, associated with hyperthyroidism, while Tg-abs was marginally significantly related to hypothyroidism at the presence of TPO-abs.

CONCLUSION

TPO-abs might be treated as a biomarker of RCBD. Further exploring the underlying mechanism might help understand the nature of RCBD and find out new treatment target for it.

Structural brain changes in hyperthyroid Graves' disease: protocol for an ongoing longitudinal, case-controlled study in Göteborg, Sweden-the CogThy project

INTRODUCTION

Cognitive impairment and reduced well-being are common manifestations of Graves' disease (GD). These symptoms are not only prevalent during the active phase of the disease but also often prevail for a long time after hyperthyroidism is considered cured. The pathogenic mechanisms involved in these brain-derived symptoms are currently unknown. The overall aim of the CogThy study is to identify the mechanism behind cognitive impairment to be able to recognise GD patients at risk.

METHODS AND ANALYSIS

The study is a longitudinal, single-centre, case-controlled study conducted in Göteborg, Sweden on premenopausal women with newly diagnosed GD. The subjects are examined: at referral, at inclusion and then every 3.25 months until 15 months. Examinations include: laboratory measurements; eye evaluation; neuropsychiatric and neuropsychological testing; structural MRI of the whole brain, orbits and medial temporal lobe structures; functional near-infrared spectroscopy of the cerebral prefrontal cortex and self-assessed quality of life questionnaires. The primary outcome measure is the change in medial temporal lobe structure volume. Secondary outcome measures include neuropsychological, neuropsychiatric, hormonal and autoantibody variables. The study opened for inclusion in September 2012 and close for inclusion in October 2019. It will provide novel information on the effect of GD on medial temporal lobe structures and cerebral cortex functionality as well as whether these changes are associated with cognitive and affective impairment, hormonal levels and/or autoantibody levels. It should lead to a broader understanding of the underlying pathogenesis and future treatment perspectives.

ETHICS AND DISSEMINATION

The study has been reviewed and approved by the Regional Ethical Review Board in Göteborg, Sweden. The results will be actively disseminated through peer-reviewed journals, national and international conference presentations and among patient organisations after an appropriate embargo time.

TRIAL REGISTRATION NUMBER

44321 at the public project database for research and development in Västra Götaland County, Sweden (https://www.researchweb.org/is/vgr/project/44321).

Graves' disease and mental disorders

Mental disorders merge highly with thyroid diseases. Because of its regulatory effects on serotonin and noradrenalin, T3 has been linked closely to depression and anxiety. It has known that in many cases, the mental symptoms persist even after normalization of thyroid function by treatment. Psychosocial factors including stress have been associated with mental symptoms even after thyroid function normalization in Graves’ disease and a combination of mental disorders have been related to the exacerbation of hyperthyroidism. These findings suggest that psychosomatic approaches based on the bio-psycho-social medical model are important for the treatment of mental disorders associated with Graves’ disease.

Low-normal free triiodothyronine and high leukocyte levels in relation to stroke severity and poor outcome in acute ischemic stroke with intracranial atherosclerotic stenosis

BACKGROUND

It is uncertain that the effect of free triiodothyronine (FT3) within normal ranges on initial severity and early functional outcomes in acute ischemic stroke (AIS) patients with Intracranial Atherosclerotic Stenosis (ICAS). The predictive values of white blood cell (WBC) and FT3 are also unclear in symptomatic ICAS (sICAS) patients.

METHODS

We consecutively reviewed 848 ischemic stroke patients admitted into Xiangya Hospital within 72 h after symptom onset. sICAS was defined as AIS patient with degree of ICAS ≥50% proved by magnetic resonance angiography, computed tomography angiography or digital subtraction angiography. WBC and FT3 were assessed within 24 h after admission. Neurological severity was evaluated on admission using the National Institutes of Health Stroke Scale (NIHSS). Stroke outcomes were defined by the modified Rankin Scale (mRS) on the 14th day after admission.

RESULTS

Logistic regression analysis showed that hypertension, lower FT3 and higher WBC concentrations independently associated with severe stroke [FT3 (odds ratio(OR) = 0.543, 95% confidence interval(95% CI): 0.383-0.769); hypertension (OR = 0.436, 95% CI: 0.238-0.800); WBC (OR = 1.17; 95% CI:1.041-1.316]. Besides, lower FT3, higher FT4, higher WBC and higher plasma glucose concentrations independently associated with unfavorable outcomes [FT3 (OR = 0.460; 95% CI: 0.306-0.690); FT4 (OR = 1.151; 95% CI: 1.055-1.255); WBC (OR = 1.178; 95% CI: 1.039-1.334); Plasma glucose (OR = 1.160; 95% CI: 1.002-1.342)].

CONCLUSIONS

Lower FT3 levels within normal ranges and higher WBC count are independently associated with the severity and early poor prognosis of sICAS simultaneously, FT3 and WBC count might be important biomarkers for sICAS patients.

Behavior in dogs with spontaneous hypothyroidism during treatment with levothyroxine

Background

Thyroid hormone supplementation anecdotally has been described as a valid treatment option for dogs with aggression‐related problems. However, prospective, controlled, and blinded trials evaluating behavior and neurohormonal status in hypothyroid dogs during treatment with levothyroxine are lacking.

Objective

Levothyroxine supplementation will have a significant influence on the behavior and neurohormonal status of dogs with spontaneous hypothyroidism.

Animals

Twenty client‐owned dogs diagnosed with spontaneous hypothyroidism.

Methods

This prospective study was to evaluate the behavior of dogs, which was screened at initial presentation, and after 6 weeks, and 6 months of treatment with levothyroxine (starting dosage 10 μg/kg PO q12h) using the standardized Canine Behavioral Assessment and Research Questionnaire (C‐BARQ). At each time period, circulating serotonin and prolactin (PRL) concentrations were evaluated using a commercially validated ELISA kit and heterologous radioimmunoassay, respectively.

Results

After 6 weeks of thyroid hormone supplementation, C‐BARQ scores demonstrated a significant increase in activity of hypothyroid dogs (P < .01). No significant change in any of the behavioral signs was observed after 6 months of treatment. No significant difference in circulating concentrations of serotonin (P > .99 and P = .46) and PRL (P = .99 and P = .37) were noted between the 6‐week and 6‐month periods compared with baseline.

Conclusions and Clinical Importance

The results of this study indicate increased activity of hypothyroid dogs after 6 weeks of thyroid hormone supplementation. None of the hypothyroid dogs in this cohort showed a significant change in any of the evaluated behavioral signs and neurohormonal status after 6 months of thyroid hormone supplementation.

Thyroid Storm Presenting as Psychosis

Thyroid storm is a life-threatening endocrine emergency with an incidence rate of 1% to 2%. It is a systemic condition of excessive thyroid hormone production and release leading to thermoregulatory, adrenergic, neuropsychiatric, cardiovascular, and abdominal manifestations. Although it is a rare condition, it carries a significant mortality rate. Hence, knowing the common and uncommon presentations of thyroid storm is important for its prompt diagnosis and treatment. In this article, we present an unusual case of a young woman who presented with psychosis as the manifesting symptom of thyroid storm. She did not respond adequately to conventional medical treatment, requiring plasmapheresis and a definitive thyroidectomy, which ultimately led to the return of patient’s baseline mental status and a dramatic recovery.

Adult-onset of mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS) syndrome with hypothyroidism and psychiatric disorders

Mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS) is a clinical syndrome associated with mitochondrial disorders (MIDs). This report illustrates a case of MELAS syndrome with hypothyroidism and psychiatric disorders, which is different from the common clinical manifestations of MELAS syndrome, such as exercise intolerance, migraine-like headaches, hearing loss and seizures etc. There are considerable interests in the possibility that mitochondrial dysfunction may play a role in the pathogenesis of endocrine dysfunctions and psychiatric disorders in MELAS syndrome.

Do some anxiety disorders belong to the prodrome of bipolar disorder? A clinical study combining retrospective and prospective methods to analyse the relationship between anxiety disorder and bipolar disorder from the perspective of biorhythms

BACKGROUND

In clinical practice, some patients diagnosed with anxiety disorder (AD) may develop bipolar disorder (BD) many years later, and some cases of AD may be cured by the use of mood stabilizers. However, the relationship between AD and BD should be explored further.

METHOD

To track how many cases of AD turned to BD and to discover the differences between them, we recruited 48 patients diagnosed with BD, who were assigned to the BD group for the retrospective analysis, and we also recruited 186 patients diagnosed with AD at enrolment; this latter group was asked to complete follow-up surveys conducted 3 months, 6 months, 12 months and 18 months after the primary stage of the study. We defined another two groups according to the usage of mood stabilizers, the rates of reduction in scores on the Hamilton Anxiety Scale and Yale-Brown Obsessive Compulsive Scale, and the changes in Clinical Global Impression scores at different follow-up times: the anxiety group and the atypical BD group (who used mood stabilizers to treat AD). All subjects also completed the NEO Five-Factor Inventory and supplied blood samples to be tested for several endocrine indices (TSH, T3, FT3, T4, FT4, ACTH,PTC) and inflammatory cytokines (IL-6, IL-8, IL-10, TNF-α, CRP) at enrolment.

RESULTS

In total, 14 subjects developed BD by the end of the study. One hundred eleven subjects were included in the anxiety group. Sixty-three subjects were assigned to the atypical BD group, and they had similar features to the 48 subjects in the BD group in terms of personality traits, abnormality rates of endocrine indices and levels of inflammatory cytokines. From the anxiety group to the atypical BD group and then the BD group, the age of first onset gradually decreased, while the frequency of onset and the score of suicidal ideation gradually increased. Furthermore, the atypical BD group showed markedly higher levels of TSH, IL-6, TNF-α and CRP than the other two groups.

CONCLUSIONS

Some ADs with unique features might belong to the prodromal stage or the atypical presentation of BD, and recognizing these ADs early will economize many medical resources.

Psychiatric and physical comorbidities and their impact on the course of bipolar disorder: A prospective, naturalistic 4-year follow-up study

OBJECTIVES

The aim of the present study was to increase the available evidence on how physical and psychiatric comorbidities influence the long-term outcome in bipolar I and II disorder.

METHODS

We examined the prevalence of comorbid physical (metabolic, cardiovascular, thyroid, and neurological) diseases and psychiatric (neurotic, stress-related, somatoform, and personality) disorders and their impact on the risk of relapse in bipolar disorder. A total of 284 consecutively admitted patients with ICD-10 bipolar I (n=161) and II (n=123) disorder were followed up naturalistically over a period of 4 years.

RESULTS

Globally, 22.0% patients had metabolic, 18.8% cardiovascular, 18.8% thyroid, and 7.6% neurological diseases; 15.5% had neurotic, stress-related, and somatoform disorders; 12.0% had personality disorders; and 52.9% had nicotine dependence. We did not find any effect of comorbid metabolic, cardiovascular or neurological diseases or psychiatric disorders on the relapse risk. However, the presence of thyroid diseases, and especially hypothyroidism, was associated with an increased risk of manic relapse in bipolar disorder I (thyroid disease: hazard ratio [HR]=2.7; P=.003; hypothyroidism: HR=3.7;, P<.001). Among patients with hypothyroidism, higher blood levels of baseline thyroid-stimulating hormone (bTSH) were also associated with an increased risk of manic relapse (HR=1.07 per milli-international units per liter; P=.011), whereas blood levels of free triiodothyronine (fT₃ ) or free thyroxine (fT₄ ) were not found to have an influence.

CONCLUSIONS

Our data underline the negative long-term impact of thyroid diseases, and especially hypothyroidism with high blood levels of bTSH, on bipolar disorder with more manic episodes, and the importance of its detection and treatment.

Association between autoimmune thyroiditis and depressive disorder in psychiatric outpatients

Thyroid diseases are often associated with psychiatric disorders. The prevalence of autoimmune thyroiditis in the general population is estimated to be at about 5-14 %. A clinical study was conducted to evaluate the association between autoimmune thyroiditis and depression in psychiatric outpatients. Fifty-two patients with depression and nineteen patients with schizophrenia (serving as control group), attending a psychiatric outpatient unit, were included. In addition to the measurement of thyroid-stimulating hormone (TSH), free triiodothyronine, free thyroxine, antithyroid peroxidase (anti-TPO) antibodies, and anti-thyroglobulin antibodies, ultrasound examination of the thyroid gland was performed. The proportion of pathologically increased anti-TPO levels in patients with depression was high. Furthermore, the distribution of pathologically increased anti-TPO levels was significantly (χ (2) = 5.5; p = 0.019) different between patients with depression (32.7 %) and patients with schizophrenia (5.3 %). In a gender- and age-adjusted logistic regression, the odds ratio of uni- or bipolar patients with depression for an autoimmune thyroiditis was ten times higher (95 % CI = 1.2-85.3) when compared with schizophrenia patients. TSH basal level did not differ between patients with depression and patients with schizophrenia. Our study demonstrates a strong association between anti-TPO levels, which are considered to be of diagnostic value for autoimmune thyroiditis (in combination with a hypoechoic thyroid in ultrasonography) with uni- or bipolar depression. It should be noted that the routinely measured TSH level is not sufficient in itself to diagnose this relevant autoimmune comorbidity.

Thyroid functioning in patients with bipolar disorder with mixed features

We compared the prevalence of thyroid dysfunction in patients with bipolar disorder with and without mixed features by measuring of thyroid function test. We reviewed the medical charts between 2005 and 2013. These results did not show a significant difference in the association between thyroid dysfunction and the mixed features.

Postpartum psychosis in a woman with Graves' disease: a case report

OBJECTIVE

Thyroid dysfunction is common during pregnancy and the postpartum period and is known to cause psychiatric disturbances. A woman with Graves' disease and psychosis in the postpartum period is described.

METHODS

A 22-year-old woman with Graves' disease developed fluctuating orientation, catatonia, delusions of persecution and auditory hallucinations 3 days following childbirth.

RESULTS

The report discusses the clinical presentation. Treatment of both conditions led to the resolution of symptoms.

CONCLUSION

Graves' disease with postpartum psychosis may present with delirium, catatonia and prominent auditory hallucinations and responds well to a combination of psychotropic and antithyroid drugs. Thyroid dysfunction should be assessed for and managed adequately in postpartum psychosis.

Thyroid axis function after in-patient treatment of acute psychosis with antipsychotics: a naturalistic study

BACKGROUND

Endocrine function in psychiatric patients may be affected by mental disorder itself as well as by antipsychotic medications.The aim of this naturalistic observational study was to determine if treatment of acute psychotic episode with antipsychotic medication affects thyroid axis hormone concentrations and if such changes are associated with symptomatic improvement.

METHODS

Eighty six adult acute psychotic patients, consecutively admitted to a mental hospital, were recruited for the study. All patients were physically healthy and without thyroid disease. During the hospitalization period all study patients received treatment with antipsychotic medication according to clinical need. Severity of the psychotic episode was evaluated using the Brief Psychiatric Rating Scale (BPRS) and venous blood samples were drawn for analysis of free triiodothyronine (FT3), free thyroxine (FT4), and thyroid stimulating hormone (TSH) concentrations on the day of admission and on the day of discharge from the hospital.

RESULTS

Antipsychotic drug treatment was associated with decrease of mean FT3 (p < 0.001) and FT4 (p = 0.002) concentrations; and with increase of mean TSH (p = 0.016) concentrations. Changes in thyroid hormone concentrations were mostly predicted by baseline hormone concentrations. Individual changes were not limited to decrease in high hormone concentrations; in patients who had low FT3 or FT4 concentrations, treatment resulted in increase in concentrations. Such an increase was established in one-quarter of patients for FT3 concentrations and in one-third of patients for FT4 concentrations. Fall in FT4 concentrations negatively correlated with the improvement in the BPRS score (r = -0.235, p = 0.023).

CONCLUSIONS

The study indicates that antipsychotic treatment resulted in a decrease in mean FT3 concentrations and in an increase in mean TSH concentrations after recovery from acute psychosis. Symptomatic improvement was less evident in patients who experienced a decrease in FT4 concentrations.

TRIAL REGISTRATION

EudraCT No.2007-001541-18.

Multimorbidity patterns: a systematic review

OBJECTIVES

The aim of this review was to identify studies on patterns of associative multimorbidity, defined as the nonrandom association between diseases, focusing on the main methodological features of the studies and the similarities among the detected patterns.

STUDY DESIGN AND SETTING

Studies were identified through MEDLINE and EMBASE electronic database searches from their inception to June 2012 and bibliographies.

RESULTS

The final 14 articles exhibited methodological heterogeneity in terms of the sample size, age and recruitment of study participants, the data source, the number of baseline diseases considered, and the statistical procedure used. A total of 97 patterns composed of two or more diseases were identified. Among these, 63 patterns were composed of three or more diseases. Despite the methodological variability among studies, this review demonstrated relevant similarities for three groups of patterns. The first one comprised a combination of cardiovascular and metabolic diseases, the second one was related with mental health problems, and the third one with musculoskeletal disorders.

CONCLUSION

The existence of associations beyond chance among the different diseases that comprise these patterns should be considered with the aim of directing future lines of research that measure their intensity, clarify their nature, and highlight the possible causal underlying mechanisms.

Ischemic stroke functional outcomes are independently associated with C-reactive protein concentrations and cognitive outcomes with triiodothyronine concentrations: a pilot study

Elevated concentrations of C-reactive protein (CRP) and decreased concentrations of triiodothyronine (T3) were shown to predict poor outcomes in patients with stroke. However, the prognostic value of CRP and T3 has not been studied simultaneously in relation to stroke functional and cognitive outcomes despite of close interaction between inflammatory markers and thyroid function. We evaluated the association of thyroid hormone and CRP concentrations with immediate outcomes after ischemic stroke. Eighty-eight ischemic stroke patients on admission to the stroke unit were evaluated for clinical stroke severity (Scandinavian stroke scale or SSS) and concentrations of thyroid-stimulating hormone, free thyroxin, free T3, and CRP. Functional outcome (modified Rankin scale) and cognitive outcome (Mini mental state examination) were evaluated at discharge. Greater ln CRP concentrations (r = -0.35, p = 0.001), but not thyroid hormone concentrations, correlated with score on the SSS. In univariate analyses lower free T3 concentrations and higher CRP concentrations were associated with poor functional and poor cognitive outcomes. After adjustment for clinical stroke severity, higher CRP concentrations (β = 0.18, p = 0.04) remained associated with worse functional outcome and lower free T3 concentrations with worse cognitive outcome (β = 0.23, p = 0.03). In sum, clinical stroke severity is associated with elevated CRP concentration. Higher CRP concentration is independently associated with worse functional outcomes and lower free T3 concentration with worse cognitive outcomes at discharge. T3 and CRP can be important biomarkers in patients with acute ischemic stroke.

Depression but not anxiety is associated with metabolic syndrome in primary care based community sample

INTRODUCTION

Metabolic syndrome (MetS) and depression are considered important risk factors for diabetes and cardiovascular disease. Recent evidence suggests that depression can be an important predictor of MetS. Data on the association between anxiety and MetS remain mixed. In a large primary care based community sample we investigated an association of depressive and anxiety disorders and symptoms with MetS.

METHODS

A total of 1115 (51% men, mean age 62.0 ± 9.6 years) randomly selected individuals of 45 years and older were evaluated for: (i) MetS using the World Health Organization (WHO), National Cholesterol Education Program Adult Treatment Panel III (NCEP/ATP III) and International Diabetes Federation (IDF) criteria; (ii) current major depressive episode (MDE) and current generalized anxiety disorder (GAD), the Mini International Neuropsychiatric interview; (iii) lifetime MDE; and (iv) symptoms of depression and anxiety, the Hospital Anxiety and Depression scale (HADS). Socio-demographic characteristics (education, residence, marital status and social status) and medical histories (physical activity, smoking status, alcohol consumption and histories of myocardial infarction and stroke) were also evaluated.

RESULTS

After adjusting for socio-demographic status, medical histories and current GAD, current MDE and lifetime MDE were associated with greater prevalence of MetS according to the WHO criteria (OR=1.7, 95%CI [1.1-2.7] and OR=3.7, 95%CI [2.4-5.7], respectively, p ≤ 0.001). Lifetime MDE was also associated with MetS according to the IDF and NCEP/ATP III criteria. On the other hand, current GAD was not associated with MetS in multivariate regression models when adjusted for current MDE. Similar results were obtained when evaluating an association between depression/anxiety symptoms and MetS, since elevated depressive, but not anxiety, symptoms were independently associated with MetS.

CONCLUSIONS

Depressive, but not anxiety, disorders and symptoms are associated with greater prevalence rate of MetS. Assessment and management of MetS risk factors should be considered in depressed individuals.

Hyperthyroidism and psychiatric morbidity: evidence from a Danish nationwide register study

OBJECTIVE

Thyroid hormones are essential for the normal development of the fetal brain, while hyperthyroidism in adults is associated with mood symptoms and reduced quality of life. In this study, we aimed to investigate the association and temporal relationship between hyperthyroidism and psychiatric morbidity.

DESIGN

Register-based nationwide cohort study.

METHOD

Data on hyperthyroidism and psychiatric morbidity were obtained by record linkage of the Danish National Patient Registry and the Danish National Prescription Registry. A total of 2631 hyperthyroid individuals were identified and matched 1:4 with non-hyperthyroid controls and followed for a mean duration of 6 years (range 0-13). Logistic and Cox regression models were used to assess the risk of psychiatric morbidity before and after the diagnosis of hyperthyroidism respectively.

RESULTS

BEFORE THE DIAGNOSIS OF HYPERTHYROIDISM, SUCH INDIVIDUALS HAD AN INCREASED RISK OF BEING HOSPITALIZED WITH PSYCHIATRIC DIAGNOSES (ODDS RATIO (OR): 1.33; 95% CI: 0.98-1.80) and an increased risk of being treated with antipsychotics (OR: 1.17; 95% CI: 1.00-1.38), antidepressants (OR: 1.13; 95% CI: 1.01-1.27), or anxiolytics (OR: 1.28; 95% CI: 1.16-1.42). After the diagnosis of hyperthyroidism, there was a higher risk of being hospitalized with psychiatric diagnoses (hazard ratio (HR): 1.51; 95% CI: 1.11-2.05) and an increased risk of being treated with antipsychotics (HR: 1.46; 95% CI: 1.20-1.79), antidepressants (HR: 1.54; 95% CI: 1.36-1.74), or anxiolytics (HR: 1.47; 95% CI: 1.27-1.69).

CONCLUSIONS

Hyperthyroid individuals have an increased risk of being hospitalized with psychiatric diagnoses and being treated with antipsychotics, antidepressants, and anxiolytics, both before and after the diagnosis of hyperthyroidism.

Gender differences in thyroid system function: relevance to bipolar disorder and its treatment

OBJECTIVES

Thyroid hormones play a critical role in the functioning of the adult brain, and thyroid diseases impair both mood and cognition. This paper reviews gender differences in thyroid system function that are relevant to the diagnosis and treatment of bipolar disorder.

METHODS

The study comprised a comprehensive literature review of gender differences in thyroid disease that are pertinent to mood disorders.

RESULTS

The prevalence of thyroid disease was found to be much higher in females than males, and to increase with age. The most commonly detected abnormality was subclinical hypothyroidism, which was found to occur in up to 20% of postmenopausal women. Females also had higher rates of thyroid autoimmunity. Individuals at risk for thyroid disease, such as adult females, may have had less ability to compensate for additional challenges to thyroid metabolism, including lithium treatment. Thyroid abnormalities were associated with a poorer response to standard treatments for mood disorders. Females with treatment-resistant mood disorders may have responded better than males to adjunctive therapy with thyroid hormones.

CONCLUSIONS

Disturbances of thyroid system function, which occur commonly in females, may complicate the diagnosis and treatment of mood disorders. In particular, this is clinically relevant during lithium treatment because lithium may impair vital thyroid metabolic pathways secondary to its anti-thyroid activity.

Thyroid disease and the nervous system

Thyroid disorders are common in the general population and in hospitalized patients. Thyroid disease may present first with neurological complications or else may occur concurrently in patients suffering other neurological disorders, particularly those with an autoimmune etiology. For this reason neurologists will commonly encounter patients with thyroid disease. This chapter provides an overview of the neurological complications and associations of disorders of the thyroid gland. Particular emphasis is placed on conditions such as thyrotoxic periodic paralysis and myxedema coma in which the underlying thyroid disorder may be occult leading to a first, often emergency, presentation to a neurologist. Information about clinical features, diagnosis, pathogenesis, therapy, and prognosis is provided. Emphasis is placed on those aspects most likely to be relevant to the practicing neurologist and the interested reader is directed to references to good, recent review articles for further information.

Cost-efficiency of laboratory testing among psychiatric inpatients

BACKGROUND

A set of tests to rule out medical conditions among psychiatric inpatients is still to be defined. A first step in this direction is to determine the utility of lab tests commonly used by psychiatrists.

METHODS

Biochemical tests have been routinely performed on inpatients in a psychiatric hospitalization unit from 2006 to 2009. This study examines the prevalence of abnormal values in 1,278 laboratory tests performed on 894 patients. The number of subjects screened and the direct expenditure needed to find results outside the normal range were computed. Differences in clinical profiles were compared between diagnostic groups according to main diagnosis.

RESULTS

We found high rates of seropositive patients for human immunodeficiency virus (14.3%) and hepatitis B virus (15.7%). Most patients met at least one criteria of metabolic syndrome (67.6%). The detection of hepatic abnormalities was very efficient (65.71%), particularly for patients diagnosed with alcohol use disorders.

CONCLUSIONS

The cost-efficiency of lab tests in psychiatric units is greatly variable. Though results of this study may not be generalized due to the different prevalence of medical conditions, the methodology can be easily implemented across psychiatric services. Cost-effectiveness and costbenefit analyses are warranted.

Low triiodothyronine syndrome as a predictor of poor outcomes in patients undergoing brain tumor surgery: a pilot study

Object

A low triiodothyronine (T3) state is highly prevalent and is associated with a poor prognosis in critically ill patients. The authors investigated, in patients undergoing brain tumor surgery, the direct association of a perioperative low T3 syndrome with clinical outcomes and also with symptoms of depression and anxiety.

Methods

Ninety consecutive patients (71% women, median age 55 years), on admission for brain tumor surgery, were evaluated for sociodemographic and clinical characteristics. Their thyroid function profile was assessed on the morning of brain tumor surgery and on the morning after brain tumor surgery. Patients with free T3 concentrations of 3.1 pmol/L or less were considered to have low T3 syndrome. The patients were evaluated for symptoms of depression and anxiety using the Hospital Anxiety and Depression Scale (HADS) before and after surgery and for clinical outcomes using the Glasgow Outcome Scale (GOS) at discharge.

Results

After brain tumor surgery, free T3 concentrations decreased (p < 0.001) and the proportion of patients with low T3 levels increased from 38% to 54% (p = 0.02). Lower preoperative (rho = 0.30, p = 0.004) and postoperative (rho = 0.33, p = 0.002) free T3 concentrations correlated with low GOS scores at discharge. Preoperative low T3 syndrome (OR 5.49, 95% CI 1.27–23.69, p = 0.02) and postoperative low T3 syndrome (OR 8.73, 95% CI 1.49–51.21, p = 0.02) both increased risk for unfavorable clinical outcomes (GOS scores < 5) at discharge, after adjusting for age, sex, histological diagnosis of brain tumor, preoperative functional impairment, previous treatment for brain tumor, and depressive symptoms. Preoperative low T3 syndrome increased the risk for preoperative (HADS-depression subscale score ≥ 11; OR 4.12, 95% CI 1.16–14.58, p = 0.03) but not postoperative depressive symptoms independently from sociodemographic and clinical factors.

Conclusions

Low T3 syndrome is a strong independent predictor of unfavorable clinical outcomes and depressive symptoms, and its diagnosis and preoperative management should be considered in patients undergoing neurosurgery for the treatment of brain tumors.

Incremental Healthcare Expenditures Associated with Thyroid Disorders among Individuals with Diabetes

Objective. To estimate incremental healthcare expenditures associated with thyroid disorders among individuals with diabetes. Research Design and Methods. Cross-sectional study design with data on adults over 20 years of age with diabetes (N = 4, 490) from two years (2007 and 2009) of the Medical Expenditure Panel Survey (MEPS) was used. Ordinary least square regressions on log-transformed total expenditures and type of healthcare expenditures (inpatient, emergency room, outpatient, prescription drug, and other) were performed to estimate the incremental expenditures associated with thyroid disorders after controlling for demographic, socioeconomic, health status, lifestyle risk factors, macrovascular comorbid conditions (MCCs), and chronic conditions (CCs). Results. Among individuals with diabetes, those with thyroid disorders had significantly greater average annual total healthcare expenditures ($15,182) than those without thyroid disorders ($11,093). Individuals with thyroid disorders had 34.3% greater total healthcare expenditures compared to those without thyroid disorders, after controlling for demographic, socio-economic, and perceived health status. Furthermore, controlling for CCs and MCCs, this increase in expenditures was reduced to 21.4%. Conclusions. Among individuals with diabetes, thyroid disorders were associated with greater healthcare expenditures; such excess expenditures may be due to CCs and MCCs. Comanagement of CCs and reducing MCCs may be a pathway to reduce high healthcare expenditures.

A patient with Graves' disease showing only psychiatric symptoms and negativity for both TSH receptor autoantibody and thyroid stimulating antibody

Background

Both thyroid stimulating hormone (TSH) and thyroid stimulating antibody (TSAb) negative Graves’s disease (GD) is extremely rare. Here we present such a patient.

Case presentation

The patient was a 76-year-old woman who was diagnosed as having schizophrenia forty years ago. She did not show characteristic symptoms for hyperthyroidism, such as swelling of thyroid, exophthalmos, tachycardia and tremor, however, she showed only psychomotor agitation. Serum free triiodothyronine and free thyroxine levels were elevated and TSH level was suppressed, suggesting the existence of hyperthyroidism. However, both the first generation TSH receptor autoantibody (TRAb1) and the thyroid stimulating autoantibody (TSAb) were negative. Slightly increased blood flow and swelling was detected by thyroid echography. Thyroid scintigraphy demonstrated diffuse and remarkably elevated uptake of ¹²³I uptake. Finally, we diagnosed her as having GD. She was treated by using methimazole, and hyperthyroidism and her psychiatric symptoms were promptly ameliorated.

Discussion

We experienced a patient with GD who did not show characteristic symptoms except for psychiatric symptoms, and also showed negativity for both TRAb1 and TSAb. Thyroid autoantibody-negative GD is extremely rare. Thyroid scintigraphy was useful to diagnose such a patient.

Thyroid dysfunction and the elderly patient: a primer for pharmacists

Thyroid dysfunction is a common problem in the elderly and is often masked by comorbid conditions and medications. Left untreated, thyroid dysfunction can cause or exacerbate numerous symptoms, and can eventually lead to death. Pharmacists and other practitioners need to have a baseline understanding of thyroid function and know how to dose and monitor medications that treat thyroid dysfunction.