Thyroid hormone treatment in the management of treatment-resistant unipolar depression: a systematic review and meta-analysis

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Prevalence of self-reported thyroid disease among adults with depression

BACKGROUND

Thyroid disorders are a common comorbidity in patients with depression, yet there is limited information available about the clinical epidemiology of thyroid diseases in this specific population. This study aims to describe the prevalence of thyroid disease among US adults with depression from 2007 to 2018.

METHODS

This cross-sectional study used nationally representative data collected through the National Health and Nutrition Examination Survey (NHANES) between January 1, 2007, to December 31, 2018. Age-standardized prevalence of thyroid disease among depressed patients was calculated within 4-year survey periods (2007-2010, 2011-2014, and 2015-2018), and adjusted to the 2000 U.S. standard population.

RESULTS

In our weighed sample, 6.1% of depressed individuals and 4.3% of non-depressed individuals reported thyroid disease between 2007 and 2018 (P < 0.0001). The age-standardized prevalence of thyroid disease in patients with depression increased over time, from 5.4% (95%CI, 4.6%-6.2%) in 2007-2010 to 6.8% (95%CI, 5.8%-8.0%) in 2015-2018 (P for trend = 0.0270). Furthermore, thyroid disease prevalence was highest in non-Hispanic white individuals, increased with age, and tended to be higher in women. Mean depression scores in patients with thyroid disease (9.1; 95%CI, 8.7-9.5) did not significantly different from those without thyroid disease (9.1; 95%CI, 9.0-9.3) (P = 0.96).

CONCLUSION

The age-standardized prevalence of thyroid disease among US adults with depression exhibited a consistent increase from 2007 to 2018, with the highest rate occurring in older, non-Hispanic white individuals, and women.

Thyroid Axis and Vestibular Physiopathology: From Animal Model to Pathology

A recent work of our group has shown the significant effects of thyroxine treatment on the restoration of postural balance function in a rodent model of acute peripheral vestibulopathy. Based on these findings, we attempt to shed light in this review on the interaction between the hypothalamic-pituitary-thyroid axis and the vestibular system in normal and pathological situations. Pubmed database and relevant websites were searched from inception through to 4 February 2023. All studies relevant to each subsection of this review have been included. After describing the role of thyroid hormones in the development of the inner ear, we investigated the possible link between the thyroid axis and the vestibular system in normal and pathological conditions. The mechanisms and cellular sites of action of thyroid hormones on animal models of vestibulopathy are postulated and therapeutic options are proposed. In view of their pleiotropic action, thyroid hormones represent a target of choice to promote vestibular compensation at different levels. However, very few studies have investigated the relationship between thyroid hormones and the vestibular system. It seems then important to more extensively investigate the link between the endocrine system and the vestibule in order to better understand the vestibular physiopathology and to find new therapeutic leads.

Relationship between thyroid hormones and central nervous system metabolism in physiological and pathological conditions

Thyroid hormones (THs) play an important role in the regulation of energy metabolism. They also take part in processes associated with the central nervous system (CNS), including survival and differentiation of neurons and energy expenditure. It has been reported that a correlation exists between the functioning of the thyroid gland and the symptoms of CNS such as cognitive impairment, depression, and dementia. Literature data also indicate the influence of THs on the pathogenesis of CNS diseases, such as Alzheimer's disease, epilepsy, depression, and Parkinson's disease. This review describes the relationship between THs and metabolism in the CNS, the effect of THs on the pathological conditions of the CNS, and novel options for treating these conditions with TH derivatives.

Augmentation strategies for treatment resistant major depression: A systematic review and network meta-analysis

OBJECTIVE

To compare the efficacy and discontinuation of augmentation agents in adult patients with treatment-resistant depression (TRD). We conducted a systematic review and network meta-analyses (NMA) to combine direct and indirect comparisons of augmentation agents.

METHODS

We included randomized controlled trials comparing one active drug with another or with placebo following a treatment course up to 24 weeks. Nineteen agents were included: stimulants, atypical antipsychotics, thyroid hormones, antidepressants, and mood stabilizers. Data for response/remission and all-cause discontinuation rates were analyzed. We estimated effect-size by relative risk using pairwise and NMA with random-effects model.

RESULTS

A total of 65 studies (N = 12,415) with 19 augmentation agents were included in the NMA. Our findings from the NMA for response rates, compared to placebo, were significant for: liothyronine, nortriptyline, aripiprazole, brexpiprazole, quetiapine, lithium, modafinil, olanzapine (fluoxetine), cariprazine, and lisdexamfetamine. For remission rates, compared to placebo, were significant for: thyroid hormone(T4), aripiprazole, brexpiprazole, risperidone, quetiapine, and olanzapine (fluoxetine). Compared to placebo, ziprasidone, mirtazapine, and cariprazine had statistically significant higher discontinuation rates. Overall, 24% studies were rated as having low risk of bias (RoB), 63% had moderate RoB and 13% had high RoB.

LIMITATIONS

Heterogeneity in TRD definitions, variable trial duration and methodological clinical design of older studies and small number of trials per comparisons.

CONCLUSIONS

This NMA suggests a superiority of the regulatory approved adjunctive atypical antipsychotics, thyroid hormones, dopamine compounds (modafinil and lisdexamfetamine) and lithium. Acceptability was lower with ziprasidone, mirtazapine, and cariprazine. Further research and head-to-head studies should be considered to strengthen the best available options for TRD.

Exploring the potential of thyroid hormones to predict clinical improvements in depressive patients: A machine learning analysis of the real-world based study

BACKGROUND

Although undergoing antidepressant treatments, many patients continue to struggle with chronic depression episode. Seeking the potential biomarkers and establishing a predictive model of clinical improvements is vital to optimize personalized management of depression. Mounting evidence showed thyroid hormones changes are central to leading paradigms of depression.

METHODS

Here, we conducted a real-world based retrospective study using clinical and biochemical data of 2086 depressive inpatients during period of 2014-2020. We first performed regression analyses to evaluate the contributing effect of free triiodothyronine (FT3), free thyroxine (FT4) and thyroid stimulating hormone (TSH) in predicting the clinical outcomes of depression. Then we established 7 predictive models using different combination of such hormones by supervised learning methods and tested the actual prediction efficacy on clinical outcomes, in order to select the one with the best predictive power.

RESULTS

The results showed that lower values of FT3 and FT4 can both predict a poor clinical outcome in depression. Further, a model with the best performance was selected (sensitivity=0.91, specificity=0.79, and ROC-AUC=0.86), including the values of FT3 and FT4, and the scores of Hamilton Depression Scale (HAMD) and Hamilton Anxiety Scale (HAMA) as features.

LIMITATIONS

The predictive model requires further external validation, and multi-center researches to confirm its clinical applicability.

CONCLUSIONS

Our findings present a crucial role of thyroid measurements in predicting clinical outcomes of depression. Assessment of thyroid hormone should be extended to routine practice settings to determine which patients should be most in need of earlier or intensive interventions for preventing continued dysfunction.

Association of Subclinical Hypothyroidism With Anxiety Symptom in Young First-Episode and Drug-Naïve Patients With Major Depressive Disorder

BACKGROUNDS

Subclinical hypothyroidism (SCH) was reported to be associated with depression; however, its role in coexisting anxiety symptom in young patients with major depressive disorder (MDD) remains unclear. The objective of this study was to explore the relationship between SCH and anxiety symptom in young first-episode and drug-naïve (FEDN) MDD patients.

METHODS

A total of 520 outpatients diagnosed as FEDN MDD with SCH were recruited in this study. Their socio-demographic, clinical data and thyroid function parameters were collected. The Hamilton Anxiety Rating Scale (HAMA) and the Hamilton Depression Rating Scale (HAMD) were employed to measure the severity of anxiety symptom and depressive symptom, respectively. Based on the HAMA scores, patients who scored ≥ 25 were defined as anxious major depressive disorder (A-MDD) while others as non-anxious major depressive disorder (NA-MDD).

RESULTS

The prevalence rate of A-MDD was 15.8% in young FEDN MDD patients with comorbid SCH. Moreover, serum thyroid stimulating hormone (TSH) levels were significantly higher in patients with A-MDD compared with those with NA-MDD (p < 0.001). Multivariate binary logistic regression analysis indicated that A-MDD was associated with serum TSH levels with an odds ratio (OR) of 1.602. Serum TSH level of 6.17 mIU/L was the critical value to distinguish A-MDD and NA-MDD, with sensitivity of 0.805 and specificity of 0.539. There were no statistically significant differences between NA-MDD and A-MDD patients in terms of socio-demographic variables, serum free triiodothyronine (FT3), free thyroxine (FT4), thyroid peroxidases antibody (TPOAb) and anti-thyroglobulin (TgAb) levels.

CONCLUSIONS

A-MDD patients presented higher serum TSH level. It is suggested that serum TSH level may be a potential biomarker for predicting moderate and severe anxiety symptoms in young FEDN MDD patients with SCH.

Subclinical thyroid dysfunction and major depressive disorder

PURPOSE

This review attempts to investigate the link between subclinical thyroid dysfunction (SCH) and major depressive disorder (MDD). It has been speculated that SCH may be related to MDD through an autoimmune mechanism.

METHODS

A comprehensive literature search was conducted in the PubMed database for relevant research and review articles.

RESULTS

There appears to be an association between an autoimmune mechanism, possibly involving the thyroid gland, and depressive disorders, but the available evidence is so far inconclusive.

CONCLUSION

Lifetime prevalence of depression is significantly higher in patients with SCH, a finding reflecting a possible effect of SCH in lowering the threshold for the emergence of MDD. The relationship between SCH and MDD is, however, not clear, with large and well-designed studies investigating possible links between reference-range thyroid hormone levels and MDD having as yet found no relation between the two.

The effect of thyroid function on the risk of psychiatric readmission after hospitalization for major depressive disorder

The relationship between thyroid function and depression has long been recognized, but little is known about the effect of thyroid function on the risk of readmission after hospitalization for major depressive disorder (MDD). This retrospective cohort study was aimed to explore the effect of thyroid function on psychiatric readmission after hospitalization for MDD. Data was derived from electronic medical records (EMR) of the Shanghai Mental Health Center (SMHC), Shanghai, China. Univariate and multivariate logistic regression analyses were conducted in subjects aged ≥ 18 years who had been hospitalized for MDD between January 1, 2007, and May 31, 2019. Of the 1803 eligible patients, 85 and 132 patients experienced psychiatric readmission within 90 days and 180 days after discharge respectively. Multivariate analyses showed that serum FT3 level (aOR=1.271; 95%CI=1.051-1.537) and comorbidity of thyroid disease (aOR=2,179; 95%CI=1.136-4.179) was independently associated with the risk of 90-day and 180-day readmission respectively. These findings indicated that high serum FT3 levels and comorbidity of thyroid disease could increase the risk of readmission after hospitalization for MDD. It is warranted to provide routine assessment and intervention of the thyroid function during the treatment of depression so as to prevent re-hospitalization.

Multivesicular liposome: A lipid-based drug delivery system for efficient drug delivery

The advancement of delivery tools for therapeutic agents has brought several novel formulations with increased drug loading, sustained release, targeted delivery, and prolonged efficacy. Amongst the several novel delivery approaches, multivesicular liposome has gained potential interest because this delivery system possesses the above advantages. In addition, this multivesicular liposomal delivery prevents degradation of the entrapped drug within the physiological environment while administered. The special structure of the vesicles allowed successful entrapment of hydrophobic and hydrophilic therapeutic agents, including proteins and peptides. Furthermore, this novel formulation could maintain the desired drug concentration in the plasma for a prolonged period, which helps to reduce the dosing frequencies, improve bioavailability, and safety. This tool could also provide stability of the formulation, and finally gaining patient compliance. Several multivesicular liposomes received approval for clinical research, while others are at different stages of laboratory research. In this review, we have focused on the preparation of multivesicular liposomes along with their application in different ailments for the improvement of the performance of the entrapped drug. Moreover, the challenges of delivering multivesicular vesicles have also been emphasized. Overall, it could be inferred that multivesicular liposomal delivery is a novel platform of advanced drug delivery with improved efficacy and safety.

Treatment-resistant depression: An overview for psychiatric advanced practice nurses

PURPOSE

Treatment-resistant depression (TRD) can require complex management. The purpose of this paper is to provide an update on the hypothesized neurobiology of depression, and to describe treatment options for patients impacted by TRD.

CONCLUSIONS

Recent neurobiological findings support the use of augmenting pharmacological agents, neuromodulation techniques, and esketamine as effective in achieving remission for those with TRD.

PRACTICE IMPLICATIONS

First-line interventions for depression can be safely managed by primary care providers. Psychiatric advanced practice nurses must be well versed and capable of treating more complicated cases, including TRD, that may require second- or third-line approaches.

The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

OBJECTIVES

To provide advice and guidance regarding the management of mood disorders, derived from scientific evidence and supplemented by expert clinical consensus to formulate s that maximise clinical utility.

METHODS

Articles and information sourced from search engines including PubMed, EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (e.g. books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Relevant information was appraised and discussed in detail by members of the mood disorders committee, with a view to formulating and developing consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous consultation and external review involving: expert and clinical advisors, key stakeholders, professional bodies and specialist groups with interest in mood disorders.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists mood disorders clinical practice guidelines 2020 (MDcpg²⁰²⁰) provide up-to-date guidance regarding the management of mood disorders that is informed by evidence and clinical experience. The guideline is intended for clinical use by psychiatrists, psychologists, primary care physicians and others with an interest in mental health care.

CONCLUSION

The MDcpg²⁰²⁰ builds on the previous 2015 guidelines and maintains its joint focus on both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

MOOD DISORDERS COMMITTEE

Gin S Malhi (Chair), Erica Bell, Darryl Bassett, Philip Boyce, Richard Bryant, Philip Hazell, Malcolm Hopwood, Bill Lyndon, Roger Mulder, Richard Porter, Ajeet B Singh and Greg Murray.