Grades of thyroid failure in 100 depressed and anergic psychiatric inpatients

Thyroid function and mental disorders: an insight into the complex interaction

OBJECTIVE

To assess the serum levels of Thyroxine (T4), Triiodothyronine (T3) and the thyroid stimulating hormone (TSH) in patients with depression.

METHODS

Sixty clinically diagnosed and drug naive depressed patients and an equal number of healthy, age and sex matched control subjects were included in this study. The Ham-D scale was used to classify the degree of depression into the mild, moderate and the severe grades. The biochemical parameters (T3, T4 and TSH) were estimated by using commercially available kits. The data were analyzed by using the SPSS-10 software, one way ANOVA and the χ2 test.

RESULT

The female depressive (n = 48) cases outnumbered the male depressive cases. The distributions of the patients in the mild, moderate and the severe categories were similar. A significant decline in the T3 level and an elevation in the T4 level were found in the depressive cases as compared to those in the healthy controls. ANOVA with multiple comparisons testing among the patient group showed no significant difference in the TSH level when the depressive cases with various degrees of depression were compared. A total of twelve depressive patients were found to have thyroid abnormalities.

CONCLUSION

This study therefore observed the presence of thyroid dysfunction among the depressive cases, which is most often characterized as the "Lower Thyroid Syndrome". Thus, the inclusion of the thyroid screening test among the depressive patients may be helpful in the proper management of the cases.

Antenatal thyroid correlates of postpartum depression

We previously found significantly higher T3-resin uptake and nearly significantly lower total thyroxine concentrations at 38 weeks of pregnancy in women with higher postpartum depression ratings. This study further examined the relationship between thyroid status during late pregnancy and antenatal and postpartum depression scores. Thyroid measures were obtained at 32-35, 36, and 37 weeks of pregnancy in 31 women with normal range thyroid hormone levels. Subjects rated their mood at these antenatal time points and every other week between postpartum weeks 2 and 24 on the Edinburgh Postnatal Depression Scale and the Beck Depression Inventory. Mean antenatal thyroxine concentrations and free thyroxine indices correlated significantly and negatively with mean depression scores during each of three postpartum time periods (postpartum weeks 2-6, 14-18, 20-24). Women with total and free thyroxine concentrations that were, respectively, <10.1 microg/dl and <1.06 ng/dl at all three antenatal time points had significantly higher mean depression scores during all postpartum time periods. The fraction of subjects with pregravid major or minor depression history that was in the low antenatal thyroid group was significantly higher than the fraction of subjects with negative history (5/6 vs. 7/25). Women with antenatal total and free thyroxine concentrations in the lower euthyroid range may be at greater risk of developing postpartum depressive symptoms. Study of the relationships with antenatal thyroid status may provide new insights into the pathophysiology of perinatal mood disturbances.

Low yield of thyroid-stimulating hormone testing in elderly patients with depression

Although hypothyroidism is purportedly an important cause of depression, prior studies have involved small samples of young people and produced conflicting results. We examined the yield of thyroid-stimulating hormone (TSH) testing in a large group of elderly patients with major depression or dysthymic disorder. The study sample comprised 883 outpatients aged 60 years or older from 18 primary care sites enrolled in the intervention arm of a clinical trial of depression management. Thyroid function was assessed by a single TSH value. Depressive diagnoses were confirmed with the Structured Clinical Interview for DSM-IV (SCID) and depression severity was assessed with the HSCL-20, a modified depression scale of the Hopkins Symptom Checklist. TSH results were available for 725 (82.1%) participants. Although 32 (4.4%) of those tested had TSH>5 mIU/L, the vast majority (27/32) had marginally elevated results (5.1-9.4 mIU/L). Only five patients (0.7%) had TSH levels >10 mIU/L. Patients with elevated TSH did not differ from those with TSH < or = 5 mIU/L in the severity or symptom pattern of depression as measured by the baseline HSCL-20 score (P=.37) or SCID score (P=.44). These findings should caution physicians against acceptance of borderline TSH values as the primary cause of a patient's clinical depression.

Different neuroendocrine profiles of remitted and nonremitted schizophrenic patients

BACKGROUND

Thyrotropin-releasing hormone (TRH) test and Dexamethasone Suppression Test (DST) are two neuroendocrine tests that have been extensively used in an attempt to predict treatment response and outcome in schizophrenia. The objectives of this study were to investigate (1) the relationship between TRH test and DST and various psychiatric symptoms and (2) the potential value of these tests in prediction of short-term outcome in schizophrenic patients.

METHODS

TRH test and DST were administered to 58 patients with schizophrenia. All patients were evaluated with a battery of rating scales before neuroendocrine test procedures and at regular intervals for 1 year. Patients were divided into two groups as remitted (RP; n = 30) and nonremitted patients (NRP; n = 28). Baseline results of these two groups were compared with each other and 30 healthy controls.

RESULTS

Basal levels of total T3 (T3T) and free T3 (T3F) were higher in RP group than controls. Basal prolactin (PRL) level was higher in RP group, but not in NRP, compared to controls. Basal growth hormone (GH) and thyroid-stimulating hormone (TSH) levels of NRP were significantly higher than those of RP. DST nonsuppression was observed at a significantly higher rate in RP than NRP and control group. Blunted TSH response rate in RP group was higher significantly compared to other two groups.

CONCLUSIONS

The data implicate that higher basal TSH and GH levels may be associated with a poorer treatment response, whereas higher total and free T3 levels, a blunted TSH response to TRH and nonsuppression on the DST may indicate a better response in schizophrenics.

Utility of thyroid function screening in adolescent psychiatric inpatients

OBJECTIVE

Thyroid function abnormalities have been associated with psychiatric symptoms. This study examines the utility of thyroid screening among adolescent psychiatric inpatients.

METHOD

A retrospective chart review of 196 first-time admissions to an adolescent psychiatric unit was conducted. Charts were screened for demographics, presence/absence of thyroid function testing, history of thyroid disease, medication/illicit substance use, and other factors of influence on thyroid testing. Thyroid test results were reviewed for abnormalities.

RESULTS

Thyroid function testing was conducted in 150 of the 196 admissions. Fifty-two patients had abnormalities, most of which were isolated abnormalities of thyroxine (T4) or triiodothyronine uptake (T3U). Laboratory diagnosis of hyperthyroidism and mild hypothyroidism was met by two and eight patients, respectively; five had profiles that were normal upon subsequent testing 1 week later. None of the patients was symptomatic, and none required thyroid supplementation or antithyroid medications. Gender differences in T4 and T3U were noted, and age was positively correlated with T3U.

CONCLUSIONS

Thyroid function tests may be spuriously abnormal in routine screening of newly admitted psychiatric patients. Routine thyroid screening among adolescent psychiatric inpatients is unwarranted except in patients who display physical signs or symptoms suggestive of thyroid disease.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Thyrotropin response to TRH stimulation in depressed patients with autoimmune thyroiditis

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

Basal thyroid indices in adolescent depression and bipolar disorder

OBJECTIVE

Abnormalities of the thyroid axis are documented in adult mood disorders. The most consistent findings have been observed in major depressive disorder with elevations of thyroxine (T4) or free-T4 (fT4) within the euthyroid range that decrease with treatment. The literature on adolescents is limited, and it is unknown whether similar findings might be present in this population.

METHOD

First admissions to a university hospital adolescent psychiatry unit were reviewed. Fourteen depressed and 13 manic patients satisfied inclusion and exclusion criteria. None had a history of thyroid illness or medical illness or were taking medications known to affect thyroid function. Basal serum thyrotropin, T4, fT4, triiodothyronine (T3), reverse-T3, free thyroxine index (FTI), and T3 resin uptake levels were compared with those of a group of adolescent normal controls.

RESULTS

T4 (but not fT4) was elevated in depressed and manic patients compared with controls (p < .05). In manic patients, T3 was decreased and reverse-T3 was increased (p < .05). There were no significant differences in relation to age, sex, or suicidality.

CONCLUSIONS

We observed significant differences in basal thyroid hormone levels in depressed and manic adolescents. Our results suggest the presence of abnormalities of thyroid function in adolescent mood disorders similar to those described in mood-disordered adults.

Physiological causes of depression in the elderly

Depression represents the most common psychiatric disorder in the elderly. Physiological processes can often cause depressive symptoms. The psychiatric nurse provides an important role in assisting the depressed elderly client through interventions, such as talking, exercise, touch, and relaxation.

Psychoendocrinological aspects of affective disorders

Psychoendocrinological studies have opened a new approach to understanding affective disorders. In this study, the links of affective illnesses to changes in endocrine secretions--particularly adrenal, gonadal, growth, pineal, thyroidal, and prolactin--were reviewed with the object of adding to the number of depressed whose symptoms can be relieved.

Hyperthyroxinemia in major affective disorders

Ninety-nine patients fulfilling DSM-III criteria for primary major affective disorder, either bipolar or unipolar, were studied. A 12% prevalence of elevated thyroxine levels was found. Three of the 12 hyperthyroxinemia patients also had elevated free thyroxine index. No statistically significant difference in response to antidepressant treatment was observed between the hyperthyroxinemia group and the normal serum thyroxine group.

Thyroid hormones in the treatment of affective disorders

The experience of using thyroid hormones in affective disorders is summarized. This includes: 1) Using thyroid hormones alone in depression; 2) their combined use with tricyclic antidepressants; 3) addition of thyroid hormones to nontricyclic antidepressants; 4) the use of thyroid stimulating hormone; and 5) thyrotropin releasing hormone in depression. Suggested mechanisms of action are discussed. A special attention is paid to the place of thyroid hormones in the treatment of rapid cycling affective disorder.

Antithyroid antibodies in major depression

Antithyroid antibodies were measured in 58 patients with unipolar major depressive disorder. None of the patients had received prior lithium treatment. Five patients had antimicrosomal and antithyroglobulin antibodies. The prevalence rate of detectable antibody titers approximates that found in normal subjects. The presence of detectable antibody titers was not related to abnormal thyroid function tests. The implications of these findings are discussed.

Neuroendocrine aspects of primary endogenous depression--IV. Pituitary-thyroid axis activity in patients and matched control subjects

In order to ascertain the extent of hypothalamo--pituitary--thyroid (HPT) axis dysfunction in endogenous depression, we determined nocturnal serum thyrotropin (TSH) concentrations, TSH responses to thyrotropin releasing hormone (TRH) administration, and serum triiodothyronine (T3) and thyroxine (T4) concentrations in 40 Research Diagnostic Criteria primary, definite endogenous depressives and 40 individually matched normal control subjects. We also examined the relationships of the HPT measures to pre- and post-dexamethasone (DEX) serum and urine cortisol measures and, in the patients, to subject characteristics, the diagnosis of endogenous/melancholic depression by different systems, and the overall severity and specific dimensions of depressive symptomatology. Compared to their matched controls, the patients showed significant reductions in nocturnal serum TSH and serum T3 concentrations. Neither the TSH responses to TRH nor serum T4 concentrations were significantly different between the two groups of subjects. In the patients, none of the subject characteristics, diagnostic schemes for endogenous/melancholic depression or specific aspects of depressive symptomatology were significantly related to HPT activity. The measures of HPT activity were unrelated to measures of hypothalamo--pituitary--adrenal cortical (HPA) axis activity in both groups of subjects.

Grades 1 and 2 hypothyroidism in a state mental hospital: risk factors and clinical findings

Thirty-six chronically psychotic patients (nine men and 27 women, mean age 56.7 +/- S.D. 13.4 years) were found to have elevated thyroid stimulating hormone (TSH) levels during review of thyroid function screening tests of 1150 patients over a 15 month period in a 700 bed state mental hospital. This study population of 36 patients was more likely to be female and older than the general hospital population. The spectrum and frequency of psychiatric diagnoses included dementia (3); schizoaffective disorder (12); bipolar disorder (6); schizophrenic disorder (4); organic affective disorder (7); major depression (3); and mental retardation (1). Only nine of these 36 patients failed to receive the goitrogens lithium (LI), carbamazepine (CBZ) and/or phenytoin (PTN) and five of those nine patients had a history of thyroid disease. Sex did not predict age, thyroxine (T4) level, triiodothyronine (T3) uptake, or TSH. The distribution of psychiatric diagnoses were the same for both sexes. Expectedly, there was an inverse relationship between TSH and T4 and T3 uptake. Using T4 to separate grades 1 and 2 hypothyroidism revealed that six (17%) patients had grade 1 disease. Men were more likely to have a seizure disorder and receive LI, CBZ, and PTN. Women were more likely to have a history of thyroid disease. The goitrogenic effects of LI + CBZ seemed additive compared with patients receiving LI alone. While T4, T3 uptake, and LI levels were the same for the two groups, patients receiving LI + CBZ had higher TSH values (p = 0.028) than did patients receiving LI alone.(ABSTRACT TRUNCATED AT 250 WORDS)

Trends in research and treatment of affective disorders

Trends in research on affective disorders were reviewed. Studies which described the contribution of neurotransmitters and neuroendocrines to depression, unipolar and bipolar, and manic states were cited. Women more frequently suffer from affective disorders but women's response to different therapies sometimes is more favorable than men's. Age and married status influence sex differences in the incidence of affective disorders. Symptoms of pain and depression intertwine, and response to analgesia may emerge as an index of response to therapy for depression. Trends in pharmacotherapies for affective disorders were reviewed: lithium, tricyclic antidepressants, and MAOI drugs, as well as trends in the employment of ECT and sleep deprivation to relieve symptoms of affective disorders were reviewed.