Treatment of hypothyroidism and psychosis

Myxedema Psychosis: Systematic Review and Pooled Analysis

BACKGROUND AND OBJECTIVE

The term myxedema psychosis (MP) was introduced to describe the occurrence of psychotic symptoms in patients with untreated hypothyroidism, but the optimal assessment and treatment of this condition are unclear. We aimed to synthesize data from the literature to characterize the clinical presentation and management of MP.

METHODS

We performed a systematic review according to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines in PubMed (Medline), Embase, Google Scholar, and Cochrane databases, including observational studies, case series, and case reports published from 1/1/1980 to 31/12/2019 in the English language. Descriptive statistics along with univariate and multivariate analysis were used for data synthesis.

RESULTS

Out of 1583 articles screened, 71 case reports met our inclusion criteria providing data on 75 MP cases. The median age at diagnosis was 42 years [32-56]. About 53% had no prior hypothyroidism diagnosis. Delusions occurred in 91%, with a predominance of persecutory ideas (84%), while hallucinations occurred in 78%. Physical symptoms and signs of hypothyroidism were absent in 37% and 26%, respectively. If symptoms occurred, nonspecific fatigue was seen most frequently (63%). The median thyroid-stimulating hormone value was 93 mIU/L [60-139]. Thyroid peroxidase antibodies were found positive in 75% (23/33) of reported cases. Creatinine kinase was reported abnormal in seven cases. Cranial imaging (CT or MRI) and electroencephalogram were normal in 89%, 75%, and 73% of the cases reported. The majority of patients were treated orally with thyroxine in combination with short-term antipsychotics. More than 90% of them showed complete recovery. Univariate analysis revealed a trend towards a shorter duration of psychosis with IV thyroid hormone therapy (p= 0.0502), but the effect was not consistent in a multivariate analysis.

CONCLUSION

While we identified a substantial lack of published research on MP, our pooled analysis of case observations suggests that the condition presents a broad spectrum of psychiatric and physical symptoms lending support to the value of screening for thyroid dysfunction in patients with first-ever psychosis.

PROSPERO REGISTRATION NUMBER

CRD42020160310.

Risperidone and Levothyroxine for Managing "Myxedema Madness"

Hypothyroidism is one of the common comorbidities seen in patients with psychiatric conditions. Sometimes few patients may present with neuropsychiatric symptoms such as cognitive slowing, depression, or psychosis (“myxedema madness”). These patients are managed with antipsychotic medications while admitting laboratory works are processed. It has been found that antipsychotic use is associated with lower free thyroxine levels, so untreated hypothyroid patients may experience worsening of symptoms with antipsychotic use. It is recommended that hypothyroid patients with psychosis be treated for the underlying hypothyroidism with thyroid hormone replacement. In this article, we are presenting a case of a hypothyroid patient presenting to a psychiatric facility for worsening psychosis and persecutory delusions, and medication non-compliance to levothyroxine. We also discuss the management of psychosis in a patient with worsening hypothyroidism with a combination regimen: levothyroxine and risperidone.