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Roa Dueñas OH, Hofman A, Luik AI, Medici M, Peeters RP, Chaker L. The Cross-sectional and Longitudinal Association Between Thyroid Function and Depression: A Population-Based Study. J Clin Endocrinol Metab 2024; 109:e1389-e1399. [PMID: 37855318 PMCID: PMC11031221 DOI: 10.1210/clinem/dgad620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/21/2023] [Accepted: 10/16/2023] [Indexed: 10/20/2023]
Abstract
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.
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Affiliation(s)
| | - Amy Hofman
- Department of Epidemiology, Erasmus University Medical
Center, 3000 CA Rotterdam, The Netherlands
| | - Annemarie I Luik
- Department of Epidemiology, Erasmus University Medical
Center, 3000 CA Rotterdam, The Netherlands
- Trimbos Institute—The Netherlands Institute of Mental Health and
Addiction, 3521 VS Utrecht, The Netherlands
| | - Marco Medici
- Academic Center for Thyroid Diseases, Erasmus University Medical
Center, 3000 CA Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus University Medical
Center, 3000 CA Rotterdam, The Netherlands
| | - Robin P Peeters
- Academic Center for Thyroid Diseases, Erasmus University Medical
Center, 3000 CA Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus University Medical
Center, 3000 CA Rotterdam, The Netherlands
| | - Layal Chaker
- Department of Epidemiology, Erasmus University Medical
Center, 3000 CA Rotterdam, The Netherlands
- Academic Center for Thyroid Diseases, Erasmus University Medical
Center, 3000 CA Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus University Medical
Center, 3000 CA Rotterdam, The Netherlands
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Zhou H, Zhu H, Wang J, Gao X, Jiang C. Association between hypothyroidism subtypes and major depression: A two-sample Mendelian randomization study. J Affect Disord 2024; 351:843-852. [PMID: 38341154 DOI: 10.1016/j.jad.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/28/2024] [Accepted: 02/06/2024] [Indexed: 02/12/2024]
Abstract
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.
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Affiliation(s)
- Hongliang Zhou
- Department of Medical Psychology, The Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China.
| | - Haohao Zhu
- Department of Psychiatry, Wuxi Mental Health Center, Nanjing Medical University, Wuxi, Jiangsu, China
| | - Jun Wang
- Department of Psychiatry, Wuxi Mental Health Center, Nanjing Medical University, Wuxi, Jiangsu, China
| | - Xuezheng Gao
- Department of Psychiatry, Wuxi Mental Health Center, Nanjing Medical University, Wuxi, Jiangsu, China
| | - Chenguang Jiang
- Department of Psychosomatics and Psychiatry, ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, China
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Odawara S, Shimbo T, Yamauchi T, Kobayashi D. Association of Low-Normal Free T4 Levels With Future Major Depression Development. J Endocr Soc 2023; 7:bvad096. [PMID: 37528949 PMCID: PMC10387582 DOI: 10.1210/jendso/bvad096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Indexed: 08/03/2023] Open
Abstract
Context Hyperthyroidism and overt and subclinical hypothyroidism are associated with major depression; however, the association of major depression across the spectrum of thyroid function within the normal range is unknown. Objective We investigated whether higher or lower levels of free thyroxine (T4) and thyrotropin (TSH) within the normal range are associated with major depression. Methods This was a retrospective cohort study of 66 960 participants with normal thyroid function who visited for health checkups (St. Luke's International Hospital, 2005-2018). The primary outcome was the development of major depression during the follow-up period. Participants were divided into 3 equal groups based on baseline free T4 or TSH values (low-, middle-, or high-normal), and the incidence of major depression was compared using the Cox proportional hazard model after adjusting for potential covariates. Results During the median follow-up of 1883 days, 1363 (2.0%) patients developed major depression. The low-normal free T4 group had a significantly higher risk of major depression (adjusted HR 1.15; 95% CI, 1.01-1.31), but not the high-normal free T4 group or TSH groups. The association between low-normal free T4 and the development of major depression was maintained, rather more obvious, upon exclusion of participants whose thyroid hormone levels became abnormal during follow-up compared with data from all participants (adjusted HR 1.24; 95% CI, 1.07-1.43). Conclusion In this cohort, low-normal free T4 was associated with an increased risk of future major depression, even if subsequent hormone levels were maintained within the normal range. The magnitude of the impact of low-normal free T4 was relatively mild.
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Affiliation(s)
- Sara Odawara
- Correspondence: Sara Odawara, MD, PhD, Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
| | - Takuro Shimbo
- Department of Medicine, Ohta Nishinouchi Hospital, Fukushima 963-8558, Japan
| | - Toshimasa Yamauchi
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Daiki Kobayashi
- Division of General Internal Medicine, Department of Medicine, Tokyo Medical University Ibaraki Medical Center, Ibaraki 300-0332, Japan
- Department of Medicine, Fujita Health University, Aichi 470-1192, Japan
- Department of General Medicine, Juntendo University Faculty of Medicine, Tokyo 113-8421, Japan
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Zhao S, Du Y, Zhang Y, Wang X, Xia Y, Sun H, Huang Y, Zou H, Wang X, Chen Z, Zhou H, Yan R, Tang H, Lu Q, Yao Z. Gray matter reduction is associated with cognitive dysfunction in depressed patients comorbid with subclinical hypothyroidism. Front Aging Neurosci 2023; 15:1106792. [PMID: 36845662 PMCID: PMC9945283 DOI: 10.3389/fnagi.2023.1106792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 01/17/2023] [Indexed: 02/11/2023] Open
Abstract
Introduction To explore the association between regional gray matter volume (GMV) and cognitive impairments and ascertain whether the regional brain alterations related to cognitive impairments occur in major depressive disorder (MDD) patients with comorbid subclinical hypothyroidism (SHypo). Methods We enrolled 32 MDD patients, 32 MDD patients with comorbid SHypo, and 32 normal controls and subjected them to thyroid function tests, neurocognitive tests, and magnetic resonance imaging (MRI). Using voxel-based morphometry (VBM) analysis, we examined the pattern of gray matter (GM) in these participants. We also used ANOVA to detect group differences and partial correlation to explore the potential association between GMV alterations and cognitive tests in comorbid patients. Results The comorbid patients exhibited significantly smaller GMV in the right middle frontal gyrus (MFG) than the non-comorbid group. Furthermore, the partial correlation analysis showed that GMV of the right MFG was associated with poor executive function (EF) performance in comorbid patients. Conclusion These findings provide valuable insight into the relationship between the alteration of GMV and cognitive dysfunction of MDD patients with comorbid SHypo.
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Affiliation(s)
- Shuai Zhao
- Department of Psychiatry, The Affiliated Psychological Hospital of Anhui Medical University, Hefei, China,Hefei Fourth People’s Hospital, Hefei, China,Anhui Mental Health Center, Hefei, China,Anhui Clinical Research Center for Mental Disorders, Hefei, China,Department of Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Yishan Du
- Department of Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Yu Zhang
- Department of Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaoqin Wang
- Department of Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Yi Xia
- Department of Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Hao Sun
- Department of Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Yinghong Huang
- Nanjing Brain Hospital, Medical School of Nanjing University, Nanjing, China
| | - Haowen Zou
- Department of Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Xumiao Wang
- Department of Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Zhilu Chen
- Department of Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Hongliang Zhou
- Department of Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Rui Yan
- Department of Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Hao Tang
- Department of Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Qing Lu
- School of Biological Sciences & Medical Engineering, Southeast University, Nanjing, China,Child Development and Learning Science, Key Laboratory of Ministry of Education, Nanjing, China,*Correspondence: Qing Lu, ; Zhijian Yao,
| | - Zhijian Yao
- Department of Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China,Nanjing Brain Hospital, Medical School of Nanjing University, Nanjing, China,*Correspondence: Qing Lu, ; Zhijian Yao,
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Association of high BMI with subclinical hypothyroidism in young, first-episode and drug-naïve patients with major depressive disorder: a large-scale cross-sectional study. Eur Arch Psychiatry Clin Neurosci 2023; 273:183-190. [PMID: 35546358 DOI: 10.1007/s00406-022-01415-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 04/11/2022] [Indexed: 12/11/2022]
Abstract
Thyroid dysfunction is known to be associated with obesity, but the reliability of this relationship is easily affected by drug treatment, age, and subclinical hypothyroidism (SCH) with no apparent symptoms. Our research aims to compare obese and overweight BMI ranges with SCH and without SCH in a large sample of young, first-episode and drug-naïve (FEDN) patients with major depressive disorder (MDD), which has received little systemic investigation. A total of 1289 FEDN MDD young outpatients were recruited for this study. Serum thyroid function and lipid level parameters were measured; HAMD and PANSS scales were used to assess patients' depression and positive symptoms. A self-administered questionnaire collected other clinical and demographic data. The prevalence of SCH in FEDN MDD young patients was 58.26%. Compared to patients without SCH, the patients with SCH had a more prolonged illness duration, higher BMI levels, increased prevalence of overweight and obesity, higher HAMD score and PANSS-positive symptom scores, higher levels of TG, TC, LDL-C, and lower levels of HDL-C. Further logistic regression indicated that overweight BMI, obese BMI, illness duration, HAMD score, HDL-C, and TC were significantly associated with SCH. Our results indicate that obesity and overweight may be associated with SCH in young, FEDN MDD patients. The importance of regular thyroid function assessment in young FEDN MDD patients with high BMI should be taken into account.
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Hirtz R, Hölling H, Grasemann C. Subclinical Hypothyroidism and Incident Depression in Adolescents and Young Adults: Results from a Nationwide Representative Prospective Study. Thyroid 2022; 32:1169-1177. [PMID: 35946076 DOI: 10.1089/thy.2022.0205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Although the relationship between subclinical hypothyroidism and major depressive disorder (MDD) has been studied in adults in cross-sectional and prospective population-based studies, this has not yet been done in adolescents. However, since thyroid function and MDD risk are subjected to maturational processes and ramifications of illness duration over the life span, these findings may not readily transfer to adolescents. Methods: The relationship between subclinical hypothyroidism and MDD was studied in a representative subsample of the nationwide KIGGS ("The German Health Interview and Examination Survey for Children and Adolescents") survey. A total of 4118 adolescents were examined over a median period of 6 years, and data were analyzed by a logistic regression approach accounting for important covariates related to thyroid function and/or MDD risk. The same approach was chosen to investigate the relationship between quartiles of thyrotropin (TSH) and free thyroxine (fT4) levels and incident MDD in euthyroid participants to broaden the focus on the relationship between thyroid hormone levels and MDD in a dose-response manner. Results: During the observation period, 121 cases of MDD were reported. There was no association between subclinical hypothyroidism and MDD when comparing 111 adolescents with subclinical hypothyroidism with 4007 euthyroid adolescents, representative of ∼106,000 and 3,610,000 adolescents from the general pediatric population, respectively. This also applied when studying the relationship between quartiles of TSH and fT4 levels and MDD in euthyroid participants. All results were confirmed by sensitivity analyses accounting for thyroid autoimmunity. Conclusions: Consistent with findings in adults, there is no association between subclinical hypothyroidism or quartiles of TSH and fT4 levels in the normal range and MDD in adolescents, despite potential age-related differences regarding thyroid function and MDD risk.
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Affiliation(s)
- Raphael Hirtz
- Division of Pediatric Endocrinology and Diabetology, Department of Pediatrics II, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Heike Hölling
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Corinna Grasemann
- Department of Pediatrics and Center for Rare Diseases Ruhr CeSER, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
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Ahmed ZS, Sherin RPV, Fonseca TL, Hoang TD, Shakir MKM. Improvement of depression in a patient with hypothyroidism and deiodinase polymorphism with LT3 Therapy. Clin Case Rep 2022; 10:e05651. [PMID: 35432999 PMCID: PMC9005678 DOI: 10.1002/ccr3.5651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 01/29/2022] [Accepted: 03/07/2022] [Indexed: 11/24/2022] Open
Abstract
We report a 54‐year‐old man with treatment‐resistant depression (TRD) and hypothyroidism who responded to LT3/LT4 combination, rather than LT4 alone. He was able to discontinue all antidepressant medications eventually. Interestingly, the patient has a DIO2 polymorphism.
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Affiliation(s)
- Ziyan S. Ahmed
- Endocrinology Division Walter Reed National Military Medical Center Bethesda Maryland USA
| | - Rinsha P. V. Sherin
- Endocrinology Division Walter Reed National Military Medical Center Bethesda Maryland USA
| | - Tatiana L. Fonseca
- Section of Adult and Pediatric Endocrinology Diabetes & Metabolism University of Chicago Chicago Illinois USA
| | - Thanh D. Hoang
- Endocrinology Division Walter Reed National Military Medical Center Bethesda Maryland USA
- Endocrinology Division Uniformed Services University of the Health Sciences Bethesda Maryland USA
| | - Mohamed K. M. Shakir
- Endocrinology Division Walter Reed National Military Medical Center Bethesda Maryland USA
- Endocrinology Division Uniformed Services University of the Health Sciences Bethesda Maryland USA
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Ross DS. Treating hypothyroidism is not always easy: When to treat subclinical hypothyroidism, TSH goals in the elderly, and alternatives to levothyroxine monotherapy. J Intern Med 2022; 291:128-140. [PMID: 34766382 DOI: 10.1111/joim.13410] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The majority of patients with hypothyroidism feel better when levothyroxine treatment restores thyroid-stimulating hormone (TSH) concentrations to normal. Increasingly, a significant minority of patients remain symptomatic and are dissatisfied with their treatment. Overzealous treatment of symptomatic patients with subclinical hypothyroidism may contribute to dissatisfaction among hypothyroidism patients, as potential hypothyroid symptoms in patients with minimal hypothyroidism rarely respond to treatment. Thyroid hormone prescriptions have increased by 30% in the United States in the last decade. The diagnosis of subclinical hypothyroidism should be confirmed by repeat thyroid function tests ideally obtained at least 2 months later, as 62% of elevated TSH levels may revert to normal spontaneously. Generally, treatment is not necessary unless the TSH exceeds 7.0-10 mIU/L. In double-blinded randomized controlled trials, treatment does not improve symptoms or cognitive function if the TSH is less than 10 mIU/L. While cardiovascular events may be reduced in patients under age 65 with subclinical hypothyroidism who are treated with levothyroxine, treatment may be harmful in elderly patients with subclinical hypothyroidism. TSH goals are age dependent, with a 97.5 percentile (upper limit of normal) of 3.6 mIU/L for patients under age 40, and 7.5 mIU/L for patients over age 80. In some hypothyroid patients who are dissatisfied with treatment, especially those with a polymorphism in type 2 deiodinase, combined treatment with levothyroxine and liothyronine may be preferred.
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Affiliation(s)
- Douglas S Ross
- Endocrine Division, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts, USA
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Zheng YS, Dong SY, Gong Y, Wang JH, Wang F, Zeng Q. Comparison of Five Different Criteria for Diagnosis of Subclinical Hypothyroidism in a Large-Scale Chinese Population. Front Endocrinol (Lausanne) 2022; 13:820414. [PMID: 35242111 PMCID: PMC8887626 DOI: 10.3389/fendo.2022.820414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/20/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Several different criteria for subclinical hypothyroidism (SCH) have been used in the literature, but the performance of these criteria was unknown. OBJECTIVE This retrospective study was to evaluate the diagnostic criteria for SCH. METHODS Eligible participants were based on centration of thyroglobulin antibodies (TG-Ab), thyroid peroxidase antibodies (TPO-Ab), and five thyroid-related hormones including total thyroxine (TT4), total triiodothyronine (TT3), free thyroxine (FT4), free triiodothyronine (FT3), and thyroid-stimulating hormone (TSH). Euthyroid individuals were identified via specific criteria. Five different SCH diagnostic criteria were compared based on the distributions of those indicators. An appropriate TSH cut-off value was reconsidered. RESULTS The study included 145,015 participants. The number of SCH cases diagnosed using criterion 5 was significantly different compared to the cases diagnosed using criteria 1-4 (P<0.05) and had the highest positive proportions of TG-Ab and TPO-Ab. Analysis of 60,515 subjects with normal other thyroid hormones revealed a median TSH concentration of 2.04 mIU/L, and the P 2.5-P 97.5 CI was 0.48-7.03 mIU/L. When the threshold for TSH elevation was elevated from ≥4.5 mIU/L to ≥6.50 mIU/L, the number of diagnosed SCH cases decreased from 7.30% to 2.09% and the proportions of positive TG-Ab and TPO-Ab increased from 23.69% and 24.07% to 33.75% and 35.06%, respectively (P<0.01). CONCLUSIONS Combination of an elevated TSH and normal TT3, TT4, FT3, and FT4 concentrations is a must for the diagnosis of SCH. A new TSH threshold should be identified for better patient monitoring and management, according to the real-world characteristics of TSH distribution in Chinese population.
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Bode H, Ivens B, Bschor T, Schwarzer G, Henssler J, Baethge C. Association of Hypothyroidism and Clinical Depression: A Systematic Review and Meta-analysis. JAMA Psychiatry 2021; 78:1375-1383. [PMID: 34524390 PMCID: PMC8444067 DOI: 10.1001/jamapsychiatry.2021.2506] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
IMPORTANCE Hypothyroidism is considered a cause of or a strong risk factor for depression, but recent studies provide conflicting evidence regarding the existence and the extent of the association. It is also unclear whether the link is largely due to subsyndromal depression or holds true for clinical depression. OBJECTIVE To estimate the association of hypothyroidism and clinical depression in the general population. DATA SOURCES PubMed, PsycINFO, and Embase databases were searched from inception until May 2020 for studies on the association of hypothyroidism and clinical depression. STUDY SELECTION Two reviewers independently selected epidemiologic and population-based studies that provided laboratory or International Statistical Classification of Diseases and Related Health Problems diagnoses of hypothyroidism and diagnoses of depression according to operationalized criteria (eg, Diagnostic and Statistical Manual of Mental Disorders or International Statistical Classification of Diseases and Related Health Problems) or cutoffs in established rating scales. DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted data and evaluated studies based on the Newcastle-Ottawa Scale. Summary odds ratios (OR) were calculated in random-effects meta-analyses. MAIN OUTCOMES AND MEASURES Prespecified coprimary outcomes were the association of clinical depression with either hypothyroidism or autoimmunity. RESULTS Of 4350 articles screened, 25 studies were selected for meta-analysis, including 348 014 participants. Hypothyroidism and clinical depression were associated (OR, 1.30 [95% CI, 1.08-1.57]), while the OR for autoimmunity was inconclusive (1.24 [95% CI, 0.89-1.74]). Subgroup analyses revealed a stronger association with overt than with subclinical hypothyroidism, with ORs of 1.77 (95% CI, 1.13-2.77) and 1.13 (95% CI, 1.01-1.28), respectively. Sensitivity analyses resulted in more conservative estimates. In a post hoc analysis, the association was confirmed in female individuals (OR, 1.48 [95% CI, 1.18-1.85]) but not in male individuals (OR, 0.71 [95% CI, 0.40-1.25]). CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, the effect size for the association between hypothyroidism and clinical depression was considerably lower than previously assumed, and the modest association was possibly restricted to overt hypothyroidism and female individuals. Autoimmunity alone may not be the driving factor in this comorbidity.
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Affiliation(s)
- Henry Bode
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Beatrice Ivens
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Tom Bschor
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, Technical University of Dresden, Dresden, Germany
| | - Guido Schwarzer
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Jonathan Henssler
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Cologne, Cologne, Germany,Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christopher Baethge
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Cologne, Cologne, Germany
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Karakatsoulis GN, Tsapakis EM, Mitkani C, Fountoulakis KN. Subclinical thyroid dysfunction and major depressive disorder. Hormones (Athens) 2021; 20:613-621. [PMID: 34427900 DOI: 10.1007/s42000-021-00312-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 07/20/2021] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Grigorios N Karakatsoulis
- 3rd Department of Psychiatry, Aristotle University of Thessaloniki, University General Hospital AHEPA, Stilponos Kyriakidi Str. 1, Thessaloniki, Greece.
- , Thessaloniki, Greece.
| | - Eva-Maria Tsapakis
- 1st Department of Psychiatry, Aristotle University of Thessaloniki, Papageorgiou General Hospital, 564 29, Thessaloniki, Greece
- "Agios Charalambos" Mental Health Clinic, 71305, Heraklion, Crete, Greece
| | - Calypso Mitkani
- "Agios Pavlos" General Hospital, Ethnikis Antistaseos Ave. 161, Thessaloniki, Greece
| | - Konstantinos N Fountoulakis
- 3rd Department of Psychiatry, Aristotle University of Thessaloniki, University General Hospital AHEPA, Stilponos Kyriakidi Str. 1, Thessaloniki, Greece
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Patterns of Thyroid Hormone Prescription in Patients with Bipolar or Schizoaffective Disorder: Findings from the LiSIE Retrospective Cohort Study. J Clin Med 2021; 10:jcm10215062. [PMID: 34768582 PMCID: PMC8584539 DOI: 10.3390/jcm10215062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/22/2021] [Accepted: 10/25/2021] [Indexed: 11/17/2022] Open
Abstract
The prescription of thyroid hormone replacement therapy (THRT) has increased in the general population; the thyroid stimulating hormone (TSH) threshold to initiate THRT has decreased. It remains unclear whether a similar trend has occurred in patients with bipolar disorder (BD). In this work we explore patterns and trends of prescribing THRT in patients with BD or schizoaffective disorder (SZD) with an observational study and time-trend analysis in the framework of the LiSIE (Lithium-Study into Effects and Side Effects) retrospective cohort study. In most patients, THRT was initiated for subclinical hypothyroidism. The median TSH at which THRT was started was 6.0 (IQR 4.0) mIU/L and the median free serum thyroxine (fT4) at which THRT was started was 11.8 (IQR 3.9) pmol/L. The median TSH concentration at the start of THRT decreased annually with 0.10 mIU/L (p = 0.047) and was higher in patients treated with lithium than in patients treated with other mood stabilisers (p = 0.02). In conclusion, THRT was typically initiated in the context of mild or absent alterations of thyroid function tests with a decreasing TSH threshold. As THRT is rarely reversed once initiated, clinicians need to weigh up potential benefits and risks when prescribing THRT for subclinical hypothyroidism in patients with BD or SZD.
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Koehler VF, Bojunga J. [Autoimmune thyroid disease]. Dtsch Med Wochenschr 2021; 146:1329-1336. [PMID: 34644793 DOI: 10.1055/a-1258-5674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Autoimmune thyroiditis (AIT) is not only one of the most prevalent human autoimmune diseases, but also the most frequent cause of primary hypothyroidism. It is characterized by lymphocytic infiltration of the thyroid gland with subsequent gradual destruction and fibrous replacement of thyroid tissue. Genetic predisposition, epigenetic modifications and environmental factors are suspected as disease triggers. Signs and symptoms of hypothyroidism include fatigue, bradycardia, constipation and cold intolerance. In subclinical hypothyroidism, symptoms may be absent. The diagnosis of AIT is based on the presence of antibodies against thyroid specific antigens, primarily anti-thyroid peroxidase antibodies and on a sonographically proven reduced echogenicity of the thyroid parenchyma. The diagnosis of concomitant hypothyroidism is primarily based on clinical signs and symptoms as well as measurement of thyroid-stimulating hormone (TSH)-concentration. Subclinical hypothyroidism is characterized by elevated TSH with normal serum free thyroxine (fT4) and triiodothyronine (fT3) levels, while in manifest hypothyroidism serum fT4 and fT3 levels are reduced. Levothyroxine (LT4) treatment in subclinical hypothyroidism is a controversy in the scientific literature and should be discussed individually. It not only depends on the level of TSH-elevation, but also on other factors, such as patient age, presence of comorbidities and clinical symptoms of hypothyroidism. In contrast, overt hypothyroidism and subclinical hypothyroidism with a TSH-level > 10 mIU/L is a strong indication for LT4 administration, aiming at rapid achievement of euthyroidism. In patients with dissatisfaction due to persistence of symptoms despite optimal LT4-treatment LT4/T3-combination therapy should be considered, based on expert opinion.
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Subclinical hypothyroidism and symptoms of depression: Evidence from the National Health and Nutrition Examination Surveys (NHANES). Compr Psychiatry 2021; 109:152253. [PMID: 34147730 DOI: 10.1016/j.comppsych.2021.152253] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 05/07/2021] [Accepted: 06/03/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Subclinical hypothyroidism has been associated with increased risk for depression, yet the findings remain controversial. It is possible that subclinical hypothyroidism is associated with some, but not all symptoms of depression. We examined symptom-specific associations between depression and subclinical hypothyroidism. METHODS Participants (N = 7683 adults) were from the National Health and Nutrition Examination Surveys of 2007-2008, 2009-2010, and 2011-2012 We included participants who had data on their thyroid profile and depressive symptoms (measured using Patient Health Questionnaire), and excluded those with overt hypothyroidism or hyperthyroidism, and those on thyroid hormone replacement therapy. Logistic regression with sampling weights was used to examine the association between subclinical hypothyroidism and depression symptoms. We also ran sensitivity analysis using different cut-off points for defining subclinical hypothyroidism. RESULTS Of all the participants, 208 (2.7%) had subclinical hypothyroidism and of them only six had depression. Subclinical hypothyroidism was not associated with depression (OR = 0.61, 95% CI 0.20-1.87) nor with the specific depression symptoms. Using lower criteria for subclinical hypothyroidism diagnosis resulted in similar findings. CONCLUSIONS In a nationally representative sample of US adults, we observed no association between subclinical hypothyroidism and overall depression risk or any of the individual symptoms of depression.
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15
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Yoo WS, Chung HK. Subclinical Hypothyroidism: Prevalence, Health Impact, and Treatment Landscape. Endocrinol Metab (Seoul) 2021; 36:500-513. [PMID: 34139799 PMCID: PMC8258336 DOI: 10.3803/enm.2021.1066] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 05/10/2021] [Indexed: 12/13/2022] Open
Abstract
Subclinical hypothyroidism (sHypo) is defined as normal serum free thyroid hormone levels coexisting with elevated serum thyroid-stimulating hormone (TSH) levels. sHypo is a common condition observed in clinical practice with several unique features. Its diagnosis should be based on an understanding of geographic and demographic differences in biochemical criteria versus a global reference range for TSH that is based on the 95% confidence interval of a healthy population. During the differential diagnosis, it is important to remember that a considerable proportion of sHypo cases are transient and reversible in nature; the focus is better placed on persistent or progressive forms, which mainly result from chronic autoimmune thyroiditis. Despite significant evidence documenting the health impacts of sHypo, the effects of levothyroxine treatment (LT4-Tx) in patients with sHypo remains controversial, especially in patients with grade 1 sHypo and older adults. Existing evidence suggests that it is reasonable to refrain from immediate LT4-Tx in most patients if they are closely monitored, except in women who are pregnant or in progressive cases. Future research is needed to further characterize the risks and benefits of LT4-Tx in different patient cohorts.
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Affiliation(s)
- Won Sang Yoo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Hyun Kyung Chung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
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Varella AC, Benseñor IM, Janovsky CCPS, Goulart AC, Birck MG, Santos IS, Brunoni AR, Lotufo PA. Thyroid-stimulating hormone levels and incident depression: Results from the ELSA-Brasil study. Clin Endocrinol (Oxf) 2021; 94:858-865. [PMID: 33386609 DOI: 10.1111/cen.14407] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 12/20/2020] [Accepted: 12/22/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study aimed to prospectively evaluate whether TSH levels at baseline were associated with incident depression after four years of follow-up in a cohort of middle-aged adults, the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). METHODS TSH and free-thyroxine (FT4) levels were evaluated at baseline. Depression diagnoses were performed using the Clinical Interview Schedule-Revised (CIS-R) at baseline and after a 4-year follow-up. Poisson regression models (95% Confidence Intervals) were built to evaluate the association between TSH quintiles at baseline and incident depression. All analyses were stratified by sex. Models were presented crude, adjusted for age and sex; and further adjusted for race, education, BMI, smoking, alcohol consumption, use of antidepressants/benzodiazepines, kidney function and comorbidities. RESULTS Mean age was 51.5 years, and 51.2% were women. Overall, low TSH levels (1st quintile) were associated with incident depression (adjusted RR = 1.36, 95% CI 1.02-1.81), remaining significant for women (adjusted RR = 1.64, 95% CI 1.15-2.33), but not for men. The same results were found when restricting analysis to euthyroid participants (adjusted RR = 1.46, 95% CI 1.08-1.99), also significant for women only (adjusted RR = 1.63, 95% CI 1.12-2.38). CONCLUSIONS Our results showed that low TSH levels were positively associated with incident depression, particularly among women. Similar results were found when restricting the analysis to euthyroid participants. In contrast, high TSH levels were inversely associated with incident depression, also among women.
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Affiliation(s)
- Ana C Varella
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Isabela M Benseñor
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
- Departamento de Medicina Interna, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Carolina C P S Janovsky
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Alessandra C Goulart
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Marina G Birck
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Itamar S Santos
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
- Departamento de Medicina Interna, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Andre R Brunoni
- Departamento de Psiquiatria, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Paulo A Lotufo
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
- Departamento de Medicina Interna, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
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Park SK, Ryoo JH, Kang JG, Jung JY. Association of left ventricular hypertrophy with the level of thyroid hormone in euthyroid state. J Endocrinol Invest 2021; 44:111-117. [PMID: 32383145 DOI: 10.1007/s40618-020-01277-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 04/24/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE It has been demonstrated that variation in thyroid hormone levels even within normal range was associated with increased cardiovascular risk. However, available data are still insufficient on association between left ventricular hypertrophy (LVH) and thyroid hormone levels within euthyroid state. METHODS In 69,298 Koreans with euthyroid function, we evaluated association between echocardiographically detected LVH and thyroid hormone levels within the normal range. Study participants were categorized into elderly (age ≥ 40) and younger (age < 40) groups, where subjects were divided into four groups according to quartile levels of thyroxine (FT4), triiodothyronine (FT3), and thyroid-stimulating hormone (TSH). Multivariable adjusted logistic regression analysis was used to calculate odds ratios (ORs) and 95% confidence interval (CI) for LVH (adjusted ORs [95% CI]) across quartile levels of thyroid hormones. RESULTS In elderly group, adjusted ORs for LVH generally higher in the first quartile group than other quartile groups, despite no statistical significance in some cases (first quartile: reference, second quartile: 0.86 [0.67-1.11] in TSH, 0.75 [0.58-0.95] in FT4 and 0.63 [0.49-0.81] in FT3, third quartile: 0.70 [0.54-0.92] in TSH, 0.79 [0.61-1.02] in FT4 and 0.72 [0.55-0.93] in FT3, fourth quartile: 0.81 [0.65-1.04] in TSH, 0.85 [0.65-1.10] in FT4 and 0.58 [0.44-0.77] in FT3). This finding was similarly found in the younger group, despite discrepancy in some cases. CONCLUSION In euthyroid state, low normal levels in FT4, FT3 and TSH were more strongly associated with LVH.
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Affiliation(s)
- S K Park
- Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae-Hong Ryoo
- Department of Occupational and Environmental Medicine, School of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - J G Kang
- Total Healthcare Center, KangBuk Samsung Hospital, Sungkyunkwan University, School of Medicine, Seoul, Korea
| | - J Y Jung
- Total Healthcare Center, KangBuk Samsung Hospital, Sungkyunkwan University, School of Medicine, Seoul, Korea.
- School of Medicine, Sungkyunkwan University, Seoul, Korea.
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Shao Q, Wu Y, Ji J, Xu T, Yu Q, Ma C, Liao X, Cheng F, Wang X. Interaction Mechanisms Between Major Depressive Disorder and Non-alcoholic Fatty Liver Disease. Front Psychiatry 2021; 12:711835. [PMID: 34966296 PMCID: PMC8710489 DOI: 10.3389/fpsyt.2021.711835] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/11/2021] [Indexed: 12/12/2022] Open
Abstract
Major depressive disorder (MDD), which is highly associated with non-alcoholic fatty liver disease (NAFLD), has complex pathogenic mechanisms. However, a limited number of studies have evaluated the mutual pathomechanisms involved in MDD and NAFLD development. Chronic stress-mediated elevations in glucocorticoid (GC) levels play an important role in the development of MDD-related NAFLD. Elevated GC levels can induce the release of inflammatory factors and changes in gut permeability. Elevated levels of inflammatory factors activate the hypothalamic-pituitary-adrenal (HPA) axis, which further increases the release of GC. At the same time, changes in gut permeability promote the release of inflammatory factors, which results in a vicious circle among the three, causing disease outbreaks. Even though the specific role of the thyroid hormone (TH) in this pathogenesis has not been fully established, it is highly correlated with MDD and NAFLD. Therefore, changing lifestyles and reducing psychological stress levels are necessary measures for preventing MDD-related NAFLD. Among them, GC inhibitors and receptor antagonists may be key in the alleviation of early and mid-term disease progression. However, combination medications may be important in late-stage diseases, but they are associated with various side effects. Traditional Chinese medicines have been shown to be potential therapeutic alternatives for such complex diseases.
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Affiliation(s)
- Qi Shao
- College of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Yiping Wu
- College of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Jing Ji
- College of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Tian Xu
- College of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Qiaoyu Yu
- College of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Chongyang Ma
- College of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Xuejing Liao
- College of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Fafeng Cheng
- College of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Xueqian Wang
- College of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
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19
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Tsou M, Chen J. Burnout and metabolic syndrome among healthcare workers: Is subclinical hypothyroidism a mediator? J Occup Health 2021; 63:e12252. [PMID: 34286911 PMCID: PMC8291686 DOI: 10.1002/1348-9585.12252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/17/2021] [Accepted: 06/25/2021] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Evidence suggests that subclinical hypothyroidism (SCH) is associated with burnout and metabolic syndrome (MetS). We examined the relationship between burnout and MetS among healthcare workers (HCWs) and investigated the potential mediation of SCH. METHODS This cross-sectional study included HCWs from a tertiary medical center; demographic data were obtained using a questionnaire. Burnout was evaluated according to the Chinese version of the Maslach Burnout Inventory-Health Services Survey (MBI-HSS). MetS and thyroid function data were obtained from a physical check-up. Logistic regression models were used to evaluate the adjusted odds ratio (aOR), and mediation analysis was employed to examine the mediation effect. RESULTS Among 945 non-doctor/nurse and 1868 doctor/nurse staff, MetS was 30% and 14%, respectively, and the prevalence of burnout was nearly 6.5%. The results showed that burnout induced higher aOR of MetS in the doctor/nurse group (1.27, 95% confidence interval [CI]: 1.05-3.62). Thyroid-stimulating hormone (TSH) showed a positive association factor of MetS in doctor/nurse group-adjusted burnout (aOR = 1.15, 95% CI: 1.01-4.19). A higher TSH level was associated with an increased odds of MetS in younger doctor/nurse staff with burnout syndrome (aOR = 1.74; 95% CI: 1.04-3.22). There was a borderline significant mediation effect of SCH in the association between burnout and MetS in doctor/nurse staff. CONCLUSIONS The results showed that higher TSH levels were positively associated with burnout and MetS in doctor/nurse professionals, especially in the young cohort. Burnout may rely on the borderline mediation effect of SCH, which is likely to affect MetS.
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Affiliation(s)
- Meng‐Ting Tsou
- Department of Family MedicineMacKay Memorial HospitalTaipei CityTaiwan
- Department of Occupation MedicineMacKay Memorial HospitalTaipei CityTaiwan
- Department of MacKay Junior College of Medicine, Nursing, and ManagementNew Taipei CityTaiwan
| | - Jau‐Yuan Chen
- Department of Family MedicineChang‐Gung Memorial HospitalLinkou BranchTaiwan
- Chang Gung University College of MedicineTaoyuanTaiwan
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20
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Wildisen L, Del Giovane C, Moutzouri E, Beglinger S, Syrogiannouli L, Collet TH, Cappola AR, Åsvold BO, Bakker SJL, Yeap BB, Almeida OP, Ceresini G, Dullaart RPF, Ferrucci L, Grabe H, Jukema JW, Nauck M, Trompet S, Völzke H, Westendorp R, Gussekloo J, Klöppel S, Aujesky D, Bauer D, Peeters R, Feller M, Rodondi N. An individual participant data analysis of prospective cohort studies on the association between subclinical thyroid dysfunction and depressive symptoms. Sci Rep 2020; 10:19111. [PMID: 33154486 PMCID: PMC7644764 DOI: 10.1038/s41598-020-75776-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 10/20/2020] [Indexed: 01/07/2023] Open
Abstract
In subclinical hypothyroidism, the presence of depressive symptoms is often a reason for starting levothyroxine treatment. However, data are conflicting on the association between subclinical thyroid dysfunction and depressive symptoms. We aimed to examine the association between subclinical thyroid dysfunction and depressive symptoms in all prospective cohorts with relevant data available. We performed a systematic review of the literature from Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library from inception to 10th May 2019. We included prospective cohorts with data on thyroid status at baseline and depressive symptoms during follow-up. The primary outcome was depressive symptoms measured at first available follow-up, expressed on the Beck's Depression Inventory (BDI) scale (range 0-63, higher values indicate more depressive symptoms, minimal clinically important difference: 5 points). We performed a two-stage individual participant data (IPD) analysis comparing participants with subclinical hypo- or hyperthyroidism versus euthyroidism, adjusting for depressive symptoms at baseline, age, sex, education, and income (PROSPERO CRD42018091627). Six cohorts met the inclusion criteria, with IPD on 23,038 participants. Their mean age was 60 years, 65% were female, 21,025 were euthyroid, 1342 had subclinical hypothyroidism and 671 subclinical hyperthyroidism. At first available follow-up [mean 8.2 (± 4.3) years], BDI scores did not differ between participants with subclinical hypothyroidism (mean difference = 0.29, 95% confidence interval = - 0.17 to 0.76, I2 = 15.6) or subclinical hyperthyroidism (- 0.10, 95% confidence interval = - 0.67 to 0.48, I2 = 3.2) compared to euthyroidism. This systematic review and IPD analysis of six prospective cohort studies found no clinically relevant association between subclinical thyroid dysfunction at baseline and depressive symptoms during follow-up. The results were robust in all sensitivity and subgroup analyses. Our results are in contrast with the traditional notion that subclinical thyroid dysfunction, and subclinical hypothyroidism in particular, is associated with depressive symptoms. Consequently, our results do not support the practice of prescribing levothyroxine in patients with subclinical hypothyroidism to reduce the risk of developing depressive symptoms.
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Affiliation(s)
- Lea Wildisen
- grid.5734.50000 0001 0726 5157Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland ,grid.5734.50000 0001 0726 5157Graduate School for Health Sciences, University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
| | - Cinzia Del Giovane
- grid.5734.50000 0001 0726 5157Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
| | - Elisavet Moutzouri
- grid.5734.50000 0001 0726 5157Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland ,grid.5734.50000 0001 0726 5157Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland
| | - Shanthi Beglinger
- grid.5734.50000 0001 0726 5157Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland ,grid.5734.50000 0001 0726 5157Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland
| | - Lamprini Syrogiannouli
- grid.5734.50000 0001 0726 5157Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
| | - Tinh-Hai Collet
- grid.8515.90000 0001 0423 4662Service of Endocrinology, Diabetes and Metabolism, Department of Medicine, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Anne R. Cappola
- grid.25879.310000 0004 1936 8972Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Pennsylvania School of Medicine, 3400 Civic Center Boulevard, Philadelphia, PA 19104 USA
| | - Bjørn O. Åsvold
- grid.5947.f0000 0001 1516 2393K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Postboks 8905 MTFS, 7491 Trondheim, Norway ,grid.52522.320000 0004 0627 3560Department of Endocrinology, St. Olavs Hospital, Trondheim University Hospital, Postbox 3250 Torgarden, 7006 Trondheim, Norway
| | - Stephan J. L. Bakker
- grid.4830.f0000 0004 0407 1981Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Bu B. Yeap
- grid.1012.20000 0004 1936 7910Medical School, University of Western Australia Perth, The University of Western Australia (M582), 35 Stirling Highway, Crawley, WA 6009 Australia
| | - Osvaldo P. Almeida
- grid.1012.20000 0004 1936 7910Medical School, University of Western Australia Perth, The University of Western Australia (M582), 35 Stirling Highway, Crawley, WA 6009 Australia
| | - Graziano Ceresini
- grid.411482.aDepartment of Medicine and Surgery, Unit of Internal Medicine and Onco-Endocrinology, University Hospital of Parma, Via Gramsci, 14 - 43126 Parma, Italy
| | - Robin P. F. Dullaart
- grid.4830.f0000 0004 0407 1981Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Luigi Ferrucci
- grid.419475.a0000 0000 9372 4913Longitudinal Studies Section, Translational Gerontology Branch, National Institute on Aging, 251 Bayview Boulevard, Suite 100, Baltimore, MD 21224 USA
| | - Hans Grabe
- grid.5603.0Institute for Community Medicine, Clinical-Epidemiological Research, University Medicine Greifswald, Walter Rathenau Str. 48, 17475 Greifswald, Germany
| | - J. Wouter Jukema
- grid.10419.3d0000000089452978Department of Cardiology, Leiden University Medical Center, Postbus 9600, 2300 RC Leiden, The Netherlands
| | - Matthias Nauck
- grid.5603.0Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475 Greifswald, Germany ,grid.452396.f0000 0004 5937 5237DZHK (German Centre for Cardiovascular Research), Partner Site Greifswald, University Medicine, Ferdinand-Sauerbruch-Straße, 17475 Greifswald, Germany
| | - Stella Trompet
- grid.10419.3d0000000089452978Section Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Henry Völzke
- grid.5603.0Department of Psychiatry and Psychotherapy, University Medicine Greifswald, Ellernholzstrasse 1-2, 17489 Greifswald, Germany
| | - Rudi Westendorp
- grid.5254.60000 0001 0674 042XDepartment of Public Health and Center for Healthy Aging, University of Copenhagen, Gothersgade 160, 1123 København K, Mærsk Tower, Copenhagen, Denmark
| | - Jacobijn Gussekloo
- grid.10419.3d0000000089452978Section Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands ,grid.10419.3d0000000089452978Department of Public Health and Primary Care, Leiden University Medical Center, LUMC Education Building, Hippocratespad 21, 2333 ZD Leiden, the Netherlands
| | - Stefan Klöppel
- grid.5734.50000 0001 0726 5157University Hospital of Old Age Psychiatry, University of Bern, Murtenstrasse 21, 3008 Bern, Switzerland
| | - Drahomir Aujesky
- grid.5734.50000 0001 0726 5157Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland
| | - Douglas Bauer
- grid.266102.10000 0001 2297 6811Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, 550 16th St., Box 0560, San Francisco, CA 94158 USA
| | - Robin Peeters
- grid.5645.2000000040459992XDepartment of Medicine, Erasmus Medical Center, Postbus 2040, 3000 CA Rotterdam, The Netherlands
| | - Martin Feller
- grid.5734.50000 0001 0726 5157Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland ,grid.5734.50000 0001 0726 5157Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland
| | - Nicolas Rodondi
- grid.5734.50000 0001 0726 5157Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland ,grid.5734.50000 0001 0726 5157Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland
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Sohn W, Chang Y, Cho YK, Kim Y, Shin H, Ryu S. Abnormal and Euthyroid Ranges of Thyroid Hormones in Serum and Liver Cancer Mortality: A Cohort Study. Cancer Epidemiol Biomarkers Prev 2020; 29:2002-2009. [PMID: 32699077 DOI: 10.1158/1055-9965.epi-20-0283] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 05/21/2020] [Accepted: 07/13/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND This study aimed to evaluate the relationship of serum thyrotropin (TSH) and thyroid hormone concentration with liver cancer mortality. METHODS A cohort of 517,996 Korean adults, who did not have liver cancer at baseline and attended a health screening including free thyroxine (FT4) and TSH, were followed for up to 16 years. High and low TSH and FT4 were defined as those above the upper bound of reference interval and those below the lower bound of reference interval of their corresponding reference intervals, respectively. Mortality information was ascertained through National Death Records. The adjusted HR (aHR) with 95% confidence interval (CI) were estimated using a Cox proportional hazard model. RESULTS During a median follow-up of 8.1 years, 376 deaths from liver cancer were identified. Subjects with low FT4 levels were associated with an elevated risk of liver cancer mortality with a corresponding multivariable aHR 2.25 (95% CI: 1.62-3.12) compared with those with normal FT4 levels. Within the euthyroid range, there was also a dose-dependent inverse relationship between FT4 level and liver cancer mortality (P < 0.001). Levels of TSH and free T3 had no significant association with liver cancer mortality. CONCLUSIONS The risk of liver cancer mortality increased as FT4 level decreased, both within the normal and abnormal ranges of thyroid function. IMPACT Thyroid function within the abnormal and normal ranges might affect liver cancer mortality. Further study is warranted to elucidate the role of thyroid hormone in development of liver cancer including the underlying biological mechanism.
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Affiliation(s)
- Won Sohn
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yoosoo Chang
- Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Department of Occupational and Environmental Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, South Korea
| | - Yong Kyun Cho
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Yejin Kim
- Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hocheol Shin
- Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Department of Family Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seungho Ryu
- Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea. .,Department of Occupational and Environmental Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, South Korea
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22
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Wytrychiewicz K, Pankowski D, Janowski K, Benoit CE, Bargiel-Matusiewicz K, Pisula E, Walicka M. The role of beliefs about the impact of illness on fertility and close relationships for psychopathological symptoms in women treated for hypothyroidism. J Clin Psychol 2020; 76:2314-2328. [PMID: 32592617 DOI: 10.1002/jclp.23011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 11/05/2022]
Abstract
OBJECTIVE As demonstrated in a pilot study, hypothyroidism has a highly stressful impact on some areas of functioning. This study aims to evaluate the connection between illness-related beliefs (IRBs) and the impact of hypothyroidism on fertility and close relationships, which were the strongest stressors, and the level of depressive, anxiety, and anger symptoms. METHODS Two hundred and thirteen women being treated for hypothyroidism took part in an online survey and completed the modified Hospital Anxiety and Depression Scale, Hypothyroidism Symptoms Severity rating scales, and a measure of IRBs. Other relevant clinical data were also collected. RESULT Mean levels of thyroid-stimulating hormone indicated that the women were euthyroid. Four groups of participants were identified based on IRBs. The group holding a strong IRB about the negative impact of illness only on close relationships scored significantly higher on depressive symptoms than women in the other groups. The group holding strong IRBs about the negative impact of illness on both close relationships and fertility scored significantly higher on anxiety symptoms than the women in the other groups. Regression analysis showed that IRBs about the negative impact of hypothyroidism predicted anxiety, depressive, and anger symptoms. CONCLUSIONS Negative IRBs about the impact of illness on fertility and close relationships contribute to increased levels of emotional distress symptoms in women being treated for hypothyroidism.
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Affiliation(s)
- Kinga Wytrychiewicz
- Faculty of Psychology, University of Warsaw, Warsaw, Poland.,Faculty of Psychology, University of Economics and Human Sciences in Warsaw, Warsaw, Poland
| | - Daniel Pankowski
- Faculty of Psychology, University of Warsaw, Warsaw, Poland.,Faculty of Psychology, University of Economics and Human Sciences in Warsaw, Warsaw, Poland
| | - Konrad Janowski
- Faculty of Psychology, University of Economics and Human Sciences in Warsaw, Warsaw, Poland
| | - Charles E Benoit
- Faculty of Psychology, University of Economics and Human Sciences in Warsaw, Warsaw, Poland
| | | | - Ewa Pisula
- Faculty of Psychology, University of Warsaw, Warsaw, Poland
| | - Magdalena Walicka
- Department of Internal Diseases, Endocrinology and Diabetology, Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw, Warsaw, Poland
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23
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Lieber I, Ott M, Öhlund L, Lundqvist R, Eliasson M, Sandlund M, Werneke U. Lithium-associated hypothyroidism and potential for reversibility after lithium discontinuation: Findings from the LiSIE retrospective cohort study. J Psychopharmacol 2020; 34:293-303. [PMID: 31670617 PMCID: PMC7005931 DOI: 10.1177/0269881119882858] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The association between lithium and thyroid dysfunction has long been known. However, it remains unknown if lithium-associated hypothyroidism is reversible once lithium treatment has been stopped. AIMS To determine whether lithium-associated hypothyroidism was reversible in patients who subsequently discontinued lithium. METHODS A retrospective cohort study in the Swedish region of Norrbotten into the effects and side- effects of lithium treatment and other drugs for relapse prevention (Lithium - Study into Effects and Side Effects). For this particular study, we reviewed medical records between 1997 and 2015 of patients with lithium-associated hypothyroidism who had discontinued lithium. RESULTS Of 1340 patients screened, 90 were included. Of these, 27% had overt hypothyroidism at the start of thyroid replacement therapy. The mean delay from starting lithium to starting thyroid replacement therapy was 2.3 years (SD 4.7). In total, 50% of patients received thyroid replacement therapy within 10 months of starting lithium. Of 85 patients available for follow-up, 41% stopped thyroid replacement therapy after lithium discontinuation. Only six patients reinstated thyroid replacement therapy subsequently. Of these, only one had overt hypothyroidism. CONCLUSIONS Lithium-associated hypothyroidism seems reversible in most patients once lithium has been discontinued. In such cases, thyroid replacement therapy discontinuation could be attempted much more often than currently done. Based on the limited evidence of our study, we can expect hypothyroidism to recur early after thyroid replacement therapy discontinuation, if at all.
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Affiliation(s)
- Ingrid Lieber
- Department of Clinical Sciences,
Division of Psychiatry, Umeå University, Sunderby Research Unit, Luleå, Sweden
| | - Michael Ott
- Department of Public Health and Clinical
Medicine – Medicine, Umeå University, Umeå, Sweden
| | - Louise Öhlund
- Department of Clinical Sciences,
Division of Psychiatry, Umeå University, Sunderby Research Unit, Luleå, Sweden
| | | | - Mats Eliasson
- Department of Public Health and Clinical
Medicine, Umeå University, Sunderby Research Unit, Luleå, Sweden
| | - Mikael Sandlund
- Department of Clinical Sciences,
Division of Psychiatry, Umeå University, Umeå, Sweden
| | - Ursula Werneke
- Department of Clinical Sciences,
Division of Psychiatry, Umeå University, Sunderby Research Unit, Luleå, Sweden,Ursula Werneke, Sunderby Hospital –
Psychiatry, Luleå, 97180, Sweden.
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24
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Lang X, Hou X, Shangguan F, Zhang XY. Prevalence and clinical correlates of subclinical hypothyroidism in first-episode drug-naive patients with major depressive disorder in a large sample of Chinese. J Affect Disord 2020; 263:507-515. [PMID: 31759671 DOI: 10.1016/j.jad.2019.11.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/14/2019] [Accepted: 11/02/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND The coexistence of subclinical hypothyroidism (SCH) and depression has been intensively examined in the patients receiving thyroxine or antidepressant treatment. This study aimed to investigate the prevalence and clinical correlates of severe SCH in Chinese first-episode drug naïve patients with major depressive disorder (MDD). METHODS Using a cross-sectional design, we recruited a total of 1706 MDD patients. Depressive symptoms were evaluated using the 17-item Hamilton Depression Rating Scale (HAMD). Severity of anxiety and psychiatric symptoms were evaluated by the Hamilton Anxiety Rating Scale (HAMA) and the Positive and Negative Syndrome Scale (PANSS), respectively. Serum thyroid function parameters were measured by a chemiluminescence immunoassay. Based on the serum thyroid stimulating hormone (TSH) level, SCH was further divided into mild (TSH < 10 mIU/L) and severe SCH (TSH ≥ 10 mIU/L). RESULTS More patients with severe SCH had severe anxiety, psychotic symptoms, suicide attempts (all p < 0.001), compared with those without severe SCH. Logistic regression showed that suicide attempts and psychiatric symptoms were associated with severe SCH (both p < 0.001). Multiple linear regression showed that age (p < 0.05), BMI (p < 0.001), HAMD score (p < 0.001), HAMA score (p < 0.001), PANSS positive subscore (p = 0.001) and CGI score (p = 0.001) were associated with TSH levels. CONCLUSION Our findings suggest that suicide attempts and psychiatric symptoms may be associated with severe SCH. Moreover, severe anxiety, depressive and psychotic symptoms, as well as older age and higher BMI are possibly related to elevated TSH levels.
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Affiliation(s)
- XiaoE Lang
- Department of Psychiatry, The First Clinical Medical College, Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Xin Hou
- Department of Psychiatry, The First Clinical Medical College, Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Fangfang Shangguan
- Beijing Key Laboratory of Learning and Cognition, School of Psychology, Capital Normal University, Beijing, China.
| | - Xiang Yang Zhang
- CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China; Department of Psychology, University of Chinese Academy of Sciences, Beijing, China.
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25
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Subclinical hypothyroidism and anxiety may contribute to metabolic syndrome in Sichuan of China: a hospital-based population study. Sci Rep 2020; 10:2261. [PMID: 32041973 PMCID: PMC7010766 DOI: 10.1038/s41598-020-58973-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 01/08/2020] [Indexed: 02/06/2023] Open
Abstract
The prevalence of Metabolic syndrome (MetS) in Sichuan of China has not yet been estimated. Meanwhile the association among anxiety, subclinical hypothyroidism (SCH) and MetS was less well-studied. The data was retrieved retrospectively from Health Promotion Center of West China Hospital database between 2014 and 2017. Internal validation by randomizing into training and testing panel by 9:1 and external validation with National Health and Nutrition Examination Survey (NHNES) were conducted. 19006 subjects were included into analysis, and 3530 (18.6%) of them were diagnosed with MetS. In training panel, age, sex (male), SCH (presence), SAS score, alcohol (Sometimes & Usual) and smoking (Active) were identified as independent risk factors for MetS, which was confirmed in testing panel internally. NHNES data validated externally the association between free thyroxine (fT4) and MetS components. The C-indices of predicting MetS nomogram were 0.705 (95% CI: 0.696–0.714) and 0.728 (95% CI: 0.701–0.754) in training and testing panel respectively. In conclusion, MetS prevalence was 18.6% in Sichuan. SCH and anxiety may be associated with MetS independently. A risk scale-based nomogram with accurate and objective prediction ability was provided for check-up practice, but more cohort validation was needed.
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26
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To Treat or Not to Treat Subclinical Hypothyroidism, What Is the Evidence? ACTA ACUST UNITED AC 2020; 56:medicina56010040. [PMID: 31963883 PMCID: PMC7022757 DOI: 10.3390/medicina56010040] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE levothyroxine prescriptions have increased remarkably during the last decade, and it is most likely to be prescribed in subclinical hypothyroidism. The aim of this review was to present data on when levothyroxine treatment should be initiated, and the effects of treatment in subclinical hypothyroidism on symptoms such as weight, quality of life, vitality, cognition, and cardiovascular disease. We also discuss evidence for different thyroid-hormone medications. In addition, the option to withhold medication when there is uncertain diagnosis or lack of clinical improvement is discussed. METHODS a literature search in PubMed on the term "treatment of subclinical hypothyroidism" in combination with "quality of life", "weight", "cognition", and "cerebrovascular disease". RESULTS current research supports that levothyroxine should be initiated in patients with a thyroid stimulating hormone (TSH) >10 mIU/L. Treatment for hypothyroidism is becoming more frequent. Symptoms related to vitality, weight, and quality of life in subclinical disease often persist with levothyroxine treatment, and other causes should be explored. Patients with cardiovascular-risk factors may benefit from treatment, especially younger patients. Caution is necessary when treating elderly subjects with levothyroxine. CONCLUSION lifelong treatment with levothyroxine should normally only be considered in manifest hypothyroidism. However, in subclinical hypothyroidism with a TSH >10 mIU/L, therapy is indicated. In milder subclinical forms, a wait-and-see strategy is advocated to see if normalization occurs. Subgroups with cardiovascular risk and subclinical hypothyroidism may benefit from levothyroxine therapy.
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27
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Wildisen L, Moutzouri E, Beglinger S, Syrogiannouli L, Cappola AR, Åsvold BO, Bakker SJL, Ceresini G, Dullaart R, Ferrucci L, Grabe H, Jukema JW, Nauck M, Trompet S, Völzke H, Westendorp RGJ, Gussekloo J, Peeters RP, Klöppel S, Aujesky D, Bauer DC, Rodondi N, Del Giovane C, Feller M. Subclinical thyroid dysfunction and depressive symptoms: protocol for a systematic review and individual participant data meta-analysis of prospective cohort studies. BMJ Open 2019; 9:e029716. [PMID: 31350252 PMCID: PMC6661665 DOI: 10.1136/bmjopen-2019-029716] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Prospective cohort studies on the association between subclinical thyroid dysfunction and depressive symptoms have yielded conflicting findings, possibly because of differences in age, sex, thyroid-stimulating hormone cut-off levels or degree of baseline depressive symptoms. Analysis of individual participant data (IPD) may help clarify this association. METHODS AND ANALYSIS We will conduct a systematic review and IPD meta-analysis of prospective studies on the association between subclinical thyroid dysfunction and depressive symptoms. We will identify studies through a systematic search of the literature in the Ovid Medline, Ovid Embase, Cochrane Central Register of Controlled Trials (CENTRAL) and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases from inception to April 2019 and from the Thyroid Studies Collaboration. We will ask corresponding authors of studies that meet our inclusion criteria to collaborate by providing IPD. Our primary outcome will be depressive symptoms at the first available individual follow-up, measured on a validated scale. We will convert all the scores to the Beck Depression Inventory scale. For each cohort, we will estimate the mean difference of depressive symptoms between participants with subclinical hypothyroidism or hyperthyroidism and control adjusted for depressive symptoms at baseline. Furthermore, we will adjust our multivariable linear regression analyses for age, sex, education and income. We will pool the effect estimates of all studies in a random-effects meta-analysis. Heterogeneity will be assessed by I2. Our secondary outcomes will be depressive symptoms at a specific follow-up time, at the last available individual follow-up and incidence of depression at the first, last and at a specific follow-up time. For the binary outcome of incident depression, we will use a logistic regression model. ETHICS AND DISSEMINATION Formal ethical approval is not required as primary data will not be collected. Our findings will have considerable implications for patient care. We will seek to publish this systematic review and IPD meta-analysis in a high-impact clinical journal. PROSPERO REGISTRATION NUMBER CRD42018091627.
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Affiliation(s)
- Lea Wildisen
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Elisavet Moutzouri
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Shanthi Beglinger
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Anne R Cappola
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Pennsylvania, School of Medicine, Philadelphia, Pennsylvania, USA
| | - Bjørn O Åsvold
- Department of Public Health and Nursing, K.G. Jebsen Center for Genetic Epidemiology, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Endocrinology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Stephan J L Bakker
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Graziano Ceresini
- Department of Clinical and Experimental Medicine, Geriatric Endocrine Unit, University Hospital of Parma, Parma, Italy
| | - Robin Dullaart
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Luigi Ferrucci
- Longitudinal Studies Section, Translational Gerontology Branch, Harbor Hospital, Baltimore, National Institute on Aging NIA-ASTRA Unit, Baltimore, Maryland, USA
| | - Hans Grabe
- Institute for Community Medicine, Clinical-Epidemiological Research, University Medicine Greifswald, Greifswald, Germany
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Matthias Nauck
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
- DZHK, German Centre for Cardiovascular Research, Partner Site Greifswald, University Medicine, Greifswald, Germany
| | - Stella Trompet
- Section Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Henry Völzke
- Institute for Community Medicine, Clinical-Epidemiological Research, University Medicine Greifswald, Greifswald, Germany
| | - Rudi G J Westendorp
- Department of Public Health and Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | - Jacobijn Gussekloo
- Section Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Robin P Peeters
- Department of Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Stefan Klöppel
- University Hospital of Old Age Psychatry, University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Douglas C Bauer
- Departments of Medicine and Epidemiology & Biostatistics, University of California, San Francisco, California, USA
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Martin Feller
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Abstract
IMPORTANCE Subclinical hypothyroidism, defined as an elevated serum thyrotropin (often referred to as thyroid-stimulating hormone, or TSH) level with normal levels of free thyroxine (FT4) affects up to 10% of the adult population. OBSERVATIONS Subclinical hypothyroidism is most often caused by autoimmune (Hashimoto) thyroiditis. However, serum thyrotropin levels rise as people without thyroid disease age; serum thyrotropin concentrations may surpass the upper limit of the traditional reference range of 4 to 5 mU/L among elderly patients. This phenomenon has likely led to an overestimation of the true prevalence of subclinical hypothyroidism in persons older than 70 years. In patients who have circulating thyroid peroxidase antibodies, there is a greater risk of progression from subclinical to overt hypothyroidism. Subclinical hypothyroidism may be associated with an increased risk of heart failure, coronary artery disease events, and mortality from coronary heart disease. In addition, middle-aged patients with subclinical hypothyroidism may have cognitive impairment, nonspecific symptoms such as fatigue, and altered mood. In the absence of large randomized trials showing benefit from levothyroxine therapy, the rationale for treatment is based on the potential for decreasing the risk of adverse cardiovascular events and the possibility of preventing progression to overt hypothyroidism. However, levothyroxine therapy may be associated with iatrogenic thyrotoxicosis, especially in elderly patients, and there is no evidence that it is beneficial in persons aged 65 years or older. CONCLUSIONS AND RELEVANCE Subclinical hypothyroidism is common and most individuals can be observed without treatment. Treatment might be indicated for patients with subclinical hypothyroidism and serum thyrotropin levels of 10 mU/L or higher or for young and middle-aged individuals with subclinical hypothyroidism and symptoms consistent with mild hypothyroidism.
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Affiliation(s)
- Bernadette Biondi
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Anne R Cappola
- Perelman School of Medicine, Division of Endocrinology, Diabetes, and Metabolism, the University of Pennsylvania, Philadelphia
- Associate Editor
| | - David S Cooper
- Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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29
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Zhang Z, Zhao D, Hong YS, Chang Y, Ryu S, Kang D, Monteiro J, Shin HC, Guallar E, Cho J. Long-Term Particulate Matter Exposure and Onset of Depression in Middle-Aged Men and Women. ENVIRONMENTAL HEALTH PERSPECTIVES 2019; 127:77001. [PMID: 31268362 PMCID: PMC6792358 DOI: 10.1289/ehp4094] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 06/04/2019] [Accepted: 06/12/2019] [Indexed: 05/20/2023]
Abstract
BACKGROUND Long-term exposure to particulate matter (PM) air pollution is associated with all-cause mortality and adverse cognitive outcomes, but the association with developing depression remains inconsistent. OBJECTIVE Our goal was to evaluate the prospective association between PM air pollution and developing depression assessed using the Center for Epidemiological Studies Depression (CES-D) scale. METHODS Subjects were drawn from a prospective cohort study of 123,045 men and women free of depressive symptoms at baseline who attended regular screening exams in Seoul and Suwon, South Korea, from 2011 to 2015. Exposure to PM with an aerodynamic diameter of [Formula: see text] ([Formula: see text] and [Formula: see text], respectively) was estimated using a land-use regression model based on each subject's residential postal code. Incident depression was defined as a CES-D score [Formula: see text] during follow-up. As a sensitivity analyses, we defined incident depression using self-reports of doctor's diagnoses or use of antidepressant medications during follow-up. RESULTS The mean baseline 12-month concentrations of [Formula: see text] and [Formula: see text] were 50.6 (4.5) and [Formula: see text], respectively. The hazard ratios (HRs) and 95% confidence intervals (CIs) for developing depression associated with a [Formula: see text] increase in 12- and 60-month [Formula: see text] exposure were 1.11 (95% CI: 1.06, 1.16) and 1.06 (95% CI: 1.01, 1.11), respectively. The corresponding HRs for 12-month [Formula: see text] exposure was 0.96 (95% CI: 0.64, 1.43). Similar results were obtained when incident depression was identified using self-reports of doctor's diagnoses or the use of antidepressant medications. CONCLUSION In this large cohort study, we found a positive association between long-term exposure to outdoor [Formula: see text] air pollution and the developing depression. We did not find an association for outdoor [Formula: see text] air pollution; however, we had a much shorter follow-up for subjects' exposure to [Formula: see text]. https://doi.org/10.1289/EHP4094.
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Affiliation(s)
- Zhenyu Zhang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Di Zhao
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Yun Soo Hong
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Yoosoo Chang
- Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
- Department of Occupational and Environmental Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seungho Ryu
- Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
- Department of Occupational and Environmental Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Danbee Kang
- Department of Occupational and Environmental Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | | | - Ho Cheol Shin
- Department of Family Medicine, Kangbuk Samsung Hospital and Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eliseo Guallar
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Juhee Cho
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
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30
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Tang R, Wang J, Yang L, Ding X, Zhong Y, Pan J, Yang H, Mu L, Chen X, Chen Z. Subclinical Hypothyroidism and Depression: A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2019; 10:340. [PMID: 31214119 PMCID: PMC6558168 DOI: 10.3389/fendo.2019.00340] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 05/10/2019] [Indexed: 12/15/2022] Open
Abstract
Background: Thyroid function is closely associated with neuropsychological functions, including mental state and cognitive functions. Although thyroid function is routinely examined in persons with depressive symptom, the association between subclinical hypothyroidism (SCH) and depression remains inconclusive. Objective: This systematic review and meta-analysis aimed to evaluate the risk of depression in persons with SCH. Methods: The PubMed, Embase, and Web of Science databases were searched up to August 2018. The primary outcome was the prevalence of depression, as evaluated by various types of self-reported depression scales. Odds ratios (ORs) were calculated to compare the risk of depression between persons with SCH and those with euthyroidism. Results: Twenty-one studies were included in the systematic review, with a total of 103,375 subjects from 7 studies being pooled for the meta-analysis to evaluate the risk of depression. The meta-analysis showed that persons with SCH had a significantly elevated risk of depression than persons with euthyroidism (OR = 1.78, 95% confidence interval [CI]: 1.11-2.86, P = 0.02). No publication bias was found, as indicated by Egger's test (t = -0.49, P = 0.647) and Begg's test (z = -0.15, P = 0.881). In addition, the funnel plot showed a symmetric distribution. Conclusions: This meta-analysis demonstrated that SCH was positively associated with the risk of depression, especially in persons above 50 years of age, suggesting it is necessary to pay close attention to depressive symptoms in persons with SCH.
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Affiliation(s)
- Rong Tang
- Department of Endocrinology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jian Wang
- Department of Hand Surgery and Peripheral Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Lili Yang
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaohong Ding
- The First Clinical Medical School, Wenzhou Medical University, Wenzhou, China
| | - Yufan Zhong
- The Second Clinical Medical School, Wenzhou Medical University, Wenzhou, China
| | - Jiexue Pan
- Reproductive Medicine Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Haiyan Yang
- Reproductive Medicine Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Liangshan Mu
- Reproductive Medicine Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xia Chen
- Reproductive Medicine Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Xia Chen
| | - Zimiao Chen
- Department of Endocrinology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- *Correspondence: Zimiao Chen
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Delitala AP, Capobianco G, Cherchi PL, Dessole S, Delitala G. Thyroid function and thyroid disorders during pregnancy: a review and care pathway. Arch Gynecol Obstet 2018; 299:327-338. [PMID: 30569344 DOI: 10.1007/s00404-018-5018-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 12/12/2018] [Indexed: 12/28/2022]
Abstract
PURPOSE To review the literature on thyroid function and thyroid disorders during pregnancy. METHODS A detailed literature research on MEDLINE, Cochrane library, EMBASE, NLH, ClinicalTrials.gov, and Google Scholar databases was done up to January 2018 with restriction to English language about articles regarding thyroid diseases and pregnancy. RESULTS Thyroid hormone deficiencies are known to be detrimental for the development of the fetus. In particular, the function of the central nervous system might be impaired, causing low intelligence quotient, and mental retardation. Overt and subclinical dysfunctions of the thyroid disease should be treated appropriately in pregnancy, aiming to maintain euthyroidism. Thyroxine (T4) replacement therapy should reduce thyrotropin (TSH) concentration to the recently suggested fixed upper limits of 2.5 mU/l (first and second trimester) and 3.0 mU/l (third trimester). Overt hyperthyroidism during pregnancy is relatively uncommon but needs prompt treatment due to the increased risk of preterm delivery, congenital malformations, and fetal death. The use of antithyroid drug (methimazole, propylthiouracil, carbimazole) is the first choice for treating overt hyperthyroidism, although they are not free of side effects. Subclinical hyperthyroidism tends to be asymptomatic and no pharmacological treatment is usually needed. Gestational transient hyperthyroidism is a self-limited non-autoimmune form of hyperthyroidism with negative antibody against TSH receptors, that is related to hCG-induced thyroid hormone secretion. The vast majority of these patients does not require antithyroid therapy, although administration of low doses of β-blocker may by useful in very symptomatic patients. CONCLUSIONS Normal maternal thyroid function is essential in pregnancy to avoid adverse maternal and fetal outcomes.
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Affiliation(s)
- Alessandro P Delitala
- Azienda Ospedaliero-Universitaria Di Sassari, Clinica Medica, Viale San Pietro 8, 07100, Sassari, Italy.
| | - Giampiero Capobianco
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100, Sassari, Italy
| | - Pier Luigi Cherchi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100, Sassari, Italy
| | - Salvatore Dessole
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100, Sassari, Italy
| | - Giuseppe Delitala
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100, Sassari, Italy
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32
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Samuels MH. Subclinical Hypothyroidism and Depression: Is There a Link? J Clin Endocrinol Metab 2018; 103:2061-2064. [PMID: 29481656 PMCID: PMC6457006 DOI: 10.1210/jc.2018-00276] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 02/16/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Mary H Samuels
- Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, Oregon
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