[ ISSN : 2576-5477 ]
Euthyroid Hyperthyroxinemia, Primary Hyperparathyroidism, Depression with Psychosis
Acute psychiatric illness is associated with alterations of serum thyroid hormone levels including normal or high T3 levels and elevated T4 levels with normal or high TSH that have no clinical signs or symptoms and resolve within 2 weeks. This phenomenon is called euthyroid hyperthyroxinemia. We present a case of primary hyperparathyroidism contributing to a patient’s depression with psychosis that developed euthyroid hyperthyroxinemia. We also review the literature to present current thoughts about pathophysiology and treatment.
There are several disorders that can cause hyper thyroxinemia without thyrotoxicosis. These include abnormalities of serum thyroid hormone binding proteins, peripheral resistance to thyroid hormone, acute non-thyroidal illness, drug-induced conditions and acute psychiatric illness [1-2]. The association between thyrotoxicosis and an altered mental state was recognized as early as 1835 by Graves [3]. Further research has demonstrated that thyrotoxicosis can cause prominent psychiatric symptoms such as restlessness, nervousness, hyperactivity and emotional liability [4-5]. Nevertheless, overt psychosis is not a common occurrence [6]. Thyroid function studies are commonly obtained in patients hospitalized with psychiatric illnesses, in order to detect undiagnosed thyroid disorders. Patients admitted with acute psychiatric illnesses have been found to have normal or high T3 levels and elevated T4 levels with normal or high TSH. Generally, the thyroid function tests normalize within 2 weeks [7-8]. Potential etiologic mechanisms for these findings include increased T4 bound in the plasma due to an increased amount of binding proteins, a shift of T4 from the peripheral tissues to the extracellular compartment or hyper secretion of T4 from the thyroid. A prospective study from Roca et al., which found elevated T4 levels in 36% of cases, supported the hypothesis of a TSH induced increase in thyroidal secretion of T4 by taking serial measurements of TSH, T4, T3, thyroid binding globulin (TBG) and T3 resin uptake [9]. They postulated that this could occur from a disturbance in the pituitary feedback system resulting in a transient increase in the TSH secretion at the onset of acute psychiatric illness.
81 year old Caucasian female with a history of Depression NOS and Anxiety disorder NOS who presented to the Emergency Department reporting suicidal ideation due to worsening symptoms of depression and guilt over her daughter’s pregnancy (later determined to be a delusion). During work-up of possible organic causes she was discovered to have an elevated free T4 level of 2.03 ng/ dL (normal 0.80-1.90), normal Thyroid Stimulating Hormone (TSH) of 1.63 mIU/L (0.55-4.78), and an elevated calcium of 11.4 mg/dL (normal 8.4-10.2) with an elevated Parathyroid Hormone (PTH) of 227.9 pg/mL (normal 14-72). TSH, Free T4, Free T3 and PTH all were performed using Chemi luminescent Micro particle Immunoassay (CMI) methodology. Calcium was Arsenazo III methodology.
On physical exam, vital signs revealed a Temperature of 97 °F (36.1° C), Blood Pressure of 136/63 mmHg, Pulse 86 and Respiratory Rate 18. In general she appeared well-developed and well-nourished. Her head was normocephalic and atraumatic. Eyes showed pupils being equal, round, and reactive to light without scleral icterus. Her neck demonstrated no tracheal deviation or thyromegaly. No nodules were palpable. Cardiovascular examination showed normal rate, regular rhythm and normal heart sounds with no gallop, friction rub or murmur. Pulmonary exam showed normal effort and breath sounds, without respiratory distress, wheezes, or rales. Her abdomen was soft without distension, masses, tenderness and normal bowel sounds. Extremities demonstrated no edema. Neurologically she had a delayed reflex with mild clonus, but otherwise the exam was normal. Upon psychiatric evaluation she had delayed speech and she appeared slowed and withdrawn. Her thought content was delusional and she exhibited a depressed mood. She did not have any suicidal or homicidal ideation.
The patient was admitted to the inpatient psychiatric unit and she was started on treatment with a tetracyclic antidepressant, Mirtazapine, and a 2nd generation antipsychotic, Olanzapine. Repeat thyroid function tests revealed similar results with a normal TSH of 1.01 mIU/L, elevated Free T4 of 2.0803 ng/dL and normal Free T3 of 3.2pg/mL (2.3-4.2). Thyroid stimulating immunoglobulin, thyroid peroxidase antibody and thyroglobulin antibody were undetectable. Further work-up of the patient’s hyperparathyroidism with a technetium sestamibi parathyroid scan with SPECT/CT revealed a 1 cm left inferior parathyroid adenoma. The patient was not on biotin. A previous bone density exam supported a diagnosis of osteoporosis, with a T-score of -2.6 of the left hip, -2.5 of the right hip, -2.3 of L1-L4, and -4.4 of the distal radius. The patient had no history of fractures or nephrolithiasis.
The patient was treated for refractory depression with psychosis with 7 sessions of electroconvulsive therapy. Because of the patient’s depression, decreased bone mineral density and elevated calcium levels, she also underwent a left inferior parathyroidectomy with intraoperative PTH returning back to normal. She had return of euthymia at completion of her electroconvulsive therapy and normalization of her serum calcium and PTH levels. Thyroid function tests were repeated a week after the initial lab abnormalities were found, and showed the resolution of euthyroid hyper thyroxinemia with a Free T4 of 1.63 ng/dL. Upon follow-up, the patient continued to have euthymia several months after her initial presentation.
Euthyroid hyper thyroxinemia has been associated with acute psychiatric illness, although the exact mechanism is not understood. The complex neuro chemical alterations of adrenergic, serotonergic and dopaminergic neurotransmission in major psychiatric illness may influence the feedback loop in the hypothalamic-pituitary-thyroid axis at the pituitary level through several mechanisms. One possible mechanism could be a decrease in intra pituitary conversion of T4 to T3, which blunts the negative pituitary feedback by the thyroid hormones and leads to a temporary surge in TSH production. Since TSH has a much shorter half-life of 50 minutes [10] than T4’s 7 days [11], the thyroid function tests could reveal an increase in both TSH and T4 levels when obtained early at the onset of psychiatric illness, or only an increase in T4 levels when obtained later. TSH hyper secretion could lead to down-regulation of pituitary TRH receptors, and decrease in TSH responsiveness to exogenous administration of TRH, a finding frequently encountered in severely depressed patients [12].
Our final diagnosis was euthyroid hyper thyroxinemia accompanying acute psychiatric illness. The initial elevated Free T4 was confirmed, in order to exclude lab error. A Free T3 was checked to rule out subclinical hyperthyroidism, as well as thyroid stimulating immunoglobulin to assess for possible Graves’ disease. The exam was not notable for signs or symptoms of thyrotoxicosis, with a normal heart rate, and no diaphoresis nor tremor. The patient had no clinical findings of Graves’s disease, including orbitopathy, nail changes and dermopathy. The hyper thyroxinemia was resolved when repeat lab testing was performed one week later, which is consistent with previous observations of this phenomenon. It is also appears likely that the patient’s primary hyperparathyroidism and hyper calcemia contributed to her depressive episode which was severe enough to cause associated psychosis.
Weber’s study showed that preoperatively, patients with Primary Hyperparathyroidism (pHPT) suffered more from depression, suicidal ideation, and anxiety, and they had reduced Health-Related Quality of Life (HRQOL), compared with a control group with nontoxic thyroid diseases and the general population. After receiving a parathyroidectomy, symptoms of depression and anxiety declined, and HRQOL significantly improved in the first year. Para thyroid ectomies were also associated with a 51% reduced prevalence of suicidal ideation. These findings suggest that successful Para Thyroid ectomies not only cure pHPT physical symptoms but reduce patients’ psychologic distress and improves their HRQOL [13].
In conclusion, while psychiatric illnesses can be associated or even triggered by various thyroid disorders, there also appears to be frequent instances of abnormal thyroid findings secondary to the onset of an acute psychiatric illness. The common thyroid function profile is that of normal or high T3 with high T4 and high or normal TSH. There is currently no data to suggest a clinical significance of this manifestation of euthyroid hyper thyroxinemia, and the thyroid function tests return to normal within a few weeks. No intervention is required to correct the abnormal findings, but repeat thyroid function tests should be obtained within a few weeks to confirm the return to normal levels.
1. Borst GC, Eil C, Burman KD. Euthyroid hyperthyroxinemia. Ann Intern Med. 1983; 98: 366-378.
6. Burste NB. Psychosis associated with thyrotoxicosis. Arch Gen Psychiatry. 1961; 4: 267-274.
Mathews JW and Sora nd. Euthyroid Hyper Thyroxinemia in Acute Psychiatric Illness with Associated Primary Hyperparathyroidism. SM J Psychiatry Ment Health. 2017; 2(1): 1006.
In Japan, there is a recognized need for further research into stigma in the workplace toward persons with mental illness. Toward that end, I will discuss here two studies that we have conducted with the aim of (I) elucidating the stigma experienced in the workplace by persons with mental illness, and (II) elucidating employers’ attitudes toward persons with mental illness.
Hatsumi Yoshii*
International literature has detected high levels of academic stress in students of universities and colleges, which manifests itself with clinical symptoms [1] and constitutes an obstacle to the activation of adaptive, functional and coping responses
Giulia Savarese*, Luna Carpinelli, Oreste Fasano, Monica Mollo, Nadia Pecoraro and Antonio Iannaccone
T he scientific literature has highlighted how the incoming and outgoing transitions through the university represent stressful moments for students. Generally, an adaptation of one’s self it’s needed
Giulia Savarese*, Luna Carpinelli, Oreste Fasano, Monica Mollo, Nadia Pecoraro, Pierpaolo Cavallo
It is known that edema is a rare side effect of quetiapine. Until now only nine cases of peripheral edema related to quetiapine have been reported in the literature. We have determined five cases of pretibial edema associated with quetiapine during two years period of time. The common feature of these cases reported here are comorbid medical disorders, such as venous insufficiency, bladder tumor, chronic obstructive pulmonary disease, diabetes mellitus with excessive elevation of blood sugar. Although treatment protocol of edema and those comorbid medical diseases have been applied separately, at the end of these treatments it is seen that PTE has not been resolved. In all cases reported here that when the dose of quetiapine is reduced, it is observed that PTE is reduced or disappeared. This result brings to mind that there could be a relation between edema and quetiapine.
Hayriye Dilek Hamurcu¹*, Ersin Hatice Karslıoğlu¹, Mehmet Öztürk¹, Elvan Özalp¹ and Ali Çayköylü²
War, quarrel, and some conflict were devastating. In some family for reasons of emotion, influence by other people, ideology, honor, politics, geography or the simple environment, elder brother can find themselves on opposing sides of a war and force them to be in facing battlefield. If we searching the reason for the quarrel between incent brothers, there may be the negligible reason. In straightforward, reasons for the quarrel were not very big.
Ashok Pandey*
Background: In Canada, industrial wind operations are important parts of the country’s long-term energy strategy and Wind Turbines (WTs) are represented as environmentally friendly projects; however, suspected health-related effects of exposure to WT noise have attracted much public attention. Sleep disturbance and degraded Health-Related Quality of Life (HRQoL) have been among the most common complaints reported by residents living close to wind farms.
Objective: The objective of this study was to evaluate the association between changes in sleep quality and HRQoL among residents living close to wind farms.
Methods: Pre- and post-natural experiments were conducted with two data collection periods, before and after WTs became operational; sleep quality was measured by using the Pittsburgh Sleep Quality Index (PSQI), and HRQoL was measured using the 12-item Short Form (SF-12) Health Survey of 50 participants.
Results: Changes in the SF-12 mental component summary (ΔMCS) were correlated inversely with the changes in PSQI score (ΔPSQI, Spearman’s correlation r_S= -0.595). The median values for ΔMCS were significantly associated with ΔPSQI (p=0.039) after controlling for age, sex, distance and attitude to WTs, in a quantile regression analysis.
Conclusion: Changes in sleep quality reported by residents living nearby WTs were a significant independent predictor of the degraded mental health domain of HRQoL.
Leila Jalali*, Ashok Chaurasia, Philip Bigelow, Shannon Majowicz and Stephen McColl
One-third of people living with dementia also experience depression. Treating symptoms of depression may be a protective factor and reduce cognitive decline in dementia. People suffering from depression experience sad mood, reduced energy, poor concentration, loss of interest, diminished activity and they are at risk for death by suicide. Screening instruments include the Cornell Scale for Depression in Dementia (CSDD) and the Geriatric Depression Scale (GDS). Typical treatments include antidepressant medications, which may have limited efficacy; and Electroconvulsive Therapy (ECT), which may heighten memory loss. Psychotherapeutic approaches, including cognitive–behavioral therapy, interpersonal therapy and supportive counseling can be helpful. Lifestyle modifications addressing healthy diet, exercise and the inclusion of enjoyable activities can promote improved quality of life. Providing needed education and support to caregivers, who often experience depression, anxiety and sleep disorders themselves is critical. This paper provides health professionals with an overview of approaches for recognizing and responding to co-occurring dementia and depression.
Sherri Melrose*
This study investigated potential correlation between the inflammatory marker, Calprotectin, and a S.O.S questionnaire from forty-nine Autistic children. Symptom and behavioral questionnaires were completed contemporaneously with stool sample collection. Mixed Model data analysis showed strong correlation between some questionnaire parameters and Calprotectin. ‘Need for a fixed routine’ was highly significantly correlated with Calprotectin (????<0.00009) with Multivariate Coefficient of 3.227, whilst paradoxically ‘constipation’ indicated significant change (????<0.02) with negative Multivariate Coefficient (-1.584). The negative ‘constipation’ appears to associate with the positive ‘need for a fixed routine’ indicating possibility of reciprocal, independent prediction of gastrointestinal inflammation. Results suggest that ‘need for a fixed routine’ and ‘constipation’ be included in a screening questionnaire as independent predictors of bowel dysfunction in these children.
Ioná Bramati-Castellarin¹*, Vinood Patel¹ and Ian P Drysdale²
Background: Improved real world functioning is the ultimate goal of cognitive rehabilitation (which was developed for an acquired brain injury population), however, cognitive remediation for psychiatric populations focuses primarily on cognitive interventions (e.g., computerized cognitive training) and utilizes cognitive test results as outcomes. A broader range of neuropsychological interventions and outcome measures, incorporating real-world measures of functioning, is recommended for cognitive remediation program evaluation.
Objective: To determine the feasibility and explore the effectiveness of a holistic cognitive remediation program administered by clinical neuropsychologists for a community-based mixed psychiatric treatment seeking sample.
Method: Twenty-five adults of mixed psychiatric aetiology were referred for a 10-week intervention (including four hours of weekly individual and group-based sessions). A broad array of outcomes was assessed post-intervention. Functional status, self-reported cognitive symptoms and quality of life was assessed at 11.3 months follow-up.
Results: Eighteen of the referred participants (72%) completed the intervention. Completers showed: a high rate of functional cognitive goal attainment; increased employment rates; improved symptoms of psychological distress and quality of life; reduced self-report of cognitive difficulties; and improved auditory attention span and verbal memory. Self-report of reduced cognitive difficulties and improved quality of life was maintained approximately one year later. The majority of participants reported very high levels of satisfaction with the program.
Conclusions: This intervention was acceptable to participants and associated with high satisfaction rates and gains in cognitive, psychological and functional outcomes. Findings suggest there are multiple benefits to adopting an intervention program that is holistic, individualized to the goals of the patient and facilitated by trained neuropsychologists.
Jamie Berry¹,²*, Donel Martin¹, Karen Wallace¹, Anthony Miller², Travis Wearne² and Melanie Porter²
We are witnessing a rapidly growing type of Mobile Health. Mobile devices have allowed the control of activity levels in people, their habits and even their mobility through GPS. Vital signs, moods, sleep disorders, heart rates, or skin temperature can also be monitored. Literature specializing in psychosocial therapies addresses the usefulness of mobile phones in patients in general, with greater production from psychology and to a lesser extent from social work. We highlight the research developed in the USA and identify opportunities and limitations in terms of data privacy, access to and use of mobile phones; to reach isolated or poor populations or to facilitate access to social and health services. We conclude with possible orientations, hypotheses and goals for prospective investigation works.
Yolanda García Vázquez*