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Year : 2018  |  Volume : 15  |  Issue : 1  |  Page : 10-14

Depression, anxiety, and somatization in patients with clinical and subclinical hypothyroidism: An exploratory study

Department of Pathology, Pravara Institute of Medical Sciences, Rahata, Maharashtra, India

Date of Web Publication23-Mar-2018

Correspondence Address:
Dr. Kavita Sanjiv Kale
Department of Pathology, Pravara Institute of Medical Sciences, Loni, Rahata, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/trp.trp_42_17

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Background: Hypothyroidism and subclinical hypothyroidism (SCHT) are common disorders seen in clinical practice. A large proportion of patients with these disorders show psychiatric comorbidity. The current study was carried out to assess the prevalence and proportion of depression, anxiety, and somatization symptoms and compare the same between these two groups of patients.
Methodology: Patients attending a medical outpatient department were screened for thyroid dysfunction using laboratory parameters, and patients detected with clinical and SCHT were included in the study. The sample consisted of 34 patients with CHT and 36 patients with SCHT. The patients were administered the Hamilton Rating Scale for Depression, Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 Questionnaire, and PHQ-15 for somatization. The data were analyzed statistically using computerized software.
Results: The study groups were well matched on sociodemographic profile and basic data. On assessing the severity of depression and anxiety, more cases of mild depression were reported in the subclinical hypothyroid group compared to moderate and severe depression being higher in the clinical hypothyroid group (P = 0.0001). Anxiety was well matched in both groups while somatization was higher in the subclinical hypothyroid group (P = 0.0001). Scores on depression scales were higher in the clinical group (P = 0.0001) and anxiety and somatization scores were higher in the subclinical group (P = 0.0001).
Conclusions: Depression is usually seen in CHT while anxiety and somatization may be greater in SCHT. Further studies in larger populations are needed to validate the findings.

Keywords: Anxiety, depression, hypothyroidism, somatization, subclinical hypothyroidism, thyroxine

How to cite this article:
Kale KS, Baviskar B. Depression, anxiety, and somatization in patients with clinical and subclinical hypothyroidism: An exploratory study. Thyroid Res Pract 2018;15:10-4

How to cite this URL:
Kale KS, Baviskar B. Depression, anxiety, and somatization in patients with clinical and subclinical hypothyroidism: An exploratory study. Thyroid Res Pract [serial online] 2018 [cited 2022 Dec 5];15:10-4. Available from: https://www.thetrp.net/text.asp?2018/15/1/10/228376

  Introduction Top

Hypothyroidism and subclinical hypothyroidism (SCHT) are common conditions seen in clinical practice and are diagnosed often based on laboratory parameters.[1] These conditions are more common in women and are often undiagnosed in clinical practice.[2] It is paramount that these clinical conditions be treated as soon as they are diagnosed as nontreatment may lead to a host of complications that ensue over a period of time.[3] A variety of neuropsychiatric and cognitive complications have been noted in patients with SCHT and CHT. These range from a comorbid depression to depressive features that may exist with or without anxiety.[4] There have been reports of neuropsychiatric manifestations such as cognitive problems, memory deficits, and defects in executive function in this group of patients.[5] It is now well known that thyroid hormones act on the adult brain and affect neuronal development and have certain actions in the stress response and via neurotransmitters.[6] Neuropsychiatric symptoms refer to a spectrum of emotional and cognitive problems directly related to changes in the brain of multiple factors.[7]

In hypothyroidism, the patient slows down and the mood is depressed and typical symptoms of major depression may be present. Apathy and fatigue have also been noted.[8] There may be a difficulty-sustaining attention even for short periods and a slowing of thought processes, which suggests the presence of cognitive impairment.[9] Symptoms in SCHT may be patchy and few; of these, the most frequent is depression. Controlled studies suggest that the cognitive and mood symptoms respond to treatment, although the data are controversial and methodologically limited.[10] Many of these patients may manifest with mild anxiety, occasional panic attacks, and somatic symptoms such as headache, joint pains, and backache.[11] There is a dearth of Indian literature on the psychopathology associated with both hypothyroidism and SCHT. Hence, this study was undertaken to determine the levels of depression, anxiety, and somatization in patients with CHT and SCHT.

  Methodology Top

The patients for the study were chosen from patients attending the medical outpatient department in a tertiary general hospital. All patients visiting the clinic were screened for thyroid problems using laboratory parameters. Patients detected with hypothyroidism and SCHT were selected for the study. A total of 309 patients were screened and the first seventy patients with hypothyroidism (clinical or subclinical) were chosen for the study. The patients were explained the nature and purpose of the study and were offered treatment for their thyroid condition as well. Written informed valid consent from all patients was taken before the study. The entire study was approved by the institutional ethics committee of the hospital.

Laboratory criteria for diagnosis

SCHT was defined by a serum thyroid-stimulating hormone (TSH) concentration higher than the upper limit of the laboratory reference range associated with a normal serum thyroxine (T4; either total or free) and serum triiodothyronine (T3) levels.[12]

CHT was defined by a serum TSH concentration which was higher than the upper limit of the laboratory reference range and accompanied by low serum thyroxine (T4; either total or free) and low or normal serum triiodothyronine (T3) levels.[13]

Clinical assessments in the study

The study consisted of two groups of patients, i.e., CHT (n = 34) and SCHT (n = 36). No other control group was used in the study, and these two groups were directly compared.

A semi-structured pro forma was used to collect sociodemographic data of the patients and the following rating scales were used in the assessment.

Hamilton Rating Scale for depression

This is a time-tested scale to evaluate the severity of depression in patients before, during, and after treatment. It is administered by a clinician experienced in working with psychiatric patients and classifies depression as mild, moderate, and severe based on the scores obtained. The scale consists of 21 items and the first 17 are usually used in the scoring. The score ranges are 0–7 (normal), 8–13 (mild depression), 14–18 (moderate depression), 19–22 (severe depression), and ≥23 (very severe depression).[14]

The Patient Health Questionnaire – 9 Scale

The 9-item Patient Health Questionnaire (PHQ-9) was developed to facilitate the identification and diagnosis of major depressive disorder (MDD) in medical samples. Consistent with the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV) MDD diagnostic criteria, each item is rated according to how persistent symptoms have been in the past 2 weeks, from 0 (not at all) to 3 (nearly every day), with the total score ranging from 0 to 27. The PHQ-9 showed good internal consistency (Cronbach's α =0.89) and test–retest reliability (r = 0.84) in a study of primary care patients.[15],[16]

The Generalized Anxiety Disorder-7 Scale

It is a widely used self-report measure developed to screen for generalized anxiety disorder (GAD). This study used the GAD-7 module included in the full PHQ, in which participants rate the presence of symptoms on a 3-point scale as occurring “not at all” (0), “several days” (1), or “more than half the days” (2) during the past 2 weeks. Items are summed to create a symptom severity score ranging from 0 to 14. Participants met the measure's established categorical criteria of GAD if the total score on the GAD-7 was 8 or higher, they also endorsed the first question (feeling nervous, anxious, on edge, or worrying a lot about different things), and three or more of the remaining items were rated “more than half the days.” For this study, continuous and categorical scores were considered.[17],[18]

The Patient Health Questionnaire-15 somatization scale

Somatization was measured using the somatic symptom module of the PHQ, the PHQ-15. The items include the most prevalent DSM-IV somatization disorder somatic symptoms. Participants were asked for the last 4 weeks to rate the severity of 13 symptoms as 0 (not bothered at all), 1 (bothered a little), or 2 (bothered a lot). Two additional physical symptoms – feeling tired or having little energy and trouble sleeping – are included in the PHQ-9 depression module. For scoring, response options for these two symptoms are coded as 0 (not at all), 1 (several days), or 2 (more than half the days or nearly every day). Thus, the total PHQ-15 score ranges from 0 to 30 and scores of ≥5, ≥10, and ≥15 represent mild, moderate, and severe levels of somatization, respectively. The reliability and validity of the PHQ-15 are high in clinical and occupational health-care settings.[19],[20]

Statistical analysis

Descriptive statistics and percentages were used in the evaluation of the sociodemographic data. The severity of depression, generalized anxiety, and somatization across both groups were assessed using the Chi-square test or Fisher's exact test where applicable. The mean scores across all the scales in both groups were assessed using the unpaired t-test. The Kruskal–Wallis test was also used to determine if the data are normally distributed. The entire data were analyzed using computerized statistical software online called Graph Pad statistics (Graph Pad Inc., New York, USA).

  Results Top

Both groups were well matched on sociodemographic profile, and no major differences were noted [Table 1]. On assessment of mild, moderate, and severe depression and somatization scores across both the groups, a statistically significant difference was noted on both scales used for depression and the somatization scale [Table 2] while no differences among both the groups were noted on scores of the generalized anxiety scale.
Table 1: Sociodemographic data of both groups

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Table 2: Scores across both groups in all the scales (for all parameters clinical hypothyroidism [n=34], subclinical hypothyroidism

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On comparing scores between the two groups on various scales, it was noted that there was a statistically significant difference between both groups on all the scales. Patients with hypothyroidism had significantly greater scores on both the Hamilton Rating Scale for Depression and PHQ-9 when compared to subclinical hypothyroid patients (P< 0.0001). However, patients with SCHT showed greater scores on generalized anxiety and somatization subscales (P< 0.001) [Table 3].
Table 3: Mean scores across all scales in both groups

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  Discussion Top

This is one of the first studies that have a head-on comparison between SCHT patients and those with hypothyroidism in the realm of psychopathology. Mild-to-moderate depression was more common in the SCHT group compared to moderate-to-severe depression, which was more common in the clinical hypothyroid group. Patients in both groups showed similar profiles with moderate generalized anxiety being high in both groups. Depression has been reported to have a clinical association with hypothyroidism with 10%–40% of patients with hypothyroidism reporting depressive features.[21] Depression is also known to affect the hypothalamic–pituitary–thyroid axis whereby TSH secretion has shown to be affected.[22] In fact, there are a large number of studies that advocate the augmentation of antidepressants with thyroxine, indicating that SCHT may be present in patients with depression.[23] Anxiety has been commonly associated with both hypothyroidism and hyperthyroidism.[24] Generalized anxiety has been reported in patients with hypothyroidism and is commonly seen with depression as well.[25] Somatization was, however, higher in the SCHT group. This may be due to the fact that SCHT is not severe enough to cause mood symptoms but may initially manifest with physical symptoms. Somatization may also be the causes of multiple aches and pain due to stress that may be manifested in patients with SCHT.[26]

On comparing the scores on all scales between the two groups, depression scores were higher in the CHT group in keeping with studies done in the past.[27] Anxiety and somatization scale scores were higher in the subclinical hypothyroid group, indicating that somatic and anxiety symptoms may precede depression in these cases.[28] Thus, our study has helped elucidate some clinical differences between the two groups, but larger studies in bigger study populations are needed to validate our findings.

The limitations of our study include small sample size and not taking into consideration the medical comorbidities and hormonal levels in the analysis of data. The concomitant medications that patients were on were also not taken into consideration.

  Conclusion Top

It is important that we learn to differentiate clinically between CHT and SCHT as apart from laboratory parameters that aid in diagnosis and there is a dearth of clinical differentiation points between the two conditions. Further studies with details will aid in differentiating between these two similar yet clinically different conditions.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, et al. Guidelines for the treatment of hypothyroidism: Prepared by the American thyroid association task force on thyroid hormone replacement. Thyroid 2014;24:1670-751.  Back to cited text no. 1
Selmer C, Olesen JB, Hansen ML, von Kappelgaard LM, Madsen JC, Hansen PR, et al. Subclinical and overt thyroid dysfunction and risk of all-cause mortality and cardiovascular events: A large population study. J Clin Endocrinol Metab 2014;99:2372-82.  Back to cited text no. 2
Pasqualetti G, Pagano G, Rengo G, Ferrara N, Monzani F. Subclinical hypothyroidism and cognitive impairment: Systematic review and meta-analysis. J Clin Endocrinol Metab 2015;100:4240-8.  Back to cited text no. 3
Joffe RT, Pearce EN, Hennessey JV, Ryan JJ, Stern RA. Subclinical hypothyroidism, mood, and cognition in older adults: A review. Int J Geriatr Psychiatry 2013;28:111-8.  Back to cited text no. 4
Samuels MH. Psychiatric and cognitive manifestations of hypothyroidism. Curr Opin Endocrinol Diabetes Obes 2014;21:377-83.  Back to cited text no. 5
Schroeder AC, Privalsky ML. Thyroid hormones, T3 and T4, in the brain. Front Endocrinol (Lausanne) 2014;5:40.  Back to cited text no. 6
Napthali K, Boyle M, Tran H, Schofield PW, Peel R, McEvoy M, et al. Thyroid antibodies, autoimmunity and cognitive decline: Is there a population-based link? Dement Geriatr Cogn Dis Extra 2014;4:140-6.  Back to cited text no. 7
Ittermann T, Völzke H, Baumeister SE, Appel K, Grabe HJ. Diagnosed thyroid disorders are associated with depression and anxiety. Soc Psychiatry Psychiatr Epidemiol 2015;50:1417-25.  Back to cited text no. 8
Medici M, Direk N, Visser WE, Korevaar TI, Hofman A, Visser TJ, et al. Thyroid function within the normal range and the risk of depression: A population-based cohort study. J Clin Endocrinol Metab 2014;99:1213-9.  Back to cited text no. 9
Fjaellegaard K, Kvetny J, Allerup PN, Bech P, Ellervik C. Well-being and depression in individuals with subclinical hypothyroidism and thyroid autoimmunity – A general population study. Nord J Psychiatry 2015;69:73-8.  Back to cited text no. 10
Pityk O, Tkachuk L, Pityk M, Kuzhda I. Severity of psychopathological symptoms in patients with primary hypothyroidism. Eur Psychiatry 2015;30:606-13.  Back to cited text no. 11
Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, et al. 2016 American thyroid association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid 2016;26:1343-421.  Back to cited text no. 12
Biondi B, Bartalena L, Cooper DS, Hegedüs L, Laurberg P, Kahaly GJ, et al. The 2015 European thyroid association guidelines on diagnosis and treatment of endogenous subclinical hyperthyroidism. Eur Thyroid J 2015;4:149-63.  Back to cited text no. 13
Zimmerman M, Martinez JH, Young D, Chelminski I, Dalrymple K. Severity classification on the Hamilton depression rating scale. J Affect Disord 2013;150:384-8.  Back to cited text no. 14
Manea L, Gilbody S, McMillan D. A diagnostic meta-analysis of the patient health questionnaire-9 (PHQ-9) algorithm scoring method as a screen for depression. Gen Hosp Psychiatry 2015;37:67-75.  Back to cited text no. 15
Martin-Subero M, Kroenke K, Diez-Quevedo C, Rangil T, de Antonio M, Morillas RM, et al. Depression as measured by PHQ-9 versus clinical diagnosis as an independent predictor of long-term mortality in a prospective cohort of medical inpatients. Psychosom Med 2017;79:273-82.  Back to cited text no. 16
Jordan P, Shedden-Mora MC, Löwe B. Psychometric analysis of the generalized anxiety disorder scale (GAD-7) in primary care using modern item response theory. PLoS One 2017;12:e0182162.  Back to cited text no. 17
Wild B, Eckl A, Herzog W, Niehoff D, Lechner S, Maatouk I, et al. Assessing generalized anxiety disorder in elderly people using the GAD-7 and GAD-2 scales: Results of a validation study. Am J Geriatr Psychiatry 2014;22:1029-38.  Back to cited text no. 18
Kocalevent RD, Hinz A, Brähler E. Standardization of a screening instrument (PHQ-15) for somatization syndromes in the general population. BMC Psychiatry 2013;13:91.  Back to cited text no. 19
Hinz A, Ernst J, Glaesmer H, Brähler E, Rauscher FG, Petrowski K, et al. Frequency of somatic symptoms in the general population: Normative values for the patient health questionnaire-15 (PHQ-15). J Psychosom Res 2017;96:27-31.  Back to cited text no. 20
Dayan CM, Panicker V. Hypothyroidism and depression. Eur Thyroid J 2013;2:168-79.  Back to cited text no. 21
Duntas LH, Maillis A. Hypothyroidism and depression: Salient aspects of pathogenesis and management. Minerva Endocrinol 2013;38:365-77.  Back to cited text no. 22
Papaleontiou M, Cappola AR. Thyroid-stimulating hormone in the evaluation of subclinical hypothyroidism. JAMA 2016;316:1592-3.  Back to cited text no. 23
Bathla M, Singh M, Relan P. Prevalence of anxiety and depressive symptoms among patients with hypothyroidism. Indian J Endocrinol Metab 2016;20:468-74.  Back to cited text no. 24
Praharaj SK. How prevalent are depression and anxiety symptoms in hypothyroidism? Indian J Endocrinol Metab 2016;20:882-3.  Back to cited text no. 25
Demartini B, Ranieri R, Masu A, Selle V, Scarone S, Gambini O, et al. Depressive symptoms and major depressive disorder in patients affected by subclinical hypothyroidism: A cross-sectional study. J Nerv Ment Dis 2014;202:603-7.  Back to cited text no. 26
Najafi L, Malek M, Hadian A, Ebrahim Valojerdi A, Khamseh ME, Aghili R, et al. Depressive symptoms in patients with subclinical hypothyroidism – The effect of treatment with levothyroxine: A double-blind randomized clinical trial. Endocr Res 2015;40:121-6.  Back to cited text no. 27
Pelúcio L, Nardi AE, Ornelas AC, Levitan M. Psychiatric disorders and quality of life in patients with hypothyroidism: A narrative review. J Depress Anxiety 2016;5:2167-84.  Back to cited text no. 28


  [Table 1], [Table 2], [Table 3]

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