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Year : 2018  |  Volume : 15  |  Issue : 3  |  Page : 147-148

Somatization, anxiety, and depression triad in hypothyroidism

Department of Psychiatry, Kasturba Medical College, Manipal, Karnataka, India

Date of Web Publication15-Nov-2018

Correspondence Address:
Dr. Samir Kumar Praharaj
Department of Psychiatry, Kasturba Medical College, Manipal - 576 104, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/trp.trp_31_18

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How to cite this article:
Praharaj SK. Somatization, anxiety, and depression triad in hypothyroidism. Thyroid Res Pract 2018;15:147-8

How to cite this URL:
Praharaj SK. Somatization, anxiety, and depression triad in hypothyroidism. Thyroid Res Pract [serial online] 2018 [cited 2022 Dec 6];15:147-8. Available from: https://www.thetrp.net/text.asp?2018/15/3/147/245564


I read with interest the study on depression, anxiety and somatization in patients with clinical and subclinical hypothyroidism by Kale and Baviskar[1] in January–April issue of 2018. Three self-rated instruments, patient health questionnaire-9 (PHQ-9), generalized anxiety disorder-7, and PHQ-15 somatization were used along with Hamilton Depression (HAM-D), which is an objective measure. The authors compared both the groups and found higher rates of depression in clinical hypothyroidism group, whereas, those with subclinical hypothyroidism had higher anxiety and somatization.

In the study, 69/70 (98.5%) had depression of any severity on the PHQ-9, and 61/70 (87.1%) had at least moderate severity of depression. Similarly, 66/70 (94.2%) of the patients had anxiety and 66/70 (94.2%) had somatization as per the self-report measures. It is not specifically mentioned whether English language or translated versions of self-reported measures were used in this study. These rates are clearly higher than previously reported studies.[2],[3],[4],[5] As PHQ-9 is a self-report screening instrument, it is likely to overestimate the rates, and a diagnosis of depression should involve further assessment. Interestingly, HAM-D, which is a clinician-administered scale also found any depression in 69/70 (98.5%) although moderate and severe depression was seen in 45/70 (64.2%) patients. However, it is not apparent from the manuscript whether the scale was administered by a trained person. Furthermore, the absence of a control group precludes conclusions regarding the prevalence rates. Large studies in individuals who do not have thyroid disease do not show an association between mild hypothyroidism and depression.[5],[6],[7] In contrast, those with clinical hypothyroidism have more symptoms suggestive of depression, but as several symptoms such as difficulty in attention and concentration, memory difficulties, and fatiguability could be the manifestation of hypothyroidism itself, thus making it difficult to assess true prevalence of depression in these patients.[6],[7]

The authors have mentioned using Kruskal–Wallis test to examine data normality. In fact, Kruskal–Wallis test is a rank-based nonparametric test that is used to examine differences in scores (continuous or ordinal) between three or more groups.[8] This test is used when the interval or ratio data are not normally distributed and are more powerful than parametric tests in such situations. To test data normality, Kolmogorov–Smirnov test or Shapiro–Wilk test is widely used and is available in commonly used statistical software such as Statistical Package for the Social Sciences (SPSS, IBM).[9] Moreover, there are several other tests for normality available such as Anderson–Darling test, Cramer–von Mises test, D'Agostino skewness test, Anscombe-Glynn kurtosis test, D'Agostino-Pearson omnibus test, and the Jarque–Bera test.[9]

Nevertheless, the study is important as somatization, anxiety, and depression (SAD) triad is common in general population and there is a considerable overlap between these syndromes,[10] and has been associated with hypothyroidism.[6],[7] It is good clinical practice to screen for thyroid dysfunction in patients presenting with SAD triad symptoms.

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  References Top

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.  Back to cited text no. 1
  [Full text]  
Vishnoi G, Chakraborty B, Garda H, Gowda SH, Goswami B. Low mood and response to levothyroxine treatment in Indian patients with subclinical hypothyroidism. Asian J Psychiatr 2014;8:89-93.  Back to cited text no. 2
Almeida C, Brasil MA, Costa AJ, Reis FA, Reuters V, Teixeira P, et al. Subclinical hypothyroidism: Psychiatric disorders and symptoms. Rev Bras Psiquiatr 2007;29:157-9.  Back to cited text no. 3
Chueire VB, Romaldini JH, Ward LS. Subclinical hypothyroidism increases the risk for depression in the elderly. Arch Gerontol Geriatr 2007;44:21-8.  Back to cited text no. 4
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. 5
Dayan CM, Panicker V. Hypothyroidism and depression. Eur Thyroid J 2013;2:168-79.  Back to cited text no. 6
Cooper DS. Clinical practice. Subclinical hypothyroidism. N Engl J Med 2001;345:260-5.  Back to cited text no. 7
Nahm FS. Nonparametric statistical tests for the continuous data: The basic concept and the practical use. Korean J Anesthesiol 2016;69:8-14.  Back to cited text no. 8
Ghasemi A, Zahediasl S. Normality tests for statistical analysis: A guide for non-statisticians. Int J Endocrinol Metab 2012;10:486-9.  Back to cited text no. 9
Kohlmann S, Gierk B, Hilbert A, Brähler E, Löwe B. The overlap of somatic, anxious and depressive syndromes: A population-based analysis. J Psychosom Res 2016;90:51-6.  Back to cited text no. 10


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