ORIGINAL ARTICLE Evaluation of anxiety and depression in patients with thyroid function disorder Nurcan Akbas Gunes1 1. Bolu Abant Izzet Baysal University, Faculty of Medicine, Department of Family Medicine, Bolu, Turkey http://dx.doi.org/10.1590/1806-9282.66.7.979 SUMMARY OBJECTIVES: We aim to determine the anxiety and depression levels of patients treated for hypothyroidism who assumed euthyroid status. These patients also frequently attend family medicine outpatient clinics. METHODS: This study was conducted on 76 euthyroid volunteer participants (patient groups) who were treated for hypothyroidism and followed-up and 22 healthy volunteers (control group). Questionnaires were administered to all participants to assess anxiety and depression levels. The Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) were applied to all the groups. In addition, BAI sub-parameters were evaluated in detail. RESULTS: At least mild depression was detected in 54.5% of the first group, 41.7% of the second group, and 33.3% of the third group. When the BDI and BAI total scores of the participants in different groups were compared, statistically significant differences were determined. Statistically significant results were detected related to different BAI sub-parameters between the patient groups and in comparison to the fourth group. CONCLUSIONS: We found that patients were predisposed to anxiety and depression even if they were euthyroid. When the sub-parameters of BAI were evaluated in detail, we observed that the duration of the disease significantly affected some anxiety-related symptoms. KEYWORDS: Anxiety. Depression. Thyroid diseases. INTRODUCTION It is known there is a relationship between brain Initially, nonspecific symptoms are seen. However, functions and thyroid hormone levels. Intracranial depression, forgetfulness, deceleration in thought, and receptors and intracerebral biochemical reactions are concentration problems may be seen in later stages closely related to thyroid hormones. There is also a in hypothyroidism. In severe clinical conditions, psy- common relationship between thyroid hormone levels chotic symptoms may appear3. A depressive mood is and anxiety-depression in hypothyroid patients1. It is the most common psychiatric symptom in patients known that anxiety disorder, major depression, and with thyroid dysfunction. In addition, anxiety and psychosis are seen in an average of 30%, 40%, and 5% sleep disorders are common in these patients. Some of the patients with hypothyroidism2. It has been also of these signs and disorders persist after thyroid func- reported that thyroid dysfunction may affect mood tions have improved. Most of the symptoms disappear and the progression of mood disorders. after treatment4. DATE OF SUBMISSION: 30-Dec-2019 DATE OF ACCEPTANCE: 06-Feb-2020 CORRESPONDING AUTHOR: Nurcan Akbas Gunes Kılıçarslan Neighborhood, Orhangazi Street, Number 21 / B / 6 Bolu, Turkey – Tel: +905054929079 E-mail: [email protected] 979 REV ASSOC MED BRAS 2020; 66(7):979-985 EVALuation OF ANXIETY AND DEPRESSION IN Patients WITH THYROID FUNCTION disoRDER Chronic hypothyroidism may cause permanent drug within the previous year were excluded. The con- cognitive changes5. In patients with thyroid dysfunc- trol group consisted of healthy participants who had tion, many symptoms, such as dyspnoea, sweating, no health problems. and palpitations may be observed in patients with panic attacks. Nevertheless, anxiety disorders asso- Patient evaluation scales used in the study ciated with thyroid dysfunction still remain unclear6. The participants in the patient group were eval- Patients with thyroid dysfunction frequently uated for age, gender, duration of thyroid disease in attend family medicine outpatient clinics. Therefore, years, and whether they were attending regular fol- we aimed to determine the anxiety and depression low-ups. Then, the BAI and Beck Depression Inventory levels of the patients who were treated due to hypo- (BDI) were applied to the volunteers in the patient and thyroidism and became euthyroid in terms of family control groups. medicine. In addition, we aimed to raise awareness The patient group was divided into three sub - among family physicians about mood disorders that groups. Group 1 consisted of euthyroid patients who may develop due to thyroid dysfunctions. Also, we were followed-up for 1 year due to thyroid dysfunc- aimed to evaluate the sub-parameters of the Beck tion. Patients with euthyroid status followed-up for at Anxiety Scale (BAI) in detail. When the literature was least 5 years due to thyroid dysfunction who become evaluated, we did not find any studies in which the euthyroid constituted Group 2. Patients with euthy- sub-parameters of the BAI were evaluated in detail in roid status followed-up for at least 10 years due to patients with thyroid disorders. thyroid dysfunction were included in Group 3. The healthy volunteers constituted Group 4. The BAI and BDI total scores were compared METHODS between the groups. The differences in the BAI sub-pa- Study population rameters between groups were also analyzed in detail. Necessary permissions were obtained (2018-320- The sub-parameters of the BAI included in the evalu- 14). This study was conducted as a prospective and ation are presented in Table 1. randomized controlled study. The study was per- formed to determine the anxiety and depression lev- els of patients who were followed up due to thyroid TABLE 1. THE SUB-PARAMETERS OF THE BECK ANXIETY SCALE (BAI) USED AND EVALUATED IN THE dysfunction in our family medicine outpatient clinic. STUDY All patients who were followed-up and treated for Sub-parameters of the BAI hypothyroidism between November 1, 2018, and May Tingling or numbness in any of your body parts? 1, 2019, were evaluated. 76 patients were included in Feeling hot? the study. Wobbliness of legs The 76 volunteered participants who were treated Unable to relax and followed-up for hypothyroidism were included in Fear of the worst happening the study. In addition, 22 healthy volunteers between Feeling dizzy or lightheaded the ages of 25-45 years were included as a control Heart pounding/racing group. Participants in the control group were ran- Feeling unsteady domly selected. Feeling terrified or afraid Patients who were followed-up for hypothyroid- Nervousness ism, received thyroid hormone replacement therapy, Feeling of choking and had euthyroidism based on thyroid function test Hands trembling Feeling shaky/unsteady results were included in our study. Complete blood Fear of losing control counts and the biochemical test results of the partic- Difficulty in breathing ipants were evaluated. Participants with additional Fear of dying hematological disorders were excluded from the study. Being scared In addition, participants who were diagnosed with sys- Indigestion temic diseases such as hypertension (HT) or diabetes Fainting/lightheaded mellitus (DM) during the study and who had a history Facial flushing of using anti-depressants or a different psychiatric Sweating (unrelated to environment temperature) REV ASSOC MED BRAS 2020; 66(7):979-985 980 GUNES, N. A. Statistical Analysis are presented in Table3. The mean BDI and BAI scores Numerical data were calculated as arithmetic of each group are also presented in Figures 1 and 2. mean ± standard deviation and percentage (%). The Chi-square test and T-test were used to compare the data between the groups. In addition, Cronbach’s DISCUSSION alpha value was calculated in a reliability analysis In the clinical practice of family medicine, there because our study was a survey. p <0.05 was consid- are many patients with thyroid dysfunction who ered statistically significant. Data were analyzed using become euthyroid and are followed-up with drug the SPSS v21. therapy. Therefore, we think that family physicians should also evaluate whether these patients are affected psychologically. RESULTS Thyroid hormones have an important role in The mean age of the patient groups was 39.05 ± 5.9 many organ functions and their deficiencies cause (min: 23, max: 45) and the control group was 38.73 ± diseases of a wide clinical spectrum 7. The rate of 5.71 (min: 25, max: 45) years. Sixty-four (84.2%) female psychiatric symptoms is between 2-12% in these and 12 (15.8%) male participants were included in the patients8. In cases of acute hypothyroidism, anxiety patient group. Sixteen (72.7%) female and 6 (27.3%) rates are in the range of 30-40%9. In this study, we male participants were in the control group. There mainly evaluated the relationship between anxiety was no statistically significant difference between the and depression in patients with euthyroid status fol- groups in terms of age, education level, and gender. lowing thyroid hormone replacement therapy. Also, The Cronbach’s alpha value found was 0.876 (> 0.7). in the literature, BAI sub-parameters in different BDI scores of ≥ 14 points were detected in the disease states have been evaluated in detail10. How- respective number of patients in groups, and at least ever, there are no studies evaluating the sub-param- mild depression was detected in these patients. The eters of BAI in individuals with thyroid dysfunction total scores of BAI and BDI in the patient groups were who achieved euthyroid status with treatment. In a evaluated; the mean BAI and BDI scores of the groups were estimated. The mean BAI score of the 76 partici- pants was determined as 14.53 ± 9.39. The mean BAI TABLE 2. BECK DEPRESSION SCALE (BDI) AND BECK score