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Article history: Background: Bipolar affective disorder may be associated with alterations in thyroid function. A
Received 16 March 2012 comprehensive thyroid assessment is important for assessing clinical and sub-clinical imbalances linked
Received in revised form 5 July 2012 to a variety of mood disorders like bipolar affective disorder.
Accepted 6 August 2012
Aim: To nd out the association between bipolar affective disorder and thyroid dysfunction.
Materials and method: The present cross-sectional study was conducted at Government District Wenlock
Keywords: Hospital, Mangalore (GDWH), India. A total of 50 newly diagnosed bipolar affective disorder patients and
Bipolar affective disorder
50 age and sex matched controls without bipolar affective disorder as conrmed by the application of
Thyroid dysfunction
Bipolar Spectrum Diagnostic Scale were included in the study. Thyroid function was assessed among the
Cross-sectional study
Association patients and control group to study the association between bipolar affective disorder and thyroid
Bipolar Spectrum Diagnostic Scale dysfunction. Odds ratio was calculated to nd out the strength of association between thyroid gland
dysfunction and bipolar affective disorder.
Results: The mean Bipolar Spectrum Diagnostic Scale score among patients diagnosed with bipolar
affective disorder was 20.84 and that of the control group was 1.98. The proportion of thyroid
dysfunction among bipolar affective disorder patients and among control group was 14% and 6%
respectively. The odds ratio was calculated to be 2.55. Mean T3 values were higher in the bipolar affective
disorder patients than the control group and this association was found to be statistically signicant
(p = 0.031). Mean T4 and TSH values were higher among the bipolar affective disorder patients but did
not show any signicant differences when compared with the control group.
Conclusion: The present study concludes that a statistically signicant association exists between
elevated T3 hormone and bipolar affective disorder and observes that the patients with bipolar affective
disorder are 2.55 times more commonly associated with thyroid dysfunction.
2012 Elsevier B.V. All rights reserved.
1876-2018/$ see front matter 2012 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.ajp.2012.08.003
V.N. Krishna et al. / Asian Journal of Psychiatry 6 (2013) 4245 43
treatment option for refractory bipolar affective disorder (Bauer outpatient department of GDWH. The clinical diagnosis was
et al., 1998; Baumgartner et al., 1994). Sub-clinical hypothyroid- reached by the consultant psychiatrist. The diagnosis was
ism has also been suspected of being a risk factor for depression conrmed by the application of Bipolar Spectrum Diagnostic
(Haggerty et al., 1993; Kraus et al., 1997; Oomen et al., 1996). A Scale (Nassir Ghaemi et al., 2005). The Bipolar Spectrum
number of studies have investigated the association between Diagnostic Scale (BSDS) developed by Dr. Ronald Pies is a self-
thyroid dysfunction and mood disorders. The investigators in these report questionnaire that is found to be highly sensitive and
studies had observed an altered thyroid function in mood disorder specic for bipolar spectrum illness (Nassir Ghaemi et al.,
(Baumgartner et al., 1988; Kraus et al., 1997; Maes et al., 1993; 2005) in its original format and even when the local versions of
Poirier et al., 1995). It is evident from earlier studies that there the BSDS are used (Zaratiegui et al., 2011). With regards to
exists an association between thyroid gland dysfunction and BSDS score, a total score of 2025 indicates that bipolar
psychiatric disorders. To the best of our knowledge no previous spectrum disorder is highly likely; a score from 13 to 19
study had investigated such an association in the bipolar disorder indicates moderate probability; a score from 7 to 12 indicates
psychiatric group. low probability; and a score from 0 to 6 indicates that bipolar
The manifestations in patients with bipolar affective disorder disorder is highly unlikely. The severity of symptoms in the
are exceptionally diverse ranging from mild hypomania or mild present study was measured using Hamilton rating scale for
depression to severe forms of mania or depression accompanied depression (Hamilton, 1967) and Young mania rating scale
by profound psychosis. The lifetime prevalence of bipolar (Young et al., 1978).
affective disorder is 1.31.6% with mortality rates being 23 All the newly diagnosed bipolar affective disorder (ICD-10)
times higher than that of the general population. Equally patients aged between 18 and 50 years without any thyroid
prevalent among both sexes (except rapid cycling bipolar disorder dysfunction clinically and without any prior history of lithium or
which is more common in females), nearly one third of the thyroid hormone treatment were included in the study and
affected patients admit to at least one suicide attempt (Muller- constituted the bipolar affective disorder group. Control group
Oerlinghausen et al., 2002). Bipolar affective disorder has been consisted of participants aged between 18 and 50 years who
eating into the vitals of mankind leading to obesity, loss of work were employed in various industries and did not suffer from
efciency, impairment of mental functions, deteriorating social bipolar affective disorder as conrmed by the application of
relationships and nally deliberate self-harm (Elmslie et al., BSDS. While recruiting participants in the control group
2001). Lewnsohn et al. (2003) found that the onset of bipolar individual matching was done for age and sex, i.e. once the
affective disorder occurred mostly during adolescence and also bipolar affective disorder patients were included in the study,
pointed out that relatives of bipolar affective disorder adolescents the corresponding age and sex matched participants were
have elevated rates of sub threshold bipolar disorder and major included in the control group. Thus, a total of 24 males and 26
depressive disorder. Preventing bipolar affective disorder, thus, females were included in each group. Mean age of participants in
becomes a high public health priority. It has been suggested that of both groups was 36.9 years. All participants had at least
all the endocrine systems thought to be linked to the pathophysi- completed their high school education and were able to
ology of bipolar affective disorder, the hypothalamicpituitary understand and comprehend English language well. It was
thyroid axis is the prime candidate (Muller-Oerlinghausen et al., ensured that the participants had no thyroid dysfunction
2002). Thus, it has been assumed that bipolar affective disorder clinically or any prior history of lithium or thyroid hormone
may be associated with alterations in thyroid function and hence treatment. Participants who were on steroid treatment, amio-
the need for a comprehensive thyroid assessment is important for darone and antihypertensive drug therapy or had taken cough
assessing clinical and sub-clinical imbalances linked to a variety medicines within last two weeks, or had any contrast medium
of mood disorders like bipolar affective disorder (Nath and Sagar, during the previous eight months for any investigation were
2001). excluded from the study.
The present cross-sectional study is intended to test the For assessment of thyroid function, blood samples were
association between thyroid dysfunction and bipolar disorder collected from the cases and controls and analyzed for T3, T4 and
spectrum in patients with newly diagnosed bipolar affective TSH levels using ECLIA electrochemiluminescence immunoas-
disorder (ICD-10). In the present investigation, the strength say. The normal ranges for thyroid hormones as indicated in the
of association would be dened using odds ratio. The degree of assessment kit was were 0.62.02 ng/mL, 5.1314.06 mg/dL, and
association between the two might help in a better prognosis of 0.275.5 mIU/mL for T3, T4 and TSH respectively. Presence of a
patients with bipolar affective disorder as appropriate treatment genuine thyroid dysfunction was in accordance with dened
can be administered to both the problems without undermining biochemical parameters. Participants having T3 > 2.02 ng/mL,
the importance of this association. T4 > 14.06 mg/dL and TSH < 0.27 mIU/mL were considered
hyperthyroid while participants with T3 < 0.6 ng/mL,
2. Materials and methods T4 < 5.13 mg/dL and TSH > 5.5 mIU/mL were considered hypo-
thyroid.
The present cross-sectional study was conducted at Govern- The details of all participants in both groups were collected
ment District Wenlock Hospital, Mangalore (GDWH) which is a using a pretested proforma that was lled by interviewing the
550 bed tertiary care hospital providing comprehensive health participants. The proforma contained patients individual infor-
care to the patients of Dakshina Kannada district in Karnataka. mation, personal history, family history, childhood experiences,
GDWH is also a teaching hospital for Kasturba Medical College investigation reports, BSDS score, Young mania rating scale score
(KMC), Mangalore. The present research included 50 newly and Hamilton rating scale for depression score.
diagnosed bipolar affective disorder patients and 50 age and sex The data collected was analyzed statistically using SPSS
matched controls without bipolar affective disorder. Institutional (Statistical Package for Social Sciences) computer software version
ethical committee approval was taken prior to the study. Informed 11.0. Students t-test was done to compare mean values of thyroid
consent was obtained from each participant before undertaking hormone levels among cases and controls. A p-value of <0.05 was
the research. considered as signicant. Odds ratio was calculated to nd out the
Bipolar affective disorder patients for this study were strength of association between thyroid gland dysfunction and
taken from amongst those who attended the psychiatric bipolar affective disorder.
44 V.N. Krishna et al. / Asian Journal of Psychiatry 6 (2013) 4245
Table 1
Thyroid prole among bipolar affective disorder and control group.
Thyroid prole BAD group (n = 50) (Mean S.D.) Control group (n = 50) (Mean S.D.) t-Value p-Value
Co-morbid conditions in patients as well as in controls have not We wish to acknowledge ICMR for their support and thank the
been ruled out using a standardized instrument such as the MINI. participants of the study without whom the study would not have
been accomplished.
6. Conclusion
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