Low Thyroid Hormone Levels Linked to Poorer Response to Depression Treatment

Lower levels of certain thyroid hormones may predict a poor treatment response in people hospitalized with depression, a study in the Journal of Affective Disorders suggests.

Zhifen Liu, M.D., of First Hospital of Shanxi Medical University in Taiyuan, China, and colleagues studied data from 2,086 patients who were admitted to the hospital with depression between 2014 and 2020. All patients received thyroid function evaluation—including assessments of serum free triiodothyronine (FT3), free thyroxine (FT4), and thyroid stimulating hormone (TSH)—the morning after they were admitted. The patients’ depression symptoms were measured using the Hamilton Depression Rating Scale (HAM-D). The researchers analyzed changes in the patients’ HAM-D scores from the time of admission to discharge. Treatments during hospitalization varied by patient but included pharmacotherapy, repetitive transcranial magnetic stimulation, and/or psychotherapy.

After controlling for the patients’ age, education level, and other factors, the researchers found that lower levels of FT4 on admission were significantly associated with higher HAM-D scores, and lower levels of FT3 on admission were significantly associated with longer stays in the hospital—even when the levels of these hormones were within the normal range. The researchers also found that higher FT4 levels on admission were associated with greater improvements in HAM-D scores over the course of treatment between admission and discharge.

“[T]his study quantified the effectiveness and contribution of thyroid hormones in predicting the clinical outcomes of depression,” Liu and colleagues wrote. “[F]uture research can confidently explore deeper insights into endocrinology data, especially thyroid hormones, of depressed patients and [explore] more robust prediction models for predicting the response to antidepressant treatment in the real-word setting.”

For related information, see the American Journal of Psychiatry article “Hormonal Treatments for Major Depressive Disorder: State of the Art.”

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Don’t Miss Your Chance to Submit Ideas for 2022 Annual Meeting Posters

Submit your ideas for new research posters for the 2022 APA Annual Meeting, to be held May 21 to 25 in New Orleans, by Thursday, December 9. The theme of the meeting is “Social Determinants of Mental Health.” To be considered, all abstracts must be submitted through APA’s online abstract submission system.

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APA Poll Reveals COVID-19 and Other Worries During Holiday Festivities

Forty-one percent of Americans said their level of stress increases during the holidays, compared with just 7% percent who said it diminishes, according to a nationwide poll commissioned by APA.

Top areas of concern were contracting COVID-19 during gatherings (38%) and finding (40%) and affording (46%) gifts. People who are vaccinated are more worried about contracting COVID-19 than those who are not vaccinated (43% vs. 28%). Additionally, nearly half of adults (47%) were anxious about missing family members around the holidays.

The poll, conducted by Morning Consult on behalf of APA, was fielded between November 17 to 21 among a nationally representative sample of 2,119 adults.

“This holiday season, as many are returning to pre-COVID traditions like seeing family and shopping, it’s normal to feel a mixture of emotions,” said APA President Vivian Pender, M.D. “It’s important to take joy in the moments we can and to know that it’s OK not to feel OK. Check in with yourself, and if you’re feeling overwhelmed or anxious, talk to friends or family, and know that help is available.”

Among the poll’s top findings:

• 40% of health care workers are worried about working long hours in the holiday season. 54% of them reported that their stress increases during holidays generally, with 33% anticipating higher stress levels than in 2020.
• Parents said they are particularly worried about the holidays, with nearly half concerned about contracting (48%) or spreading (47%) COVID-19 at gatherings. Mothers are more likely than fathers to worry about affording gifts (61% vs. 47%) and are more likely than fathers to say the level of stress in their life increases during the holidays (53% vs. 39%).
• Younger adults were consistently more likely than older adults to say they are anxious about the holidays, particularly about social and family dynamics.
• Hispanic adults were more likely than those of other racial and ethnic groups to say they anticipate feeling more stress compared with last year.

Despite these worries, the holidays are still associated with positive, festive feelings. In response to an open-ended question—"In a word or two, how would you describe your emotions toward the upcoming holiday season?”—34% of adults said they were “excited,” 15% said they were “happy,” 6% responded with “good,” and 5% responded with “looking forward to it.”

“While we are pleased to be rejoining our families and friends, depending on who you are or where you work, stress may be a bigger factor,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “It’s particularly important in this season of celebrating to remember how hard our health care workforce continues to labor to ensure the rest of us can be safe and that this work has an emotional toll. Remember to protect yourselves and those around you by following health guidelines in these COVID times.”

The interviews were conducted online, and the data were weighted to approximate a target sample of adults based on gender, educational attainment, age, race, and region. Results have a margin of error of plus or minus 2 percentage points.

For related information on Americans’ reaction to the pandemic, see the Psychiatric News article “Pandemic Has Taken Toll on Mental Health of Americans, APA Poll Finds.”

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Make Informed Choice When Voting in APA's 2022 Election

Learn more about the candidates for president-elect, treasurer, trustee at large, Area 3 and 6 trustees, and resident-fellow member trustee-elect in a series of town halls from December 13 to December 16 and submit questions for them to answer.

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COVID-19 Most Deadly for Patients With Schizophrenia, Study Suggests

Patients with schizophrenia are significantly more likely to die from COVID-19 than those without the disorder, even though they appear to have lower rates of infection, according to a study in JAMA Network Open. Further, while patients with mood disorders and anxiety were found less likely to die from COVID-19 than those with schizophrenia, they still died at higher rates from the virus than those without mental disorders.

“This study’s findings suggest the need to foster recognition of pandemic risks on specific groups of patients with psychiatric conditions and may drive alternative approaches to COVID-19 disease testing and interventions to improve clinical outcomes,” wrote Antonio L. Teixeira, M.D., Ph.D., of the University of Texas Health Science Center at Houston and colleagues.

Teixeira and colleagues analyzed data from the electronic health records (EHRs) of more than 2.5 million patients in the Optum COVID-19 Electronic Health Record database, derived from a network of health care provider organizations across the United States. Of these, 317,849 patients tested positive for COVID-19; more than 2.4 million patients tested negative.

Patients with psychiatric disorders were categorized into three mutually exclusive psychiatric diagnostic categories based on diagnostic codes in the EHR documented before March 1, 2020: schizophrenia spectrum disorders (n=3,350), mood disorders (n=26,610), and anxiety disorders (n=18,550). The authors compared the risk of testing positive for COVID-19 and COVID-19–related death for these three groups with a reference group of patients who had received laboratory tests for COVID-19 but had no documented psychiatric disorder.

They found that the COVID-19 positivity rate in patients with schizophrenia matched that of patients with mood disorders at 9.86%—a lower positivity rate than the reference group’s positivity rate (11.91%). The anxiety disorders cohort had a positivity rate of 11.17%.

After adjusting for demographic factors and comorbid conditions, patients with schizophrenia were found to be 3.74 times more likely to die from COVID-19 than patients in the reference group. Patients with mood disorders and those with anxiety disorders were 2.76 times and 2.39 times, respectively, more likely to die from COVID-19 compared with those in the reference group.

“It is possible that patients with major psychiatric disorders—schizophrenia and mood disorders—being more socially withdrawn are less exposed to the virus, explaining the lower positivity rate in the current study,” the authors wrote. “Alternatively, the lower positivity rate would reflect not a true reduced risk of infection, but lower testing numbers.”

For related information, see the Psychiatric News article “COVID-19 Greatly Increases Mortality Risk for Schizophrenia Patients, Research Shows.”

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Participate in Tonight's Town Hall on Social Determinants of Mental Health

Join APA leaders today, Wednesday, December 1, at 6 p.m. ET for a town hall on the public health significance and health consequences of social determinants of mental health in psychiatry.

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Young Cancer Survivors May Experience Cognitive Problems, Suicidal Thoughts

Child and adolescent survivors of cancer—particularly those experiencing cognitive problems—may be at higher risk of suicidal thoughts than other youth their age, suggests a report in Psycho-Oncology.

“Survivors of pediatric cancer are at elevated risk for both neurocognitive and psychological difficulties following cancer treatment,” wrote Christina M. Sharkey, Ph.D., of Children’s National Hospital in Washington, D.C., and colleagues. Studies of adult cancer survivors suggest there may be a link between neurocognitive deficits and suicidal ideation, but little is known of whether such deficits are also linked to suicidal ideation in younger cancer survivors, the authors wrote.

To examine the prevalence of suicidal ideation in young survivors of cancer, Sharkey and colleagues recruited youth who had been diagnosed with cancer between the ages of 6 and 19 and were receiving care at a pediatric neuropsychology clinic. Patients included in the study were medically stable at the time of the evaluation; had completed multiple behavioral and cognitive assessments; and had parents and teachers who had filled out assessments of the youth’s suicidal ideation, executive function, symptoms of attention-deficit/hyperactivity disorder, and more. Patients were an average age of 11.5 years old and had been diagnosed with cancer more than five years ago.

Of the 166 pediatric cancer patients in the analysis, 17.5% had experienced suicidal ideation. Those with suicidal ideation had significantly more parent-reported inattention symptoms compared with those without suicidal ideation, the authors reported. Additionally, those with suicidal ideation had significantly greater impairments in global executive functioning and behavioral regulation compared with youth without suicidal ideation according to both parent and teacher reports. Youth with suicidal ideation did not significantly differ on measures of IQ, working memory, and processing speed from those without suicidal ideation.

The researchers concluded, “Although replication of these findings is needed and a clearer understanding of the relationship between [executive function] impairments and suicidal ideation is essential, the present study underscores the importance of screening and examining suicidality among youth treated for pediatric cancer.”

For related information, see the Psychiatric News article “Pediatric Consultation-Liaison Psychiatry—Yesterday, Today, and Tomorrow.”

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Participate in Upcoming Virtual Events

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• Tonight (November 30) at 8 p.m. ET: Fireside chat on COVID-19 and the mental health of Indigenous people.
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PCPs Sought Advice More Often on Youth Mental Illness First Year of Pandemic

Pediatric primary care providers (PCPs) made more calls to two state programs seeking advice on how to treat youth with mental illness, especially those with comorbid conditions, during the COVID-19 pandemic than before the pandemic. These findings were published today in Psychiatric Services in Advance.

The research is based on data from Pediatric Mental Health Care Access (PMHCA) programs in Maryland and Mississippi, which provide PCPs with free services to help bolster their knowledge and skills in managing common mental health problems in children and adolescents. Services include mental health care education, consultation, and referrals; some PMHCA programs also provide direct-to-patient consultation and treatment services.

“These programs, now operating in >30 states, have shown positive effects on mental health outcomes; these benefits include decreases in antipsychotic prescriptions, increased provider capacity for addressing mental health concerns, and increased identification and connection to mental health supports,” wrote Amie Bettencourt, Ph.D., of the Johns Hopkins School of Medicine and colleagues.

Bettencourt and colleagues examined the trends in the types of calls received by the PMHCAs that support PCPs in Maryland and Mississippi between January (Maryland) or September (Mississippi) 2019 and March 2021. They found that both programs experienced an uptick in call volume starting in April 2020, when the pandemic took hold in the United States, especially calls involving depression and anxiety.

The proportion of calls involving patients with comorbid diagnoses also increased sharply in both states. In Maryland, 37% of all PMHCA calls were for patients with multiple diagnoses during the pandemic, compared with 20% before the pandemic; in Mississippi, 11% of PMHCA calls were related to patients with multiple diagnoses during the pandemic compared with 0% before the pandemic. In contrast, the proportion of calls involving patients with severe mental health concerns (a patient with a score of >4 on the seven-point Clinical Global Impressions scale) dropped in both states during the pandemic, going from 11% pre-COVID-19 to 7% during COVID-19 in Maryland, and from 29% to 9% in Mississippi.

“[T]his highly similar pattern was observed in two PMHCA programs in operation for different durations; moreover, these programs had very different racial-ethnic and geographic features, health systems, and state responses to COVID-19,” the authors wrote. “Taken together, the increased utilization of PMHCA programs in these two states underscores the growing mental health needs during COVID-19 and how PMHCA programs are well situated to respond to this increased demand.”

For related information, see the Psychiatric News article “Long-Term Impact of COVID-19 on Children, Adolescents Constitutes Public Health Emergency.”

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Cognitive-Behavioral Therapy for Insomnia May Prevent Depression in Older Adults

Cognitive-behavioral therapy for insomnia (CBT-I) may help to prevent depression in older adults with insomnia disorder, according to a report published today in JAMA Psychiatry.

“Insomnia, occurring in nearly 50% of persons 60 years or older, contributes to a 2-fold greater risk of major depression,” wrote Michael R. Irwin, M.D., of the David Geffen School of Medicine at UCLA and colleagues. “In this trial of older adults without depression but with insomnia disorder, delivery of CBT-I prevented incident and recurrent major depressive disorder by more than 50% compared with [sleep education therapy], an active comparator.”

CBT-I—a first-line treatment for insomnia disorder—combines cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation. Sleep education therapy (SET) teaches about the day-to-day behavioral and environmental factors that contribute to poor sleep.

For the study, Irwin and colleagues enrolled 291 adults 60 years or older who lived within 15 miles of UCLA and met DSM-IV criteria for insomnia disorder. Individuals with a history of depression could participate in the study, but those who had experienced depression within the past year were excluded.

The 291 participants (including 123 with a history of depression) were randomized to receive either CBT-I or SET in weekly two-hour group sessions for two months. The participants were evaluated monthly using the Patient Health Questionnaire (PHQ-9) and every six months using the Structured Clinical Interview of the DSM-5 for 36 months.

Incident or recurrent major depression occurred in 19 participants in the CBT-I group (4.1 events per 100 person-years) and 35 participants in the SET group (8.6 events per 100 person-years). The proportion of participants who achieved remission of insomnia disorder after treatment was greater in the CBT-I group (50.7%) compared with the SET group (37.7%). Similarly, a greater proportion of participants in the CBT-I group achieved sustained remission of insomnia (defined as the absence of insomnia disorder at each follow-up assessment) compared with those in the SET group: 26.3% vs. 19.3%.

“This study indicates that an intervention aimed at insomnia can effectively reduce the incidence of major depression in those without a depressive disorder at the start of the intervention, meaning that depression can be prevented effectively without even using the word depression and thus avoid the associated stigma,” Pim Cuijpers, Ph.D., of Vrije Universiteit Amsterdam and Charles F. Reynolds III, M.D., of the University of Pittsburgh School of Medicine wrote in an accompanying editorial. “If prevention of major depression can be realized by focusing on insomnia, would it be possible to prevent depressive disorder by focusing on other problems that are associated with depression?”

Cuijpers and Reynolds added, “This major finding offers exciting new opportunities for the prevention field and opens a new field of research into indirect preventive interventions for avoiding the stigma of mental disorders.”

For related information, see the American Journal of Psychiatry article “The Evolving Nexus of Sleep and Depression.”

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Lithium Does Not Appear to Lower Risk of Suicidal Behavior in Veterans With Mood Disorders

Adding lithium to the treatment plan of veterans with depression or bipolar and recent suicidal behavior does not appear to reduce the risk of subsequent suicidal behavior, according to a report in JAMA Psychiatry.

“The present double-blind, placebo-controlled study found no benefit of lithium over placebo for preventing or delaying suicide-related events (suicide attempts, interrupted attempts, hospitalizations to prevent attempts, or deaths from suicide) when it was added to usual VA mental health management,” wrote Ira R. Katz, M.D., Ph.D., emeritus professor of psychiatry at the University of Pennsylvania Perelman School of Medicine, and colleagues. “However, lithium still has a role in the management of mood disorders, especially bipolar disorder.”

Veterans at 29 VA medical centers who had an episode of suicidal behavior or an inpatient admission to prevent suicide within the past six months were randomized to receive lithium or placebo in addition to their existing medications and treatment. Individuals were included in the study if they had a DSM-IV-TR diagnosis of major depression or bipolar disorder; they were excluded if they had schizophrenia, six or more lifetime suicide attempts, or had used lithium within the past six months.

Katz and colleagues tracked the occurrence of any suicide-related events in the participants for one year.

The trial was halted for futility after 519 participants had been randomized (255 with lithium and 264 with placebo), as the data indicated no difference in suicide-related events between the participants who received lithium and those who received placebo. A total of 127 participants (24.5%) had suicide-related outcomes: 65 in the lithium group and 62 in the placebo group. One death occurred in the lithium group and three in the placebo group.

The authors cautioned that their data had some notable limitations, including that only half of participants assigned to lithium achieved clinically adequate blood levels of the medication (0.5 mEq/L or higher).

“Our findings are not necessarily generalizable to other health care settings or to other patient populations with differing proportions of individuals with bipolar disorder, lower rates of comorbidities, or higher treatment adherence,” Katz and colleagues wrote.

In an accompanying editorial, Ross J. Baldessarini, M.D., and Leonardo Tondo, M.D., M.S., of Harvard Medical School suggest that the report should be read with the study limitations in mind. “In our opinion, this rigorously designed and conducted trial has much to teach but cannot be taken as evidence that lithium treatment is ineffective regarding suicidal risk.”

They added, “The new trial did not find evidence of an antisuicidal effect of adding lithium to complex treatment regimens in relatively small numbers of mostly male veterans with complex, although realistic, psychopathological conditions, given relatively brief treatment with low circulating levels of lithium. Thus, its findings cannot be taken as evidence that lithium lacks antisuicidal effects.”

For related information, see the Psychiatric Services article “Suicide Mortality Among Veterans Health Administration Care Recipients With Suicide Risk Record Flags.”

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