This material was presented in the 25th European Congress of Psychiatry which was organised by the European Psychiatry Association in Florence, Italy from 1-4th April 2017. I had access to the material as I attended the full Congress. Please note that this material remains the intellectual property of the European Psychiatry Association and its authors and any citation should include a full reference to it. For more information on the EPA and how to become a member, please visit: http://www.europsy.net/

1. Thyroid Profile and its Relationship with Response
to Treatment with Lithium in Bipolar Mood
Disorder Patients
Presenter: Dr. Priyaranjan Avinash
Asst. Professor ,
HIMS, Dehradun, India
&
Online Consultant @
Epsyclinic.com

2. Faculty Disclosure
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3. Outline
 Introduction
 Aims & Objectives
 Methods
 Results
 Discussion
 Limitations
 Conclusion
 Q&A

4. Introduction
• The association between thyroid functions and behavioural disturbances
has been known for the last several hundred years.
• The primary focus of interest has been on the connection between thyroid
functions and depressive disorders.
• Abnormalities of thyroid functions may also play an important role in the
pathophysiology of bipolar affective disorder

5. • There is substantial evidence that even minor perturbation of thyroid
function plays a significant role in clinical course and treatment outcome
• Keeping this premise in our mind we did this study to check the
relationship of pre-treatment thyroid profile and response to treatment
by lithium in patients of Bipolar Mood Disorder.

6. Aims & Objectives
• To study the relationship between thyroid profile and Bipolar disorder
subtypes
• To study the relationship between pre-treatment thyroid profile and
response to treatment with Lithium in Bipolar Mood Disorder
• To study other predictors of response to treatment with Lithium in cases
of Bipolar Mood Disorder.

7. Methods
• Study Site: Indoor of LGBRIMH, Tezpur
• Study Period: 1 year
• Sample size: 45
• Sampling technique: Consecutive sampling
• Study design- Prospective follow up study
• Study population : patients diagnosed as Bipolar Mood Disorder using
DSM IV TR and admitted in the indoor facility of LGBRIMH in the year
2012.

10. Results

11. Socio demographic and clinical variables
• 28 (62.8%)were male and 17( 37.2%)were female.
• The mean age of the sample was 39.44 years.
• 20 of them were users of some substance or other while rest were non
users of any substance
• Maximum no(20) of patients were having 4th or later episode of bipolar
disorder
• Mean duration of the illness of the total sample was 11 years
• Biggest group was that of bipolar mood disorder current episode mania
that was 69 %

12. Response to treatment with lithium
• Using Wilcoxon Signed Ranks Test we found that there is a significant fall
in the grandiosity subscale of BPRS 24
• least significant fall was in the depression subscale ( Z=-2.7), while the
most significant fall was in the grandiosity subscale (Z=-5.3).
BPRSG2-BPRSG1 Z=-5.33
BPRSD2-BPRSD1 Z=-2.70
BPRSS2-BPRSS1 Z=-3.90

13. Predictors of the response to lithium treatment
• Age , illness duration , use of substance , family history of mood disorder
were negatively correlated with the fall ratio of the BPRS score
• Episode of the bipolar disorder was found to be a significant predictor of
the lithium response .
• 1st episode of bipolar mood disorder has the maximum fall in BPRS24
score , i.e 60%.

14. • Post Hoc Tests (ANOVA)
• LSD-Least significant difference ( Post Hoc test for ANOVA)
• The difference of fall ratio was most significant for the 1st episode in
comparison to 2nd 3rd or later episode(p=.002,.0001 & .001 respectively) .
• There was no significant inter-episodic difference of fall between, 2nd ,3rd
and later episodes.
Current
episode(Fall Ratio
24)
Current episode Sig.
1st 2nd .002
1st 3rd .0001
1st Later .001
2nd 3rd .145
2nd Later .912
3rd Later .141

15. • One of the most significant predictors of the lithium response turned out
to be the subtype of bipolar mood disorder.
• bipolar mood disorder current episode manic showing the most significant
fall in the BPRS score.
• with p value 0.001 on ANOVA.

16. Relationship of Baseline thyroid level to treatment response in
Bipolar Disorder patients:
• One of the hypotheses of this study was that baseline thyroid level of a
patient of bipolar disorder affects its treatment response.
• This was checked using Linear regression
• The R square value of .138 signifies that if we are aware of the values of
T3,T4,TSH,FT3 and FT4,then we can predict the score fall in 13.8% of the
cases.
R R square Adjusted R Square
.372 .138 .028

18. Discussion
Sociodemographic Characteristics
• The mean age of the sample was 39.44 years.
• This mean age in the range of middle age can be understood in the light of
that 44% of the patients were having 4th or later episode of the illness at
the time of the study.
• The biggest group in the study sample was that of bipolar mood disorder
current episode mania , which can be explained by the unmanageability of
manic patients through domiciliary treatment leading to their admission in
inpatient facilities.

19. Response to treatment with Lithium:
• Lithium was significantly effective in reducing the total score(p=.0001) and
scores on subscales of grandiosity(p=.0001) ,suicidality(p=.0001), motor
hyperactivity(p=.0001), anxiety(p=.0001), hostility(p=.0001) and
depression(p=.007) , however the fall on depression subscale was less
significant than other subscale with maximum fall on the grandiosity
subscale (This is in accordance with the study of Rohayem ,et al in 2008
where he concluded that classical pattern of elated manic episodes with
grandiosity is a favorable predictor of lithium response).

20. Predictors of response to lithium treatment:
• In this current study we found that age (z=-.031), illness duration (z=-
.089), use of substance (z=-.404), family history of mood disorder (z=-.760)
were negatively correlated with the fall ratio of the BPRS score(Kusalic et
al study finding that the strongest univariate predictors were mood
quality, illness subtype, illness duration, and substance abuse).
• one of the most important predictor of lithium response was the number
of the index episode, with higher the episode poorer the response
(Rohayem et al in 2008, which shows that high number of previous
affective episodes in the illness course before lithium initiation was
statistically significant predictors of non –response).

21. Relationship of Baseline thyroid level to treatment response in
Bipolar Disorder patients:
• TSH has a negative correlation with the BPRS score fall, I e. lesser the TSH
more is the fall in BPRS score (t= -.707), while
• while on the other hand T4 has a positive correlation with the BPRS score
fall (t=2.049), i.e. higher the T4 more is the score fall.
• Among all the thyroid indices only T4 has significant relation with the fall
ratio of the BPRS score with sig. p= 0.047.

22. • Cole et al found that higher values of TSH were significantly associated
with longer times to remission, i.e., slower response to treatment.
• Zhang et al in a 2006 paper found that more episodes were associated
with lower T4 levels; whereas , longer illness duration was associated with
higher TSH levels.
• Chang et al study in 1998 found that the mean TSH concentration was
significantly higher, and the mean T4 concentration was significantly lower
in patients with mixed mania compared with pure mania

23. Limitation
• The sample size is relatively small
• The high cost incurred by the institute for each thyroid profile was a factor
which kept us from recruiting more patients.
• Due to poor educational background of the patients and poor record
keeping prior lithium use can’t be ruled out beyond all doubts.
• As the patients were only followed up for 1 month so the maintenance
potential of lithium and predictors of the same could not be evaluated.

24. Conclusion
• Lithium mono-therapy proved to be a good agent for 1st episode of
Bipolar Mood disorder patients specially in the young age group and with
prominent manic symptoms.
• Patients with substance use and family history of mood disorder have
poor response .
• Pretreatment T4 and TSH level were predictors of treatment response.

25. References
• M. Bauer, T. Goetz, T. Glenn, and P. C. Whybrow,
“The thyroid-brain interaction in thyroid disorders
and mood disorders,” Journal of
Neuroendocrinology, vol. 20, no. 10, pp. 1101 -
1114, 2008
• V. Hendrick, L. Altshuler, and P.C. Whybrow,
“Psychoneuroendocrinology of mood disorders.
The hypothalamic-pituitary-thyroid axis,”
Psychiatric Clinics of North America, vol. 21, no. 2,
pp. 277 -292, 1998.
• Thomsen, and L.V. Kessing, “Increased risk of
hyperthyroidism among patients hospitalized with