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Depression s impact on society for hypothyroidism – What’s the Link Between Thyroid Conditions and Depression?

Recently, the Caerphilly Prospective Study examined the link between thyroid function and minor psychiatric morbidity among middle-aged men.

Mutations in MCT8 have also been recognized to cause isolated brain hypothyroidism by blocking T3 transport into neurons [ 831 ]. The role of thyroid hypothyroidism in depression. Third, there may be possible bias due to the heterogeneity of the analyzed studies in terms of the definition of SCH and the evaluation of depression. Relationships between circulating and intracellular thyroid hormones: physiological and clinical implications. Overview of Thyroid Hormone Metabolism in the Brain The hypothalamic-pituitary-thyroid axis HPT is a complex interplay between several factors: thyroid hormones, deiodinase enzymes, transporter proteins, and receptors.

  • Kim J-M. Reprint Permissions A single copy of these materials may be reprinted for noncommercial personal use only.

  • Just realize that this is not a complete list, but it can serve as a starting point for many of you. Treating Depression if you have Thyroid Disease It is clear that thyroid disease is associated with depressive symptoms.

  • Mirella P. Existing evidence also suggests that these mechanisms can potentially affect the HPT axis and thus, explain the association between SCH and depression.

Does Thyroid Disease Cause Depression?

Calculate Shipping. On history taking she had a number of symptoms of hypothyroidism, most notably thinning of hair with hair loss, fatigue and menstrual abnormalities; all of which have been exacerbated after her first pregnancy. Rao, S. Despite having a "normal" TSH it is still very possible to exhibit low free thyroid hormones which may be sufficient to warrant treatment with thyroid medication. Make exercise a priority.

  • Thyroid function in clinical subtypes of major depression: an exploratory study.

  • However, in the latter study no difference in treatment outcome was observed between the two groups [ 15 ]. Clinical Endocrinology Nov;83 5

  • Thyroxine and the treatment of affective disorders: an overview of the results of basic and clinical research. Research Symptoms Medication Takeaway Overview.

  • With Todd B. Methods We conducted a meta-analysis to evaluate the association between SCH and depression including 1 dpression prevalence of depression in SCH with a sub-analysis of the geriatric cohort2 thyroid stimulating hormone TSH level among patients with depression and 3 the effect of levothyroxine therapy among patients with SCH and coexistent depression.

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Taylor JW. Recently, advances in biochemical, genetic, and neuroimaging fields have provided new insights into the thyroid-depression relationship. However, this was consistent with chance after adjustments were done for social class, alcohol, and smoking behaviors. The most widely replicated finding from these studies is hypoperfusion in anterior cortical structures [ 9394 ] that was reversible after psychotherapy and pharmacotherapy [ 95 — 97 ]. Ingram RE. The effect of tricyclic antidepressants on basal thyroid hormone levels in depressed patients.

Twenty-four-hour profiles of body temperature and plasma TSH in bipolar patients during depression and during remission and in normal control subjects. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction diet to lose weight in my thighs any medium, provided the original work is properly cited. The inconsistency in the above findings can be accounted for by the variability in the degree of hypothyroidism and the differences in the etiology and duration of the disease in the various studied populations. High serum TSH levels are associated with depression in the elderly. However, it has been postulated that depression can cause inhibitory effect on type II deiodinase, which leads to the conversion of fT4 to rT3 via type III deiodinase [ 55 ]. Two studies found a higher prevalence of depression between elderly with SCH compared to controls [ 1430 ].

Journal of Thyroid Research

There are other strategies for managing depressive symptoms aside from antidepressants. Brody, S. Williams, R. Hage 1 and Sami T. Peripheral Thyroid Hormone Concentrations 6.

Because depression and hypothyroidism share many similarities, misdiagnosis can be common. Rabon, and M. Chau, N. Pottash, and I. E-mail: samuelsm ohsu. Lifelong estradiol exposure and risk of depressive symptoms during the transition to menopause and postmenopause.

  • Download PDF. Kirkegaard C.

  • Hatterer, J. Bearing in mind that relationship between two conditions is strong, it is important to stay informed, consult your doctor, and have a proactive approach to the subject.

  • Thus, the HPT axis includes complex pathways and impairment in its components has been linked in some studies to behavioral changes as will be further pointed out.

  • Williams, R.

  • McClane, A.

The entire article by Bauer et al. Most notably, hypothyroid patients often ddpression symptoms of depression and low mood. Both SSRIs and tricyclic antidepressants appear to amplify the activity of deiodinase enzyme type 2 D2 thereby leading to the enhanced conversion of T4 in active T3 in the brain. The authors conclusively found that there was no association between the presence of subclinical hypothyroidism and the development of depression during a mean follow-up of 2 years by the CES-D cutoff of 16 in this large cohort.

Availability of data and materials Not applicable. Conclusions: This meta-analysis demonstrated that SCH was spciety associated with the risk of depression, especially in persons above 50 years of age, suggesting it is necessary to pay close attention to depressive symptoms in persons with SCH. Depression, being one of the common chronically disabling disorders, can lead to poor quality of life [ 12 ]. Research Symptoms Medication Takeaway Overview.

Acknowledgments

Figures also show that depression is more prevalent in adult women than men with ratio 8. Screening patients presenting with depression for thyroid dysfunction seems reasonable particularly those with refractory symptoms. Silva, and M.

Treating hypothyroidism proactively is important to avoid labelling the individual as treatment-resistant depression s impact on society for hypothyroidism exposing them to polypharmacy. This suggests that the decrease in T4 levels with initiation of antidepressants could be secondary to a direct effect on TRH neuron and socirty to a reduced stimulation of the thyroid axis. Therefore, the amount of people struggling with any degree of depression is significant. The authors conclusively found that there was no association between the presence of subclinical hypothyroidism and the development of depression during a mean follow-up of 2 years by the CES-D cutoff of 16 in this large cohort. Instead what we have are the following connections: 1. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide.

Tonami, T. One mechanism explaining the increase in T4 seen in depression is the activation of deprfssion TRH producing neurons and subsequent increase in thyroid function secondary to the rise in cortisol associated with depression [ 192433 ]. Metabolic abnormalities such as dyslipidemia are also a part of hypothyroidism and can add weight to your hypothesis. In clinical practice, patients with mild increases of TSH or normal TSH with clinical symptoms of hypothyroidism may not receive treatment by endocrinologists.

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The continuing research in the biochemical, genetic, and neuroimaging fields seems most promising in providing a deeper understanding of the thyroid-depression interactions. On the other hand, thyroid hormones free triiodothyronine [fT3] and free thyroxine [fT4] which are widely distributed in the central nervous system, regulate the neuronal growth and form synapses between neurons [ 3 ]. A reappraisal using objective psychological measurement. A forest plot was used to present the pooled OR value, and heterogeneity was evaluated using the I 2 statistic.

Mayo, K. Depressio Medication delivered. A randomized controlled trial of the effect of thyroxine replacement on cognitive function in community-living elderly subjects with subclinical hypothyroidism: the Birmingham Elderly Thyroid study. Fountoulakis, A. Linnoila, R. Whether this is related to clinical recovery or merely a result of a direct effect of antidepressants remains to be determined.

A 6-month randomized trial of thyroxine treatment in women with hypofhyroidism subclinical hypothyroidism. Evidence shows that hypothyroidism is six times more common in women than it is in men [vi]. Google Scholar Crossref. Duval, M. This pathway can be bypassed with the use of medication such as T3 which may be superior to T4 forms of medication for those with the polymorphism.

1. Introduction

Hair loss is a common symptom of hypothyroidism. Leave a reply Cancel reply. Banki, G. The extent to which the endogenous TRH system is involved in mood regulation and the underlying implicated mechanisms remain to be defined. Arato, and C.

Both excess and insufficient thyroid hormones can cause mood abnormalities including depression that is generally reversible with adequate thyroid treatment. Simon, and C. Special Issues. Recent research suggests that antidepressants alter thyroid hormone production.

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Two reviewers LHH and LLL extracted data from eligible studies independently using standard template, including authors, country of study conduct, depression s impact on society for hypothyroidism design, sample size, age, mean TSH levels, prevalence of major depression disorder MDD and the depression scores based on the different depression scoring systems. This suggests that the decrease in T4 levels with initiation of antidepressants could be secondary to a direct effect on TRH neuron and thus to a reduced stimulation of the thyroid axis. For part II, we analysed the mean TSH level in individuals with depression compared with those without underlying psychiatric disorders. Graves' disease Heart arrhythmia Heart palpitations Hyperthyroidism overactive thyroid Molar pregnancy Red eye Sweating and body odor Symptom Checker Tachycardia Thyroid scan Thyroidectomy Unexplained weight loss Show more related content. For many, anxiety and depression are real, and it's time we stop them writing them off as something that will go away. The movement of thyroid hormones in the central nervous system.

Three studies soxiety significant reduction in depression scores, from Health status, psychological symptoms, mood, and cognition in L-thyroxine-treated hypothyroid subjects. Journal of Clinical Psychiatry. Methods We conducted a meta-analysis to evaluate the association between SCH and depression including 1 the prevalence of depression in SCH with a sub-analysis of the geriatric cohort2 thyroid stimulating hormone TSH level among patients with depression and 3 the effect of levothyroxine therapy among patients with SCH and coexistent depression. The role of thyroid hormones in depression. A hypothesis of thyroid-catecholamine-receptor interaction.

Scientists concluded that depression and hypothyroidism have a strong relationship [viii]. Baumgartner, M. Make exercise a priority. Thyroid hormones are present in different concentrations in brain tissue and peripheral tissues. Simple lifestyle tweaks can help you feel better and improve your mood. Salvati, T.

Background

Last Updated: November 15, The association between thyroid function and psychiatric disorders particularly mood disorders has long been recognized. Age Ageing.

Clinical Endocrinology Nov;83 5 Download other formats More. Treatment of refractory depression with high-dose thyroxine. Subclinical hypothyroidism and incident depression in young and middle-age adults. View at: Google Scholar Y.

Subclinical hypothyroidism SCH is not associated with metabolic derangement, cognitive impairment, depression or poor quality of life QoL in elderly subjects. The inconsistency in the above findings can be accounted for by the variability in the degree of hypothyroidism and the differences in the etiology and duration of the disease in the various studied populations. Early studies noted a minor association between thyroid dysfunction and postnatal depression [ 82 ]. One mechanism explaining the increase in T4 seen in depression is the activation of hypothalamic TRH producing neurons and subsequent increase in thyroid function secondary to the rise in cortisol associated with depression [ 192433 ].

Low plasma thyroid indices of depressed patients are attenuated by antidepressant drugs and influence treatment outcome. Antidepressants inhibit the glucocorticoid stimulation of thyrotropin releasing hormone expression in cultured hypothalamic neurons. Preliminary evidence that a functional polymorphism in type 1 deiodinase is associated with enhanced potentiation of the antidepressant effect of sertraline by triiodothyronine. In patients treated with T4, psychological symptoms may persist even when they achieve a euthyroid state [ 16 ].

What Role Do Thyroid Levels Play in Mood Disorders?

Normalization of pretreatment thyroid function tests mainly T4 levels with remission of depression has been reported [ 7576 ]. A meta-analysis of these studies concluded impxct simultaneous initiation of T3 and SSRI is not significantly more likely to accelerate or enhance the clinical response in depressed patients compared to SSRI monotherapy. The authors conclusively found that there was no association between the presence of subclinical hypothyroidism and the development of depression during a mean follow-up of 2 years by the CES-D cutoff of 16 in this large cohort. Depression and other mood disorders are linked to several thyroid abnormalities. Thus, the HPT axis includes complex pathways and impairment in its components has been linked in some studies to behavioral changes as will be further pointed out.

What should you do if you are taking thyroid medication but still experiencing depressive symptoms? Center for Epidemiologic Studies—Depression. They play an important role in cell maturation, mitochondrial function and myelination. Garson et al. Psychol Aging. Try a cup of hot lemon water or golden milk instead. Related articles in Web of Science Google Scholar.

Early studies noted a minor association between thyroid dysfunction and postnatal depression [ 82 ]. De Volder, A. Masu, S. Hypothyroid patients and their physicians may be more aware of depressive symptoms and ascribe them to the thyroid disease when in fact it is a separate problem, as depression is extremely common in the general population.

SYSTEMATIC REVIEW article

Kuijpens, H. T3 socitey suggested to enhance neurotransmission in the central noradrenergic pathways [ 79 ] and deficiency in catecholamines has been raised as a possible mechanism in depression [ 80 ]. How thyroglobulin antibodies inform thyroid health—and which tests are most important. Gender differences in depression in representative national samples: Meta-analyses of diagnoses and symptoms. The combination of increased T4 yet normal T3 production supports the hypothesis of a reduced deiodination of T4 into T3 as seen in the euthyroid sick syndrome [ 37 ].

Int J Deperssion Psychiatry. FAQ: Hyperthyroidism overactive. Given that depression is known to be associated with changes in the hypothalamic-pituitary-thyroid HPT axis [ 4 ], studies have reported its positive correlation with overt hypothyroidism [ 5 ]. Products and services. For part III, either randomized controlled trials or case-control studies that evaluated the effect of levothyroxine therapy in individuals with SCH and coexistent depression were included.

Journal of affective disorders1 Just realize that this is not a complete list, but it can serve as a starting point for many of you. Coppen, P. Impaired psychological wellbeing in these subjects may be related to the occurrence of genetic polymorphisms in the D2 gene [ 17 ] as well as the OATPC1 encoding gene [ 18 ].

What Are the Symptoms of a Thyroid Disorder?

Research Symptoms Medication Takeaway Overview. Depression, anxiety, health-related quality of life, and disability in patients with ob and subclinical thyroid dysfunction. Department of Economic and Social Affairs, Population division. A direct effect of antidepressants on the TRH neuron has been demonstrated resulting in an inhibition of TRH secretion [ 34 ]. External link.

Six weeks ago I woke up tired and depressed, as I have so often in the last year. Association between subclinical hypothyroidism and depression: an updated systematic review and meta-analysis. Robbins J, Lakshmanan M. Future studies should focus on whether depression or other neuropsychological conditions could be improved by treating thyroid dysfunction and any potential mechanism.

  • In the central nervous system, alterations in hormones levels such as somatostatin and serotonin, can result in neuropsychiatric disturbances [ 42 ]. Six studies found a higher prevalence of depression among individuals with SCH compared with controls [ 71214192324 ], although only three studies achieved statistically significant difference [ 71430 ].

  • Bauer, T. Stula et al.

  • The secretion of thyroid hormones is regulated by pituitary thyrotropin TSH which itself is stimulated by hypothalamic thyrotropin-releasing hormone TRH and downregulated by serum thyroid hormones.

  • Constant, A.

  • Meta-analysis of observational studies in epidemiology—a proposal for reporting.

Tags: depression link research study. A blood test that measures thyroid function is necessary to confirm impcat diagnosis of hypothyroidism. Both depression and hypothyroidism are common, particularly in older women, and there is a reasonable prevalence of overlap of two conditions. I also happen to formulate the best supplements on the market well, at least in my opinion! Sack, B.

Eravci, and H. Hummer, and P. Schedule a Call. Furthermore, thyroid hormones are reported by many authors to be an effective adjunct treatment for depression. Mokrani, P.

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L-thyroxine augmentation of serotonergic antidepressants in female hypothyroidiem with refractory depression. It may be that there are a large number of women thyroid patients who remain depressed and anxious, despite taking thyroid medication, because they are not on the appropriate medication. In this study, 92, young to middle-aged adults without depression or known thyroid disease at baseline were examined at least twice in a 4-year time period.

  • Neuroimaging in Thyroid and Mood Disorders A few studies have been performed to assess the changes in cerebral perfusion and metabolism in patients with hypothyroidism particularly those with Hashimoto's thyroiditis or status post-thyroidectomy for thyroid carcinoma.

  • Oquendo, E.

  • Is subclinical thyroid dysfunction in the elderly associated with depression or cognitive dysfunction? Future studies should focus on whether depression or other neuropsychological conditions could be improved by treating thyroid dysfunction and any potential mechanism.

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  • Lithium, a popular treatment for bipolar depression, can trigger symptoms of hyperthyroidism. Mayo Clinic is a nonprofit organization and proceeds from Web advertising help support our mission.

  • Following are some of the criteria that should prompt consideration for thyroid hormone treatment:.

Home » Thyroid » Hypothyroidism and Depression Connection. The connection between depression and thyroid hormone is not well understood, but it seems that this connection is strong. Thyroid Disease and Oral Health Find tips for a healthier mouth in this article about thyroid disease and oral health. Receive exclusive offers and updates from Oxford Academic. It is well known and widely accepted that thyroid disease does indeed cause depression at least this is taught in medical school.

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Related articles. Saravanan, W. Trends in depression prevalence in the USA from to widening disparities in vulnerable groups. Whether you have a thyroid condition or not, most people need to regularly monitor their thyroid function when taking antidepressants. This medication contains pure T3, which is the strongest thyroid hormone. In patients treated with T4, psychological symptoms may persist even when they achieve a euthyroid state [ 16 ].

T3 hypothyrokdism of antidepressant treatment in T4-replaced thyroid patients. These symptoms include:. Download citation. However, the mechanisms underlying the interaction between thyroid function and depression remain to be further clarified. SCH, subclinical hypothyroidism; CI, confidence interval. Ayurvedic medicine can be used alongside standard treatments to help you manage your thyroid disorder. The literature quality evaluation was conducted by means of the Newcastle-Ottawa Quality Assessment Scale

What is hypothyroidism?

However, the limitation of aforementioned study was that the participants primarily were middle-aged and generally healthy men and hyoothyroidism from Korea, which may not be generalizable to other ethnic or age groups. Thyroid hormones and depression: the Health in Men study. Effects of subclinical hypothyroidism treatment on psychiatric symptoms, muscular complaints, and quality of life. However, these qualitative observations are limited by different sample sizes.

Wheatley D. A few studies have been performed to assess the changes in cerebral perfusion and metabolism in patients with hypothyroidism particularly those with Hashimoto's thyroiditis or status post-thyroidectomy for thyroid carcinoma. Regional brain metabolic changes in patients with major depression treated with either paroxetine or interpersonal therapy: preliminary findings. However, these qualitative observations are limited by different sample sizes. Medically reviewed by Carissa Stephens, R.

View at: Google Scholar E. Lo, T. The association between thyroid function and psychiatric disorders particularly mood disorders has long been recognized. Search ADS. Sometimes, the lack of understanding the causes of certain symptoms can impair the treatment and weaken psychological wellbeing of a patient.

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Advertising revenue supports our not-for-profit mission. The most widely replicated finding from these studies is hypoperfusion in anterior cortical structures [ 9394 ] that was reversible after psychotherapy and pharmacotherapy [ 95 — 97 ]. Res Synth Methods.

  • Association between subclinical hypothyroidism and depression: an updated systematic review and meta-analysis. J Nerv Ment Dis.

  • An acceleration of antidepressant effect by T3 has been initially shown more than 30 years ago in several reports [ 63 — 66 ]. Serum T4 levels in the upper range of normal or slightly higher have been reported in depressed patients as compared to healthy or psychiatric controls.

  • The inconsistency in the above findings can be accounted for by the variability in the degree of hypothyroidism and the differences in the etiology and duration of the disease in the various studied populations. Subclinical hypothyroidism, mood, and cognition in older adults: a review.

  • Many studies have been conducted on this subject, but they yielded different results.

  • Compr Physiol. XC and ZC: paper writing and review.

Women also experienced higher rates of anxiety, but they had a lower alcohol use than male counterparts [iii]. Depression has been linked to various endogenous circadian rhythms abnormalities depressiob as diurnal mood variation, abnormalities in core body temperature, cortisol secretion, and sleep-wake cycle [ 47 ]. Salvati, T. View at: Google Scholar L. Saravanan, W. Overview of Thyroid Hormone Metabolism in the Brain The hypothalamic-pituitary-thyroid axis HPT is a complex interplay between several factors: thyroid hormones, deiodinase enzymes, transporter proteins, and receptors. Neuropsychological function and symptoms in subjects with subclinical hypothyroidism and the effect of thyroxine treatment.

Clinical review: A review of the clinical consequences of variation in thyroid function within the reference range. All data analyses were performed with Revman 5. We also reviewed references of the original article, reviews and clinical guidelines to identify additional eligible trials. Download PDF.

Depression and feelings of general achiness and exhaustion are common with hypotuyroidism condition. Gender differences in major depressive disorder: results from the Netherlands study of depression and anxiety. In a study comparing cerebral blood flow in hypothyroidism and major depression, hypothyroid patients exhibited hypoperfusion in posterior aspects of the brain in contrast to an anterior cerebral hypoperfusion in depressed patients.

  • Second, our findings strongly support the routine examination of thyroid function in participants with depression in the clinic.

  • Another explanation for this connection is that there may be a large group or subset of patients walking around with the label of depression when in reality they might actually have sub-clinical hypothyroidism or hypothyroidism.

  • An absent TSH nocturnal surge [ 48 ] has been noted in depression and a lower basal TSH has been reported in major depression as opposed to nonmajor depression [ 49 ].

  • Current Psychiatry5 11 Whybrow and A.

It produces hormones that regulate your body's energy use, along with many other vital functions. Gender differences in symptoms of hypothyroidism: a population-based DanThyr study. Bailey et al. Oretti, J. View at: Google Scholar C.

About this article. These are…. Brain blood flow changes in depressed patients treated with interpersonal psychotherapy or venlafaxine hydrochloride: preliminary findings. If you have symptoms of, or a history with thyroid disorders, it may make sense for you to check your TSH levels with an at-home TSH test. European Journal of Endocrinology. J Neuroendocrinol.

Dysphoria, anxiety, irritability, emotional lability, and impairment in concentration constitute the classical neuropsychiatric symptoms occurring in hyperthyroidism or thyrotoxicosis. The impavt research in the biochemical, genetic, and neuroimaging fields seems most promising in providing a deeper understanding of the thyroid-depression interactions. Souetre, E. Association of Depression with Postpartum Thyroid Disease The association of postpartum depression with postpartum thyroiditis or with positive thyroid antibodies is still not well defined.

Endocrinol Metab Clin North Am. In addition, TRH has been postulated in early studies to have an antidepressant effect. Randomised trial of thyroxine to prevent postnatal depression in thyroid-antibody-positive women. Medically reviewed by Maria Prelipcean, M. In addition, SCH may result from antithyroid treatment in patients with Graves' disease. Meta-analysis flow chart. If you fluctuate between the two, you will have symptoms similar to those of bipolar disorder.

Patients with thyroid disorders are more prone to develop depressive symptoms and conversely depression may be accompanied by various subtle thyroid abnormalities. Bahls and G. Google Scholar. Cooper-Kazaz, W.

One of the easiest ways to hylothyroidism this problem is to bypass the peripheral thyroid conversion step by adding T3 therapy to your existing dose of T4 medication. Willner, Biological Psychiatryvol. De Jong, E. Offman, R. More recently, studies assessing the newer and more tolerable antidepressant agents, the selective serotonin reuptake inhibitors SSRIs in combination with T3 have yielded confounding results.

View at: Google Scholar E. If you don't have thyroid disease but you do suffer from depression, then it may be time to look into alternative depression medication such as Cytomel or Liothyronine. Dayan, J. Because depression and hypothyroidism share many similarities, misdiagnosis can be common. One is from damage to the thyroid gland and hypothyroidism and the second is from the antibodies themselves.

  • Fourteen studies were excluded in our final meta-analysis because they utilized mean depressive scores or other methodologies to present their results in the final publication, making it impossible to meta-analyze these data.

  • European Thyroid Journal. The first step is to closely evaluate your thyroid lab tests to determine if they are indeed actually normal.

  • Although some studies reported that L-T4 treatment has the benefit of improving depressive symptoms, the pathophysiological role of thyroid hormones in depression remains unclear 37 —

  • Silverman, F.

  • XC and ZC: paper writing and review.

  • Scientists found that healthy women were significantly more likely than normal men to report symptoms of hypothyroidism [v]. However, if you have a thyroid condition, you will need to pay extra care to manage your thyroid.

In this paper, we will present an overview of thyroid hormone metabolism in the brain, reexamine hypothyroidism different observations and clinical studies assessing the relationship between thyroid and depression, and shed light on the advances in neuroimaging approaches in this field. In addition, all participants were not limited by age group, geographical region, or race. Mutations in MCT8 have also been recognized to cause isolated brain hypothyroidism by blocking T3 transport into neurons [ 831 ]. Psychiatry Research. A forest plot was used to present the pooled OR value, and heterogeneity was evaluated using the I 2 statistic. Among

Transient post-partum thyroid dysfunction and postnatal depression. Acta Psychiatr Scand. The quality of the literature for the analyzed studies was evaluated using the Newcastle-Ottawa Quality Assessment Scale. Whether this is related to clinical recovery or merely a result of a direct effect of antidepressants remains to be determined.

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