THE THYROID AXIS FUNCTION IN ACUTE PSYCHOTIC EPISODE

Transcription

1 LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY Vesta Steiblienė THE THYROID AXIS FUNCTION IN ACUTE PSYCHOTIC EPISODE Doctoral Dissertation Biomedical Sciences, Medicine (06B) Kaunas, 2012

2 Dissertation was prepared at the Institute of Behavioral Medicine, Lithuanian University of Health Sciences, Medical Academy, during Scientific Supervisor Dr. Habil. Robertas Bunevičius (Lithuanian University of Health Sciences, Medical Academy, Biomedical Sciences, Medicine 06B)

3 CONTENT CONTENT... 3 INTRODUCTION REVIEW OF LITERATURE Acute psychosis in schizophrenia and other psychiatric disorders Thyroid axis hormones and the brain Thyroid axis hormones secretion and metabolism Tissue markers of thyroid hormone actions Thyroid hormones transport to the brain Thyroid hormone receptors and homeostasis in the brain Genetic determination of the thyroid function Thyroid axis function and psychiatric disorders Hypothyroidism and psychiatric disorders Unrecognized severe hypothyroidism manifested as an acute psychotic episode Myxedema Madness : everyday clinical practice Thyroid axis function during acute psychotic episode Thyroid axis function and schizophrenia Effect of Antipsychotic Medication on Thyroid Axis Hormones Thyroid axis hormones in treatment of mental disorders MATERIAL AND METHODS Ethics Study population A clinical trial (Study III) A cross-sectional study (Study I) A prospective study (Study II) Methods Psychiatric evaluations Endocrine measurements Statistical analysis RESULTS Thyroid axis function in psychotic patients during hospital admission (Study I) Thyroid axis hormone concentrations in acute psychotic patients comparing to blood donor controls Prevalence of hyperthyroxinemia in acute psychotic patients during hospital admission comparing to blood donor controls... 55

4 Thyroid axis hormone concentrations in psychotic patients upon hospital admission: effects of prior psychiatric medication use The Factor Structure of the Brief Psychiatric Rating Scale (BPRS) in acute psychotic patients An association between thyroid axis hormone concentrations and severity of psychiatric symptoms in acute psychotic patients during hospital admission Thyroid axis function during in-patient treatment of acute psychotic episode (StudyII) Thyroid axis hormone concentrations before and after acute psychotic episode treatment with antipsychotics Associations between changes in thyroid axis hormone concentrations and changes in severity of psychotic symptoms Factors predicting changes in thyroid axis hormone concentrations and changes in psychiatric symptoms during acute psychotic episode treatment The direction and magnitude of thyroid axis hormone concentrations changes during acute psychotic episode treatment with antipsychotics Sex hormone binding globulin (SHBG) concentrations during in-patient treatment of acute psychotic episode (Study II) Sex hormone binding globulin concentrations before and after acute psychotic episode treatment with antipsychotics The direction and magnitude of thyroid axis hormone concentrations changes during acute psychotic episode treatment with antipsychotics Associations between changes in sex hormone binding globuline concentrations and changes in severity of psychotic symptoms before and after acute psychotic episode treatment with antipsychotics The effects of adjuvant treatment with L triiodthyronine (T3) on acute schizophrenia treatment with risperidone (Study III) The efficacy of adjuvant treatment with T3 on acute schizophrenia treatment with risperidone The safety of RIS+T3 combinations during acute schizophrenia treatment The effect of RIS+T3 combination on thyroid axis function during acute schizophrenia treatment DISCUSSION... 89

5 4.1. Thyroid axis function in acute psychotic patients during hospital admission Stabilization of thyroid axis hormone concentrations and changes in SHBG concentrations during acute psychotic episode treatment with antipsychotics The accelaration and enhancement effects of adjuvant treatment with L triiodthyronine (T3) on acute schizophrenia treatment with atypical antipsychotic risperidone CONCLUSIONS SCIENTIFIC SIGNIFICANCE OF THE STUDY ACKNOWLEDGEMENTS REFERENCES PUBLICATIONS ON THE DISSERTATION THEME ANNEXES

6 LIST OF ABBREVIATIONS AITD Autoimmune thyroid disease AHDS Allan-Herndon-Dudley syndrome BP Blood presure BPRS Brief Psychiatric Rating Scale Beta, β Standardised regression coefficient CGI-I Clinical Global Impression, Improvement scale CGI-S Clinical Global Impression, Severity of illness scale CNS Central nervous system CIDI Composite International Diagnostic Interview CSF Cerebrospinal fluid D1 Type- I deiodinase D2 Type- II deiodinase D3 Type- III deiodinase DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision ECT Electroconvulsive therapy FT3 Free triiodothyronine FT4 Free thyroxine GABA δ - aminobutyric acid HPT axis Hypothalamic-pituitary-thyroid axis HNF4A Hepatocyte nuclear factor 4 alpha IQR Interquartile range MCT 8 Monocarboxylate trasporter-8 MCT 10 Monocarboxylate trasporter-10 MINI Plus Mini International Neuropsychiatric Interview Version MRI magnetic resonance imaging MRS Magnetic resonance spectroscopy OATP1c1 Organic anion transporter protein 1c1 p/o Per os PLB Placebo Pro Prolactin rt3 Reverse T3 RIS Risperidone SCID Structured Clinical Interview for DSM-IV SD Standard deviation SHBG Sex hormone binding globulin SPSS Statistical Package for the Social Sciences

7 SSRI Selective serotonin reuptake inhibitor TPOAb thyroid peroxidase antibody TRH Thyrotropin-releasing hormone TSH Thyroid-stimulating hormone T3 Triiodothyronine T4 Thyroxine TRs T3 receptors TAAR Trace-amine-associated receptor T1AM 3-iodothyronamine SNPs Single nucleotide polymorphisms

8 INTRODUCTION Acute psychosis such as schizophrenia and other schizophrenia spectrum disorders have a life time prevalence up-to 2 3 % in general population [245], evoke strong consequences on social functioning and quality of life of the patient and are associated with a huge economical burden for the society [155]. An improved understanding of the etiology and pathophysiology of schizophrenia and other psychosis gave the opportunity to develop prevention strategies and treatments based on this enhanced knowledge. In view of the heterogeneity of risk factors, the potential contribution of pharmacogenomics and other biological markers to optimizing individual treatment and outcome in the future are evaluated. In this context potential psychopatho-logical treatment targets are discussed [239]. Dysfunction of the thyroid gland, either hyper-function or hypo-function, is frequently associated with mental disorders, including psychoses that sometimes resemble schizophrenia [38]. An increased prevalence of thyroid function abnormalities has been reported in families of patients with schizophrenia [65], suggesting possible genetic linkage between the endocrine and mental disorders. Nevertheless, most schizophrenic patients are euthyroid with normal basal concentration of thyroid stimulating hormone (TSH) and normal TSH response to thyrotropin-releasing hormone (TRH) challenge [23, 182]. The fluctuations in the levels of thyroid hormones at various times during human development and throughout life can impact on psychiatric disease manifestation and response to treatment (Santos, 2011). It is well known that illness, certainly including mental illness, may affect the thyroid axis, and this affect is often noted when acute psychotic patients are admitted to the hospital. Several studies have reported elevated serum concentrations of thyroxine (T4), but not of triiododthyronine (T3), in acute psychiatric disorders, an abnormality that usually resolves during recovery and is called transient hyperthyroxinemia [24, 198]. However, data on the prevalence of hyperthyroxinemia in acute psychotic patients are scanty and need further evaluations. Moreover, factors predicting hyperthyroxinemia needs to be studied. Tissue responses to changes in thyroid hormone concentrations may be better indicators of the significance of thyroid axis activity than thyroid hormone concentrations themselves. Response of the anterior pituitary gland, evident by changes in TSH concentrations, is a sensitive marker of thyroid dysfunction. Another sensitive tissue marker of thyroid activity is 8

9 liver production of sex hormone binding globulin (SHBG) [186]. However, there are no data pertaining to serum SHBG concentrations in patients with acute psychoses. Introduction of second-generation, atypical antipsychotic drugs brought new options; however, their efficacy advantage was not so high as expected [135]. A better understanding of the mechanisms related to the efficacy and side effects of antipsychotic drugs may open new venues preventing side effects and advancing treatment of acute psychosis. Some studies reported that treatment with atypical antipsychotic quetiapine may decrease thyroid hormone concentrations [114, 119]. One study reported decrease in SHBG concentrations after treatment with the atypical antipsychotic olanzapine [29]. The behavioral disturbances, physical and psychological signs and symptoms of hypothyroidism usually respond to adequate replacement treatment with thyroid hormones [258]. The majority of patients subjectively prefer combined treatment with T4 and T3 [36, 71]. Several trials have confirmed the clinical value of thyroid hormones in the treatment of depression [4, 9, 12, 56] and improvement of psychological wellbeing [206]. Despite the fact that the majority of schizophrenic patients are euthyroid, thyroid hormones have been tried as a treatment of schizophrenia as well as depression. In contrast to evidence for the adjunctive use of T3 in the treatment of depression [4, 9, 12], only a few studies have addressed the adjunctive use of T3 in the neuroleptic treatment of schizophrenia. In chronic schizophrenic patients one study found that T3 did not enhance the effects of phenothiazines [264]. However, in acute schizophrenic patients T3 decisively enhanced the antipsychotic effects of chlorpromazine [172]. There are no studies of T3 effects on schizophrenia treatment with second-generation antipsychotic drugs. This provided the rationale to evaluate the effects of T3 on the antipsychotic actions of atypical antipsychotics in acute schizophrenia treatment. 9

10 AIM AND OBJECTIVES The aim of the study was to evaluate thyroid axis function in acute psychotic patients. The objectives of the study: 1. To evaluate thyroid axis hormone concentrations in acute psychotic patients compared to blood donor controls, to severity of psychosis, and to prior use of psychiatric medication. 2. To evaluate changes in thyroid axis hormone concentrations during antipsychotic treatment of acute psychotic episode in relation to baseline hormone concentrations and to clinical characteristics of psychotic episode. 3. To evaluate changes in sex hormone binding globuline concentrations during antipsychotic treatment of acute psychotic episode in relation to baseline hormone concentrations and to clinical characteristics of psychotic episode. 4. To evaluate efficacy and safety of adjuvant treatment with L- triiodthyronine (T3) on acute schizophrenia treatment with risperidone. Scientific novelty of the study The findings of this study generated in naturalistic setting, but with careful attention to background of thyroid illness and to prior drug use supported the finding of earlier investigators about the case prevalence of euthyroid hyperthyroxinemia in acute psychotic patients, furthermore, it also revealed novel findings about higher psychotic male patients SHBG concentrations; and a possible interaction between euthyroid hyperthyroxinemia and SHBG secretion in the liver. The findings of this study for the first time presented that the acute psychotic patients treatment with antipsychotics results in stabilization of thyroid hormone concentrations; suppressing high concentrations and enhancing low concentrations. For the first time the study evaluated the effect of treatment with different antipsychotics on sex hormone binding globulin 10

11 (SHBG) concentrations and revealed that the treatment led to endocrine abnormalities such as decrease in SHBG concentrations, especially when women were treated with typical antipsychotic haloperidol. Results of our study for the first time demonstrated the efficacy and safety of adjuvant treatment with triiodthyronine (T3) on acute schizophrenia treatment with atypical antipsychotic risperidone in randomized, double blind, parallel group, placebo controlled trial design. Finally, our study presented a better understanding of interactions related to thyroid axis function and pathophysiology of severe metal disorders, such as acute psychotic episode, acute schizophrenia and other schizophrenia spectrum psychosis. 11

12 1. REVIEW OF LITERATURE 1.1. Acute psychosis in schizophrenia and other psychiatric disorders Acute psychosis is defined as mental disorder with grossly impaired reality testing. Psychotic patients incorrectly evaluate the accuracy of their perceptions and thoughts and make incorrect inferences about external reality, even in face of contrary evidence. During acute psychosis severe impairment of social and personal functioning is characterized by social withdrawal and inability to perform the usual household and occupational roles [202]. Psychosis (or psychotic episode) is not exclusive to schizophrenia and occurs in various diagnostic categories of psychotic disorder [67, 82, 176]. In schizophrenia, schizoaffective, schizophreniform, brief psychotic, delusional disorders and psychotic disorders related to general medical conditions psychotic symptoms could include delusions, any prominent hallucinations, disorganized speech, and disorganized or catatonic behavior. These disorders are conventionally characterized by having psychotic symptoms as the defining feature. In clinical picture of bipolar disorder and major depressive disorder psychotic symptoms also could present. The criteria used in DSM-IV-TR to distinguish between these different categories of psychotic disorder are based on duration, dysfunction, bizarreness of delusions, and presence of other medical condition, depression or mania [10]. Acute schizophrenia consists of various degrees of psychosis, characterized by the sudden onset of personality disorganization. Positive symptoms include delusions, which may be bizarre in nature; hallucinations, especially auditory; disorganized speech; inappropriate affect; and disorganized behavior. Negative symptoms include flat affect, lack of volition, alogia, and anhedonia. Episodes appear suddenly in persons whose previous behavior has been relatively normal and are usually of short duration. Recurrent episodes are common, and in some instances a more chronic type of the disorder may develop [10, 105]. About 1% of the population is affected by schizophrenia [158], which associated with progressing personality deficits and frequently life-long course, is a mental illness that evokes strong consequences on social functioning and quality of life of the patient and appeares among the world's top ten leading causes of disease-related disability [150, 159] and is linked to a huge economical burden for the society [139, 155]. According to the State Mental Health Centre for the last 6 years of data (Table 1.1.1), every year in Lithuania about 800 people are experiencing a first lifetime acute psychotic episode and a half of which is diagnosed with acute schizophrenia. The incidence of schizophrenia spectrum disorders dur- 12

13 ing this period did not show great changes and in 2011 we counted 24.5 new cases of schizophrenia spectrum disorders per year/ inhabitants. A total number of patients with schizophrenia spectrum disorders in Lithuania during the last 6 years is increasing gradually over patients and we counted prevalence (morbidity) of schizophrenia spectrum disorders in 2011 as 745.1/ inhabitants. Figure shows the changes in the incidence and the morbidity of patients with schizophrenia spectrum disorders during years period. per inhabitants The morbidity The incidence Figure The incidence and the morbidity of patients with schizophrenia spectrum disorders during (per inhabitants) Despite an increasing use of second-generation antipsychotic drugs, the effectiveness of schizophrenia spectrum disorders treatment is not sufficient and the patients are experiencing psychosis relapse; dynamics of the last 6 year in Lithuania shows only a slight decline in rate of hospital treatment. In patients were hospitalised for the acute psychotic episode treatment, in which 5037 were hospitalised for the treatment of acute schizophrenia. Overall hospital days were spent for the acute schizophrenia spectrum psychotic episodes treatment in Calculating the price of hospital treatment for the acute psychotic episodes of schizophrenia spectrum disorders in Lithuania, as 1 hospital day mean cost as 100 litas, the costs of hospital care during 1 year period go over 43 mln. litas. 13

14 First lifetime diagnosis of acute psychotic episode, n* Of which: First lifetime diagnosis of acute schizophrenia, n* The incidence of schizophrenia spectrum disorders (new cases per year/ inhabitants) Diagnosis of schizophrenia spectrum disorders, n* Of which: Number of patients with schizophrenia diagnosis* The morbidity of schizophrenia spectrum disorders, n (per inhabitants) Hospitalization for the acute psychotic episode treatment, n** Of which: Hospitalization for the acute schizophrenia treatment, n** Hospital days for the acute psychotic episodes treatment** Disability due to schizophrenia, n Of which: For the first time disability due to schizophrenia, n *Data from outpatient health care centers in Lithuania; ** Data from the psychiatric hospitals in Lithuania; n, number of patients Table Dinamic of schizophrenia spectrum disorders in Lithuania between 2006 and 2011

15 Despite the high costs of schizophrenia and schizophrenia spectrum psychotic episodes treatment, the treatment effectiveness remains questionable, because every second patient with schizophrenia diagnosis have disturbances in social and work functioning, and level of disability. In patients had disability due to schizophrenia and among them 200 had for the first time disability due to schizophrenia. There are different primary psychotic episodes in DSM-IV-TR clasification. A Brief psychotic disorder is defined by DSM-IV-TR as a psychotic episode that involves the sudden onset of psychiatric symptoms which lasts 1 day or more, but less than 1 month. The first psychotic episode patients, even with schizophrenia symptoms, have diagnosis of brief psychotic disorder or schizophreniform disorder. Schizophreniform disorder is similar to schizophrenia, except that it symptoms last at least 1 month but less than 6 month. In contrast for the patient to meet the diagnostic criteria for schizophrenia, the symptoms must have been present for at least 6 month. The schizoaffective disorder has features of both schizophrenia and affective disorders. During bipolar disorder, severe with psychotic features or major depressive disorder, severe with psychotic features psychotic symptomsdelusions or hallucinations are mood-congruent or mood-incongruent [10]. Acute psychosis such as schizophrenia and catch-all diagnostic categories of psychotic disorders revealed a life time rate of 2 3% of population [245]. There is not a full consensus how to classify various psychosis spectrum disorders into etiological and pathophysiological based categories [46, 59]. Most diagnostic categories of psychotic disorders may have common underlying etiology, overlap in genetic liability and pathophysiological mechanisms among themselves [42, 157, 245]. Epidemiological and molecular genetic studies support the hypothesis that acute psychotic episode a clinical phenotype with multifactorial etiologies [43, 238]. Data from family, twin and adoption studies show strong evidence supporting genetic causation in schizophrenia [118, 151], but phenotypic discordance for schizophrenia in monozygotic twins clearly indicates involvement of environmental factors as key determinants in the disease development [90]. Genes interacting with environmental factors may predetermine vulnerability of psychosis [162, 245, 247]. It remains clear that environmental factors both add to and interacts with genetic factors to produce the psychotic disorders [165, 213, 234, 243]. Psychotic disorders are typically complex illnesses that involve both genetic and environmental aetiological components [242]. Aethiology involves the hypothesis of dopaminergic, serotonergic, glutamatergic and GABAergic systems dysfunctions, neurodevelopmental imbalance in excitatory/inhibitory neural systems leading to impaired neural plasticity, as well as pathophysiological processes such as in- 15

16 flammation and oxidative stress [44, 86, 112, 115, 137, 211]. In acute psychotic episode some endocrine changes are described [237] and changes in thyroid axis function in schizophrenia patients were found [220, 266]. It is known that thyroid hormones are not only essential for normal development of the central nervous system, but also regulate the expression of many neurotransmitters, their synthesizing enzymes and receptors. Functional and positional candidate genes include brain thyroid hormone receptors and deiodinases, which synthesize triiodothyronine, involved in their inactivation, so thyroid hormones could serve as bridges between genes and environment in schizophrenia [167]. An improved understanding of the etiology and pathophysiology of schizophrenia gave the opportunity to develop prevention strategies and treatments based on this enhanced knowledge. In this context potential psychopathological treatment targets are discussed. In view of the heterogenity of risk factors, the potential contribution of pharmacogenomics and other biological markers to optimizing individual treatment and outcome in the future are evaluated [239]. Schizophrenia and other psychoses are linked to unique etiological and pathophysiological processes that may yield unique treatment targets. Innovative approaches are needed to elucidate the biological substrates of these entities because such clarity is vital for replicable research. Identifying the critical gaps in the knowledge, and unmet needs in our approaches to care, and outline steps that can move the field forward [160]. Clinical experience as well as controlled treatment trials suggests that acute psychosis across many diagnostic categories including schizophrenia, bipolar disorder, psychotic depression, functional and organic psychoses show a similar pharmacological treatment response [45, 46]. Although the introduction of second-generation antipsychotics for schizophrenia over the past two decades brought new options for the treatment of acute psychosis and generated considerable optimism about possibilities for recovery, their treatment until now remains unsatisfactory [5, 88]. There is a need for truly innovative treatments and strategies that can make significant advantages for persons with schizophrenia and related psychotic disorders [57, 135] Thyroid axis hormones and the brain Thyroid hormones are essential for the growth and differentiation of several organs, including the development of the brain [27, 269]. A variety of factors influences the effects of thyroid hormones in the brain: availability of iodine; thyroid diseases and dysfunction; genetic variations that affect 16

17 thyroid axis-related proteins, such as deiodinases, thyroid hormone transporters and receptors; and timing of events. Interaction of these factors contributes to the development of the brain as well as to presentation of psychiatric symptoms and disorders in mature brain. Clinical and subclinical thyroid dysfunction, thyroid autoimmunity as well as individual genetic variations and mutations of thyroid axis-related proteins may contribute not only to presentation of psychiatric symptoms and disorders, but also to response to psychiatric treatments. A better understanding of genomic and nongenomic mechanism related to thyroid hormone metabolism in the brain opens new venues for finding new markers, new targets, and new agents for the treatment of mental disorders [39] Thyroid axis hormones secretion and metabolism Secretion of thyroid hormones is regulated by the pituitary thyroidstimulating hormone (TSH), which is stimulated by hypothalamic thyrotropin-releasing hormone (TRH) and suppressed by negative feedback from serum thyroid hormones. In serum more than 99% of thyroid hormones are bound to specific proteins, but only free hormones are active. The thyroid gland secretes several hormones, including thyroxine (T4), triiodothyronine (T3) and metabolically inactive reverse T3 (rt3) [38]. The main secretion of the thyroid gland is T4.The thyroid gland is the only source of this hormone. Synthesis of T4 also requires the active uptake of dietary iodine by the gland. Triiodothyronine (T3) is the most biologically active thyroid hormone, but no more than 20% of this hormone is secreted by the thyroid gland.t3 is produced in other tissues by removal of iodine from the T4 molecule by enzyms, called deiodinases [28], which exist in several forms and are located in cells. Type I deiodinase (D1) is located primarily in the liver and kidney and is responsible for producing as much as 80% of circulating T3. Type II deiodinase (D2) is located primary in brain glial cells, including astrocytes, and in muscles and mainly accounts for T3 tissue concentrations. Deiodinases type I and II are differentially regulated in order to protect the brain from T3 excess or deficiency. In accordance, during hypothyroidism, type I deiodinase is downregulated while type II is upregulated; the opposite occurs in hyperthyroid conditions. Therefore, the activity of deiodinases is a key step to regulate the availability of active T3. Inactivation of thyroid hormone is mainly carried out by the action of type III deiodinase (D3) [131], which converts T4 to inactive rt3, and also degrades T3. In brain D3 is located in neurons [39]. 17

18 The major cause of disturbed thyroid hormone secretion is autoimmune thyroid disease (AITD), when auto-antibodies against the normal elements of the thyroid axis are produced. Results of biopsy as well as autopsy show that up to 40% of women have AITD [255]. There are two major forms of AITD: Graves disease, a common cause of hyperthyroidism; and autoimmune thyroiditis, a common cause of hypothyroidism [174]. Other major causes of hyperthyroidism are toxic nodular goiters and adenomas; other major causes of hypothyroidism are treatments of thyroid disorders (radiation, thyroidectomy), thyroid dysgensesis and iodine deficiency. In overt hyperthyroidism thyroid hormone secretion is increased and thyroidstimulating hormone secretion is suppressed. In overt hypothyroidism thyroid hormone secretion is decreased and thyroid-stimulating hormone secretion is augmented. In subclinical thyroid dysfunction only thyroidstimulating hormone secretion, but not thyroid hormone secretion is altered [39] Tissue markers of thyroid hormone actions Thyroid hormones affect almost all peripheral target tissues: T3 and T4 act on pituitary gland as central target organ. In addition, they affect the peripheral target tissues, like muscle, the heart and the liver. Tissue responses to changes in thyroid hormone concentrations may be better indicators of the significance of thyroid axis activity than thyroid hormone concentrations themselves. The circulating hormone levels, as measured in patients, do not always reflect the clinical effects at the target tissues. Response of the anterior pituitary gland, evident by changes in TSH concentrations, is a sensitive marker of thyroid dysfunction. Another sensitive tissue marker of thyroid activity is liver production of sex hormone binding globulin (SHBG) [186]. SHBG is a glycoprotein. Reference range for serum concentrations of SHBG is different for men and women. SHBG binds sex hormones, mainly estradiol and testosterone, regulating their free concentrations. The hepatic synthesis of SHBG is stimulated by thyroid hormones. Latest studies supposed that SHBG is regulated by nuclear receptor hepatocyte nuclear factor-4alfa (HNF-4a) in response to changes in the metabolic state of the liver; and T3 and T4 increased SHBG production indirectly by increasing HNF-4A gene expression [212]. SHBG- as the test of tissue response has diagnostic values for detecting even mild thyroid hormones changes and showing the biological effect of thyroid hormones at the tissue level. Plasma SHBG measurements can be used clinically to assess liver sensitivity to thyroid hormones [207]. There 18

19 are applications for the tissue markers in the borderline conditions, such as subclinical hypothyroidism and subclinical hyperthyroidism before and after some treatment with different medications. Tissue marker is indispensable tool for the clinical research reflecting the cellular action on thyroid hormones and providing informations about the metabolic status of thyroid dysfunction in humans. So thyroid function tests have achieved the highest level of perfection for diagnosis of thyroid dysfunction, as they have been obtained at the molecular and metabolic levels [230]. The measure of SHBG concentration has diagnostic values for detecting even mild thyroid hormones changes and showing the biological effect of thyroid hormones at the tissue level [36, 207]. Even borderline elevations of thyroid hormones can show marked effects on the organs, producing severe clinical pictures [232] Thyroid hormones transport to the brain The genomic actions of T3 are mediated by nuclear T3 receptors (TRs) [268]. Because the active sites of the deiodinases and the TRs are located intracellularly, thyroid hormones metabolism and action require transport of the hormone from extracellular compartments (e.g. the bloodstream) across the plasma membrane. Until recently, it was assumed that cellular entry by free thyroid hormones was mediated via passive diffusion because of their lipophilic nature. Now it is recognized that thyroid hormones enter target cells mainly through transporters [1, 104, 108, 268]. Several thyroid hormones transporter families have been identified, however, only monocarboxylate trasporter 8 (MCT8), monocarboxylate trasporter-10 (MCT10) and organic anion transporter protein 1c1 (OATP1c1) have been shown to be specific thyroid hormones transporters [250]. To enter the brain thyroid hormones must cross the blood brain barrier or the choroid-plexus-cerebrospinal fluid (CSF) barrier. OATP1c1 is distributed widely in the human brain and specifically transport T4 across the blood brain barrier [79, 108, 250]. MCT10 demonstrated a substantial uptake of T3 and T4 by cells [78]. MCT8 may transport T3 as well as T4 [78]. In brain T4 enters astrocytes, where it is converted to T3 by local D2. T3 is generated in the astrocytes as well as T3 from the general circulation is transported into neurons via MCT8, where after completion of its action, it is degraded by D3 [235, 262]. The special attention has been paid to transporter MCT8. It has been recognized, that mutations in MCT8 affect T3 transport into the neuron causing isolated brain hypothyroidism with elevated serum T3 concentrations [235, 262]. Clinical features of MCT8 mutations include severe mental retardation, axial hypotonia, absence of speech, and 19

20 resemblance to patients with Allan-Herndon-Dudley syndrome (AHDS) [80, 81, 170]. Sijens et al used brain MRI in two children with MCT8 mutation [219]. MCT8 gene mutation resulted in deviant myelinization and in general atrophy of the brain. Different mutations in the MTC8 transporter led to different expression of dysmyelinization and magnetic resonance spectroscopy (MRS) showed the different changes in brain metabolism. In fact, MCT8 mutations were found in all families with AHDS, providing a molecular basis for this syndrome [250] and also importance of transporter MCT8 function in normal brain development Thyroid hormone receptors and homeostasis in the brain The T3 moves into the cell nucleus, where it binds nuclear thyroid hormone receptors (TRs). TRs are the members of the steroid/thyroid family. TRs have two isoforms: thyroid hormone receptor alpha and thyroid hormone receptor-beta. Most thyroid-hormone-mediated actions are controlled by transcriptional regulation [19, 269]. T3 interacts with TRs that function as ligand-activated transcription factors. Two genes encode TRs, THR-alfa and THR-beta, and for each there are splicing variants with distinct developmental and tissue distribution patterns. Within the nucleus, TRs recognize hormone response elements in target genes. The metabolism of thyroid hormones is linked through their main mechanism of action at the transcription level [174]. In the mature brain thyroid hormones regulate expression of several genes that may affect mood and cognition, including genes for neurotrophins, such as nerve growth factor and brain derived neurotrophic factor. By genomic and possibly non-genomic mechanisms T3 interacts with several important neurotransmitters such as serotonin and norepinephrine, which are crucial for mood regulation, and with acetylcholine, which is essential for cognition [136]. Regulation of thyroid hormone homeostasis in specific regions of the brain is achieved by temporal and spatial regulation of the deiodinase system. Expression of D3 in early gestation suppresses thyroid hormone activity in fetal tissues maintaining proliferation and inhibiting differentiation. Later, expression of D2 activity initiates tissue differentiation. Deiodinase activity is different in specific regions of the brain. It also maintains brain thyroid hormone homeostasis in hyperthyroidism by increasing expression of D3 and suppressing expression of D2, and in hypothyroidism by increasing expression of D2 [262]. 20

21 Genetic determination of the thyroid function Circulating thyroid axis hormone concentrations in euthyroid individuals have much greater inter-individual than intra-individual variation, in which genetic variations play a major role. Although the population reference ranges for these parameters are wide, each individual appears to have their own set point within this. The levels of TSH only fluctuate within a very narrow range in response to changing free T4 [11]. This has significant implications given that small changes in thyroid function, even within the population reference range, have been shown to have clinically detectable effects on phenotypes as varied as cholesterol, mood [206] and longevity [95].Therefore at what point an individual started within the range is very important when one is trying to determine if an alteration in thyroid function has resulted in a clinical problem. Findings from twin studies show that each person has a genetically determined FT4 TSH set point [100]. For TSH set point approximately 65%, but perhaps less for FT4 and FT3 (both around 40 50%). These findings suggest that individual thyroid function set points are mainly genetically derived, however,the genes responsible have until recently not been known [168]. It is clear that a significant proportion of TSH, FT4 and FT3 variation is genetically derived. Polymorphisms within three genes have been shown to be associated with thyroid function in healthy subjects at genome-wide levels of significance: phosphodiesterase 8B (PDE8B), iodothyronine deiodinase 1 (DIO1) and F-actin-capping protein subunit beta (CAPZB). A polymorphism in the TSH receptor gene (TSHR) has been shown to have associations with thyroid function in multiple studies in different populations [168]. Whilst only a few genes have been found to influence thyroid function, it has become clear that genes involved in thyroid hormone action can have clinically detectable effects with no effect on circulating thyroid hormone concentrations. There are many elements which can affect the final binding of T3 to the TR in the cell nucleus, and therefore circulating (measureable) concentrations of thyroid hormones may be a poor reflection of individual tissue levels. This may be particularly pertinent in tissues such as the brain in which there are mechanisms in place to protect the local tissue from swings in circulating levels [168]. One of the best examples of this principle is the association between the DIO2 SNP rs and psychological wellbeing in subjects on thyroxine. 21

22 It was found an association between rs and psychological well being [169]. Genetic variation in deiodinase enzymes and thyrotropin receptors causes alteration in the balance of circulating thyroid hormones and their tissue concentrations affecting thyroid hormone-related endpoints [175] including physiological consequences Thyroid axis function and psychiatric disorders Hypothyroidism and psychiatric disorders Hypothyroidism is the most common clinical condition caused by the inadequate production of thyroid hormone or inadequate action of thyroid hormone in target tissues [8]. Hypothyroidism affects from 0.5% to 18% of population and incidence rate varies 10-fold in women than in men; it is more common in elderly. [72, 128, 196]. It is most often caused by some disorder of the thyroid gland that leads to a decrease in thyroidal production and secretion of thyroxyne (T4) and triiodthyronine (T3), in which case it is referred to as primary or thyroidal hypothyroidism. Primary hypothyroidism is invariable accompanied by increased thyroid-stimulating hormone (TSH) secretion. Most common causes of primary hypothyroidism are chronic autoimmune thyroiditis or infiltrative thyroid diseases, radioactive iodine treatment or external radiation therapy, thyroidectomy, drugs with antithyroid actions or iodine deficiency. Iatrogenic hypothyroidism caused by lithium preparations or antipsychotics is also described [41, 146, 180]. Much less often hypothyroidism is caused by decreased thyroidal stimulation by TSH, which is reffered to as central or secondary hypothyroidism. Secondary hypothyroidism may be caused by pituitary or hypothalamic disease, causing deficiency of thyroid releasing hormone (TRH). It is usually accompanied by low or inappropriately normal serum TSH concentrations. Althought most of the daily production of T3 occurs in extrathyroidal tissue, and extrathyroidal T3 production is decreased and serum T3 concentrations are low in patients with nonthyroidal illness, the decrease in T3 production in these patients is accompanied by few if any manifestations of hypothyroidism [32]. Changes in the function of the hypothalamic-pituitary-thyroid axis (HPT) and in thyroid hormones transport and metabolism are common in patients with non-thyroid illness. It comprises all non-thyroidal disorders, surgical and non-surgical trauma and starvation. Many patients with nonthyroidal illness also receive drugs affecting thyroid hormone regulation and metabolism [260]. A decrease in serum T3 concentration and a parallel 22

23 increase in rt3 concentration are the most common changes in non-thyroid illness, which is often referred to as the low T3 syndrome. Sometimes low T3 syndrome has also been called euthyroid sick syndrome, tending to minimize its clinical significance. An alternative designation, which does not presume metabolic significance, is nonthyroidal illness syndrome. A principal mechanism underlying low serum concentration of T3 in patients with non-thyroidal illness syndrome is reduced activity of the D1 enzyme in liver. Increased concentration of cytokines, such as inteleukin 6 and tumor necrosis factor-alpha, are responsible for impaired expression of hepatic D1. Other mechanisms involved in the pathogenesis of the syndrome include a decrease in concentration of thyroid hormone binding proteins and decreased secretion of TRH [30, 39, 122]. The underlying problem in hypothyroidism is slowing of many physiological processes: slow movements, bradycardia, dry skin, hyporeflexia, cold intolerance, weight gain, decreased appetite, constipation, menstrual disturbances. Spectrum of symptoms of hypothyroidism is broad: patients with subclinical hypothyroidism have few or no symptoms and the other extreme is myxedemic coma. Hypothyrosis affects major body changes as well as mental disorders [196]. Links between hypothyroidism and mental illness were described by Richard Asher (1949) [15] as myxedema madness and focused much needed clinical attention on its treatment. Hypothyroidism is frequently accompanied by psychiatric symptoms such as diminished cognition, inability to concentrate, slowing in thought process, inability to calculate and understand complex questions, fatique, weakness and drowsiness [111, 194]. Memory for recent events is frequently poor and eventually memory for remote events also may become impaired with decreased ability to perform everyday tasks [258]. Hypothyroidism seems to be especially related to depression with melancholic features, crying, loss of appetite, insomnia, delusions of selfreproach and suicidal ideations; even sub-clinical hypothyroidism may affect mood [94]. The picture is not consistently one of depression; disorganized agitated state also has been described; also patients with psychosis, hyperactivity, irritability, anger, auditory and visual haliucinations are described, other patients become fearfull, suspicious and delusional [93, 53, 154, 161]. Hypothyroidism is also observed in manic patients [117, 241], bipolar patients [254], especially in women with the rapid-cycling form of the disorder [21]. Low T3 syndrome can play a significant role in the development of cognitive dysfunction, e.g. delirium, in patients with Alzheimer s disease 23

24 after surgical interventions [141]. It has been also described in other mental disorders such as major depression [185] and schizophrenia [266]. The psychoses that occur in patients with hypothyroidism are nonspecific, they may mimic schizophrenic, paranoid and affective psychoses. Even though confusion occurs in acute schizophrenia, together with distractibility and visual haliucinations. In patients with affective psychoses, cognitive impairment or pseudodementia is more common, especially in elderly persons, in whom it may dismissed as the dementia of the old age. The symptoms of hypothyroid psychosis may closely mimic severely psychotic-affective states [154, 161, 258] Unrecognized severe hypothyroidism manifested as an acute psychotic episode Although hypothyroidism is a common endocrine disorder characterized by thyroid hormone insuficiency and related to a wide spectrum of physical and mental disorders, the onset of disease may lead to misdiagnosis, on particular, if psychiatric disorders are present. Psychiatric disorders, such as acute psychosis, depression, bipolar disorder, acute mania or cognitive disorders may be a manifestation of hypothyroidism, even in the absence of clear physical symptoms. Endocrine dysfunction may be associated with many symptoms; it may also complicate the treatment of psychiatric disorder. Therefore, it is important to make a timely diagnosis of hypothyroidism and administer an adequate treatment when the disease manifest with psychiatric disorders. During our study we evaluated the case about the patient with severe hypothyroidism, manifested as an acute psychotic episode. 52-year-old woman, admitted to the Acute Psychosis Department for the first time with a history of psychomotor excitement, anxiety, sleep disorders and psychotic symptoms. Th severe hypothyroidism manifested with visual, auditory and visceral haliucinations, delusion of influence and steeling, anxiety, tension, sleep disorders. The somatic symptoms such as fatigue, weakness, difficulty in concentration, the appearance older than her real age, a pale face and mucous membranes, weak brittle hair, dry skin, wet, white and thick tongue coating and tenderness in epigastrium presented during 10 year period and continued during hospital treatment. The patient was diagnosed with acute psychotic episode, delusional disorder (DSM-IV-TR), suspecting schizophrenia spectrum disorder. According to a lower level of hemoglobin 106 g/l, reduction in the number of erythrocytes 45 x 10 9 /l with normal iron concentration 10.4 umol/l in the blood test, unspecified diagnosis of normochromic anemia was determined by consultant therapist. 24

25 Acute psychosis symptoms lessened after 10 days of treatment with typical antipsychotic haloperidol. However, lability of emotions did not disappear: either the patient was tearful or becoming euphoric. She suffered from consistent fatigue, sleeplessness, poor concentration; reported having bad memory, limited interests and activities. The results of thyroid axis hormones concentrations were received after the patient was discharged from the hospital: increased serum TSH concentrations more than 50 µiu/ml (reference range: µiu/ml) and decreased FT4 concentrations 1.4 pmol/l (reference range: pmol/l) and FT3 concentration 0.8 pmol/l (reference range: pmol/l) with normal SHBG concentration 48.5nmol/l. These results revealed that the patient had severe hypothyroidism and this threatening pathology of thyroid gland was not previously diagnosed, as the real cause of acute psychotic episode. High serum TPOAb concentrations 41.2 IU/ml, (reference range for TPOAb < 20 IU/ml) indicated autoimmune thyroid disease. Moreover, acute psychotic episode treatment with typical antipsychotic haloperidol significantly affected thyroid hormone concentration FT4 concentration decreased after treatment and was 0 pmol/l, FT3 concentration decreased and was 0.6 pmol/l and TSH remained more than 50 µiu/ml. The patient was started on thyroid hormone replacement and the treatment reversed the effects of hypothyroidism; after few months of treatment most of physical and mental symptoms such as sluggishness, emotional lability, reduced energy and decreased interests resolved. The patient became active, communicable again; signs of anemia were also corrected. But the insufficiency of thyroid function was diagnosed too late, and the patient could not receive a complete treatment with thyroid hormones since the onset of the disease. Acute psychotic episode treatment with typical antipsychotic haloperidol decreased the concentration of thyroid hormones and even greater influenced the severe hypothyroidism Myxedema Madness : everyday clinical practice Although the associations of hypothyroidism with psychotic disorders in the literature are described, the problems in everyday clinical practice still occur and remain as the difficulties of diagnosis in psychiatry. The literature traditionally presents classical symptoms of hypothyroidism such as fatigue, cold intolerance, dry skin, brittle hair and hair loss, dysmenorrhea, constipation. Most commonly, hoarse voice, bradycardia, non-pitting edema, a puffy face, delayed phase of relaxation of deep tendon reflexes, atrophic gastritis is observed. Blood investigation reveals normochromic 25

26 secondary anaemia, caused by the number of reduced erithrocytes, and hypoatremia. Manifestation of psychiatric symptoms in the presence of hypothyroidism is common, and their spectrum ranges from slight attention concentration disorder to dramatically presented agitated delirium or paranoid psychosis. However, psychiatric symptoms are commonly determined prior to hypothyrosis diagnosis. The associations between insufficient thyroid function and psychiatric symptoms are not rare but are frequently not recognized and evaluated as behavioural affective or cognitive disorders. Our case report hypothesized that insuficient thyroid function could be related to the onset of acute psychotic epidode and the thyroid axis could be influenced during acute psychotic episode treatment. In 1949 R. Asher wrote that hypothyroidism is one of the most important, little known and frequently forgotten cause of acute psychosis important, because it responds to adequate treatment, little known, since it is not frequntly mentioned, and forgettable as description of clinical hypothyrosis is a rule with many exceptions [15]. To describe this hypothyrosis-related psychosis Asher coined the term myxedematous maddness and presented 14 clinical cases during which he observed manifestation of symptoms of hypothyroidism and acute psychosis at the same time. All patients were women. Although doubts were raised over diagnoses since thyroid hormone concentration was not investigated, only physical examination was carried out, measurements of photography, cholesterol level, metabolic parameters, pulse and arterial blood pressure were evaluated in all cases treatment with only thyroid hormone thyroxine was administered. Out of 14 patients, 9 fully recovered, two patients showed just a partial improvement, one patient s condition remained unchanged, and two patients died. Asher stated that there were no any specific psychoses clinical picture of paranoid syndrome was common for all patients. Asher's study and resulting description of myxedema madness has been often cited as a typical example of psychosis secondary to hypothyroidism. There are described few similar cases about associations between hypothyroidism, psychotic disorders and treatment. Those associations were analysed on the basis of the clinical case of a 73-year-old woman with a history of acute psychosis lasting for 2 weeks [103]. Apart from visual and auditory hallucinations, the following signs manifested: bradicardia, dry skin, brittle hair, and in the presence of normal power of extremities, delayed phase of relaxation of deep tendon reflexes. However, similar to our described patient, this woman remained conscious, lively, and communicable. Only after examination of thyroid hormones, high level TSH in the presence of low thyroxine (T4) and total triiodothyronine (T3) 26

27 concentrations was found. The patient was started on low doses of thyroid hormones and risperidone, visual and auditory hallucinations were gradually resolving, and over a two-three-week period, psychiatric disorders disappeared. When risperidone was discontinued, recurrence of psychosis was not observed. To evaluate the caurse of psychosis authors recommended to investigate psychotic patients TSH, which is the most sensitive indicator in detecting of primary hypothyroidism. The similar case of a 39-year-old patient who was diagnosed with paranoid syndrome, hypothyroidism and vitamin B12 deficiency was decribed. Paranoid symptoms resolved after treatment with thyroid hormones and vitamin B12, moreover, improvement in patient s cognitive functions was seen [154]. In our case report the treatment with thyroid hormones also showed reduction in complaints about the decline in cognition. The case of a patient with a history of chronic paranoid schizophrenia, diagnosis of chronic thyroditis and Grade I hypothyroidism was described [61]. The course of psychosis showed improvement following treatment with thyroid hormones. Manifestation of both diseases at the same time did not allow evaluate existing personality disorder that led the patient to suicide. According to the authors, the differential diagnosis between hypothyroidism, primary axis I psychotic and depressive symptoms has always been problematic. When personality disorders are also present, the diagnostic dilemma is increased. Some clinical cases presented the manifestation of acute psychotic symptoms in associations with bipolar disorder and hypothyroidism. A poorer response to antidepressants is likely to occur in the presence of the depressive phase of bipolar type I disorder when level of FT4 is lower and level TSH is higher (although within normal range). Hypothyroidism is also thought to be a risk factor for the development of rapid cycle bipolar disorder. Although hypothyroidism is more associated with depression, 10 unusual cases of the link between hypothyroidism and mania episodes in literature are presented [118]. The case report when acute mania manifested in a young woman with hypothyroidism in the absence of classical symptoms of hypothyrosis was presented [233]. This case underscored the importance of thyroid screening in patients with mood and psychotic disorders, including patients who lack the classical psychiatric features of thyroid dysfunction. The case of a 72-year-old woman, who experienced for the first time acute mania caused by hypothyroidism in the presence of few physical symptoms of thryroid disease, was presented [243]. However, mania in the late age always suggests the organic origin of the disease. This case 27

28 highlights the importance of screening for organic causes of psychiatric symptoms presenting for the first time in older patients as well as the importance of ascertaining thyroid function in patients with affective and behavioural symptoms. In our case first time psychosis in older patient also required the exclusion of organic causes, but during hospital treatment period hypothyroidism was not diagnosed. The case of bipolar mania patient followed by primary hypothyroidism and unresponsive treatment with lithium and antipsychotics during a period of mania was decribed [18]. Similar to our case, only additional levothyroxine treatment of the primary hypothyroidism in this bipolar mania case resulted in rapid and complete recovery. The significance of the evaluation of thyroid status for patients who manifest affective, psychotic and cognitive disorders even in the absence of the symptoms of thyroid disease is shown. Examination of thyroid function of all psychiatric patients would help to avoid misdiagnoses or delayed treatment. Although there is no uniform opinion on the subject, the majority of psychiatrists traditionally are likely to examine thyroid hormone concentration in hospitalized patients with a history of acute psychotic episode or affective disorders. As in our described case, only random examination helped to determine hypothyroidism and the origin of psychosis. According to the literature, all reported cases about acute psychotic episode and hypothyroidism improved clinically after use of levothyroxine and psychotropic medications [118]. Thyroid hormone replacement therapy in hypothyroidism and psychotic episode not only reduces physical symptoms of hypothyroidism, but also significantly contributes to an improvement of symptoms of psychiatric disoders [36]. Supplementary antipsychotic medication contributes to a faster remission of psychosis symptoms than only monotherapy of thyroid hormone replacement [48]. The outcomes of our patient psychosis treatment suggested that typical antipsychotic haloperidol contributed to the reduction of free thyroxine (FT4) and free triiodothyronine (FT3) concentrations. There are no case reports about treatment with antipsychotic haloperidol and evaluating hypothyroidism, but in some studies in humans the treatment with haloperidol declined serum T4 and FT4 concentrations [23, 111, 196]. Antipsychotic drugs should be administered in low doses gradually titering, since side effect of the drugs may worsen symptoms of hypothyroidism. Atypical antipsychotics that are well tolerated are recommended to treat psychotic episode, although literature presents cases of hypothyroidism, induced by atypical antipsychotic quetiapine [189]. 28

29 As in our case, patients with hypothyroidism frequently experience a wide variety of neuropsychiatric sequelae. The range of physical and psychiatric presentations and their potential subtle manifestations make the diagnosis of hypothyroidism easy to miss. Since psychiatric complaints may be one of the earliest manifestations of hypothyroidism, they are often misdiagnosed as functional psychiatric disorders, rather than a psychiatric disorder due to a general medical condition. This confusion leads to delayed treatment and a high likelihood of increased morbidity. The frequency of misdiagnosis and mistreatment and the potential for poor prognosis point to the importance of a high degree of suspicion of thyroid dysfunction and the need for thyroid screening in psychiatric patients Thyroid axis function during acute psychotic episode Dysfunction of the thyroid gland, either hyper-function or hypo-function, is frequently associated with mental disorders, including psychoses that sometimes resemble schizophrenia [38] Bunevicius and Prange, 2010]. An increased prevalence of thyroid function abnormalities has been reported in families of patients with schizophrenia [65], suggesting possible genetic linkage between the endocrine and mental disorders. Relevance of thyroid disease to schizophrenia was discussed, according to findings of higher incidence of thyroid disease in mothers of schizophrenia patients than in control [140]. Large numbers of studies have investigated parameters of the thyroid axis in depressive disorders. In contrast, the thyroid hormone concentrations of acutely ill schizophrenic patients have been measured much less. The reports of the studies showed high rates of thyroid dysfunction in acute psychiatric inpatient [76, 102, 156, 164, 220, 229], but findings are quite controversial. Most of studies have reported results for all psychiatric inpatients, without explanation about medications used or ratings of mental state [147, 156, 198, 229]. It is well known that illness, certainly including acute mental illness, may affect the thyroid axis, and this affect is often noted when patients are admitted to hospital. Several studies have reported elevated serum concentrations of thyroxine (T4), but not of triiododthyronine (T3), in acute psychiatric disorders [23, 25, 156, 182, 198, 229]. This thyroid axis abnormality is observed in different severe mental disorders such as acute schizophrenia, major depression or mania and is called transient hyperthyroxinemia and usually resolves during recovery [23, 25, 156, 195, 198, 229]. The TSH in these cases is generally either normal or high, suggesting central activation of the hypothalamic-pituitary-thyroid axis [102]. 29

30 Some studies [50, 102, 220, 229] have found a significant elevation of both thyroid hormone concentrations in acute psychiatric patients. Other studies [164, 190] have found decreased thyroid hormone concentrations during acute psychotic episode. Mason et al observed significant difference in the FT4 levels between acute schizophrenia and acute mania patients and even hypothesized about potential usefulness of FT4 levels in the differential diagnosis of these two disorders [145]. Nevertheless, tissue responses to changes in thyroid hormone concentrations may be better indicators of the significance of thyroid axis activity than thyroid hormone concentrations themselves. Response of the anterior pituitary gland, evident by changes in TSH concentrations, is a sensitive marker of thyroid dysfunction. Most schizophrenic patients are euthyroid with normal basal concentration of thyroid stimulating hormone (TSH) and normal TSH response to thyrotropin-releasing hormone (TRH) challenge [23, 24, 84, 138, 182, 199]. Another sensitive tissue marker of thyroid activity is liver production of sex hormone binding globulin (SHBG) [186]. However, there are no data pertaining to serum SHBG concentrations in patients with acute psychoses, though one study reported decrease in SHBG concentrations after psychosis treatment with the atypical antipsychotic olanzapine [29]. Several studies described that increased levels of thyroid hormones are correlated with severity of acute psychiatric symptomatology [198, 220] and have found relations between overall symptom severity and changes in FT4 levels during clinical recovery [226] Thyroid axis function and schizophrenia Schizophrenia is one of the most severe psychiatric disorders with a chronic course and many patients responding poorly to medication and suffering frequent and disrupting relapses. This disorder arises from the interaction of a range of deviant genetic traits and environmental factors, which may begin to act in the prenatal period [139]. The clear understanding of schizophrenia s molecular mechanisms is elusive and no biological marker has been identified. In effect, a biomarker may be difficult to find if the disease results from a subtle deregulation in a biological network with impact on mental health and behavior. In this context, modulators of transcriptional activity and their carriers/receptors are good candidates in bridging the genetic and environmental determinants of schizophrenia. Among these are thyroid hormones [167]. Thyroid hormones are not only essential for the proper development of the central nervous system (CNS) [70], but also for the adult brain [28]. Several processes that have been identified as pathological in schizophrenia 30

31 are regulated by thyroid hormones. These include differentiation of the cerebellum, axonal migration and myelination [62, 64, 74, 87, 98, 113, 210], transcriptional regulation of enzymes, receptors and transporters of the neurotransmitter cascades [26]. Thyroid hormones have been directly implicated in the processes of learning and memory [270], which is intricately involved not only in language production, but also in schizophrenia [152]. Major thyroid hormone deficiency during pregnancy results in cretinism, while mild hypothyroidism is associated with poorer cognitive development. Even euthyroid hypothyroxinemia during pregnancy has been shown to impair proper neuronal migration in the somatosensory cortex and hippocampus in rodents [129]. Euthyroid hypothyroxinemic mice display increased exploratory activity and reduced signs of depressive like behavior [225]. Follow up of thyroid function throughout pregnancy and evaluation of the psychomotor development of the offspring, possibly until adulthood, would clearly be a more relevant indication of a relationship between thyroid hormones and behavior disorders such as schizophrenia [167]. It is known that thyroid hormone fluctuations in adults are associated with pathophysiology of mood disorders [21], and normal brain metabolism adapts in order to avoid thyroid hormones excess or deprivation [28]. Deficiency of thyroid hormones in neurodevelopment is known to result in impaired proliferation, migration and differentiation of hippocampal and cortical neurons [16, 129]. The expression of TRH in humans is predominant in the left hemisphere [31]. The asymmetries have been described for several neuroendocrine systems, including the thyroid axis [85]. The deficitof successful social communication is a failure of segregation of right from left hemisphere functions and such pathologies have been demonstrated in schizophrenia [152]. The researches have revealed the thyroid hormones modulation of crucial brain neurotransmitter systems [6, 22, 149, 259] including the dopaminergic, serotonergic, glutamatergic and GABAergic networks [44, 86, 112, 224, 259]. The disregulation of these pathways as well as the participation of myelination and cytokines is of particular relevance in the schizophrenic brain [44, 62, 139, 179]. Dopamine is the main catecholaminergic neurotransmitter associated with schizophrenia due to revealed enhanced dopaminergic activity of the nigrostriatal dopamine system, and the hypofunctionality of the mesoprefrontal cortical system in schizophrenic patients [127]. Thyroid hormones have been shown to regulate the levels of dopamine receptors [60] and the activity of tyrosine hydroxylase [49] the rate-limiting enzyme of the catecholaminergic pathway. Dopamine may be inhibitory of TSH secretion [191], as treatment with dopamine blockers lead to increase in TSH level or 31

32 to subclinical hypothyroidism [142], and that hypothyroidism can lead to increased dopamine receptor sensitivity [60]. The serum levels of dopamine were found to be elevated in acutely ill schizophrenic patients, while levels of TSH and T4 were decreased [190]. The increased dopaminergic activity was hypothesized to affect the pituitary secretory function, and decreased beta-adrenergic activity was inferred as consequence of decreased serum TSH concentration. The adrenergic catecholamines could be involved in maintaining deiodinase activity and thus brain thyroid status [120]. Type-1 deiodinase impairment may result in a drop in T3 levels, with unchanged T4, and type-2 or 3-deiodinase impairment may be reflected in decreased T4 metabolization. As we know, the enhanced serotonergic signaling via serotonin type 2A receptors is involved in the pathology of schizophrenia specifically during the early phases of psychoses [86, 216] and deficient central 5 HT functions may underlie some of the negative symptoms in schizophrenic patients [2]. CSF concentrations of the major metabolites of serotonin and dopamine correlated with thyroid hormones concentrations [233]: the concentration 5 hydroxyindolacetic acid (5 HIAA) significantly and negatively correlated with plasma TSH and total T3 and homovanillic acid (HVA) significantly and negatively correlated with plasma TSH, total T3 and FT3. Such findings establish links between interactions of the serotonergic system and thyroid hormones. According to the glutamatergic hypothesis of schizophrenia [109], Mendes-de-Aguiar et al. [149] proposed by some authors, who studied the role of T3 in the CNS, specifically on regulation of glutamate uptake; and concluded that T3 is capable of regulating extracellular glutamate levels by modulating the astrocytic glutamate transporters and by promoting neuronal development and neuroprotection. The role for the δ-aminobutyric acid-ergic (GABA-ergic) system in the pathogenesis of schizophrenia derives mostly from neuropathologic studies [133], but upregulation of the postsynaptic GABA-A receptors was described in schizophrenic patients [7]. GABA-ergic systems are related to thyroid dysfunction. The effect of thyroid hormones on the GABA-ergic system can take place at multiple levels: circuit formation, enzymes involved in synthesis and metabolism of GABA and glutamate, GABA release and reuptake, and GABA receptors [259]. The link between thyroid hormones and schizophrenia is pertinent [39, 148, 167]. There have been published studies with reports about thyroid hormones abnormalities in hospitalized schizophrenic patients. Some reports already mentioned of thyroid function abnormalities in schizophrenic patients and their families as well as on the resemblance between the psy- 32

33 chotic symptoms of people with severe hypo- and hyper-thyroidism and those of schizophrenic patients [15]. Elevated and normal total T4 levels have been reported in drug naive and acute schizophrenic patients and are described to normalize or decrease, respectively, as a response to treatment with different drugs [25, 114, 144, 190, 195]. Also low T3 concentrations are found in schizophrenia [266]. Other studies reported a positive correlation between circulating free T4 and free T3 with severity of disease [220]. These are a competition between thyroid hormones and medication for common metabolic pathways, and the downstream effects of therapeutic medication targets on the pituitary thyroid axis. Increased dopaminergic activity inhibits TSH pituitary secretion [190], and dopamine blockers result in subclinical hypothyroidism [142] while hypothyroidism induces increased dopamine receptor sensitivity [60]. Studies in mentally healthy individuals showed that the pituitary thyroid state correlated with central dopaminergic and serotonergic activity [233]. The role of thyroid hormones in the pathophysiology of schizophrenia is more so noteworthy when considering the possible function of thyroid hormones as neurotransmitters. Given the distribution pattern of thyroid hormones in the brain and the strong co-localization with the noradrenergic system and T3 itself might behave as a neurotransmitter [200]. It was explored a similar neurotransmitter function for 3-iodothyronamine (T1AM), which was identified as endogenous derivative of thyroid hormones. T1AM was found to block the transporters for the neurotransmitters dopamine, norepinephrine and serotonin. T1AM binds with high affinity to the trace-amineassociated receptor (TAAR) [209]. Thyroid hormone involvement in susceptibility to schizophrenia might result either from mutations or polymorphisms in genes of their metabolism or whose expression they regulate, but may also result from the altered expression of these normal genes. An increased prevalence of thyroid function abnormalities was reported in families of patients with schizophrenia [65], suggesting possible genetic linkage of two disorders. Association with thyroid disease and schizophrenia has been reported with a polymorphism on the human opposite paired (HOPA) gene, which is located on chromosome X, is linked to both hypothyroidism and schizophrenia [177, 227]. Mutations on the NR4A2 gene have been described in Swedish, but not American Caucasian patients with schizophrenia [33]. Chromosomal regions implicated in schizophrenia harbor genes from the thyroid hormone metabolic cascades. Trace-amine-associated receptor TAAR1, liganded by the thyroid hormone derivative 3-iodothyronamine, is located within the TAAR cluster at chromosome 6q23.2, a region linked to schizophrenia by several genome studies [133, 165]. Several different single 33

34 nucleotide polymorphisms (SNPs) in TRAR4/TAAR6 have been identified in schizophrenia [66]. Other genome-wide scan studies implicate chromosomal regions harboring several genes involved in thyroid hormone metabolism, namely deiodinase type I on chromosome 1p32.3 [73], THRB on 3p24.2 [187] and UDP glucuronosyltransferases on 2q37.1 [132, 261]. Therefore, the loci of the thyroid hormone metabolic cascades and genes whose expression they regulate have been often implicated in schizophrenia. Relevant support for this involvement comes from studies in rodents in which the expression of nuclear receptors and genes involved in thyroid hormone metabolism is influenced by subchronic and acute treatment with drugs such as haloperidol and clozapine [69, 126, 257]. Several candidate genes recently singled out as significantly contributing to increased vulnerability in schizophrenia [98, 99, 101, 121, 217] are directly or indirectly regulated by thyroid hormone. Among these are ERBB4, the receptor for neuregulin 1 [163]; neuropeptide Y [143]; NOTCH4 [267]; DRD2 [203]; PHOX2B, a transcription factor for RGS4 [91, 91]; dysbindin (through retinoid regulationof the expression of dystrophin-associated protein complex [47]; prohormone convertases 1 and 3 [215]; and amyloid-beta protein [249] and myelin-related genes [98, 265] Effect of Antipsychotic Medication on Thyroid Axis Hormones The introduction of antipsychotics was an important step managing acute psychoses; however, the therapeutic effect of the treatment was counterbalanced by side-effects. The second-generation of antipsychotic drugs brought new options; however, their efficacy advantage was not so high as expected [135]. In acute psychotic episode [237] as well as in patients with chronic schizophrenia [220, 266] some endocrine changes including changes in thyroid function and thyroid autoimmunity are described. Endocrine function is often affected by antipsychotic medications as well as by mental disorder itself. Atypical antipsychotics of the second-generation have even a higher risk of metabolic adverse effects than the first-generation agents [240]. A better understanding of the mechanisms related to the efficacy and side effects of antipsychotic medications may open new venues preventing side effects and advancing treatment of acute psychosis. Several early studies conducted on both humans and experimental animals have demonstrated that thyroid axis hormones enhance the toxic and behavioral effects of antipsychotics [105, 123, 171, 222, 256]. Latest studies reported that antipsychotics interfered with the thyroid physiology as a result of their action at several levels of the synthesis and metabolism of thyroid axis hormones, through a modulation of the monoaminergic systems, 34

35 whether acting upon norepinephrine, dopamine, or serotonin synthesis, metabolism, uptake, or receptors [125, 130, 189, 208, 248]. Some widely used psychoactive drugs, such as typical antipsychotics phenothiazines exhibit different side effects on the thyroid. Chlorpromazine decreases iodine uptake and it may lead to iatrogenic hypothyroidism [208]. Acting on hypothalamo-pituitary-thyroid (HPT) axis chlorpromazine and thioridazine were shown to decrease thyroid-stimulating hormone (TSH) response to thyroid releasing hormone (TRH) stimulation without altering basal TSH levels [124]. In other studies patients treated with phenothiazines (chlorpromazine, thioridazine, or trifluoperazine) displayed low T4 levels with normal or increased T3 levels, with no other change in TSH and without clinical hypothyroidism symptoms. As the HPT axis could be assumed as being intact, this could be due to an abnormal synthesis of T3 or an increased conversion of T4 into T3 [97, 144]. A study of schizophrenic patients who were treated with phenothiazine antipsychotic perazine revealed a decrease in serum T4 and rt3 concentrations but altered function of T3 concentration [25]. Contrary to other phenothiazines, perphenazine induces an increase of T4 blood levels with no clinical signs of hyperthyroidism [173]. Antipsychotic phenothiazine such as alimemazine was shown to depress thyroid hormone production and enhance thyroiditis when animals were fed with these drugs [107, 236]. Some studies showed that phenothiazines could induce thyroid autoimmunity [130, 248]. Alimemazine could play a role in the induction of thyroid autoimmune disorders [236]. In a cross-sectional study [181] increased prolactinemia was associated with an increased prevalence of thyroid autoantibodies in schizophrenic outpatients. In the latest review was concluded that phenothiazines could induce a hypothyroid state through either their deiodination effect or their thyroid autoimmune-inducing activity. In all patients receiving phenothiazines, regular monitoring of thyroid function parameters is recommended owing to the direct interference of these drugs with thyroid functioning [116]. The commonly used butyrophenone drug, typical antipsychotic haloperidol can induce specific changes in deiodinase activities in rat brain [69]. Treatment with haloperidol in humans declined serum concentrations of T4 and ft4 [23, 110, 195]. Accordingly, typical antipsychotic drugs, whether they were phenothiazines or not, can induce autoimmune thyroid abnormalities and ATPO increment [116]. Some atypical antipsychotics, such as clozapine, is piperazine-containing drug decreases type 2- deiodinase but increases type 3-deiodinase activity in several rat brain regions[69]. Clozapine- treated patients decreased T4 [195] and ft4 levels [23]. Clozapine shows inverse effect as haloperidol: after 35

36 clozapine treatment TSH response to TRH is significantly decreased; whereas the basal level of TSH remains unaltered [173]. There some studies about thyroid effects of second generation antipsychotics. After administration of amisulpride TSH levels significantly elevated compared to TSH levels after placebo administration [181]. Also patients with schizophrenia treated with amisulpride showed a significant elevation in TRH-stimulated TSH secretion in comparison to patients treated with typical antipsychotic, thioxanthene drug flupentixol [92]. Significant decrease in T4 levels was observed in the patient group receiving quetiapine, whereas other patients receiving risperidone and fluphenazine had no change in their thyroid hormone levels [114, 119]. Quetiapine treatment is even associated with development of hypothyroidism [75, 134, 180, 188]. Church and Callen 2009 described myxedema coma possibly associated with combination aripiprazole and sertraline therapy [51]. However, a clinical role of the effects of treatment with antipsychotic medications on thyroid hormone concentrations in acute psychotic patients is not well understood. One study reported decrease in SHBG, sensitive tissue marker of thyroid activity is liver concentrations after treatment with the atypical antipsychotic olanzapine [29] Thyroid axis hormones in treatment of mental disorders The behavioral disturbances, physical and psychological signs and symptoms of hypothyroidism usually respond to adequate replacement treatment with thyroid hormones [258]. However, fluctuations in thyroid hormone concentrations even within the normal range may affect mental functioning. When hypothyroidism is treated with T4 alone, as is usual practice, serum T3 concentrations may remain in the low normal range [263]. In this situation some patients do not feel entirely well despite adequate dosage of T4 and it could be related to increased psychiatric morbidity [204]. Normalization of the T3/T4 ratio produced by adding T3 to replacement therapy of hypothyroidism improves mental functioning in many patients [36, 205] but not all [52, 251]. In T4 treated patients it was found that reduced psychological well-being is associated with occurrence of polymorphism in the D2 gene [168] as well as in the OATP1c1 gene [244]. The majority of patients subjectively prefer combined treatment with T4 and T3 [71]. Two studies have evaluated whether D2 polymorphism is associated with changes in psychological well-being after combined T4 and T3 treatment. One study reported only a trend toward improvement [13]. In a second study involving a very large sample, D2 polymorphism was 36

37 associated with improvement in psychological well-being after T4 and T3 treatment [168]. Despite the fact that the majority of schizophrenic patients are euthyroid, thyroid hormones have been tried as a treatment of schizophrenia as well as depression. Gjessing successfully treated patients with periodic catatonia using high doses of desiccated thyroid gland, which contain both T4 and T3 [89]. This success, together with reports of thyroid axis dysfunction in mood disorders, has encouraged administration of synthetic thyroid hormones in patients with major depression receiving treatment with antidepressants [20]. After early T3 acceleration studies [184], several trials have confirmed the clinical value of thyroid hormones in the treatment of depression. Specifically there is conclusive evidence that a small dose of T3 can accelerate the effects of tricyclic antidepressants [9]. There is equally conclusive evidence that a small dose of T3 can convert tricyclic nonresponders to responders [14]. These therapeutic effects of T3 are not related to alterations of the pharmacodynamics or pharmacokinetics of tricyclic antidepressants; no such alterations have been found in humans [183]. The role of T3 in enhancing the antidepressive effects of selective serotonin reuptake inhibitors remains controversial at this time [4, 12]. Treatment with tricyclic antidepressants in depression [192] as well as treatment with conventional antipsychotics in schizophrenia [25] decrease T4 and rt3 concentrations in serum. It is hypothesized that antidepressants enhance the activity of the type II deiodinase in certain brain regions resulting in increased production of T3 in brain and diminished concentration of the substrate T4 in serum [25]. A similar effect on serum thyroid hormone concentrations was recently demonstrated for the atypical neuroleptic quetiapine [114]. Neuroleptics may activate the thyroid axis not only through possible effects on type II deiodinase activity in the brain, but also by diminishing inhibitional effects of dopamine on TSH secretion in the pituitary [110]. In contrast to strong evidence for the adjunctive use of T3 in the treatment of depression [54, 178], only a few studies have addressed the adjunctive use of T3 in the neuroleptic treatment of schizophrenia. In chronic schizophrenic patients one study found that T3 did not enhance the effects of phenothiazines [264]. However, in acute schizophrenic patients T3 decisively enhanced the antipsychotic effects of chlorpromazine [172]. There are no studies about adjunctive use of T3 in acute psychosis treatment with atypical antipsychotics. 37

38 Ethics 2. MATERIAL AND METHODS This study and its consent procedures were approved by the Lithuanian Bioetics Committee, Vilnius, Lithuania, Nr.P-104, Eudra CT Nr (see Annexes 1a, b). The study was performed according to the study protocol T3RIS22007, version 1.0 with permission of State Medicine Control agency at the Ministry of Health of the Respublic of Lithuania to conduct clinical trial Nr. 12KL-229 (see Annexes 2a, b) Study population The study was performed in Žiegzdriai Mental Hospital, Lithuania, according to the cooperation agreement and contract with study contracting organisation, Institute of Psychophysiology and Rehabilitation, Lithuanian University of Health Sciences. This study was supported by the Lithuanian Fund for Research and Studies; Grant # T-58/06. All acute psychotic patients, men and women, years old, consecutively admitted and hospitalized to the Acute Psychosis Department of Ziegzdriai Mental Hospital during the fourteen month period were invited to participate in the study, if they were able to understand the purpose and the procedures required for the study and had signed a written informed consent form. Exclusion criteria: history of any significant or unstable cardiovascular, respiratory, neurological, renal, hepatic, endocrine, immunological condition, were suicidal or agitated, diagnosis of psychoactive drug dependence 6 month before screening visit, received treatment with thyroid medication or somatic medication influencing thyroid function, received long- acting antipsychotics 4 months before screening visit or electroconvulsive therapy (ECT) 3 months before screening visit. All study patients were physically healthy as judged by physical examination and medical history, not pregnant or breast feeding. Fig shows the flowchart of the study population. 38

39 Figure Flowchart of the study population 39

40 Of 180 acute psychotic patients invited to participate in the primary study evaluations, 12 of them declined to participate. 32 patients were excluded after the primary evaluations: 6 patients were disable to understand study procedures and signed inform consent, 8 patients diagnosis was not acute psychotic episode according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnostic criteria, 9 patients were diagnosed with psychoactive drug dependence during 6 month before hospitalization, 2 patients were suicidal or agitated, 6 patients had clinical relevant or unstable medical conditions, or used thyroid drugs, 1 patient had history of electroconvulsive therapy (ECT) less than 3 month before hospitalization. Thus the initial study group consisted of 136 patients. The patients, who refused to attend or were excluded (n=44), did not differ from the study participants in age and gender. Overall, a number of patients approached 75.5 % who participated in the study screening visit. All 136 acute psychotic patients: 64 men (47%) and 72 women (53%) before screening visit signed informed consent to participate in the study. Our research was constructed of three study designs: cross-sectional, prospective studies and clinical trial (Study I, II and III). The selection of patients was started from clinical trial (Study III) A clinical trial (Study III) It was a randomized, double blind, parallel-group, placebo controlled clinical trial; and evaluated the efficacy and safety of adjuvant treatment with L-triiodthyronine (T3) on acute schizophrenia treatment with risperidone (RIS). Study III consisted of three phases: screening phase, wash-out phase, and treatment phase. Inclusion criteria of the Study III: current diagnosis of schizophrenia ( ) at least 6 month period before screening visit, according to DSM-IV-TR diagnostic criteria, established using Mini International Neuropsychiatric Interview (MINI-Plus); acute psychotic episode at screening (V1) and randomization (V3) visits; psysically healthy on the basis of medical history, physical examination, endocrinology consultation results with thyroid echoscopy and screening TSH concentration and thyroid peroxidase antibody (TPOAb) concentrations in the reference range, vital signs (blood pressure, pulse), ECG results and laboratory tests (blood and urine) results performed at screening; women had to agree practicing an effective method of birth control during the study and must have a negative urine pregnancy test at screening. Exclusion criteria for Study III: any medical condition that potentially can alter absorbtion, metabolism or excretion of the medications (Crohn s 40

41 disease, liver disease, renal disease, diabetes), known allergic reactions, hypersensitivity or intolereance to risperidone or T3, tretment resistency and/or currently treated with clozapine, history of neuroleptic malignant syndrome and history or current symptoms of tardive dyskinesia. Out of 136 acute psychotic patients, 32 patients were selected to participate in the Study III. Overview of the Study III design is provided in Fig Figure Overview of the Study III design 41

42 Study III Time and Events Schedule are provided in Table Screening procedures were completed during up to 3 days screening period after providing written inform consent form. Table The Study III Time and Events Schedule Screening Wash out Treatment period Visits Visit 1 Visit 2 Visit 3 Visit 4 Days -6/-4-3/-1 1 X/end of study Inform consent X Demographic data X Medical/psychiatric history X Mini Plus X Diagnosis (DSM-IV-TR) X Inclusion, exclusion criteria X X X Vital signs X X X X Somatic state evaluation X X X X Endocrinology consultation X Laboratory tests (blood, urine) X X Screening TSH and TPOAb concentrations X ECG X X Pregnancy test (females) X BPRS X X X Thyroid axis hormones concentrations X X CGI-Severity X X CGI-Improvement X Concomitant medications X X X X Randomization X Risperidoni (flexible dose mg/day) T3 25µg/placebo X X Adverse events monitoring X X During the screening (Visit 1) patients demographic data, medical, psychiatric and medication history were asssesed, standart somatic state assesments, endocrinology consultation, thyroid echoscopy, screening TSH and TPOAb concentrations, ECG, urine, blood tests, pregnancy test (female) were done, psychiatric diagnosis (DSM-IV-TR; MINI Plus 5.0.0) and sever- 42

43 ity of psychosis evaluation using Brief Psychiatric Rating Scale (BPRS) were done. During the screening period doses of used antipsychotics and other psychiatric medications were tapered off. Concomitant medications were used in all phases of Study III: lorazepam up to 6 mg/day p/o was allowed for the treatment of the agitation, irritability, restlessness or hostility, zolpidem was allowed 2.5 to 10 mg/day p/o for the treatment of insomnia and trihexyphenidyli up to 6 mg/day p/o was allowed for the treating movement disorders. If all inclusion and exclusion criteria for Study III were met, patients were continued wash-out period (Visit 2) up to 3 days, according the antipsychotics used before the Study. After completed wash-out period, at Visit 3, after overnight fast, patients venous blood samples were collected for the assessment of thyroid axis hormone concentrations; venous blood was centrifuged and serum was frozen for the storage. Patients somatic state, psychiatric symptoms using BPRS, illness severity using Clinical Global Impression-Severity of Illness (CGI-S) scale and all adverse events were evaluated. At Visit 3 patients were randomly assigned for the treatment period: in a 1:1 ratio one group of patients to receive oral RIS and T3 25 µg; the other group to receive oral RIS and Placebo. A flexible dose of RIS was applied within the approved dose range 2 8 mg per day. The study pharmacist was responsible for the randomization procedure. T3/Placebo was prepared in the same exterior capsules and was prescibed p/o once a day in the morning before breakfast. The Study III treatment period followed up to maximally 6 weeks. The Study III ended, when patient met response to treatment criteria: a score of CGI S 3 and score CGI I 3. During the treatment period patients vital signs were measured every day, somatic, psichiatric state, BPRS and CGI-S scales were evaluated on two occasions: randomization visit V3 (baseline) and end of study visit V4, CGI-I scale was evaluated at visit V4. All adverse events during the treatment period were collected and documented. At Visit 4, after overnight fast blood samples for the assessment of thyroid axis hormones concentrations were collected, serum centrafuged and frozen in the storage. Vital signs, ECG, laboratory tests (blood and urine) were performed. Therofore, 32 acute psychotic patients (17 men and 15 women, mean age 41 (SD=13) with acute schizophrenia diagnosis participated in Study III. The duration of the treatment period in the Study III was from 21 days to 42 days (mean duration of the study treatment time was 29±8 days). All 32 Study III patients participated in all study visits. 43

44 Table Sociodemographic characteristic of patients (Study III, N=32) Characteristic Gender Men, n (%) 17 (53.1) Women, n (%) 15 (46.9) Age, mean (SD) years 41 (13) Response to treatment time, mean (SD), range, day 30 (8), range Medications during treatment period, n (%) Risperidoni 32 (100) T3 14 (43.8) Placebo 18 (56.3) Lorazepam 31 (96.9) Zolpidem 14 (43.8 ) Trihexyphenidyli 20 (59.4) All 32 patients during study treatment period received oral Risperidone for the treatment of acute schizophrenia. T3 was given to 14 patients and 18 patients were treated with Placebo. Concomitant lorazepam treatment was administered to 31 patients; 14 patients were treated with zolpidem and 20 patients received trihexyphenidyli (Table ). The primary outcome measure was the time of the treatment period till response to treatment criteria were met, measured in days since randomization visit till the end of the study visit. The secondary outcome measure was a mean change in patients total BPRS scores subtracting scores during the end of the study visit from scores during randomization visit; mean changes in every BPRS item and mean changes in BPRS factors (Guy 1976) scores respectively [96]. Out of 136 acute psychotic patients, who signed inform consent and were included into the study, after selection to clinical trial (study III), the last 104 patients were selected for study I, and II A cross-sectional study (Study I) It was a quantitative, cross-sectional design study, which evaluated thyroid axis hormone concentrations in acute psychotic patients comparing to blood donor controls, to severity of psychosis, and to prior use of psychiatric medication. 44

45 Venous blood samples of 104 acute psychotic patients (47 men and 57 women) were collected in the next morning after hospital admission, after overnight fast for the assessment of thyroid axis hormones and thyroid antibody concentrations. Venous blood was centrifuged and serum was frozen for the storage at 40 C. The control group of 120 participants (69 men, 51 women) consisted of consecutive blood donors from Kaunas Donation Center, Lithuania (Permission of Kaunas Regional Biomedical Research Ethics Committee, Kaunas, Lithuania, Nr.BE-2-17; Approval of the protocol amendment Nr.P1-72/2009 (see Annexes 3a, b). All blood donors were evaluated according to the standart blood donor examination procedure (Kaunas Donation Center medical screening requirement for donors, according to the Minister of Health order Nr. V-84, ) as healthy (no severe or unstable medical conditions or psychiatric disorders and did not use any somatic and psychotropic medications). The blood samples of blood donors control group were collected in Kaunas Donation centre and were used for biochemical comparisons. Because thyroid disorders are common and their presence may skew the data, we screened all patients and controls for autoimmune thyroid disease and for thyroid dysfunction. Six psychotic patients and five control subject had TSH concentration higher than 4.05 µiu/ml, indicating hypothyroidism; and two psychotic patients had TSH concentrations less than 0.17 µiu/ml, indicating hyperthyroidism. Fifteen psychotic patients and 9 controls had TPOAb concentrations higher that 20 IU/ml, indicating autoimmune thyroid disease. All patients and controls with thyroid dysfunction and/or with autoimmune thyroid disease were excluded from the Study I. Thus 81 psychotic patients (42 men and 39 women, mean age 36 (SD=11) years) and 106 controls (65 men and 41 women, mean age 34 (SD=13) years) provided data for analyses. There were no significant differences between patients and controls regarding age, but there were a higher prevalence of men in control group. Psychiatric diagnoses of study patients were made according to DSM-IV- TR diagnostic criteria, assessed by using MINI Plus structured clinical interview, using three modules: module A for major depressive episode, module D for (hypo)manic episode and module M for psychotic disorders. Diagnostic algorithms specified diagnosis of the specific psychotic disorder. Only patients who met criteria for current psychotic disorder on module M were included in the study. The severity of psychosis was evaluated using a brief psychiatric rating scale (BPRS) in the next morning after the hospital admission. Study I patients psychiatric diagnoses are presented in Table

46 Table Study I patients psychiatric diagnoses according DSM-IV- TR diagnostic criteria (N=81) Psychiatric diagnoses N (%) Schizophrenia 44 (50.6) Schizoaffective disorder 11 (13.5) Schizophreniform disorder 5 (6.2) Brief psychotic disorder 16 (19.7) Major depressive disorder with psychotic features 2 (2.5) Bipolar I manic episode with psychotic feature 3 (3.8) No attempt was made to measure serum concentrations of psychiatric medications either in patients during hospital admission or in controls. Instead, all patients were questioned about the use of psychiatric medications one month before the admission to mental hospital. Information from patients, referring psychiatrists, and patients relatives was collected. Table Distribution of patients considered current psychiatric treatment upon hospital admission (Study I, N=81) Psychiatic medication treatment before admission N (%) Used antipsychotics 27 (33.3) haloperidol 4 (4.9) olanzapin 7 (8.6) risperidone 6 (7.5) amisulpiride 2 (2.5) ziprazidone 3 (3.8) Quetiapine 3 (3.7) clozapine 1 (1.2) tiapride 1 (1.2) Not used antipsychotics 54 (66.7) Used benzodiazepines 29 (35.8) Not used benzodiazepines 52 (64.2) Used antidepressants 16 (19.8) Not used antidepresants 65 (80.2) Not used any psychiatric medication 39 (48.1) 46

47 A patient was considered as having a history of psychiatric treatment before admission, if referring psychiatrists documented such prescription of medications and if the patient and/or his relatives confirmed its use. If such information was lacking (referring psychiatrists, the patient and/or his relative did not confirm using medications by the patient), the patient was considered to be without psychiatric medication treatment. The use of psychiatric medications before hospital admission is presented in Table A prospective study (Study II) It was a quantitative naturalistic prospective study and evaluated the changes in thyroid axis hormone concentrations and changes in sex hormone binding globuline concentrations during antipsychotic treatment of acute psychotic episode in relation to baseline hormone concentrations and to clinical characteristics of psychotic episode. Of 104 acute psychotic patients, 8 women with TSH abnormalities were excluded. Also from the latest analyses we had to exclude three patients, who did not receive antipsychotic medications during in-patient treatment. Therefore, 93 psychotic patients (45 men and 48 women, mean age 36 (SD=12) years) were included into the Study II analyses. Sociodemographic and clinical characteristics of Study II patients are presented in Table Table Sociodemographic and clinical characteristics of patients (Study II, N=93) Characteristic Gender Men, n (%) 45 (48.3) Women, n (%) 48 (51.6) Mean age (SD) 36 (12) Psychiatric diagnosis: Schizophrenia 51 (54.8 Brief psychotic disorder 18 (19.4) Schizoaffective disorder 13 (14) Schizophreniform disorder 7 (7.5) Major depressive disorder with psychotic features 2 (2.2) Bipolar I manic episode with psychotic features 2 (2.2) 47

48 Table continued Characteristic First psychotic episode, n (%) 33 (35.4) Psychotic relapse, n (%) 60 (64.6) Duration of illness, median (IQR) year 2 (IQR 0-2) range (0-40) Duration of hospitalization, mean (SD), range, day 29 (10), range 4-55 Medications during acute psychosis treatment n (%) Antipsychotics 93 (100) haloperidol 44 (47.3) olanzapin 15 (16.1) risperidone 16 (17.2) amisulpiride 6 (6.4) ziprazidone 3 (3.2) quetiapine 7 (7.5) tiapride 2 (2.1) Benzodiazepines (diazepam, clonazepam, lorazepam) 90 (96.7) Antidepressants (amitriptyline, sertraline, paroxetine, escitalopram, venlafaxine) 27 (29.7) Venous blood samples for evaluating thyroid axis hormones concentrations were collected and severity of psychosis by the Brief Psychiatric Rating Scale (BPRS) was assessed on two occasions: the next day after admission to the hospital and on the day of the discharge after acute psychosis treatment. All 93 patients during hospitalization received antipsychotics for the treatment of acute psychosis, 90 patients were treated with benzodiazepines, 27 patients were treated with antidepressants (Table ). The data of 115 euthyroid donor controls, 67 men and 48 women (TSH in reference interval), was used in this prospective study for biochemical comparison Psychiatric evaluations 2.2. Methods Psychiatric diagnoses were established according to the DSM-IV-TR diagnostic criteria (APA, 2000) using the MINI-Plus structured clinical interview (Sheehan, 1998) [10, 214]. The MINI-Plus is designed as a brief structured interview for the major Axis I psychiatric disorder in DSM-IV- 48

49 TR. The MINI-Plus is comparable to other standard diagnostic instruments such as the Structured Clinical Interview for DSM-IV (SCID) [228] or Composite International Diagnostic Interview (CIDI) [197]. This instrument has acceptably high validation and reliability scores, but can be administered in a much shorter period of time (median 15 minutes). The MINI Plus is divided into 26 modules identified by letters, each corresponding to a diagnostic category, pertaining to past and current diagnoses. At the beginning of each diagnostic module (except for the psychotic disorders module), screening questions corresponding to the main criteria of the disorder are presented. At the end of each module, a diagnostic box permits the clinician to indicate whether diagnostic criteria for a specific mental disorder have been met. We used three modules of the MINI Plus (see Annexe 4) allowing diagnoses for major depressive episode (module A), for (hypo)manic episode (module D), and for psychotic disorder (module M). It is important to note that only patients who met criteria for current psychotic disorder on module M were included into this study. Diagnostic algorithms for psychotic disorders were used to specify psychotic disorder. Severity of psychopathology was assessed by the Brief Psychiatric Rating Scale (BPRS) (see Annexe 5) on two occations before and after acute psychotic episode treatment. The BPRS assesses the level of 18 symptom constructs and is rated from 0 (symptom not present) to 6 (symptom is extremely severe) and includes positive and negative symptoms of general psychopathology. The Scale is useful in gauging the efficacy of treatment in patients with psychotic disorders. The BPRS was administrated by the same trained study psychiatrist, based on the knowledge of psychotic disorders and who was able to interpret the constructs used in the assessment. It takes minutes for the interview and scoring. Some items (e.g. mannerism and posturing) are based on the observation of the patient s behaviour; other items (e.g. anxiety) involve self reporting by the patient. The patient s family can also provide the behavior report. Severity of psychosis is measured by the total score ranging from 0 to 108. Scores below 10 are considered as normal variation. For the treatment efficacy analysis we used the change in the total BPRS scores and analysis of the BPRS factors that we derived from the data. In the clinical trial (Study III) we used another standardized assessment tool the Clinical Global Impression (CGI) scale [95]. Its goal is to allow the clinician to rate the severity of illness, a change over time, and efficacy of treatment. The CGI scale is widely used in clinical psychopharmacology trials as an outcome measure. The CGI is easy and quick to administer; it takes only 1 2 minutes to score the CGI scale after a clinical interview. 49

50 We used two items of the CGI scale to measure illness severity (CGI S) and global improvement or change (CGI I). The CGI S is rated on a 7- point scale, with the severity of illness scale using a range of responses from 1 (normal) through to 7 (amongst the most severely ill patients). The CGI I scores range from 1 (very much improved/significant improvement) through to 7 (very much worse/significant worsening). Both components of the CGI were rated separately; the instrument does not yield a global score (see Annexe 6). All adverse events during clinical trial (Study III) reported by patient or evaluated daily by psychiatrist were collected and documented Endocrine measurements Study patients venous blood samples were drawn on two occasions for the evaluation of thyroid axis hormones concentrations. The first blood sampes were drawn the next morning after the hospital admission (Study I and II), or on the day of randomization in clinical trial (Study III) after an overnight fast. The second blood samples were drawn after acute psychosis epizode treatment on the day of discharged from the hospital (Study I and II) or during the end of study visit (Study III), in the morning after an overnight fast. Blood samples from the control blood donors group were collected at Kaunas Donation center. All blood samples were collected in tubes, centrifuged and then serum samples were stored at -40 C. All samples for each biochemical variable were analyzed as a batch to avoid interassay variability at the laboratory of Vilnius University Oncology Institute, Lithuania. Serum concentrations of thyroid stimulating hormone (TSH), free thyroxin (FT4), free triiodothyronine (FT3), TPOAb and SHBG were assessed by radioimmunoassay, using commercial IMULITE kits (Czech Republic). Sensitivity of the assays were as follows: TSH, µiu/l; FT4, 0.4 pmol/l; FT3, 0.5 pmol/l; TPOAb, 2 IU/ml; SHBG, 0.2 nmol/l. The clinical laboratory provided reference intervals from manufacturers' kit inserts: a TSH reference interval of µiu/ml, a FT4 reference interval of pmol/l, FT3 reference interval of pmol/l, reference intervals for TPOAb < 20 IU/ml, SHBG reference interval of nmol/l for males and nmol/l for females. During the clinical trial (Study III) screening visit, pre-study TSH and TPOAb concentrations were evaluated using the Enzyme-Linked Immuno- Sorbent Assay (ELISA) method in the laboratory of Žiegzdriai mental hospital and after the results were obtained, endocrinology consultation was done to exclude thyroid diseases. 50

51 2.3. Statistical analysis The results are expressed as mean values; variability is indicated by SD and/or value range. All continuous data are represented as means (SD, standard deviation), all categorical data as numbers and percent. Frequency rates were compared by chi-square test or Fisher exact test. The correlation among variables was performed by using Pearson correlation coefficient, when normality assumption was satisfied, and for non-normal variables a Spearman correlation coefficient was used. Statistical analysis was started by assessment of normality of the data. Basic descriptive for each variable was calculated. Skewness of the thyroid hormone parameters and the Kolmogorov-Smirnov test was used to assess normality of the data: p<0.05 was considered to indicate a non-gaussian distribution. Values of SHBG concentrations showed a non-gaussian distribution, values of FT4 and FT3 concentrations showed a near normal distribution. SHBG was normalized using log transformation in order to use parametric tests. To compare the means in different conditions, t-test, and analysis of variance were used. Patients were divided according to gender and analyzed separately. Study I and II. General linear models for repeated measures, one way analysis of variance followed by Bonferroni post hoc pair-wise comparisons were used to explore the treatment effect on the thyroid axis hormone concentrations. For comparison of two groups, ANOVA will give results identical to a t-test. A p-value of <0.05 was considered as significant. Arbitrary normal limits of thyroid hormones reference range are chosen on the basis of the standard deviation for healthy persons. A normal reference range for the FT4 and FT3 concentrations during admission was established from serial data obtained from the 106 healthy blood donors in the study control group. Concentrations of free thyroid hormones were considered to be abnormal if they fell outside the mean +2 SD of the normal reference value. The normal reference intervals for the FT4 and FT3 were reported as mean ±2SD or 1SD of controls. The factor analysis of BPRS was performed using principal component analysis with the varimax procedure to rotate factors. The purpose of data reduction is to remove redundant (highly correlated) items from the BPRS, perhaps replacing the entire BPRS with a smaller number of uncorrelated items. To identify existence of relatively stable syndrome in BPRS a Principal-component analysis (PCA) was used to extract factors, the varimax 51

52 procedure to rotate factors, and the eingenvalue greater-than-one criterion to determine the number of factors. The loadings of 0.6 were considered "high" for Likert scale items. To interpret the factors, we focused on BPRS items with factor loadings 0.6 or greater. An eigenvalue 1 and clinical judgment determined the number of factors retained. Cronbach s coefficient alpha was used to determine the internal consistency of the factors by assessing the average correlation of items within the total factor score. For further analyses the factor score were saved as item average (item sum/item number). The Pearson correlation was calculated between changes of endocrine variables and changes of BPRS three factors components. Study III. Repeated measures ANOVA was used to test changes in symptom severity over time. A separate analysis was performed for each of the five clinical BPRS factors [96]. The time (randomization and end point) served as a within subject factor. If a significant time effect was detected, posthoc analyses were done to investigate the direction of changes. BPRS clinical factor scores for a particular factor were calculated as the linear sum of that factor divided by the number of items included in the factor. Data were analyzed with mixed two-way repeated measures analysis of variance (ANOVA) and treatment time (two point: randomization and the end of the study) and order of administration (risperidone plus T3 and risperidonr plus placebo) as fixed factors. The treatment time (two point: randomization and the end of the study) served as a within subject factor. The overall null hypothesis (placebo=t3) was tested for each outcome measured by using a continuous variable. If this null hypothesis was rejected, pairwise tests of the differences between treatments (T3 versus placebo) were performed with Student s t test with Bonferroni correction. A significance level of 0.05 was established. To rule out any possible confounding effect of other epidemiological variables (gender, age, risperidone dose, baseline score) we applied GLM Univariate ANCOVA. Continuous variables were compared by t tests and categorical variables by χ 2 tests. The Mann Whitney test was used to detect difference in median by groups. GLM univariate ANCOVA was used to test changes in severity of psychiatric symptoms assessed by BPRS over time and in score of each BPRS scale item. A separate analysis with covariates (gender, age, risperidone dose, baseline score) was performed for changes in each of the five clinical BPRS factors [96]. If significant time effect was detected, post hoc analyses were done to investigate the direction of changes. BPRS clinical factor scores for a particular factor were calculated as the linear sum of that factor divided by the number of items included in the factor. The linear regression analyses were used to examine whether gender, age, respiredone dose and baselin-randomization score predicted treatment 52

53 response. Three separate regression models were created for outcomes: treatment day, changes in total BPRS score and percentage. We conducted a multivariate analysis simultaneously to examine the adjusted relationship between outcomes and predictive covariates (gender, age, respiredone dose, baseline BPRS scores) and this set of variables was reduced by backward elimination until only those significant at p < 0.05 remained in the model. Base sample size calculation was made according to assumption about 5% estimated prevalence of patients with FT4 concentration over the mean +2SD of the normal reference value [40]. As a result, an estimated 73 patients per treatment group would provide a power of at least 0.80 to detect this prevalence with a 2-sided α = 0.05 All statistical analyses were performed using software from Statistical Package for Social Sciences 17.0 for Windows (SPSS, Inc., Chicago, Ill., USA). 53

54 3. RESULTS 3.1. Thyroid axis function in psychotic patients during hospital admission (Study I) Thyroid axis hormone concentrations in acute psychotic patients comparing to blood donor controls We obtained reference ranges for thyroid axis hormones concentrations from manufacturer s kit inserts. Of 106 healthy blood donors reference ranges of FT4, FT3 concentrations calculating them as mean ± 2SD (standard deviation) were evaluated. Normal ranges of FT4 concentrations for our study population were calculated as pmol/l and were in the range of the manufacturers kit inserts data ( pmol/l); normal values of FT3 concentrations were calculated as pmol/l and were higher than the range of the manufacturers kit inserts data ( pmol/l). As shown in Table , patients and controls presented quite similar values for FT3 and TSH concentrations. However, statistically significant differences were found for FT4 concentrations. Patients, whether as a total group (p=0.003) or subdivided by gender (p=0.015 for men, p=0.041 for women), presented higher FT4 concentrations than controls. With FT3 concentrations for patients about like those for controls, an increase in FT4 concentrations resulted in diminished ratios of FT3 to FT4. This effect was statistically significant for the total group of patients (p=0.004). When gender was considered the effect was significant in women (p=0.037), but not in men. Table Age and thyroid axis hormone concentrations in acute psychotic patients upon hospital admission versus blood donor controls (mean±sd) Age (years) Patients N=81 (M42 W39) Controls N=106 (M54 W39) On Way ANOVA All 36±11 34±13 F=1.3 p=0.25 Men 34±11 31±12 F=1.2 p=0.26 Women 38±10 37±13 F=0.0 p=0.97 Normal range a -- 54

55 Table continued FT3, pmol/l FT4, pmol/l FT3/FT4 ratio TSH, µiu/ml SHBG, nmol/l lnshbg Patients N=81 (M42 W39) Controls N=106 (M54 W39) On Way ANOVA All 5.1± ±0.8 F=0.7 p=0.35 Men 5.4± ±0.9 F=0.0 p=0.97 Women 4.8± ±0.7 F=0.6 p=0.35 All 17.9± ±2.2 F=9.1 p=0.003 Men 18.2± ±2.1 F=6.5 p=0.015 Women 17.6± ±2.2 F=4.1 p=0.041 All 0.29± ±0.05 F=8.0 p=0.004 Men 0.30± ±0.06 F=2.9 p=0.08 Women 0.28± ±0.05 F=4.5 p=0.037 All 1.60± ±0.7 F=3.2 p=0.07 Men 1.64± ±0.7 F=2.3 p=0.13 Women 1.57± ±0.8 F=0.7 p=0.41 Normal range a Men 41±17 34±14 F=6.2 p= Women 61±29 60±34 F=0.1 p= Men 3.6± ±0.4 F=5.5 p=0.020 Women 4.0± ±0.5 F=0.2 p=0.70 BPRS, Brief Psychiatric Rating Scale; FT3, free triiodothyronine; FT4, free thyroxin; TSH, thyroid stimulating hormone; SHBG, Sex hormone binding globulin; M, Men; W, Women a reference ranges for FT3 and FT4 were calculated as mean ± 2SD of controls; for TSH and SHBG - the reference range of the manufacturer s kit inserts Since SHBG concentrations normally vary substantially according to gender, we analyzed data from men and from women separately. Analysis revealed a novel finding. Concentrations of the SHBG were elevated in male patients (p=0.013) but not in female patients as compared to respective controls Prevalence of hyperthyroxinemia in acute psychotic patients during hospital admission comparing to blood donor controls All 106 control subjects and most of the 81 psychotic patients had FT4 concentrations within the normal manufacturer s ranges for the assays employed, but one female patient had a FT4 value bellow the normal limit and four (5%) other patients (two men and two women) had FT4 concentrations 55

56 above the normal limit. All study subjects had normal TSH concentration indicating euthyroidism. Thyroid hormone levels were considered elevated when patients' FT4 and FT3 concentrations exceeded the corresponding mean values for control subjects by more than two standard deviations. Such elevations of FT4 and/or FT3 concentrations occurred in 11 of 81 psychotic patients (13.5%) and in 8 (7.5%) of 106 controls subjects (Figures and ). Figure The spreadsheet showing distribution of FT4 versus TSH serum concentrations in acute psychotic patients. The solid lines show normal range, the dotted lines show the upper and lower limits of FT4 according mean ±2SD or ±1SD of controls When upper limit of normal ranges for FT4 and FT3 concentrations were considered arbitrarily as values that did not exceed 2SD above the mean of the control group, significant differences between patients and controls were found only for frequency of elevated FT4 concentrations. Nine (11.1%) of the 81 psychotic patients and four (3.8%) of the 106 controls showed level above the upper limit of the control range (Fisher exact test p=0.048), indicating hyperthyroxinemia (Figure ). FT3 concentrations were ele- 56

57 vated at same occasion in two (2.5%) patients and in four (3.8%) controls (Fisher exact test p=0.69) When upper limit FT4 and FT3 concentrations were considered arbitrarily as values that did not exceed 1SD above the mean of the control group, significant differences between patients and controls were found also only for frequency of elevated FT4 concentrations. FT4 was elevated in 25 (31%) patients and in 19 (18%) controls (χ 2 =4.3 p=0.039). FT3 was elevated at same point in 13 (16%) patients and in 14 (13%) controls (Fisher exact test p=0.67). Figure The spreadsheet showing distribution of FT3 versus TSH serum concentrations in acute psychotic patients. The solid lines show normal range, the dotted lines show the upper and lower limits of FT3 according mean ±2SD or ±1SD of controls There was no statistically significant difference in frequency of both FT4 and FT3 concentration values below mean-2sd and below mean-1sd value of controls between patients and controls (Figure ) 57

58 Thyroid axis hormone concentrations in psychotic patients upon hospital admission: effects of prior psychiatric medication use Having compared patients to controls, we next turned to comparisons between subgroups of patients. Firstly, we compared 42 patients who upon admission were taking a psychotropic drug (whatever the specific drug) to 39 patients who were not taking such a drug. We found no significant differences in any of the variables of interest (data not shown). Table Severity of psychoses and thyroid axis hormone concentrations in acute psychotic patients with and without current antipsychotic treatment upon hospital admission (mean±sd ) BPRS, score FT3, pmol/l FT4, pmol/l FT3/FT4 ratio TSH, miu/l SHBG, nmol/l No current antipsychotic use N=54 (M31 W23) Current antipsychotic use N=27 (M16 W11) On Way ANOVA All 38±9 40±6 F=1.6 p=0.22 Men 41±6 41±6 F=1.3 p=0.27 Women 35±10 38±8 F=0.0 p=0.97 All 5.1± ±0.9 F=0.5 p=0.82 Men 5.4± ±0.7 F=0.03 p=0.86 Women 4.7± ±1.0 F=0.51 p=0.48 All 18.4± ±2.8 F=4.4 p=0.039 Men 18.3± ±2.7 F=1.4 p=0.71 Women 18.5± ±2.7 F=4.7 p=0.037 All 0.28± ±0.05 F=3.2 p=0.077 Men 0.30± ±0.05 F=2.4 p=0.63 Women 0.26± ±0.06 F=4.8 p=0.035 All 1.54± ±0.85 F=9.1 p=0.34 Men 1.57± ±0.50 F=0.1 p=0.92 Women 1.49± ±1.02 F=1.7 p=0.21 Normal range a < Men 42±17 40±16 F=0.1 p= Women 66±31 55±24 F=1.3 p= lnshbg Men 3.6± ±0.4 F=0.1 p=0.77 Women 4.1± ±0.6 F=1.4 p=0.25 BPRS, Brief Psychiatric Rating Scale; FT3, free triiodothyronine; FT4, free thyroxin; TSH, thyroid stimulating hormone; SHBG, Sex hormone binding globulin; M, Men; W, Women a normal values for FT3 and FT4 were calculated as mean ± 2SD of controls; for TSH and SHBG - the reference range of the manufacturer s kit inserts 58

59 Then, as displayed in Table , we separated out the values for the 27 patients taking an antipsychotic drug and compared them to the values for the 54 patients not using an antipsychotic drug. Again, the telling variable was FT4. As a group patients using an antipsychotic had lower FT4 values than patients not taking an antipsychotic drug (F=4.4 p=0.039; age adjusted F=4.1 p=0.045). When gender was considered this effect was statistically significant in women (F=4.7 p=0.037; age adjusted F=4.6 p=0.04) but not in men. FT3/FT4 ratios changed accordingly (age adjusted for women F=4.9 p=0.034). In this set of comparisons, no significant differences were found in SHBG values. Severity of psychoses (according to BPRS) was similar in two groups of patients The Factor Structure of the Brief Psychiatric Rating Scale (BPRS) in acute psychotic patients When using Likert-type scales it is imperative to calculate and report Cronbach s alpha coefficient for internal consistency of the items in the BPRS. The Cronbach s alpha coefficient of internal consistency was determined by the number of items in the scale (18 items). Cronbach's alpha is 0.55, which indicates a moderate level of internal consistency for our scale with this specific sample. The item-total statistics table presents the Cronbach's alpha if item deleted in the final column, as shown below (Table ). We can see that removal of any item except five items: Somatic concern, Guilt feelings, Grandiosity, Depressive mood, Excitement, would result in a lower Cronbach's alpha. Removal of these five items would lead to a small improvement in Cronbach's alpha and we can also see that the corrected item-total correlation values were low (from to 0,084) for these items. This might lead us to consider whether we should remove this item. Reliability analysis of remained 13 items shows Cronbach s alpha 0.71, and removal of three items Motor retardation, Unusual thought content and Disorientation also would lead to improvement in Cronbach alpha to It should also be noted that while a value 0.73 for Cronbach s alpha indicates good internal consistency of the remained 10 items in the scale, it does not mean that the scale is unidimensional. Factor analysis is a method to determine the dimensionality of a scale. Table shows the rotated solution of the principal component analysis (PCA). PCA resulted in 3 interpretable factors accounted for 61.3% of the total variance. Kaiser-Meyer-Olkin measure of sampling adequacy is Bartlett's test of sphericity is a statistical test for the presence of corre- 59

60 lation among the variables. For this data, Barlett s test is highly significant (χ 2 = 256.3; p<0.001), and therefore factor analysis is appropriate. Table Item-Total Statistics of BPRS BPRS item Corrected Item-Total Correlation Cronbach's Alpha if Item Deleted Somatic concern Anxiety Emotional withdrawal Conceptual disorganization Guilt feelings Tension Mannerisms and posturing Grandiosity Depressive mood Hostility Suspiciousness Hallucinatory behavior Motor retardation Uncooperativeness Unusual thought content Blunted affect Excitement Disorientation The first factor (accounted for 21.5% of the variance) has high loadings from Hostility, Uncooperativeness and Mannerism and posturing. The second factor (20.7%) is strongly positively associated with Hallucinatory behavior, Suspiciousness, Emotional withdrawal, and Blunted affect. The third factor (19.1%) is strongly associated with Anxiety, Tension, and Conceptual disorganization. We named factor 1 Hostility component, factor 2 Thought disturbance/withdrawal component, factor 3 Anxiety/Tension component. Cronbach's alpha measures show how well a set of items measures a single unidimensional latent construct. All factors demonstrated adequate reliabil- 60

61 ity. Cronbach s alpha standardized values for the factors ranged from 0.61 to 0.7. Table BPRS (10 item) factor pattern loadings (Principal component analysis, Varimax rotation) Component BPRS item Communalities Hostility Thought disturbance/withd rawal Anxiety/ Tension Hostility Uncooperativeness Mannerism and posturing Emotional withdrawal Hallucinatory behavior Suspiciousness Blunted affect Anxiety Tension Conceptual disorganization % of variance (total 61.3%) Cronbach s alpha Extraction Method: Principal Component Analysis Rotation Method: Varimax with Kaiser Normalization Loadings <.5 are not showed for clarity An association between thyroid axis hormone concentrations and severity of psychiatric symptoms in acute psychotic patients during hospital admission For further analyses the factor score were saved as item average (item sum/item number). Item average of Hostility factor decreased with age in the female patients (r= 0.37; p=0.022). Item average of Thought disturbance/withdrawal factor and Anxiety/Tension factor was positively associated with female gender (r=0.28; p=0.011 and r=0.23; p=0.040 respectively), but not male gender. Item average of Thought disturbance/withdrawal 61

62 factor alone was positively associated with duration of hospitalization (r=0.23; p=0.037) (Table ). We sought to discover correlations between endocrine measurements in the patient group and mental symptoms. In fact, there were no correlations between any endocrine measurement and total BPRS scores. However, certain correlations did emerge between certain endocrine measurements and BPRS factors. Table Significant correlations of BPRS factors Age, year Gender: 1, men; 2, women Duration hospitalization, day of Hostility factor Thought disturbance/withdrawal factor Anxiety/Tension factor M W M W M W 0.37 p= p= p= p=0.037 FT4>21.2 pmol/l a 0.35 p=0.025 FT3/FT4 ratio TSH, miu/l SHBG, nmol/l 0.33 p= p= p= p= p=0.043 FT3, free triiodothyronine; FT4, free thyroxin; TSH, thyroid stimulating hormone; SHBG, Sex hormone binding globulin a FT4 > (mean+2sd) of control In male patients FT3/FT4 ratio and the elevated FT4 concentrations (> mean+2sd of control) were positively correlated with item average of the Anxiety/Tension factor (r=0.31; p=0.043 and r=0.35; p=0.025 respectively). In female patients TSH concentrations negatively correlated with item average of the Hostility factor (r= 0.38; p=0.019) (Table ). 62

63 Figure Relationship between scores on the factor 2 and SHBG on admission; scatterplot and regression lines of SHBG and factor 2 correlated values Factor 2 of BPRS, Thought disturbance/withdrawal factor An increasing level of SHBG concentrations in female patients and a decreasing level in male patients was positively correlated with item average of the Thought disturbance/withdrawal factor (r=0.35; p=0.031 and r= 0.34; p = 0.029, respectively). A two factor ANOVA with a significant interaction (factor X gender) is demonstrated in a graph with non parallel lines in Fig Thyroid axis function during in-patient treatment of acute psychotic episode (StudyII) Thyroid axis hormone concentrations before and after acute psychotic episode treatment with antipsychotics During admission to the hospital, before acute psychotic episode treatment, all patients were found to be euthyroid with normal TSH concentrations; however, 10 (11%) patients had elevated FT4 concentrations indicat- 63

64 ing hyperthyroxinemia and four (4%) patients had elevated FT3 concentrations and two (2%) lower than reference range FT3 concentrations. After acute psychotic episode treatment with antipsychotics a significant decrease in BPRS scores as well as significant changes in thyroid axis hormone concentrations and in SHBG concentrations were found in study patients. As shown in the Table , mean FT3 concentrations that did not differ from controls before treatment decreased after treatment (p<0.001) and became significantly lower compared to controls (p<0.001). Table Psychiatric symptoms and hormone concentrations a in acute psychotic in-patients before and after treatment (N=93) and in blood donor controls (N=115) BPRS, score FT3, pmol/l FT4, pmol/l TSH, miu/l Before N=93 M45W48 Treatment After N=93 M45W48 Controls N=115 M67W48 Repeated measures ANOVA vs. 2 All 38±8 19±6 F=815 p<0.001 Men 37±9 18±7 F=329 p<0.001 Women 41±6 19±5 F=522 p<0.001 All 5.1± ± ±0.9 F=26.9 p< :2 Men 5.5± ± ±0.9 F=11.9 p= :2 Women 4.8± ± ±0.7 F=14.8 p< :2 All 17.8± ±0,3 16.8±2.3 F=11.2 p= :1 Men 18.4± ± ±2.3 F=9.3 p= :1 Women 17.2± ± ±2.2 F=2.82 p=0.10 ns All 1.79± ± ±0.7 F=6.6 p= :1,2 Men 1.59± ± ±0.7 F=12.5 p= :2 Women 1.97± ± ±0.8 F=1.7 p=0.19 3:2 lntsh All 0,41±0,61 0,56±0,69 0,21±0,59 F=4,8 p=0,031 3:1,2 SHBG, nmol/l Men 40±16 38±19 34±13 F=1.2 p=0.28 3:1 Women 62±27 53±29 58±33 F=6.2 p=0.016 ns BPRS, Brief Psychiatric Rating Scale; FT3, free triiodothyronine; FT4, free thyroxin; TSH, thyroid stimulating hormone; SHBG, Sex hormone binding globulin; M, Men; W, Women a Mean ± SD b p< vs. 1and/or 2; euthyroid controls (3) vs. psychotic patients before (1) and/or after (2) treatment p b 64

65 Mean FT4 concentrations also decreased significantly (p=0.001) after antipsychotic treatment; however, in contrast to FT3 concentrations, FT4 concentrations were increased before treatment (p=0.01), and after treatment they did not differ from controls. In parallel, as it is shown in Figure , prevalence of lower than reference range FT3 (<3.5 pmol/l) concentrations significantly increased (p=0.01) while the prevalence of hyperthyroxinemia decreased (p=0.16) after acute psychosis treatment. After treatment with antipsychotics in 88 (95%) patients TSH concentrations remained in euthyroid range but in five patients TSH concentrations increased above normal range (>4.05 miu/l) suggesting possible hypothyroidism; however, FT3 and FT4 concentrations in those five patients remained normal. TSH concentrations in total group increased significantly after acute psychosis treatment (p=0.031).mean SHBG concentrations were higher compared to controls before treatment (significantly in men, p=0.017), but decreased after treatment (significantly in women, p=0.016) and were similar to controls. 100% 100% 75% 75% 50% % % 25% 0% 11 4 Before treatment N=93 Hyperthyroxinemia After treatment N=93 Normal FT4 0% 2 Before treatment N=93 Low FT3 14 After treatment N=93 Normal FT3 Fisher exact p=0.16 Fisher exact p=0.010 Figure Prevalence of hyperthyroxinemia (FT4>21.2 pmol/l) and lower FT3(<3.5 pmol/l) in acute psychotic patients before and after inpatient treatment 65

66 Associations between changes in thyroid axis hormone concentrations and changes in severity of psychotic symptoms We found no significant associations between baseline hormone concentrations and improvement in psychotic symptoms, but change in FT4 concentrations negatively correlated with baseline BPRS score (r= 0.3; p=0.003) and with change in BPRS score (r= 0.235; p=0.023) (Table ). These associations remained significant after controlling for age and gender. Change in TSH concentrations correlated negatively with change in SHBG concentrations (r= 0.209; p=0.044), and positively with change in FT3 concentrations (r=0.297 and p=0.004). Table Correlations between changes of endocrine measurements and changes of psychiatric symptoms during acute psychosis treatment TSH (0.36) Pearson correlation coefficient (p value) FT4 FT3 SHBG BPRS BPRS 0.297* (0.004)* FT (0.50) 0.209* (0.044) (0.19) FT (0.27) (0.43) 0.235* (0.023) (0.68) SHBG (0.64) (0.74) 0.3* (0.003) (0.56) (0.89) BPRS, Brief Psychiatric Rating Scale; FT3, free triiodothyronine; FT4, free thyroxin; TSH, thyroid stimulating hormone; SHBG, Sex hormone binding globulin * associations remain significant after controlling for age, gender Factors predicting changes in thyroid axis hormone concentrations and changes in psychiatric symptoms during acute psychotic episode treatment The regression analyses revealed significant associations between baseline hormone concentrations and change in their concentrations after antipsychotic treatment. In linear model baseline FT4 concentrations and baseline FT3 concentrations predicted about 40% of their change (Figure ). It is interesting to mention that treatment with antipsychotics caused not only a decrease in higher FT3 or higher FT4 concentrations, but also an increase in lower FT3 or lower FT4 concentrations. 66

67 Figure Associations between pre-treatment baseline FT3, FT4 and TSH concentrations and post-treatment change in FT3 ( FT3), FT4 ( FT4) and TSH ( TSH) concentrations 67

68 Less significant association was found between baseline TSH concentrations and change in TSH concentrations (predicting 12% of change) after acute psychotic episode treatment (F=12.9 p<0.001) (Fig ). In both linear and quadratic analysis the associations between basal SHBG concentrations and change ( ) in SHBG concentrations after acute psychotic episode treatment were not significant in male patients (F=1 p=0.32 and F=1.7 p=0.19, respectively). In female patients basal SHBG concentrations predicting 14% of SHBG concentrations changes (F=7.2 p=0.010) (Fig ). Figure Associations between pre-treatment baseline SHBG concentrations and post-treatment changes in SHBG ( SHBG) concentrations according to gender Gender, age, duration of hospitalization, durations of the disease, psychosis episode (first time psychosis or psychosis relapse), baseline hormones 68

69 concentrations and baseline BPRS scores, treatment with concomitant antidepressants and benzodiazepines medications in BPRS, each thyroid hormone and SHBG change ( BPRS, FT4, FT3, TSH and SHBG) were identified through multivariate regression analyses. We conducted a multivariate analysis simultaneously to examine a relationship between hormonal concentrations changes, psychiatric symptoms changes (outcome variable) and predictive covariates (gender, age, duration of hospitalization, psychosis episode, duration of the disease, concomitant antidepressants, benzodiazepines use, baseline hormones concentrations and baseline BPRS scores). In addition, in unvariate analysis the FT3 was significantly correlated with baseline TSH (r=0.226, p=0.029) and the SHBG was significantly correlated with baseline FT3 (r= 0.263, p=0.011). The outcome variables in the analysis were the magnitudes of FT3, FT4, TSH, SHBG and BPRS and the results are shown in Table Table Adjusted coefficients for factors simultaneously included in a multivariate linear regression model with thyroid axis hormones, SHBG and BPRS changes as the outcome variable Factor Dependent variable (DV) Standardized regression coefficient β (p) FT3 FT4 TSH SHBG BPRS Gender (1, men; 2, women).284** Age, year Hospitalization, day Psychosis episode * Duration of the disease, year.231* ** Antidepressants Benzodiazepines Baseline BPRS.173*.203* *** Baseline level of DV, respectively.733***.614***.358**.316** Baseline TSH a.011 Baseline FT3 b.269* Model: R F, p value 10.2 <0.001 *** p<0.001; ** p<0.01; * p<0.05; + p< , < <0.001 a baseline TSH included in model for FT3; b baseline FT3 included in model for SHBG. 69

70 A significant model showed significant adjusted associations with FT3 concentrations for gender (p<0.001), baseline FT3 (p<0.001), duration of hospitalization (p<0.05), baseline BPRS score (p<0.05) and a close significant (p<0.1) association with age. FT4 concentrations showed significant adjusted associations for baseline FT4 (p<0.001), baseline BPRS score (p<0.05), and for psychosis episode (p<0.05). TSH concentrations showed significant adjusted associations only for baseline TSH (p<0.01). SHBG concentrations show significant adjusted associations for its baseline concentration level (p<0.01) and baseline FT3 (P<0.05). BPRS showed significant adjusted associations for duration of disease (p<0.01) and baseline BPRS score (p<0.001). In this model the inclusion of all predictive covariates explained 46-50% of the total variation of FT3, FT4 concentrations change and BPRS scores change during acute psychosis treatment The direction and magnitude of thyroid axis hormone concentrations changes during acute psychotic episode treatment with antipsychotics Taking into account the baseline FT4 concentrations divided in tertiles, the direction and magnitude of FT4 change during recovery indicated that lower and higher FT4 concentration inversely responded to antipsychotic treatment (F=23.1 p<0.001) (Fig ). Fig The direction and magnitude of FT4 concentrations change after acute psychotic episode treatment according to baseline FT4 concentrations divided in tertiles 70

71 Mixed-model for repeated data revealed that the main effect during psychosis treatment on FT4 concentrations was significant for both gender patients, with significant interaction [treatment x tertiles] (men: F=9.9, p=0.003, interaction F=23, p<0.001; women: F=6.6 p=0.013; interaction F=8.3 p=0.001). Figure demonstrates decreasing higher FT4 concentrations to middle range value during recovery in male patients but not in female patients; and baseline lower FT4 concentrations increased to middle range values in both gender groups. Fig FT4 concentrations means in men and women psychotic patients during acute psychotic episode treatment according to baseline FT4 concentrations divided in tertiles (open circle before treatment, closed circle after treatment) The results of comparisons among tertiles in treatment before and after by General Linear Model univariate ANOVA showed a significant effect on FT4 for treatment in the first (p=0.08) and third (p<0.001) tertile of baseline FT4 concentration, but not in the second tertile in males (p=0.29). A significant decrease of FT4 concentration but lower compared with males was established in second (p=0.002) and third (p=0.005) tertiles in females (Figure ). The direction and magnitude of FT3 concentration change during acute psychosis treatment indicated that middle and higher FT3 concentration significant substantially responded to antipsychotic treatment than lower baseline FT3 concentrations (F=23.1 p<0.001) (Fig ). The results of GLM univariate ANOVA showed a significant effect on FT3 for treatment time (before after) only in the third (p<0.001) tertile of baseline FT3 concentration (p<0.001). 71

72 Fig The direction and magnitude of FT3 concentrations change after acute psychotic episode treatment according to baseline FT3 concentrations divided in tertiles Figure demonstrates a significant decrease in FT3 concentrations during recovery in both gender groups, but in male patients only highest baseline FT3 decreased (p<0.001); in female patients middle (p=0.038) and highest (p=0.001) baseline FT3 concentrations decreased (Figure ). Fig FT3 concentrations means in male and female psychotic patients during acute psychotic episode treatment according to baseline FT3 concentrations divided in tertiles (open circle before treatment, closed circle after treatment) 72

73 3,0 TSH, miu/l 2,5 2,0 1,5 1,0 p=0,003 p=0,43 p=0,036 0,5 1 2 baseline TSH tertile Fig The direction and magnitude of TSH concentrations change after acute psychotic episode treatment according to baseline TSH concentrations divided in tertiles (open circle before treatment, closed circle after treatment) The direction and magnitude of TSH concentration change after acute psychotic episode treatment according to baseline TSH concentrations divided in tertiles indicated that only lower (first tertile) and middle (second tertile) TSH concentrations significantly increased after antipsychotic treatment (F=10.4 p=0.003 and F=4.9 p=0.036, respectively). Higher baseline TSH concentrations decreased after treatment, but not significant (F=0.64 p=0.43) (Fig ). It is interesting to mention that treatment with antipsychotics caused only an increase in lower and medium TSH concentrations. 3 Fig The magnitude of FT4 concentration change during acute psychotic episode treatment according to baseline BPRS scores divided in tertiles 73

74 The effect of baseline BPRS scores tertiles (0 38, and >43) on magnitude of changes in FT4 concentration was significant (F=3.2 p=0.045) with higher mean in first tertile of BPRS score compared to the third tertile (p=0.010) (Fig ). Figure Association between baseline BPRS scores according to tertiles (0 38, and >43) and FT4 concentration means during acute psychotic episode treatment in men and women psychotic patients (open circle before treatment, closed circle after treatment) A 3 (BPRS scores tertiles) x 2 (before - after treatment) mixed-model for the repeated measures ANOVA showed that there was a significant main effect on FT4 for treatment (F=6.4, p=0.012) in men and close statistical significant (F=3.1, p=0.07) in women. Figure Association between baseline BPRS scores according to tertiles (0 38, and >43) and FT3concentration means during acute psychotic episode treatment in men and women psychotic patients (open circle before treatment, closed circle after treatment 74

75 Gender specific analyses showed that FT4 decreased significantly in first baseline BPRS tertile in male patients (F=10.2 p=0.005), but not in female patients (F=1.8 p=0.21). Females tended to have a higher decrease of FT4 in the mid tertile of BPRS score (p=0.07) (Figure ). The effect of baseline BPRS scores tertiles on magnitude of changes in FT3 concentration ( FT3) was not significant (F=1.3 p=0.26). Gender specific analyses showed that FT3 decreased significantly in first and second baseline BPRS tertile in male patients (F=6.6 p=0.018 and F=8.7 p=0.013 respectively) and decreased in all BPRS tertiles in female patients. (Figure ) Acute psychosis treatment with different antipsychotics, neither typical nor atypical did not reveal any specific differencies in FT4, FT3 and TSH concentrations changes Sex hormone binding globulin (SHBG) concentrations during inpatient treatment of acute psychotic episode (Study II) Sex hormone binding globulin concentrations before and after acute psychotic episode treatment with antipsychotics During admission to the hospital, according to the reference range, four (8%) female patients had decreased SHBG concentrations and four (8%) female patients had elevated SHBG concentrations; also three (7%) male patients had decreased SHBG concentrations and two (4%) male patients had elevated SHBG concentrations (Fig ). 100% 80% 60% 40% 8 84 Women % 80% 60% 40% Men Elevated Normal Decreased 20% 0% 8 Before treatment 18 After treatment 20% 0% 7 Before treatment 16 After treatment Fig Distribution of psychotic patients according to SHBG reference range before and after acute psychotic episode treatment 75

76 After acute psychosis treatment with antipsychotics eight (18%) female patients had elevated SHBG concentrations and only one (2%) had decreased SHBG concentrations; seven (16%) male patients had decreased and two (4%) males elevated SHBG concentrations. A reduction in the SHBG concentrations form baseline score after acute psychosis treatment varied from 2% to 55% in 56 percent of male patients, and from 2% to 90% in 67 percent of female patients. The reduction of SHBG concentrations >20% was established in 54% of female and 33% male patients. In 44% of male patients and in 33% of female patients SHBG concentrations increased after treatment. The level of the SHBG out of the total patients group and out of both gender subgroups are presented in Table In the entire sample, a repeated-measures analysis of variance revealed that the treatment produced a significant decrease in SHBG concentrations (age and gender adjusted F=3.9 p=0.005). There were no significant interactions between gender and occasions of measures. There were gender related differences in the treatment effects on SHBG concentrations. Significantly decreased SHBG concentrations were found in antipsychotic treated female patients, but not in male patients: effect of occasion (F=6.2; p=0.016) and (F=1.2; p=0.28) respectively. The mean percentage change in SHBG concentrations compared with ba-seline in female and male patients was 10.3% (95% CI= 0.5%; 21.1%) and 5% (95% CI= 3.3%; 13.4%) respectively (F=0.5 p=0.44 between gender) The direction and magnitude of thyroid axis hormone concentrations changes during acute psychotic episode treatment with antipsychotics The direction and magnitude of SHBG concentrations change after acute psychotic episode treatment with antipsychotics according to baseline SHBG concentrations divided in tertiles indicated that significantly decreased only higher (third tertile) SHBG concentrations in women (F=5.4 p=0.003) but not in men (Fig ). 76

77 Fig SHBG concentrations changes in men and women psychotic patients during acute psychotic episode treatment according to baseline SHBG concentrations divided in tertiles It is interesting to mention that treatment with antipsychotics caused only a decrease in higher SHBG concentrations in female patients Associations between changes in sex hormone binding globuline concentrations and changes in severity of psychotic symptoms before and after acute psychotic episode treatment with antipsychotics Forty four (47%) patients were assigned to treatment with typical antipsychotic haloperidol; other patients were treated with different typical and atypical antipsychotics. Patients on haloperidol experienced a greater SHBG decrease (in percent from baseline) than patients on other antipsychotics (treatment effect F=3.1 p=0.08) 14% (95% CI, 4%; 24%) and 2% ( 7%; 77

78 16%) respectively). Separately, for male and female patients, a decrease in SHBG concentrations in patients on haloperidol was greater than the SHBG response seen with other antipsychotics, but was no statistically significant (male: F=2.8 p=0.09; female: F=0.8 p=0.37). As a treatment response, reduction in the total BPRS baseline score varied from 19% to 81%; in a range from 19% to 50% in 46 percent of patients, in a range from 50% to 70% in 42 percent of patients, and in a range from 70% to 81% in 12 percent of patients. Average scores of the BPRS are shown in Table Table BPRS scores of acute psychotic patients before and after acute psychotic episode treatment BPRS, mean (SD) (range) Before treatment b All, N= (7.8) (16-53) Men, n= (8.7) (16-53) After treatment 18.8 (6.1) (4-36) 18.2 (7.1) (4-36) Repeated ANCOVA Adjusted model F=30.5; p<0.001 F=8.6; p=0.005 SHBG: F=5.4; p=0.025 Duration of hospitalization: F=5.6; p=0.022 Women, n= (6.4) 19.4 (5.0) (27-52) (6-31) F=22.1; p<0.001 a adjusted for age, duration of hospitalization, SHBG concentrations on admission b adjusted for all previous and gender BPRS scores on two occasions (on admission and on discharge) remarkably differed in male and female patient groups in univariate analysis (F=329 p<0.001 and F=522 p<0.001 respectively); and in multivariate analysis when age, duration of hospitalization and SHBG concentrations on admission were included as co-variants (F=8.6; p=0.005 and F=22; p<0.001, respectively). The repeated-measures analysis of covariance revealed that the change in BPRS total score during acute psychotic episode treatment in men associated with baseline SHBG concentration (F=5.4 p=0.025) and with duration of hospitalization (F=5.6 p=0.022) (Table ). BPRS scores on discharge in male patients negatively correlated with baseline SHBG concentrations (r= 0.31, p=0.36) and positively correlated with duration of hospitalization (r=0.29, p=0.049). 78

79 Fig Mean of SHBG concentrations according to BPRS tertiles during admission as a function of treatment in male and female patients (open circle before treatment, closed circle after treatment) After division the patients into tertiles according to disease severity measured by BPRS (0 38, and >43) one tertile of psychotic female patients (39 43) had significantly lower SHBG concentrations after treatment than other tertiles (F=7.9; p=0.02) (Fig ) The effects of adjuvant treatment with L triiodthyronine (T3) on acute schizophrenia treatment with risperidone (Study III) The efficacy of adjuvant treatment with T3 on acute schizophrenia treatment with risperidone All 32 patients during study treatment period received oral risperidone (RIS) for the acute schizophrenia treatment and psychiatrist was free to increase RIS dose (2 8 mg/day) or add benzodiazepine, hypnotic or anticholinergic medication if needed. Random 14 patients received adjuvant treatment with T3 and random 18 patients received adjuvant treatment with Placebo (PLB). The patients, who received adjuvant T3 treatment at randomization, had higher BPRS scores (F=5.3 p=0.028) but similar CGI S scores compared to patients who received adjuvant PLB. Therefore, all treatment effects were statistically adjusted for randomization (baseline) BPRS score (Table ). 79

80 Table The baseline clinical characteristics of treatment groups Treatment group* RIS+T3 N=14 RIS+PLB N=18 Men, n (%) 7 (50) 10 (56) Age, years 46±13 38±12 p=0.066 BPRS at randomization, score 58±8 53±5 F= 5.3 p=0.028 CGI-Severity at randomization, n (%) (4) Moderately ill 1 (7) 3 (17) (5) Markedly ill 13 (93) 15 (83) BPRS, Brief Psychiatric Rating Scale; RIS+PLB, risperidone plus placebo; RIS+T3, risperidone plus T3; *Values are mean ± SD unless otherwise specified; p value difference between percentages using Fisher s Exact test, otherwise using ANOVA; ns, differences between RIS+PLB and RIS+T3 groups were not significant at p<0.1 All 32 study patients during the end of the study visit met treatment response criteria and were considered as mildly ill (CGI S score 3) (Table ). Table The end of the study characteristics of treatment groups Treatment group* RIS+T3 N=14 RIS+PLB N=18 BPRS, end of the study, score 34±4 37± CGI-Severity, end of the study, n (%) ns (3) Mildly ill 14 (100) 18 (100) CGI-Improvement ns (1) Very much improved, n (%) 14 (100) 16 (89) (2) Much improved, n (%) 0 2 (11) Risperidone dose, mean ± SD mg 5.57± ±1.37 ns Concomitant medication, n (%) Lorazepami 14 (100) 17 (94) ns Zolpidemas 7 (50) 7 (39) ns Trihexyphenidyli 7 (50) 13 (72) ns RIS+PLB, risperidone plus placebo; RIS+T3, risperidone plus T3; p value difference between percentages using Fisher s Exact test, otherwise using ANOVA; ns, differences between RIS+PLB and RIS+T3 groups were no significant at p<0.1 p ns p 80

81 The BPRS scores at end of the study did not differ between treatment groups. Univariate ANOVA on BPRS scores at end of the study yielded a main effect of treatment condition (F=3.8; p=0.06). Similarly, the GLM univariate analysis of covariance at end of the study on BPRS scores, with age, gender, risperidone dose and randomization BPRS score as covariates did not produce any additional significant effect (Fig ). The repeated-measures analysis of covariance conducted on the BPRS scores before and at the end of the study yielded a main effect of response to treatment time on BPRS (F=282, p<0.001) and a significant interaction between treatment group and response to treatment time on the BPRS scores (F=13.1, p=0.001) that demonstrated different reduction in the BPRS score over response to treatment time in treatment groups (Fig ) p=.028 BPRS score placebo T3 35 p= Randomisation Study end Treatment time Fig Interaction between treatment group (placebo vs. T3) and treatment response time on BPRS scores p value significance of differences between group at treatment time point Patients who received treatment with RIS+T3 required a significantly shorter duration of response to treatment than did RIS+PLB group [32 (95% CI, 21 36) vs. 26 (95% CI, 22 29) hospital treatment days; p=0.022] (Fig ). Patients on RIS+T3 during treatment period showed close to a significant (p=0.053) greater improvement according to change in the BPRS score and a greater (p=0.048) BPRS score decrease in percent from randomization score than patients on RIS+PLB (treatment effect F=13.1 p=0.001) (Fig ). There were no significant differences between groups according to CGI Improvement scale scores. 81

82 , , ,2 17,5 p=0.048 p=0.022 p=0.053 Treatment time, day delta BPRS, score delta BPRS, % Risperidone + T3 Risperidone + placebo Fig Response to treatment time in days and changes of BPRS according to placebo and T3 groups, adjusted for gender, age, risperidone dose and baseline BPRS score (mean, 95% CI) Table Adjusted coefficients for factors simultaneously included and using backward elimination in a multivariate linear regression model with adjuvant T3 treatment response variables as outcomes Multivariate regression, dependent variable (DV) Standardized regression coefficient, β (p) Factor Gender (1, men; 2, women) Response time (0.30) Age, year (0.13) Baseline BPRS Risperidone dose Adjuvant treatment with T (0.47) (0.15) (0.022) Simultaneously included BPRS (0.49) (0.24) < (0.92) BPRS, % (0.44) (0.17) (0.006) (0.76) (0.048) Response time (0.010) Backward elimination BPRS (<0.001) (0.014 BPRS, % (0.005) (0.011) Model: R F p value < < < <

83 Regression analyses (backward selection) (Table ) revealed that adjuvant treatment with T3 (β=0.28 t=2.6 p=0.010) and baseline BPRS score (β=0.68 t=6.3 p<0.001) predicted about 69% of the change in BPRS score ( BPRS) (Model F=34.7 p<0,001 R 2 =68.5; adjusted for gender, age, RIS dose and baseline BPRS score). Therefore RIS+T3 combination was superior to RIS+PLB according to changes in BPRS scores during acute psychotic episode treatment in schizophrenia patients. Duration of hospital treatment was predicted by adjuvant treatment group (β= 0.45 t= 2.76 p=0.010; model F=7.6 p<0,010; R 2 =0.18) after controlling for gender, age, RIS dose and baseline BPRS score. Therefore RIS+T3 combination was superior to RIS+PLB according to response time to acute psychotic episodes treatment in schizophrenia patients. We compared the efficacy of adjuvant treatment according to mean of the change in BPRS total score ( BPRS), in changes of BPRS items scores and in changes of BPRS factors during treatment response period (Table ). Table Adjusted changes in BPRS total score ( BPRS), in BPRS items scores and in factors scores at the end of study, between treatment groups BPRS Adjusted changes score at endpoint T3 versus Placebo GLM univariate ANCOVA* RIS+T3 RIS+PLB F Sig. BPRS Somatic concern Anxiety Emotional withdrawal Conceptual disorganization Guilt feelings Tension Mannerisms and posturing Grandiosity Depressive mood Hostility Suspiciousness Hallucinatory behavior Motor retardation Uncooperativeness Unusual thought content Blunted affect Excitement Disorientation

84 Table continued BPRS Adjusted changes score at endpoint T3 versus Placebo GLM univariate ANCOVA* RIS+T3 RIS+PLB F Sig. BPRS factors Thinking disorder Anergia Anxiety/depression Hostility/ Suspiciousness Activity RIS+PLB, risperidone plus placebo; RIS+T3, risperidone plus T3 *Covariates: gender, age, risperidone dose and baseline BPRS item/factor score respectively Patients treated with RIS+T3 combination showed not only close to a significant greater improvement according to change in the BPRS score but also a significant greater improvement in several BPRS items. The study revealed that RIS+T3 combination was superior on the Somatic concern (p=0.028), on the Conceptual disorganization (p=0.021), on the Grandiosity (p=0.022), on the Hostility (p=0.020), on the Uncooperativeness (p=0.016), and on the Excitement (p=0.022) items scores. Only change in Disorientation item scores was less in RIS+T3 group compared to RIS+PLC group (p=0.011). A significant greater improvement in RIS+T3 treatment group also was found in the BPRS factors: Thinking disorder (p = 0.001), Hostility/ Suspiciousness (p=0.001) and close to significant in Anxiety/depression (p=0.057) scores during treatment period (Table ) The safety of RIS+T3 combinations during acute schizophrenia treatment All 32 patients fully completed all study treatment period. There were no drop outs and serious adverse events during the study. Electrocardiography (ECG), blood and urine tests were performed at both occasions, and all the ECG and lab results were within normal rage. There were no significant differences in the frequency of adverse effects reported by the RIS+T3 or RIS+PLB treatment groups, including those that might be expected to be more frequent in the patients treated with T3, such as palpitations, sweating, nervousness and tremor. All adverse effects observed by physician and reported by the patients are shown in Table

85 Table Adverse events recorded during the treatment period Adverse events RIS+T3, n (%) n =14 RIS+PLB, n (%) n = 18 Palpitations 11 (78.6) 14 (77.8) Sweating 8 (57.1) 7 (38.9) Nervousness 6 (42.9) 5 (27.8) Tremor 7(50) 13(72.2) Akathisia 3(21.4) 2(11.1) Nausea 1 (7.1) 0 (0) Headache 5 (35.7) 8 (44.4) Somnolence 9 (64.2) 8 (44.4) Insomnia 7 (50) 7 (38.9) Dry mouth 13 (92.9) 18 (100) Fatigue 2 (14.3) 4 (22.2) Irritability 5(35.7) 7(38.9) Restlessness 3(21.4) 6(33.3) Agitation 2(14.3) 2(11.1) Hostility 4(28.6) 2(11.1) Using Fisher s Exact test; all differences between RIS+PLB and RIS+T3 groups were not significant at p<0.1 Lorazepam was used for agitation, irritability, restlessness or hostility; zolpidem for insomnia and trihexyphenidyli for the tremor treatment. Table Concomitant medication use during treatment period Concomitant medication RIS+T3, mean (SD) RIS+PLB, mean (SD) p Mann-Whitney test Lorazepami 3.00 (1.33) 3.61 (1.35) 0.21 Zolpidem 5.00 (5.19) 3.89 (5.02) 0.64 Trihexyphenidyli 1.43 (1.6) 2.56 (1.7) 0.09 RIS+PLB, risperidone plus placebo; RIS+T3, risperidone plus T3; Mean dose of RIS was similar in two groups There were no significant differences in frequency (Table ) and magnitude of dose (Table ) of concomitant medication in two treatment groups. 85

86 The effect of RIS+T3 combination on thyroid axis function during acute schizophrenia treatment Patients in RIS+T3 treatment group during randomization visit had significant lower FT4 concentrations (F=9.4 p=0.004) than patients in RIS+PLB treatment group, with no differences in TSH, FT3 and SHBG concentrations. Each of the 4 repeated-measures analyses of covariance conducted on the measures (FT3, FT4, TSH and SHBG concentrations) evaluated before and after study treatment period yielded a main effect of assessment time on FT4 (F=9.4, p=0.004) and TSH concentrations (F=9.9, p=0.004) and a significant interaction between treatment group and assessment time on TSH (F=30.2, p<0.001) and on SHBG concentration in men (adjusted for age and TSH F=5.1, p=0.042). Paired t tests indicated that over the treatment time, in the RIS+T3 group there was a significant decrease in TSH concentrations (t=6.5 p<0.001) (Fig ). At baseline and at the end of study TSH concentrations were 1.72 ± 0.92 and 0.51±0.5 miu/l respectively (Table ). Table Thyroid axis hormone concentration at randomization (baseline) and at the end of the study visit Variable RIS+T3 group Baseline The end of the study Repeated measures ANOVA FT3, pmol/l 5.19 ± ± 1.26 F= 0.8 p=0.39 FT4, pmol/l ± ± 5.53 F= 2.2 p=0.17 TSH, miu/l 1.72 ± ± 0.5 F=42.3 p<0.001 Men-SHBG, nmol/l 55±29 69±22 F=1.7 p=0.24 Women SHBG, nmol/l 57±30 66±29 F=4.9 p=0.06 RIS+PLB group FT3, pmol/l 4.73 ± ± 0.63 F= 1.9 p=0.19 FT4, pmol/l ± ± 2.90 F= 11.5 p=0.004 TSH, miu/l 1.33 ± ± 1.14 F=2.7 p=0.12 Men-SHBG, nmol/l 46±21 39±21 F=2.3 p=0.17 Women- SHBG, nmol/l 57±31 49±23 F=1.4 p=0.28 RIS+PLB, risperidone plus placebo; RIS+T3, risperidone plus T3 FT3, free triiodothyronine; FT4, free thyroxin; TSH, thyroid stimulating hormone; SHBG, Sex hormone binding globulin y 86

87 Fig Interaction between treatment group (placebo vs. T3) and treatment time on TSH concentrations Fig Interaction between treatment group (placebo vs. T3) and treatment time in male patients SHBG concentrations The changes over treatment time in SHBG concentrations were found to be not significant for both gender and in both treatment groups. But due to different direction of changes at the end of the study a significant difference between treatment groups in men (F=7.7, p=0.014) (Fig ). In the RIS+placebo group, there was a slight but significant reduction in FT4 concentrations (t= 3.4, p=0.004); and no significant differences be- 87

88 tween treatment groups at the end of study visit in FT4 concentrations were found. Table Significant correlations of thyroid axis hormone concentrations and percentage change in BPRS score in the RIS+T3 group (r, (p)) FT (0.036) SHBG FT4 TSH TSH 0.71 (0.005) BPRS% a 0.64 (0.022) BPRS factor 0.56 (0.036) Anergic at the end of the study BPRS at the end of the study 0.57 (0.034) BPRS, somatic concern 0.54 (0.048) a percentage change in BPRS score from baseline Significant correlations of thyroid axis hormone concentrations changes in the RIS+T3 group are presented in Table A greater reduction in TSH concentrations among patients treated with T3 was associated with lower psychosis severity at the end of the study: TSH negatively correlated with the end of the study BPRS score (r= 0.54 p=0.034): and with the end of the study BPRS item somatic concern score (r= 0.54 p=0.048). In RIS+T3 group higher SHBG was related to lower scored anergic BPRS factor at the end of the study visit (r= 0.56 p=0.036). Changes in FT4 concentrations positively correlated with percentage changes from baseline BPRS score (r=0.64, p=0.022). We observed no similar significant correlation in RIS+PLB treatment group. The study findings documented the advantages of the RIS+T3 treatment compared to RIS+PLB in clinical outcomes. 88

89 4. DISCUSSION 4.1. Thyroid axis function in acute psychotic patients during hospital admission Our findings, generated in naturalistic setting but with careful attention to background thyroid illness and prior drug use, supported, modified, and extended the finding of earlier investigators. As a whole acute psychotic patients, compared to healthy controls, showed an increase in concentrations of FT4, and in male patients also an increase in SHBG concentrations. No significant differences in serum FT3 or TSH concentrations were found. The pattern of increase in FT4 concentrations with normal TSH concentrations corresponds to the description of euthyroid hyperthyroxinemia that has been reported in acute psychotic patients and in patients with mood disorders [24, 50, 68, 83, 198, 229]. However, in our study the frequency and magnitude of increased FT4 concentrations was somewhat less than usually reported. This may have resulted from our excluding patients and controls with background thyroid disease or primary thyroid dysfunction. We have demonstrated earlier in patients with major depression that concomitant autoimmune thyroiditis [35] and goiter [37] have significant effects on thyroid function in psychiatric patients. Therefore, in the present study exclusion of patients and controls with autoimmune thyroid disease as well as subjects with primary thyroid dysfunction, allowed us to evaluate thyroid axis hormone concentrations in association with psychoses without endocrine bias. Our study eventually indicates that increase in FT4 concentrations in acute psychotic patients may be mild, usually not exceeding the normal range. We chose to measure free rather than total thyroid hormone concentrations, despite the fact that in psychiatric patients changes in total hormone values are more evident than changes in free hormone values [50, 229]. However, free hormone values better express thyroid axis activity and are less influenced by carrier proteins, which in turn are affected by many other factors, including inflammation [252]. In this regard, inflammation has been considered as a possible factor in the pathogenesis of schizophrenia [253]. Baumgartner et al. (2000) concluded that high serum concentrations of T4, with normal T3 and TSH concentrations may be specific for acutely ill schizophrenic patients [24]. They considered that high serum T4 concentrations were induced by a disturbed T4 uptake and/or metabolism in the central nervous system. In fact, transient euthyroid hyperthyroxinemia is not 89

90 specific for schizophrenia and occurs across a range of acute psychiatric and medical conditions. Euthyroid hyperthyroxinemia may be considered as an early manifestation of non-thyroidal illness syndrome (NTIS), which is sometimes referred to as euthyroid sick syndrome or low T3 syndrome. This unspecific syndrome is manifested as a decrease in T3 concentration occurring in severe medical conditions and in fasting. In the early presentation of NTIS a marginal increase in serum FT4 concentration with no change in FT3 concentration may indicate decreased conversion of T4 to T3 in tissues including brain [175], as well as suppression of TRH secretion in the hypothalamus [76]. Other authors [102, 198] suggest that elevations of peripheral thyroid hormone concentrations in psychiatric in-patients may result from a centrally-mediated hypersecretion of TSH. However, we found no difference in TSH concentrations in psychotic patients compared to controls. SHBG secretion by liver is controlled by several factors, including thyroid hormones [186]. Increased SHBG concentrations in parallel with increased FT4 concentrations in psychotic patients indicate a possible interaction between euthyroid hyperthyroxinemia and SHBG secretion. Thyroid axis function in mental disorders is gender specific [258] ant it, at least in part, may explain our novel findings on gender differences in SHBG concentrations. SHBG is a sensitive biomarker of insulin resistance and metabolic syndrome [186] and should be taken into consideration prescribing atypical antipsychotics such as olanzapine. Moreover, it was demonstrated recently that treatment with olanzapine decreases SHBG concentrations in psychotic patients [29]. In our group of psychotic patients severity of psychoses, measured by total BPRS score was not related to FT4 concentrations; however, symptoms of anxiety/tension in males patients group positively correlated with FT3/FT4 ratio and with elevated FT4 concentrations. Moreover, in female patients group hostility symptoms negatively correlated with TSH concentrations. Earlier studies reported an association between thyroid axis function and severity of psychiatric symptoms in acute psychiatric patients [198] and in patients with mood disorders [166]. We also found a negative association between hostility symptoms and SHBG concentrations in male patients. Gender differencies also were found in SHBG correlations with Thought disturbance / Withdrawal symptoms: positive correlations with SHBG concentrations in females and negative correlations with SHBG concentrations in male patients. This finding is preliminary and needs further evaluations. Our study has demonstrated that upon hospital admission the use of antipsychotic drugs, but not other psychotropic drugs, prevented an increase in 90

91 FT4 concentrations in acute psychotic patients. Many psychotropic drugs, including lithium, carbamazepine, and antidepressants may cause diverse effects on thyroid function [102]. Antipsychotic drugs may also cause such effects [24, 114]. Antipsychotics may affect thyroid axis function by several mechanisms. Like antidepressants [25], antipsychotics may enhance type 2 deiodinase actyvity in certain brain regions resulting in increased conversion of T4 to T3 in the brain and in diminished concentration of the substrate T4 in serum. Antipsychotics may also affect thyroid axis function by diminishing the inhibiting effects of dopamine on TSH secretion in the anterior pituitary [110]. In general, our cross-sectional study confirms the presence of hyperthyroxinemia in significant proportion of acute psychotic patients. Even mild alteration in thyroid dynamics in psychotic patients may have consequences in other systems, such as liver function evident by differences in SHBG concentrations. The effects on SHBG concentrations appear to be influenced by gender. Treatment with antipsychotics prior hospital admission may also affect thyroid function; however, our cross-sectional study could not determine the cause of the endocrine changes we found. Future cohort studies of patients treated with antipsychotics may enlarge our understanding of the interplay between mental illness, thyroid state, and the effects of antipsychotic drugs Stabilization of thyroid axis hormone concentrations and changes in SHBG concentrations during acute psychotic episode treatment with antipsychotics The major new finding from our study is that antipsychotic treatment effects on FT4 concentrations are not limited to a decrease of high FT4 concentrations; but also to an increase of low FT4 concentrations. Moreover, similar changes in hormone concentrations were found for FT3 concentrations as well. These findings demonstrate that in acute psychotic patients treatment with antipsychotics results in stabilization of thyroid hormone concentrations; suppression of higher concentrations and enhancement of lower concentrations. The clinical meaning of such stabilizing effect of thyroid hormone concentration needs clarification. First of all, such finding may be explained as a regression to the mean of thyroid hormone concentrations challenged by acute psychosis. Antipsychotics may play a role or may not. We cannot answer this question unambiguously because in this study we had no patients without antipsychotic treatment. However, if it were a case that challenged thyroid hormone concentrations during acute phase of psy- 91

92 chosis simply returned to normal range after remission, then FT4 and FT3 concentrations would regress to the range of the control group. It well fits for FT4 concentrations but not at all for FT3 concentrations. Mean FT4 concentrations that were elevated before treatment returns to normal range after treatment; meanwhile, mean FT3 concentrations that were within normal range before treatment decreased significantly below concentrations of the control group after treatment. Therefore, changes at least in FT3 concentrations suggest that it is not a simple regression to the mean but most likely it is an effect of treatment with antipsychotics. Transient hyperthyroxinemia is the most prevalent endocrine abnormality in mental patients. However, only few papers discuss its course in psychotic patients, especially after antipsychotic treatment. The most comprehensive study performed by Baumgartner and colleagues (2000) reported the effects of four-week treatment with conventional antipsychotic perazine in 31 acutely ill schizophrenic in-patients [24]. In this study, before treatment elevated serum T4 concentrations with normal T3, reverse T3, and TSH concentrations were reported. After treatment, T4 concentrations decreased with no changes in TSH and T3 concentrations. Changes in BPRS rating scores after treatment positively correlated with baseline serum T4 concentrations as well as with change in T4 concentrations after treatment; the higher T4 concentrations were before treatment, the better patients responded to antipsychotic treatment; and the more T4 concentrations declined during treatment, the more patients improved. The authors concluded that elevated serum T4 concentrations with normal T3 and TSH concentrations may be specific for acutely ill schizophrenic patients. They suggested that high T4 concentrations in acute psychotic patients were induced by a disturbance in T4 uptake and/or metabolism in some tissues including brain. We have replicated data from Baumgartner and colleagues study regarding a decrease in T4 concentrations after antipsychotic treatment; however, we could not demonstrate that thyroid axis hormone concentrations before treatment predicted treatment response. Moreover, in our study magnitude of the response according to change in BPRS scores was negatively associated with magnitude of change in FT4 concentrations indicating that during antipsychotic treatment the more FT4 concentrations decreased, the less improvement in psychiatric symptoms was achieved. Patients with mild disease severity, with lower baseline BPRS scores demonstrate a higher decrease in FT4 concentrations after treatment and with higer baseline BPRS scores-a lower decrease in FT4. These discrepancies may be explained by some methodological differences between two studies. The study of Baumgartner and colleagues measured the total T4 and the total T3 concentrations while our study measured free hormone concentrations. It was demonstrated 92

93 that thyroid hormone binding proteins were acute phase proteins [17] and inflammation playing a role in acute psychoses may affect protein bound hormone concentrations [201]. Therefore, proteins bind hormone concentrations constituting major fraction of circulating hormones may express immune not endocrine mechanisms in treatment of acute psychosis. Only free fraction of thyroid hormone is metabolically active expressing endocrine effects of antipsychotic treatment. Kelly and colleagues (2005) assessed thyroid function in 38 adult treatment-resistant schizophrenia patients after 6 weeks of treatment with different antipsychotics [114]. They found little change in thyroid axis function, except of significant decrease in serum T4 concentrations in patients taking Quetiapine. All patients neither demonstrated any signs or symptoms of hypothyroidism during the study, nor there any significant changes in the free thyroxin index or TSH concentrations. The authors concluded that decrease in T4 concentrations during quetiapine treatment may be related to competitive metabolism of thyroid hormones and quetiapine by liver enzymes. This study similar to ours evaluated psychotic patients treated with different antipsychotics; however, their study population was different from ours; they studied treatment-resistant schizophrenic patients and we studied acute nonresistant psychotic patients. In our study effects of quetiapine on thyroid axis hormone concentrations was similar to other antipsychotic medications. Sluggishness of thyroid axis function in responding to antipsychotic treatment reported in Kelly and colleagues study may be an endocrine expression of resistance to treatment with antipsychotics. Yaziki and colleagues (2002) reported the differences in thyroid axis function in remitted versus not remitted schizophrenic patients [266]. Their data implicate that higher basal TSH concentrations may be associated with a poorer treatment response, whereas higher basal T3 and FT3 concentrations may indicate a better response in schizophrenics. In our study we failed to demonstrate the effects of basal thyroid axis hormone concentrations on treatment response. Interpretation of the effects of treatment with antipsychotics on thyroid axis function in our study is not a simple task because findings are controversial. On one hand, we found that antipsychotic treatment results in decrease in mean thyroid hormone concentrations and in mean SHBG concentrations in parallel with increase in mean TSH concentrations suggesting that treatment with antipsychotics suppresses thyroid function causing respective tissue responses; an increased TSH secretion in pituitary and decreased SHBG secretion in the liver. It is a full consensus in endocrine literature that hypothyroidism is associated with high TSH concentrations and with low SHBG concentrations and hyperthyroidism has an opposite effect [186]. A negative correlation between change in TSH secretion and change 93

94 in SHBG secretion in our study supports a possibility that metabolic effects caused by antipsychotics are not limited to serum thyroid hormone concentrations and their effects are extended to tissue response, at least response of pituitary and the liver. However, on the other hand, we found a positive correlation between change in FT3 concentrations and change in TSH concentrations after antipsychotic treatment suggesting other explanation for the effects of antipsychotics on thyroid axis function. Antipsychotics, suppressing dopamine signaling in pituitary, may enhance TSH secretion and consecutively stimulate T3 production by the thyroid gland and peripheral tissues. It may be explained by possible multiple, sometimes opposite effects of antipsychotics on thyroid hormone metabolism in different tissues as well as in different patients. Our study has clearly demonstrated that treatment with antipsychotics may result in a decrease, in an increase or in no change in thyroid hormone concentrations. Higher baeline FT4 concentrations decreased to middle range value during recovery in male patients; and lower baseline FT4 concentrations increased to middle range values in both gender groups. Highest baseline FT3 concentrations decreased in male patients and middle and the highest baseline FT3 concentrations -in female patients. These differences in thyroid hormone response to treatment were strongly predicted by baseline hormone concentrations, not by antipsychotic used, indicating an importance of individual differences in thyroid axis function and even of gender differencies in thyroid axis function [258]. It has been demonstrated in different populations that individual thyroid hormone concentrations are associated with specific genetic polymorphisms. For example, the study performed by Cooper-Kazas, 2009, found that T3 concentrations in patients with major depression were associated with polymorphism in DIO1 gene encoding type 1 deidionase, an enzyme responsible for conversion of T4 to more active T3 in peripheral tissues [56]. This polymorphism was also associated with response to adjuvant T3 treatment in depressed patients. In our study such genetic data were not available. It can be only a speculation that genetic polymorphism in thyroid axis proteins, such as DIO1, or others may predict change in thyroid hormone concentrations in response to treatment with antipsychotics. Activity of type-2 deiodinase (D2) that is responsible for thyroid hormone production in the brain may also be important. It was hypothesized that antidepressants and lithium enhance activity of D2 in certain brain regions resulting in increased production of T 3 in the brain that was expected to be beneficial for recovery from depression [25]. D2 activity is associated with DIO2 genetic polymorphism that was demonstrated to be linked to mental functioning in hypothyroid patients treated with T4 as well as to 94

95 mental improvement to adjuvant treatment with T3. The similar effects were demonstrated for thyroid hormone transporter OATO1c1 gene polymorphism. Our finding that treatment with antipsychotics results in a decrease in mean FT3 concentrations also needs some attention. Again, extrapolating from depression studies [54, 178] it may be hypothesized that compensation of low T3 concentrations in psychotic patients treated with antipsychotic, may benefit an improvement in psychiatric symptoms. Given the changes in thyroid hormone concentrations after antipsychotic treatment, change in TSH and in female SHBG concentrations was also predicted by baseline concentrations. In contrast to thyroid hormones, only low and medium TSH concentrations responded to antipsychotic treatment and only high female SHBG concentrations responded; however, response was either an increase or a decrease. We observed gender specific differences in changes in thyroid hormone concentrations according to severity of psychosis. The significant decrease of both thyroid hormones concentrations after acute psychosis treatment with antipsychotics were much relevant to male patients with less severe psychosis (with lower baseline BPRS scores) a decline of FT4 and FT3 concentrations was observed in the first baseline BPRS tertile and only a decrease of FT3- in the second baseline BPRS tertile. Also, severity of psychosis correlated negatively with SHBG concentrations in men. Female patients with medium severity of psychosis demonstrated the lowest FT4 and SHBG concentrations and decreased FT3 concentrations in all severity of illness. As we noticed before, acute psychosis treatment with antipsychotics affects thyroid hormone FT3 concentrations mean, and suppresses thyroid function causing the tissue response in the liver decreasing SHBG secretions. Our naturalistic study demonstrates that acute psychosis treatment with antipsychotics is associated with gender specific changes in SHBG concentrations. This significant decrease in SHBG concentrations was found ony in female patients, but not in male patients. The most significant effects on decrease in SHBG concentrations were associated with haloperidol treatment. There are only few studies that investigated the effects of treatment with antipsychotics on SHBG concentrations. The study performed by Birkenaes et al. (2009) included data from 234 patients with diagnosis of schizophrenia and other severe psychotic disorders [29]. Patients were on stable monotherapy with antipsychotic olanzapine (n=72) or other antipsychotic, typical or atypical (n=80), with median 5 month duration of treatment; one fraction of patients were free form antipsychotic medication (n=82), median duration 12 month. Groups were matched for gender and were compared for SHBG 95

96 and other endocrine hormones concentrations. The study found that olanzapine-treated patients had the lowest SHBG concentrations, and in olanzapine-treated female patients this difference was statistically significant compared to other subjects. No significant differences were found across male treatment groups in concentrations of SHBG. Authors concluded that changes in SHBG were associated with olanzapine treatment and female subjects were particularly vulnerable. The findings of our study show that short- term hospital treatment with antipsychotics produces results similar to Birkenaes et al. study; suppression of SHBG concentrations is the strongest in female patients treated with antipsychotics. Our 15 psychotic patients treated with olanzapine did not produce different from other antipsychotic effect on SHBG concentrations [29]. Other naturalistic, 9 month follow-up study [58] compared the effect of olanzapine vs. typical antipsychotics on SHBG concentrations and other endocrine parameters and sexual function in 63 male in-patients with acute psychotic episodes of schizophrenia. SHBG concentrations were measured on discharge from the inpatient unit (baseline), and again at 3 and 9 months after discharge. Time points for follow up were chosen to assess short and long-term effects of antipsychotics on endocrine function. The results of this study are similar to our findings; after acute treatment with haloperidol SHBG concentrations were lower than after acute treatment with atypical antipsychotics. Long term effects of antipsychotics on SHBG concentrations were assessed in a study of 67 consecutive outpatients with schizophrenia after two years treatment with typical antipsychotic medications [223]. The results of this study indicate that long term treatment with antipsychotic medication in females is likely to increase prolactin and is associated with hypo-gonadal state. Plasma prolactin levels correlated positively with dose of antipsychotic and were negatively associated with SHBG concentrations in female but not male patients. In our study we do not provide data on prolactin concentrations; however, changes in SHBG concentrations were more evident in female patients. Those results support the earlier findings that antipsychotics provide effective treatment for acute psychotic episode in both gender groups, but may lead to different endocrine abnormalities, such as a decrease in SHBG concentrations, according to gender. Women are more vulnerable to this side effect of antipsychotic treatment, especially when treated with haloperidol. The severity of psychosis negatively correlates with SHBG concentrations in men. The major limitation of the study is an absence of patients without antipsychotic treatment (placebo group), not allowing us to understand if 96

97 changes in thyroid axis function are caused by treatment with antipsychotics or by remission of psychosis itself. As it was mentioned above, a lack of genetic information is another weakness of the study. To compare the different effects of specific antipsychotics on thyroid axis function of psychotic patients the larger sample size is needed. Summarizing, the major finding of our study demonstrate that in acute psychotic patients antipsychotics act as stabilizers of thyroid hormone secretion, suppressing thyroid hormone production in patients with high baseline thyroid hormone concentrations and stimulating thyroid hormone secretion in patients with low thyroid hormone concentrations. Lower mean FT3 concentrations after antipsychotic treatment suggest a need for clinical trial compensating FT3 decrease. Psychosis treatment with the adjunctive use of T3 could enhance the effects of antipsychotics The accelaration and enhancement effects of adjuvant treatment with L triiodthyronine (T3) on acute schizophrenia treatment with atypical antipsychotic risperidone The most important findings of our double blind, parallel groups, placebo controlled study demonstrate that the adjuvant treatment with L- triiodthyronine (T3) 25 µg/day is associated with two different effects on acute schizophrenia treatment with atypical antipsychotic risperidone. The comparison of two treatment groups has snown RIS+T3 combination superior to RIS+placebo in acute schizophrenia treatment according to response to the treatment period in days. Patients treated with RIS+T3 showed a significant faster improvement during acute schizophrenia treatment; this demonstrates the ability of T3 to accelerate the treatment effect of atypical antipsychotic risperidone. On the other hand, the RIS+T3 treatment shows significant advantages in efficacy of acute schizophrenia treatment, presented by the greater improvement in BPRS total scores in percent from baseline score and a close significant improvement in total BPRS scores during response to treatment period. These results suggest the T3 enhancement effect on antipsychotic risperidone action. A greater improvement during response to treatment period was revealed not only on Thinking disorder and Hostility BPRS factors and BPRS items of psychotic symptoms, but also on affectivegeneral psychopatology items and factors: Somatic concern, Grandiosity item scores and close significant on Anxiety/depression factors scores. 97

98 The changes in thyroid axis hormone concentrations in RIS+T3 treatment patients are associated with changes in patients mental state. The significant decrease in TSH concentrations is associated with better treatment result: the change in TSH scores positively correlates with BPRS score after treatment and with BPRS item somatic concern score. The greater change in SHBG concentrations is related to lower BPRS Anergic factor score after treatment. The decrease in FT4 concentrations correlates with percentage change in BPRS from baseline score. According to our findings, T3 accelerates and enhances antipsychotic risperidone effect through the inhibition of FT4 and, respectively TSH secretion (brain response) and stimulation of SHBG secretion in male patients (liver response). Hormones of the thyroid axis have been used to treat patients with any of several mental illnesses. However, in the recent decade interest has focused almost exclusively on depression. T3 has been used in preference to T4 because of its rapid onset and offset of action [34] and with the availability of T3, as a viable, safe, inexpensive and effective depression augmentation treatment [3]. Only few studies were done during the sixties to evaluate T3 effect in chronic schizophrenia treatment, but they did not present any significant advantages. There is only one double blind, placebo controlled study [172], which investigated T3 effect on the antipsychotic action of chlorpromazine in acute schizophrenic patients. Twenty patients admitted to the hospital with the symptoms of acute schizophrenia were selected for the study. They were treated with chlorpromazine flexible dose; and were randomly assigned to the 25 µg of T3 daily dose or placebo treatment for 4 week period. Study treatment groups were compared according to the changes in CGI rating scores, BPRS scores, all items and BPRS factors. The study found that T3 was superior to placebo on the BPRS items: emotional withdrawal, uncooperativeness, disorientation and BPRS factor excitement/disorientation ; the most part of advantages was pertained to the entirely study period. The authors concluded that in this study antipsychotic effects of chlorpromazine were enhanced by T3. The findings of our study show the RIS+T3 superior to RIS+PLB not only in psychotic items and factors of the BPRS, but also affective-general psychopatology items and factors of BPRS; and the improvement in percent from baseline BPRS total rating score. Furthermore, our study reveals the advantage of RIS+T3 in shorter duration of hospital treatment. The ratings of psychosis severity in our study were done only on two occasions (rando- 98

99 mizations and the end of the study), therefore we could evaluate changes in the entirely study period. But a significant correlation between changes in thyroid hormones concentrations and psychosis symptoms after treatment in the RIS+T3 treatment group could be a significant evident about RIS+T3 treatment association with better clinical outcome. The mechanisms of interactions between risperidone and T3 are not clear. Changes in thyroid function in acute schizophrenia are not uniform and T3 alone probably is not effective agent in the treatment of acute schizophrenia, but it seems to underlie the response process. The possible function of T3 as a neurotransmitter is considered in the pathophysiology of schizophrenia. Talking about L-triiodothyronine dose, we know that the daily production of triiodothyronine by the human thyroid gland is about 6 µg and the rate of absorption of ingested triiodothyronine is almost 100 percent [36]. Thus, the dose of triiodothyronine given in our study somewhat exceeded the normal glandular production and T3 was well tolerated by the patients in our study. The proportion of patients, who experienced adverse effects considered typical of T3, such as nervousness, palpitations, tremor and sweating, was not greater with RIS+T3 than with RIS+PLB. Similar results were presented in T3 25 µg treatment studies with depression patients [55]. Other studies [12] have found that T3 does induce a consistent and predictable side-effect profile. Because of the small sample, the results of our study should be accepted as being only preliminary. But the positive results of our study could also help to instill confidence about the benefit of thyroid hormones to action of antipsychotics. The bigger sample size and different atypical antipsychotics should be used in the future studies to confirm the results of L triiodthyronine effects during acute schizophrenia treatment. 99

100 CONCLUSIONS 1. Acute psychotic patients compared to controls had higher FT4 concentrations and higher prevalence of hyperthyroxinemia. Alteration in thyroid function in acute psychotic patients may have consequences in other tissues, such as liver function evident by higher SHBG concentrations in male patients. Thyroid axis hormone concentrations were associated with severity of affective symptoms of psychosis and with prior antipsychotic treatment upon hospital admission. 2. Acute psychotic episode treatment with antipsychotics resulted in a decrease in mean thyroid hormone concentrations and in an increase in mean TSH concentrations. Changes in thyroid hormone concentrations were predicted by baseline hormones concentrations, eventually leading to suppression of high concentrations and enhancement of low concentrations indicating stabilization of the thyroid axis function after treatment with antipsychotics at the new metabolic level. The effect of clinical characteristics of the psychotic episode on changes in thyroid axis hormone concentrations after treatment with antipsychotics was less evident. 3. Acute psychotic episode treatment with antipsychotics led to a decrease in SHBG concentrations. Change in SHBG concentrations was predicted by basal SHBG concentrations and gender, showing changes only in women with high basal SHBG concentrations. Women were more vulnerable to this effect of antipsychotic treatment, especially when treated with typical antipsychotic haloperidol. 4. The adjuvant administration of T3 compared to placebo was safe and effective in acute schizophrenia patients treated with risperidone, accelerating and enhancing antipsychotic risperidone effects. During T3 treatment inhibition of TSH secretion and stimulation of SHBG secretion were associated with improvement of acute schizophrenia symptoms. Due to small sample size data need to be treated as preliminary. 100

101 SCIENTIFIC SIGNIFICANCE OF THE STUDY New information of scientific value on psychoendocrine challenge in acute psychosis is contained in this study. Accoding to our data, we reported for the first time in naturalistic clinical study that thyroid axis function in acute psychotic patients during hospital admission, in comparison to blood donor controls is challenged and is associated with the treatment of acute psychotic episode. Our results not only confirmed findings about euthyroid hyperthyroxinemia in acute psychotic patients during hospital admission, but also presented novel findings that concentrations of SHBG are increased in male psychotic patients. It suggests that thyroid hormone changes that occur in acute psychotic patients may have ramifications in other systems. Our study also reported the similar endocrine effects of acute psychotic episode in patients treated with typical and atypical antipsychotics. The study suggests that treatment with antipsychotics results in stabilization of thyroid hormone concentrations, suppressing high concentrations and enhancing low concentrations; however, lower than normal FT3 concentrations are more likely to occur after acute psychotic episode treatment. We also described acute psychotic episode treatment effects on thyroid hormone functional activity in the liver, demonstrating a decrease in SHBG concentrations in female patients. A deeper understanding of different physiological and psychopathological mechanisms during acute schizophrenia gives the new opportunities for the better treatment results. Our investigation of the effects of adjuvant administration of L trijodthyronine (T3) in acute schizophrenia patients treated with risperidone provide preliminary data that such an approach may augment and accelerate response to treatment with atypical antipsychotics in acute psychotic patients. Moreover, we clearly demonstrated that risperidone plus T3 combination is safe. Providing safe treatment modalities fastering and augmenting response to antipsychotic treatment is an important achievement from personal and public health perspective. 101

102 LIMITATIONS OF THE STUDY AND NEED FOR FURTHER RESEARCH We did not use wash -out period in our naturalistic study I and did not measure concentration of antipsychotic medications confirming compliance with treatment. Heterogenity of used antipsychotics did not allow to dicriminate specific endocrine effects for specific medication. However, naturalistic design of the study represents a real life situation in the treatment of acute psychotic patients. The major limitation of this study was crosssectional design that was resolved in the Study II. The study II was a prospective study. The major limitation of this prospective study evaluating endocrine effects in acute psychotic patients treated with antipsychotics is absence of patients without drug treatment (placebo group). This did not allow us to understand real causes of changes in thyroid axis function during treatment of acute psychotic episode with antipsychotics. On the one hand, changes in thyroid hormone concentrations may be direct effects of antipsychotic medications; on the other hand, it may be a biological marker of the stabilization of mental symptoms after remission of the psychosis not associated with medications used. Causality of a relationship between endocrine changes and mental state of acute psychotic patients was addressed in the last experiments of the thesis (Study III). However, a small sample of the clinical trail of the effects of adjuvant treatment with L triiodthyronine (T3) on acute schizophrenia treatment with risperidone does not allow us to reach conclusive evidence on effects of T3 and findings should be considered as preliminary. Further studies in larger populations of psychotic patients are needed to evaluate efficacy and safety of T3 on acute schizophrenia psychoses treatment with different atypical antipsychotics. Lack of genetic information is another weakness of the study. The possible information about associations between deiodinase genes or thyroid transporters genes polymorphisms with thyroid axis hormone concentrations in patients with schizophrenia and other psychotic disorders could help us to understand the molecular mechanisms, to determine pharmacogenetic markers and possibly to find new pharmacological treatment targets for patients with acute psychosis. 102

103 PRACTICAL RECOMMENDATIONS We suggest the need for thyroid function screening in acute psychotic patients admitted to mental hospital, especially during the first psychosis episode excluding thyroid dysfunctions as a possible factor affecting manifestation and presentation of psychotic disorder with the aim to prescribe effective treatment for compensation of thyroid dysfunction. Such an endocrine treatment is important for the management of psychosis. Our findings demonstrate that female psychotic patients are more sensitive to endocrine effects of antipsychotics. Antipsychotic treatment could lead to changes in thyroid axis hormone and SHBG concentrations. However, clinical significance of these changes remains to be better understood. Our findings indicate that thyroid axis function is challenged by acute psychosis and response to treatment is associated with stabilization of thyroid axis. This must be taken into account, evaluating endocrine function in acutely psychotic patients and prescribing antipsychotic treatment. We found that the use of T3 25 µg dose as adjuvant acute schizophrenia treatment with atypical antipsychotic risperidone accelerates and enhances response to treatment. Even a modest acceleration and enhancement of psychosis response to treatment could have significant personal and the public health impact. However, for clinical practice these findings should be treated as preliminary and further research on augmentation of antipsychotic treatment with T3 is needed. 103

104 ACKNOWLEDGEMENTS I am grateful to everyone who contributed to this thesis and who helped me in the process of accomplishing it. My family and my friends have been very supporting and understanding throughout these past four years. Thank you all, you have given me more help and support than you know. I am deeply indebted to my scientific supervisor and the generator of all ideas the director of Institute of Behavioral Medicine of LUHS Dr. Habil. Robertas Bunevicius, for led me to the world of science, his support and moral encouragement, meticulous supervision, invaluable advice and scientific consultations that enormously contributed to the entire thesis. My most grateful thanks to Dr. Narseta Mickuviene for consultation on endocrinology, priceless practical advice and support. Thank you for discussion evenings in your house in Palanga. I am no less grateful to scientific worker Nijole Raškauskiene of Institute of Behavioral Medicine of LUHS for dealing so patiently with my attempts not to get lost in statistics, I am grateful to her who was kind enough to comment professionally on the final thesis. My additional thanks to the head of the department of Drug technology and Social Pharmacy of LUHS Prof. Dr. Arūnas Savickas, for contributed greatly to preparation of the means for the study and helped to perform procedures of clinical trial. I am grateful to the reviewer of this thesis Prof. Habil. Dr. Daiva Rastenyte for detailed line-by-line comments helped me very substantially with the improvements of this thesis. I am grateful to the Fund of Lithuanian Science and Study, which funded the research grant that allowed me to finish the study and present the results during international scientific conferences. I must acknowledge my debt to the head of Psychiatric clinic of LUHS Prof. Dr. Virginija Adomaitiene for her understanding, support and allowing me to devote more time to preparation of this thesis. I am also grateful to the director of Ziegzdriai Psychiatric Hospital Dr. Valdone Matoniene for giving me the possibility to perform the clinical study in this hospital and supporting me in all my ideas. To the following colleagues who have helped me very substantially with the procedures of clinical study my most grateful thanks to nurses Virginija Ališauskiene, Inga Kvedariene and Violeta Varnagiriene and to the head of laboratory Audrone Laurinaitiene. 104

105 I am grateful to the Director of the State Mental Health Center Onute Davidoniene for giving me access to data of statistics; this covered the ground of my study in the context of Lithuanian mental health care. I am no less grateful to all my colleague of Institute of Behavioral Medicine of LUHS for their invaluable advice, support and encouragement in my work. It is with particular pleasure that I express my affectionate and deeplyfelt gratitude to my family, friends and colleagues, their care and support let me go forward. I am also grateful to my patients who participated in the study. My thanks to everybody who directly or indirectly contributed to the study. Finally, my thanks to my husband Arūnas for his support and tolerance during the preparation of this work that has separated me from him for too many hours. Thank you, Arunas, I love you. 105

106 REFERENCE LIST 1. Abe T, Suzuki T, Unno M, Tokui T, Ito S. Thyroid hormone transporters: recent advances. Trends Endocrinol Metab 2002;13(5): Abi-Dargham A. Alterations of serotonin transmission in schizophrenia. International Review of Neurobiology 2007;78: Abraham G, Milev R, Stuart Lawson J. T3 augmentation of SSRI resistant depression. J Affect Disord 2006;91(2-3): Agid O, Lerer B. Algorithm-based treatment of major depression in an outpatient clinic: clinical correlates of response to a specific serotonin reuptake inhibitor and to triiodothyronine augmentation. Int J Neuropsychopharmacol 2003;6(1): Agius M, Davis A, Gilhooley M, Chapman S, Zaman R. What do large scale studies of medication in schizophrenia add to our management strategies? Psychiatr Danub 2010;22(2): Ahmed OM, El-Gareib AW, El-Bakry AM, Abd El-Tawab SM, Ahmed RG.Thyroid hormones states and brain development interactions. International Journal of Developmental Neuroscience 2008;26(2): Akbarian S, Huang HS. Molecular and cellular mechanisms of altered gad1/gad67 expression in schizophrenia and relate disorders. Brain Research Reviews 2006; 52(2): Almandoz JP, Gharib H Hypothyroidism: etiology, diagnosis, and management. Med Clin North Am 2012;96(2): Altshuler LL, Bauer M, Frye MA, Gitlin MJ, Mintz J, Szuba MP, et al. Does thyroid supplementation accelerate tricyclic antidepressant response? A review and meta-analysis of the literature. Am J Psychiatry 2001;158(10): American Psychiatric Association. DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Text Revision. Washington, DC: American Psychiatric Association; Andersen S, Pedersen KM, Bruun NH, Laurberg P. Narrow individual variations in serum T(4) and T(3) in normal subjects: a clue to the understanding of subclinical thyroid disease. J Clin Endocrinol Metab 2002;87: Appelhof BC, Brouwer JP, van Dyck R, Fliers E, Hoogendijk WJ, Huyser J, et al. Triiodothyronine addition to paroxetine in the treatment of major depressive disorder. J Clin Endocrinol Metab 2004;89(12):

107 13. Appelhof BC, Peeters RP, Wiersinga WM, Visser TJ, Wekking EM, Huyser J, et al. Polymorphisms in type 2 deiodinase are not associated with well-being, neurocognitive functioning, and preference for combined thyroxine/3,5,3'-triiodothyronine therapy. J Clin Endocrinol Metab 2005;90(11): Aronson R, Offman HJ, Joffe RT, Naylor CD. Triiodothyronine augmentation in the treatment of refractory depression. A meta-analysis. Arch Gen Psychiatry 1996;53(9): Asher R. Myxoedematous madness. British Medical Journal 1949;2: Auso E, Lavado-Autric R, Cuevas E, Del Rey FE, Morreale De Escobar G, Berbel P. A moderate and transient deficiency of maternal thyroid function at the beginning of fetal neocorticogenesis alters neuronal migration. Endocrinology 2004;145: Azad RM. Abnormal serum thyroid hormones concentration with healthy functional gland: a review on the metabolic role of thyroid hormones transporter proteins. Pak J Biol Sci 2011;14(5): Balldin J, Berggren U, Rybo E, Kjellbo H, Lindstedt G. Treatment resistant mania with primary hypothyroidism: a case of recovery after levothyroxine. J Clin Psychiatry 1987;48(12): Bassett JH, Harvey CB, Williams GR. Mechanisms of thyroid hormone receptor-specific nuclear and extra nuclear actions. Mol Cell Endocrinol 2003;213(1): Bauer M, Adli M, Bschor T, et al., Clinical Applications of Levothyroxine in Refractory Mood Disorders. Clin Appl Bip Dosid 2003;2: Bauer M, Goetz T, Glenn T, Whybrow PC. The thyroid-brain interaction in thyroid disorders and mood disorders. Journal of Neuroendocrinology 2008;20: Bauer M, Heinz A, Whybrow PC. Thyroid hormones, serotonin and mood: Of synergy and significance in the adult brain. Molecular Psychiatry 2002;7(2): Baumgartner A, Graf KJ, Kurten I, Meinhold H. The hypothalamicpituitary-thyroid axis in psychiatric patients and healthy subjects: Parts 1-4. Psychiatry Res 1988;24: Baumgartner A, Pietzcker A, Gaebel W. The hypothalamic-pituitarythyroid axis in patients with schizophrenia. Schizophr Res 2000a; 44: Baumgartner A. Thyroxine and the treatment of affective disorders: an overview of the results of basic and clinical research. Int J Neuropsychopharmacol. 2000b;3(2):

108 26. Bernal J, Guadano-Ferraz A, Morte B. Perspectives in the study of thyroid hormone action on brain development and function. Thyroid 2003;13: Bernal J. Action of thyroid hormone in brain. J Endocrinol Invest 2002;25: Bianco AC, Salvatore D, Gereben B, Berry MJ, Larsen PR. Biochemistry, cellular and molecular biology, and physiological roles of the iodothyronine selenodeiodinases. Endocr Rev 2002;23: Birkenaes AB, Birkeland KI, Friis S, Opjordsmoen S, Andreassen OA. Hormonal markers of metabolic dysregulation in patients with severe mental disorders after olanzapine treatment under real-life conditions. J Clin Psychopharmacol 2009; 29: Boelen A, Kwakkel J, Fliers E. Beyond low plasma T3: local thyroid hormone metabolism during inflammation and infection. Endocr Rev 2011;32(5): Borson-Chazot F, Jordan D, Fevre-Montange M, Kopp N, Tourniaire J, Rouzioux JM, et al. TRH and LH-RH distribution in discrete nuclei of the human hypothalamus: evidence for a left prominence of TRH. Brain Res 1986;382: Braverman LE, Utiger RD. Introduction to hypothyroidism. In: Breverman LE, Utiger RD, editors. Werner & Ingbar s the thyroid: a fundamental and clinical Text. 9 th ed. Philadelphia: Lippincott Williams &Wilkins; p Buervenich S, Carmine A, Arvidsson M, Xiang F, Zhang Z, Sydow O, et al. NURR1 mutations in cases of schizophrenia and manicdepressive disorder. Am J Med Genet 2000;96: Bunevicius R, Jakuboniene N, Jurkevicius R, Cernicat J, Lasas L, Prange AJ Jr. Thyroxine vs thyroxine plus triiodothyronine in treatment of hypothyroidism after thyroidectomy for Graves' disease. Endocrine 2002;18(2): Bunevicius R, Kazanavicius G, Telksnys A. Thyrotropin response to TRH stimulation in depressed patients with autoimmune thyroiditis. Biol Psychiatry 1994;36(8): Bunevicius R, Kazanavicius G, Zalinkevicius R, Prange AJ Jr. Effects of thyroxine as compared with thyroxine plus triiodothyronine in patients with hypothyroidism. N Engl J Med 1999;340(6): Bunevicius R, Lasas L, Kazanavicius G, Prange AJ Jr. Pituitary responses to thyrotropin releasing hormone stimulation in depressed women with thyroid gland disorders. Psychoneuroendocrinology 1996;21(7):

109 38. Bunevicius R. Prange AJ Jr.Thyroid disease and mental disorder: cause and effects or only comorbidity? Curr Opin Psychiatry 2010;23(4): Bunevicius R. Thyroid disorders in mental patients. Curr Opin Psychiatry 2009;22: Caplan RH, Pagliara AS, Wickus G, Goodlund LS. Elevation of the free thyroxine index in psychiatric patients. J Psychiatr Res ;17(3): Cappelli C, Stanga B, Paini A, Gandossi E, Cumetti D, Castellano M, et al. Myxoedema coma precipitated by diabetic ketoacidosis and neuroleptic drugs: case report in an intensive care unit. Intern Emerg Med 2007;2(2): Cardno AG, Rijsdijk FV, Sham PC, Murray RM, McGuffin P. A twin study of genetic relationships between psychotic symptoms. Am J Psychiatry 2002;159: Cardno AG, Rijsdijk FV, West RM, Gottesman II, Craddock N, Murray RM, McGuffin P. A twin study of schizoaffective-mania, schizoaffective-depression, and other psychotic syndromes. Am J Med Genet B Neuropsychiatr Genet 2012;159B(2): Carlsson A. The neurochemical circuitry of schizophrenia. Pharmacopsychiatry 2006;39 (1): S Carol A. Tamminga1 and John M. Davis2.The Neuropharmacology of Psychosis. Schizophr Bull 2007;33(4): Carpenter WT, Bustillo JR, Thaker GK, van Os J, Krueger RF, Green MJ. The psychoses: cluster 3 of the proposed meta-structure for DSM V and ICD 11. Psychol Med 2009;39(12): Ceccarini M, Macioce P, Panetta B, Petrucci TC. Expression of dystrophin-associated proteins during neuronal differentiation of P19 embryonal carcinoma cells Neuromuscul. Disord 2002;12: Chari S. The lesson from a yellow psychotic patient. Hosp Med 2002;63: Chaube R, Joy KP. Thyroid hormone modulation of brain in vivo tyrosine hydroxylase activity and kinetics in the female catfish Heteropneustes fossilis. Journal of Endocrinology 2003;179(2): Chopra IJ, Solomon DH, Huang TS. Serum thyrotrophin in hospitalised psychiatric patients: evidence for hyperthyrotropinemia as measured by an ultrasensitive thyrotrophin assay. Metabolism 1990;39: Church CO, Callen EC. Myxedema coma associated with combination aripiprazole and sertraline therapy. Ann Pharmacother 2009;43(12):

110 52. Clyde PW, Harari AE, Getka EJ, Shakir KM. Combined levothyroxine plus liothyronine compared with levothyroxine alone in primary hypothyroidism: a randomized controlled trial. JAMA 2003;290(22): Colombo GM, Aguglia G, Cicchinelli M. Emergency approach to psychosis in postoperative hypothyroidism. Minerva Endocrinol 2007;32(3): Connolly KR, Thase ME. If at first you don't succeed: a review of the evidence for antidepressant augmentation, combination and switching strategies. Drugs 2011;71(1): Cooper-Kazaz R, Apter JT, Cohen R, et al. Combined treatment with sertraline and liothyronine in major depression: a randomized, doubleblind, placebo-controlled trial. Arch Gen Psychiatry 2007:64; Cooper-Kazaz R, van der Deure WM, Medici M, Visser TJ, Alkelai A, Glaser B, et al. Preliminary evidence that a functional polymorphism in type 1 deiodinase is associated with enhanced potentiation of the antidepressant effect of sertraline by triiodothyronine. Affect Disord 2009;116(1 2): Correll CU. What are we looking for in new antipsychotics? J Clin Psychiatry 2011;72(1): Costa AM, de Lima MS, Faria M, Filho SR, de Oliveira IR, de Jesus Mari J. A naturalistic, 9-month follow-up, comparing olanzapine and conventional antipsychotics on sexual function and hormonal profile for males with schizophrenia. J Psychopharmacol 2007;21(2): Craddock N, O'Donovan M, Owen M. Genes for Schizophrenia and Bipolar Disorder? Implications for Psychiatric Nosology. Schizophr Bull 2006;32(1): Crocker AD, Overstreet DH, Crocker JM. Hypothyroidism leads to increased dopamine receptor sensitivity and concentration. Pharmacol Biochem Behav 1986;24: Darko DF, Krull A, Dickinson M. The diagnostic dilemma of mixedema madness, axis I and axis II: a longitudinal case report. Int J Psychiatry Med 1988;18(3): Davis JD, Stern RA, Flashman LA. Cognitive and neuropsychiatric aspects of subclinical hypothyroidism: significance in the elderly. Curr Psychiatry Rep 2003;5(5): Dean B, Boer S, Gibbons A, et al. Recent advances in postmortem pathology and neurochemistry in schizophrenia. Current Opinion in 110

111 dopamine?" European Journal of Pharmacology 2003;480(1-3): Dean B, Boer S, GibbonsA, et al. Recent advances in postmortem pathology and neurochemistry in schizophrenia. Current Opinion in Psychiatry 2009;22(2): DeLisi LE, Boccio AM, Riordan H, Hoff AL, Dorfman A, McClelland J, et al. Familial thyroid disease and delayed language development in first admission patients with schizophrenia. Psychiatry Res 1991;38: Duan J, Martinez M, Sanders AR, Hou C, Saitou N, Kitano T, et al. Polymorphisms in the trace amine receptor 4 (TRAR4) gene on chromosome 6q23.2 are associated with susceptibility to schizophrenia. Am J Hum Genet 2004;75: Dutta R, Greene T, Addington J, McKenzie K, Phillips M, Murray RM. Biological, life course, and cross-cultural studies all point toward the value of dimensional and developmental ratings in the classification of psychosis. Schizophr Bull 2007;33(4): Eker SS, Akkaya C, Sarandol A, Cangur S, Sarandol E, Kirli S. Effects of various antidepressants on serum thyroid hormone levels in patients with major depressive disorder. Prog Neuropsychopharmacol Biol Psychiatry 2008;32(4): Eravci M, Pinna G, Meinhold H, Baumgartner A. Effects of pharmacological and nonpharmacological treatments on thyroid hormone metabolism and concentrations in rat brain. Endocrinology 2000;141: Escobar Morreale G, Obregon MJ, Escobar del Rey F. Role of thyroid hormone during early brain development. Eur J Endocrinol 2004;151: U25 U Escobar-Morreale HF, Botella-Carretero JI, Escobar del Rey F, Morreale de Escobar G. REVIEW: Treatment of hypothyroidism with combinations of levothyroxine plus liothyronine. J Clin Endocrinol Metab 2005;90(8): Faggiano A, Del Prete M, Marciello F, Marotta V, Ramundo V, Colao A. Thyroid diseases in elderly. Minerva Endocrinol 2011;36(3): Fallin MD, Lasseter VK, Wolyniec PS, McGrath JA, Nestadt G, Vall D, et al. Genomewide linkage scan for schizophrenia susceptibility loci among Ashkenazi Jewish families shows evidence of linkage on chromosome 10q22. Am J Hum Genet 2003;73: Fatemi SH, Folsom TD, Reutiman TJ, et al. Abnormal expression of myelination genes and alterations in white matter fractional anisotro- 111

112 py following prenatal viral influenza infection at e16 in mice. Schizophrenia Research 2009;112(3): Feret BM, Caley CF. Possible hypothyroidism associated with quetiapine. Ann Pharmacother 2000;34(4): Fliers E, Alkemade A, Wiersinga WM, Swaab DF. Hypothalamic thyroid hormone feedback in health and disease. Prog Brain Res 2006;153: Friesema EC, et al. Human monocarboxylate transporter 10 does transport thyroid hormone. Thyroid 2006a;16: Friesema EC, et al. Mechanisms of disease: psychomotor retardation and high T3 levels caused by mutations in monocarboxylate transporter 8. Na. Clin Pract Endocrinol Metab 2006;2: Friesema EC, et al. Thyroid hormone transport by thehuman monocarboxylate transporter 8 and its rate-limiting role in intracellular metabolism. Mol Endocrinol 2006b;20: Frints SG, Lenzner S, Bauters M, et al. MCT8 mutation analysis and identification of the first female with Allan Herndon Dudley syndrome due to loss of MCT8 expression. Eur J Hum Genet 2008;16: Fuchs O, Pfarr N, Pohlenz J, Schmidt H. Elevated serum triiodothyronine and intellectual and motor disability with paroxysmal dyskinesia caused by a monocarboxylate transporter 8 gene mutation. Dev Med Child Neurol 2009; 51: Gaebel W, Zielasek J. The DSM-V initiative deconstructing psychosis in the context of Kraepelin s concept on nosology. European archives of psychiatry and clinical neuroscience 2009;258(2), Gambi F, De Berardis D, Sepede G, Campanella D, Galliani N, Carano A, et al. Effect of mirtazapine on thyroid hormones in adult patients with major depression. Int J Immunopathol Pharmacol 2005;18(4): Garver DL. Neuroendocrine findings in the schizophrenias. Endocrinol Metab Clin North Am 1988;17(1): Gerendai I, Halasz B. Neuroendocrine asymmetry. Front Neuroendocrinol 1997;18: Geyer MA, Vollenweider FX, Serotonin research: Contributions to understanding psychoses. Trends in Pharmacological Sciences 2008;29(9): Gibiino S, Liapas I, Zisakis AK, Zisaki AK, Liappas A, Kalofoutis A, et al. Myelination hypothesis in schizophrenia: role of thyroid hormones from preclinical evidence to therapy suggestions. Clinical Neuropsychiatry 2010;7(3):

113 88. Gilmer TP, Dolder CR, Lacro JP, Folsom DP, Lindamer L, Garcia P, et al. Adherence to Treatment With Antipsychotic Medication and Health Care Costs Among Medicaid Beneficiaries With Schizophrenia. Am J Psychiatry 2004;161: Gjessing R, Jenner A. Contributions to the Somatology of Periodic Catatonia. Oxford: Pergamon Press; Goldberg TE, Ragland JD, Torrey EF, Gold JM, Bigelow LB, Weinberger DR. Neuropsychological Assessment of Monozygotic Twins Discordant for Schizophrenia. Arch Gen Psychiatry 1990;47(11): Grillet N, Dubreuil V, Dufour HD, Brunet JF. Dynamic expression of RGS4 in the developing nervous system and regulation by the neural type-specific transcription factor Phox2b. J. Neurosci 2003;23: Gründer G, Wetzel H, Schlösser R, Anghelescu I, Hillert A, Lange K, et al. Neuroendocrine response to antipsychotics: effects of drug type and gender. Biol Psychiatry 1999;45(1): 89Y Grzywa M, Kloc-Rojek M, Zaborska A. Severe depressive episode with psychotic symptoms on the basis of hypothyroidism. Pol Merkur Lekarski 2009;27(161): Guimarães JM, de Souza Lopes C, Baima J, Sichieri R. Depression symptoms and hypothyroidism in a population-based study of middle-aged Brazilian women. J Affect Disord 2009;117(1-2): Gusseklo J, van Exel E, de Craen AJ, Meinders AE, Frölich M, Westendorp RG. Thyroid status, disability and cognitive function, and survival in old age. JAMA 2004; 292: Guy W. ECDEU Assessment Manual for Psychopharmacology, Revised. Publication ADM Bethesda, MD: United States Department of Health, Education, and Welfare; Gwinup G, Rapp N. Low serum thyroxine in phenothiazinetreated psychiatric patients. Am J Clin Pathol 1975;63: Hakak Y, Walker JR, Li C, et al. Genome-wide expression analysis reveals dysregulation of myelination-related genes in chronic schizophrenia. Proceedings of the National Academy of Sciences U S A 2001;98(8): Hall D, Gogos JA, Karayiorgou M. The contribution of three strong candidate schizophrenia susceptibility genes in demographically distinct populations. Genes Brain Behav 2004;3: Hansen PS, Brix TH, Sørensen TI, Kyvik KO, Hegedu s L. Major genetic influence on the regulation of the pituitary-thyroid axis: a 113

114 study of healthy Danish twins. J Clin Endocrinol Metab 2004;89: Harrison PJ, Weinberger DR. Schizophrenia genes, gene expression, and neuropathology: on the matter of their convergence. Mol Psychiatry 2005;10: Hein MD, Jackson IM. Review: thyroid function in psychiatric illness. Gen Hosp Psychiatry 1990;12: Heinrich TW, Grahm G. Hypothyroidism presenting as psychosis: myxedema madness revisited. Prim care companion. J Clin Psychiatry 2003;5(6): Hennemann G, et al. Plasma membrane transport of thyroid hormones and its role in thyroid hormone metabolism and bioavailability. Endocr Rev 2001;22: Hofmann WH, Chodorof G, Pigott LR. Haloperidol and thyroid storm. Am J Psychiatry 1978;135: Ivleva EI, Taminga CA. Psychosis as a defining dimension in schizophrenia in: Sadock BJ, Sadock VA, Ruiz P, editors. Kaplan and Sadock's Com-prehensive Textbook of Psychiatry. 9th edition. Philadelphia: Wolters Kluwer. Lippincott Williams & Wilkins; p Jambut-Absil AC, Buxeraud J, Raby C. Phenothiazine type drugs: secondary antithyroid effect. J Pharmacol Clin 1986;5: Janson J, Friesema EC, Milici C, Visser TJ. Thyroid hormone transporters in health and disease. Thyroid 2005;15: Javitt DC. Glutamatergic theories of schizophrenia. Isr J Psychiatry Relat Sci 2010;47(1): Jefferson JW. Haldol decanoate and thyroid disease. J Clin Psychiatry 1988;49(11): Joffe RT, Pearce EN, Hennessey JV, Ryan JJ, Stern RA. Subclinical hypothyroidism, mood, and cognition in older adults: a review. Int J Geriatr Psychiatry doi: /gps Kapur S. Psychosis as a state of aberrant salience: A framework linking biology, phenomenology, and pharmacology in schizophrenia. American Journal of Psychiatry 2003;106(1): Katsel P, Davis KL, Li C, et al. Abnormal indices of cell cycle activity in schizophrenia and their potential association with oligodendrocytes. Neuropsychopharmacology 2008;33(12): Kelly DL, Conley RR. Thyroid function in treatment-resistant schizophrenia patients treated with quetiapine, risperidone, or fluphenazine. J Clin Psychiatry 2005;66(1):

115 115. Keshavan MS, Nasrallah HA, Tandon R. Schizophrenia, "Just the Facts" 6. Moving ahead with the schizophrenia concept: from the elephant to the mouse. Schizophr Res 2011;127(1-3): Khalil RB, Richa S. Thyroid adverse effects of psychotropic drugs: a review. Clin Neuropharmacol 2011;34(6): Khemka D, Ali JA, Koch CA. Primary hypothyroidism associated with acute mania: case series and literature review. Exp Clin Endocrinol Diabetes 2011;119(8): Kleinman JE, Law AJ, Lipska BK, Hyde TM, Ellis JK, Harrison PJ, et al. Genetic neuropathology of schizophrenia: new approaches to an old question and new uses for postmortem human brains. Biol Psychiatry. 2011;69(2): Kontaxakis VP, Karaiskos D, Havaki-Kontaxaki BJ, Ferentinos P, Papadimitriou GN. Can quetiapine-induced hypothyroidism be reversible without quetiapine discontinuation? Clin Neuropharmacol 2009;32: Kundu S, Biswas A, Roy S, De J, Pramanik M, Ray AKThyroid hormone homeostasis in brain: Possible involvement of adrenergic phenomenon in adult rat. Neuroendocrinology 2009;89(2): Kuromitsu J, Yokoi A, Kawai T, Nagasu T, Aizawa T, Haga S, Ikeda K. Reduced neuropeptide Y mrna levels in the frontal cortex of people with schizophrenia and bipolar disorder. Brain Res. Gene Expression Patterns 2001;1: Kwakkel J, Fliers E, Boelen A. Illness-induced changes in thyroid hormone metabolism: focus on the tissue level. Neth J Med 2011;69(5): Lake CR, Fann WE. Possible potentiation of haloperidol neurotoxicity in acute hyperthyroidism. Br J Psychiatry 1973;123: Lamberg BA, Linnoila M, Fogelholm R, Olkinuora M, Kotilainen P, Saarinen P. The effects of psychotropic drugs on the TSH response to thyroliberin (TRH). Neuroendocrinology 1977;24: Langer G, Resch F, Aschaeur H, Keshardn MS, Koinig G, Schonbeck G, et al. TSH-response patterns to TRH stimulation may indicate therapeutic mechanisms of antidepressant and neuroleptic drugs. Neuropsychobiology 1984; 11: Langlois MC, Beaudry G, Zekki H, Rouillard C, Levesque D. Impact of antipsychotic drug administration on the expression of nuclear receptors in the neocortex and striatum of the rat brain. Neuroscience 2001;106:

116 127. Laruelle, A. Abi-Dargham, R. Gil, et al. Increased dopamine transmission in schizophrenia: Relationship to illness phases. Biological Psychiatry 1999;46(1) Laurberg P, Andersen S, Bülow Pedersen I, Carlé A. Hypothyroidism in the elderly: pathophysiology, diagnosis and treatment. Drugs Aging 2005;22(1): Lavado-Autric R, Auso E, Garcia-Velasco JV, Arufe Mdel C, Escobar del Rey F, Berbel P, Morreale de Escobar G. Early maternal hypothyroxinemia alters histogenesis and cerebral cortex cytoarchitecture of the progeny. J Clin Invest 2003;111: Lazarus JH. Lithium and thyroid. Best Pract Res Clin Endocrinol Metab 2009;23(6): 723Y Leonard JL, Koehrle J. Intracellular pathways of iodothyronine metabolism. In: Braverman LE, Utiger RD. Eds. The Thyroid. Philadelphia: Lippincott Williams and Wilkins; 2000, pp Lerer B, Segman RH, Hamdan A, Kanyas K, Karni O, Kohn Y, Korner M, et al. Genome scan of Arab Israeli families maps a schizophrenia susceptibility gene to chromosome 6q23 and supports a locus at chromosome 10q24. Mol Psychiatry 2003;8: Levi A, Kohn Y, Kanyas K, Amann D, Pae CU, Hamdan A, et al. Fine mapping of a schizophrenia susceptibility locus at chromosome 6q23: increased evidence for linkage and reduced linkage interval. Eur J Hum Genet 2005;13: Liappas J, Paparrigopoulos T, Mourikis I, Soldatos C. Hypothyroidism induced by quetiapine: a case report. J Clin Psychopharmacol 2006;26(2): Lieberman JA, Stroup TS. The NIMH-CATIE schizophrenia study: What did we learn? Am J Psychiatry 2011;168: Lifschytz T, Segman R, Shalom G, et al. Basic mechanisms of augmentation of antidepressant effects with thyroid hormone. Curr Drug Targets 2006;7: Lodge DJ, Grace AA. Hippocampal dysregulation of dopamine system function and the pathophysiology of schizophrenia. Trends Pharmacol Sci 2011;32(9): Loosen PT. Hormones of the hypothalamic-pituitary-thyroid axis: a psychoneuroendocrine perspective. Pharmacopsychiatry 1986;19(6): MacDonald AW, Schulz SC. What we know: Findings that every theory of schizophrenia should explain. Schizophrenia Bulletin 2009;35(3):

117 140. MacSweeney D, Timms P, Johnson A. Preliminary Communication Thyro-endocrine pathology, obstetric morbidity and schizophrenia: survey of a hundred families with a schizophrenic proband. Psychol Med 1978;8(1): Mafrica F, Fodale V. Thyroid function, Alzheimer's disease and postoperative cognitive dysfunction: a tale of dangerous liaisons? J Alzheimers Dis 2008;14: Magliozzi JR, Gold A, Laubly JN. Effect of oral administration of haloperidol on plasma thyrotropin concentrations in men. Psychoneuroendocrinology 1989;14: Magni P. Hormonal control of the neuropeptide Y system. Curr. Protein Pept. Sci 2003;4: Martinos A, Rinieris P, Papachristou DN, Souvatzoglou A, Koutras DA, Stefanis C. Effects of six weeks' neuroleptic treatment on the pituitary thyroid axis in schizophrenic patients. Neuropsychobiology 1986;16: Mason JW, Kennedy JL, Kosten TR, Giller EL Jr. Serum thyroxine levels in schizophrenic and affective disorder diagnostic subgroups. J Nerv Ment Dis 1989;177(6): McKnight RF, Adida M, Budge K, Stockton S, Goodwin GM, Geddes JR. Lithium toxicity profile: a systematic review and metaanalysis. Lancet. 2012;379(9817): McLarty DG, Ratcliffe WA, Ratcliffe JG, Shimmins JG, Goldberg A. A study of thyroid function in psychiatric in-patients. The British Journal of Psychiatry 1978;133: Mebis L, van den Berghe G. The hypothalamus-pituitary-thyroid axis in critical illness. Netherlands Journal of Medicine 2009;67(10): Mendes-de-Aguiar CB, Alchini R, Decker H, et al. Thyroid hormone increases astrocytic glutamate uptake and protects astrocytes and neurons against glutamate toxicity. Journal of Neuroscience Research 2008;86(14): Mental Health Report Mental health: new understanding, new hope. Geneva: World Health Organization; Meyer-Lindenberg A. Imaging genetics of schizophrenia. Dialogues Clin Neurosci 2010;12(4): Mitchell RL, Crow TJ. Right hemisphere language functions and schizophrenia: the forgotten hemisphere? Brain 2005;128: Modell S, Naber D, Muller Poahn F. Paranoid psychosis in a patient with hypothyroidism and vitamin B12 deficiency. Nervenarzt 1993; 64(5):

118 154. Moeller KE, Goswami R, Larsen LM. Myxedema madness rapidly reversed with levothyroxine. J Clin Psychiatry 2009;70(11): Möller HJ. Pharmacotherapy of schizophrenic patients: Achievements, unsolved needs, future research necessities. Curr Pharm Biotechnol [Epub ahead of print] Morley JE, Shafer RB. Thyroid function screening in new psychiatric admissions. Arch Intern Med 1982;142: Moskvina N, Craddock P, Holmans I, Nikolov J, Pahwa S, Green E. Wellcome trust case control consortium, Owen MJ and O'Donovan MC. Gene-wide analyses of genome-wide association data sets: evidence for multiple common risk alleles for schizophrenia and bipolar disorder and for overlap in genetic risk. Molecular Psychiatry 2009;14: Mueser KT, McGurk SR. Schizophrenia. Lancet 2004;363(9426): Murray CJL, Lopez AD, editors. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to Cambridge, MA: Harvard University Press; Nasrallah H, Tandon R, Keshavan M. Beyond the facts in schizophrenia: closing the gaps in diagnosis, pathophysiology, and treatment. Epidemiol Psychiatr Sci 2011;20(4): Nielsen JM. I see dead people. Hypothyroid myopathy and hypothyroid psychosis. J Miss State Med Assoc 2010;51(5): Nurnberger JI, Berrettini W and Niculescu AB. Genetics of Psychiatric Disorders. The medical basis of psychiatry 2008;Part IV: Offterdinger M, Schneider SM, Huber H, Grunt TW. Expression of c- erbb-4/her4 is regulated in T47D breast carcinoma cells by retinoids and vitamin D3. Biochem Biophys Res Commun 1999;258: Othman SS, Kadir AK, Hassan J, Hong GK, Singh BB, Raman N. High prevalence of thyroid function test abnormalities in chronic schizophrenia. Aust N Z J Psychiatry 1994;28(4): Owen MJ, Williams NM, O'Donovan MC. The molecular genetics of schizophrenia: new findings promise new insights. Mol Psychiatry 2004;9: Pae CU, Mandelli L, Han C, Ham BJ, Masand PS, Patkar AA, Steffens DC, De Ronchi D, Serretti A. Thyroid hormones affect recovery from depression during antidepressant treatment. Psychiatry Clin Neurosci 2009;63(3):

119 167. Palha JA, Goodman AB. Thyroid hormones and retinoids: a possible link between genes and environment in schizophrenia. Brain Res Rev 2005;51(1): Panicer V. Genetics of Thyroid Function and Disease. Clin Biochem Rev 2011;32: Panicker V, Saravanan P, Vaidya B, Evans J, Hattersley AT, Frayling TM, Dayan CM. Common variation in the DIO2 gene predicts baseline psychological well-being and response to combination thyroxine plus triiodothyronine therapy in hypothyroid patients. J Clin Endocrinol Metab 2009; 94(5): Papadimitriou A, Dumitrescu AM, Papavasiliou A, et al. A novel monocarboxylatetransporter 8 gene mutation as a cause of severe neonatal hypotonia and developmental delay. Pediatrics 2008;121: e199 e Park S, Happy JM, Prange AJ. Thyroid action on behavioralphysiological efects and disposition of phenothiazines. Eur J Pharmacol 1972;19: Park S. Enhancement of antipsychotic effect of chlorpromazine with L-Triiodothyrone. In Prange AJJr, ed. The thyroid axis, drugs and behavior. New York: Reven Press;1974. p Paunovic VR, Timotijevic I, Marinkovic D. Neuroleptic actions on the thyroid axis: different effects of clozapine and haloperidol. Int Clin Psychopharmacol 1991;6(3): 133Y Pedersen IB, Knudsen N, Jorgensen T, et al. Thyroid peroxidase and thyroglobulin autoantibodies in a large survey of populations with mild and moderate iodine deficiency. Clin. Endocrinol (Oxf) 2003;58: Peeters RP, van der Deure WM, Visser TJ. Genetic variation in thyroid hormone pathway genes; polymorphisms in the TSH receptor and the iodothyronine deiodinases. Eur J Endocrinol 2006;155: Peralta V, Cuesta MJ. A dimensional and categorical architecture for the classification of psychotic disorders. World Psychiatry 2007; 6(2): Philibert RA, Sandhu HK, Hutton AM, et al. Population-based association analyses of the HOPA12bp polymorphism for schizophrenia and hypothyroidism. Am J Med Genet 2001;105: Posternak M, Novak S, Stern R, Hennessey J, Joffe R, Prange A Jr, Zimmerman M. A pilot effectiveness study: placebo-controlled trial of adjunctive L-triiodothyronine (T3) used to accelerate and potentiate the antidepressant response. Int J Neuropsychopharmacol 2008;11(1):

120 179. Potvin S, Stip E, Sepehry AA, Gendron A, Bah R, Kouassi E. Inflammatory cytokine alterations in schizophrenia: a systematic quantitative review. Biol Psychiatry 2008;63(8): Poutanen O, Iso-Koivisto E, Työläjärvi M, Leinonen E. Quetiapineassociated hypothyroidism in young female patients: a report of three cases. Pharmacopsychiatry 2010;43(6): Poyraz BC, Aksoy C, Balciolu I. Increased incidence of autoimmune thyroiditis in patients with antipsychotic-induced hyperprolactinemia. Eur Neuropsychopharmacol 2008;18(9):667Y Prange AJ Jr, Loosen PT, Wilson IC, Meltzer HY, Fang VS. Behavioral and endocrine responses of schizophrenic patients to TRH (protirelin). Arch Gen Psychiatry 1979;36: Prange AJ Jr, Wilson IC, Knox AE, McClane TK, Breese GR, Martin BR, Alltop LB, Lipton MA. Thyroid-imipramine clinical and chemical interaction: evidence for a receptor deficit in depression. J Psychiatr Res 1972;9(3): Prange AJ Jr, Wilson IC, Rabon AM, Lipton MA. Enhancement of imipramine antidepressant activity by thyroid hormone. Am J Psychiatry 1969;126(4): Premachandra BN, Kabir MA, Williams IK. Low T3 syndrome in psychiatric depression. J Endocrinol Invest 2006;29: Pugeat M, Nader N, Hogeveen K, Raverot G, Déchaud H, Grenot C. Sex hormone-binding globulin gene expression in the liver: drugs and the metabolic syndrome. Mol Cell Endocrinol 2010;316: Pulver AE, Lasseter VK, Kasch L, Wolyniec P, Nestadt G, Blouin JL, et al. Schizophrenia: a genome scan targets chromosomes 3p and 8p as potential sites of susceptibility genes. Am J Med Genet 1995;60: Ramaswamy S, Siddiqui Z, Saharan S, Gabel TL, Bhatia SC. Quetiapine induced hypothyroidism. J Psychiatry Neurosci 2005;30(1): Rang HP, Dale MM. Pharmacology. 3rd ed. New York: Churchill Livingstone; Rao ML, Gross G, Huber G. Altered interrelationship of dopamine, prolactin, thyrotropin and thyroid hormone in schizophrenic patients. Eur Arch Psychiatr Neurol Sci 1984;234: Rao ML, Gross G, Strebel B, et al. Serum amino acids, central monoamines, and hormones in drug-naive, drug-free, and neuroleptic-treated schizophrenic patients and healthy subjects. Psychiatry Research 1990;34(3): Rao ML, Ruhrmann S, Retey B, Liappis N, Fuger J, Kraemer M, et al. Low plasma thyroid indices of depressed patients are attenuated by 120

121 antidepressant drugs and influence treatment outcome. Pharmacopsychiatry 1996;29(5): Rao ML, Strebel B, Halaris A, Gross G, Bräunig P, Huber G, Marler M. Circadian rhythm of vital signs, norepinephrine, epinephrine, thyroid hormones, and cortisol in schizophrenia. Psychiatry Res 1995;57(1): Resta F, Triggiani V, Barile G, Benigno M, Suppressa P, Giagulli VA, et al. Subclinical hypothyroidism and cognitive dysfunction in the elderly. Endocr Metab Immune Disord Drug Targets 2012 [Epub ahead of print] Rinieris P, Christodoulou GN, Souvatzoglou A, Koutras DA, Stefanis C. Free-thyroxine index in schizophrenic patients before and after neuroleptic treatment. Neuropsychobiology 1980;6: Roberts CG, Ladenson PW. Hypothyroidism. Lancet 2004;363(9411): Robins LN, Wing J, Wittchen HU, Helzer JE, Babor TF, Burke J, Farmer A, Jablenski A, Pickens R, Regier DA, et al. The Composite International Diagnostic Interview. An epidemiologic Instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Arch Gen Psychiatry. 1988;45(12): Roca RP, Blackman MR, Ackerley MB, Harman SM, Gregerman RI. Thyroid hormone elevations during acute psychiatric illness: relationship to severity and distinction from hyperthyroidism. Endocr Res 1990; 16: Roy A, Pickar D. TRH induced prolactin release in unipolar depressed patients and controls. J Psychiatr Res 1988;22(3): Rozanov CB, Dratman MB. Immunohistochemical mapping of brain triiodothyronine reveals prominent localization in central noradrenergic systems. Neuroscience 1996;74: Rozing MP, Westendorp RG, Maier AB, Wijsman CA, Frölich M, de Craen AJ, van Heemst D. Serum triiodothyronine levels and inflammatory cytokine production capacity. Age (Dordr) 2012;34(1): Sadock BJ, Sadock VA. Kaplan & Sadock s synopsis of psychiatry: behavioral science/clinical psychiatry. 10th ed. Philadelphia: Wolters Kluwer. Lippincot Williams & Wilkins; Samad TA, Krezel W, Chambon P, Borrelli E. Regulation of dopaminergic pathways by retinoids: activation of the D2 receptor promoter by members of the retinoic acid receptorretinoid X receptor family. Proc Natl Acad Sci USA 1997;94:

122 204. Saravanan P, Chau WF, Roberts N, Vedhara K, Greenwood R, Dayan CM. Psychological well-being in patients on 'adequate' doses of l thyroxine: results of a large, controlled community based questionnaire study. Clin Endocrinol (Oxf) 2002;57(5): Saravanan P, Simmons DJ, Greenwood R, Peters TJ, Dayan CM. Partial substitution of thyroxine (T4) with tri iodothyronine in patients on T4 replacement therapy: results of a large community based randomized controlled trial. J Clin Endocrinol Metab 2005;90(2): Saravanan P, Visser TJ, Dayan CM. Psychological well-being correlates with free thyroxine but not free 3,5,3 -triiodothyronine levels in patients on thyroid hormone replacement. J Clin Endocrinol Metab 2006;91: Sarne DH, Refetoff S, Rosenfield RL & Farriaux JP. Sex hormone binding globulin in the diagnosis of peripheral tissue resistance to thyroid hormone: the value of changes after short term triiodothyronine administration. Journal of Clinical Endocrinology and Metabolism 1988;66: Sauvage MF, Marquet P, Rousseau A, Raby C, Buxeraud J, Lachâtre G. Relationship between psychotropic drugs and thyroid function: a review. Toxicol Appl Pharmacol 1998;149(2): Scanlan TS, Suchland KL., Hart ME, Chiellini G, Huang Y, Kruzich PJ, et al. 3-Iodothyronamine is an endogenous and rapid-acting derivative of thyroid hormone. Nat Med 2004;10: Schmitz T, Chew LJ. Cytokines and myelination in the central nervous system. The Scientific World Journal 2008;8: Seeman P, Schwarz J, Chen JF, Szechtman H, Perreault M, McKnight GS, et al. Psychosis pathways converge via D2high dopamine receptors. Synapse 2006;60(4): Selva DM, Hammond GL. Thyroid hormones act indirectly to increase sex hormone-binding globulin production by liver via hepatocyte nuclear factor-4alpha. J Mol Endocrinol 2009;43(1): Sharma RP. Schizophrenia, epigenetics and ligand-activated nuclear receptors: a framework for chromatin therapeutics. Schizophr Res 2005;72: Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM IV and ICD 10. J Clin Psychiatry 1998;59 (20 Suppl): 22-33, quiz

123 215. Shen X, Li QL, Brent GA, Friedman TC. Thyroid hormone regulation of prohormone convertase 1 (PC1): regional expression in rat brain and in vitro characterization of negative thyroid hormone response elements. J Mol Endocrinol 2004;33: Shin JK, MaloneDT, Crosby IT, et al. Schizophrenia: A systematic review of the disease state, current therapeutics and their molecular mechanisms of action. Curr Med Chem 2011;18(9): Shirts BH, Nimgaonkar V. The genes for schizophrenia: finally a breakthrough? Curr Psychiatry Rep 2004;6; Shoba T, Dheen ST, Tay SS. Retinoic acid influences Phox2 expression of cardiac ganglionic cells in the developing rat heart. Neurosci Lett 2002;321: Sijens PE, Rödiger LA, Meiners LC, Lunsing RJ. 1H magnetic resonance spectroscopy in monocarboxylate transporter 8 gene deficiency. J Clin Endocrinol Metab 2008;93: Sim K, Chong SA, Chan YH, Lum WM. Thyroid dysfunction in chronic schizophrenia within a state psychiatric hospital. Ann Acad Med Singapore 2002;31(5): Simpson GM, Amuso D. Treatment of chronic schizophrenia with tri iodothyronine. Can Psychiatr Assoc J 1966;11(4): Skobba T, Miya TS. Hyperthermic responses and toxicity of chlorpromazine in L thyroxine sodium treated rats. Toxicol Appl Pharm 1969;14: Smith S, Wheeler MJ, Murray R, O'Keane V. The effects of antipsychotic-induced hyperprolactinaemia on the hypothalamic-pituitarygonadal axis. J Clin Psychopharmacol 2002;22(2): Snyder SH. Dopamine receptor excess and mouse madness. Neuron 2006;49(4): Sousa JC, Grandela C, Fernandez-Ruiz J, de Miguel R, de Sousa L, Magalhaes AI, et al. Transthyretin is involved in depression-like behavior and exploratory activity. J Neurochem 2004;88: Southwick S, Mason JW, Giller EL, Kosten TR. Serum thyroxine change and clinical recovery in psychiatric inpatients. Biol Psychiatry 1989;25(1): Spinks R, Sandhu HK, Andreasen NC, Philibert RA. Association of the HOPA12bp allele with a large X-chromosome haplotype and positive symptom schizophrenia. Am J Med Genet B Neuropsychiatr Genet 2004;127B(1): Spitzer RL, Williams JB, Gibbon M, First MB. The Structured Clinical Interview for DSM III R (SCID): I. History, rationale, and description. Arch Gen Psychiatry 1992;49:

124 229. Spratt DI, Pont A, Miller MB, McDougall IR, Bayer MF, McLaughlin WT. Hyperthyroxinemia in patients with acute psychiatric disorders. Am J Med 1982;73: Staub JJ, Althaus BU, Engler H, Ryff AS, Trabucco P, Marquardt K, et al. Spectrum of subclinical and overt hypothyroidism: effect on thyrotropin, prolactin, and thyroid reserve, and metabolic impact on peripheral target tissues. Am J Med 1992;92(6): Stowell CP, Barnhill JW. Acute mania in the settings of severe hypothyroidism. Psychosomatics 2005;46(3): Straub JJ, Weyermann D, Huber P, Zulewski H, Roulet F, Burckhardt D. Tissue markers of thyroid hormone actions. In: Orgiazzi J, Leclere J, with the assistance of Hostalek U, editors. The Thyroid and Tissues. Strasbourg: Merck European Thyroid Symposium; p Strawn JR, Ekhator NN, D'Souza BB, Geracioti Jr TD. Pituitary thyroid state correlates with central dopaminergic and serotonergic activity in healthy humans. Neuropsychobiology 2004;49: Suzuki N, Oh-Nishi A, Saji M. Dopamine D2 like receptor function is reverted by thyroid hormone in early developmental hippocampus. Program No Abstract Viewer/Itinerary Planner. Washington, DC: Society for Neuroscience; Online Suzuki T, Abe T. Thyroid hormone transporters in the brain. Cerebellum 2008;7: Takorabet L, Ropars A, Stasiuk L, Raby C, Charreire J. Phenothiazine-induced increase in thyroid autoantigens and costimulatory molecules on thyroid cells: a pathophysiological mechanism for druginduced autoimmunity? Clin Exp Immunol 1998;111(2): Tandon R, Halbreich U. The second-generation atypical antipsychotics: similar improved efficacy but different neuroendocrine side effects. Psychoneuroendocrinology 2003; 28 (1): Tandon R, Keshavan MS, Nasrallah HA. Schizophrenia, "Just the Facts": what we know in 2008 part 1: overview. Schizophr Res 2008;100(1-3): Tandon R, Nasrallah HA, Keshavan MS. Schizophrenia, "just the facts" 5. Treatment and prevention. Past, present, and future. Schizophr Res 2010;122(1-3): Tandon R. Antipsychotics in the treatment of schizophrenia: an overview. J Clin Psychiatry 2011;72(1): Tor PC, Lee HY, Fones CSL. Late onset mania with psychosis associated with hypothyroidism in an elderly Chinese lady. Syngapure Med J 2007;48(4):

125 242. Tsuang MT, Stone WS, Auster TL. Gene Environment Interactions in Mental Illness. European Psychiatric Review 2010;3(2): Tsuang MT, Stone WS, Faraone SV. Genes, environment and schizophrenia. Br J Psychiatry 2001;40: s18 s van der Deure WM, Appelhof BC, Peeters RP, Wiersinga WM, Wekking EM, Huyser J, et al. Polymorphisms in the brain-specific thyroid hormone transporter OATP1C1 are associated with fatigue and depression in hypothyroid patients. Clin Endocrinol (Oxf) 2008;69(5): van Os J, Kapur S. Schizophrenia. The Lancet 2009a;374(9690): van Os J, Linscott RJ, Myin-Germeys I, Delespaul P, Krabbendam L. A systematic review and meta-analysis of the psychosis continuum: evidence for a psychosis proneness-persistence-impairment model of psychotic disorder. Psychol Med 2009b;39(2): Van Winkel R, Esquivel G, Kenis G, Wichers M, Collip D, Peerbooms O, et al. Genome-wide findings in schizophrenia and the role of gene-environment interplay. CNS Neurosci Ther 2010;16(5): e Verrotti A, Scardapane A, Manco R, et al. Antiepileptic drugs and thyroid function. J Pediatr Endocrinol Metab 2008;21(5): 401Y Villa A, Santiago J, Belandia B, Pascual A. A response unit in the first exon of the beta-amyloid precursor protein genecontaining thyroid hormone receptor and Sp1 binding sitesmediates negative regulation by 3,5,3 -triiodothyronine. Mol Endocrinol 2004;18: Visser WE, Friesema EC, Jansen J, Visser TJ. Thyroid hormone transport in and out of cells. Trends Endocrinol Metab 2008;19(2): Walsh JP, Shiels L, Lim EM, Bhagat CI, Ward LC, Stuckey BG, Dhaliwal SS, Chew GT, Bhagat MC, Cussons AJ. Combined thyroxine/liothyronine treatment does not improve well-being, quality of life, or cognitive function compared to thyroxine alone: a randomized controlled trial in patients with primary hypothyroidism. J Clin Endocrinol Metab 2003;88(10): Warner MH, Beckett GJ. Mechanisms behind the non-thyroidal illness syndrome: an update. J Endocrinol 2010; 205: Watanabe Y, Someya T, Nawa H. Cytokine hypothesis of schizophrenia pathogenesis: evidence from human studies and animal models. Psychiatry Clin Neurosci. 2010;64(3):

126 254. Weber NS, Fisher JA, Cowan DN, Niebuhr DW. Psychiatric and general medical conditions comorbid with bipolar disorder in the National Hospital Discharge Survey. Psychiatr Serv 2011;62(10): Weetman AP. Autoimmune thyroid disease. Autoimmunity 2004;37: Weiner MF. Haloperidol, hyperthyroidism and sudden death. Am J Psychiatry 1979;136: Werme M, Ringholm A, Olson L, Brene S. Differential patterns of induction of NGFI-B, Nor1 and c-fos mrnas in striatal subregions by haloperidol and clozapine. Brain Res 2000;863: Whybrow PC, Bauer M. Behavioral and psychiatric aspects of hypothyroidism. In: Breverman LE, Utiger RD, editors. Werner & Ingbar s the thyroid: a fundamental and clinical Text. 9th ed. Philadelphia: Lippincott Williams &Wilkins; p Wiens SG, Trudeau VL. Thyroid hormone and gamma-aminobutyric acid (gaba) interactions in neuroendocrine systems. Comparative Biochemistry and Physiology Part A: Molecular and Integrative Physiology 2006;144(3): Wiersinga WM. Nonthyroidal illness. In: Breverman LE, Utiger RD, editors. Werner & Ingbar s the thyroid: a fundamental and clinical Text. 9th ed. Philadelphia: Lippincott Williams &Wilkins; p Wijsman EM, Rosenthal EA, Hall D, Blundell ML, Sobin C, Heath SC, et al. Genome-wide scan in a large complex pedigree with predominantly male schizophrenics from the island of Kosrae: evidence for linkage to chromosome 2q. Mol Psychiatry 2003;8: Williams GR. Neurodevelopmental and neurophysiological actions of thyroid hormone. J Neuroendocrinol 2008;20: Woeber KA. Levothyroxine therapy and serum free thyroxine and free triiodothyronine concentrations. J Endocrinol Invest 2002;25(2): Wolpert A, Yaryura-Tobias JA, White L, Merlis S. Triiodothyronine and phenothiazines in schizophrenia. Dis Nerv Syst 1969;30(7): Yang YF, Qin W, Shugart YY, He G, Liu XM, Zhou J, et al. Possible association of the MAG locus with schizophrenia in a Chinese Han cohort of family trios. Schizophr Res 2005;75: Yazici K, Yazici AE, Taneli B. Different neuroendocrine profiles of remitted and nonremitted schizophrenic patients. Prog Neuropsychopharmacol Biol Psychiatry 2002;26(3):

127 267. Ye Q, Shieh JH, Morrone G, Moore MA. Expression of constitutively active Notch4 (Int-3) modulates myeloid proliferation and differentiation and promotes expansion ofhematopoietic progenitors. Leukemia 2004;18: Yen PM, Ando S, Feng X, Liu Y, Maruvada P, Xia X. Thyroid hormone action at the cellular, genomic and target gene levels. Mol Cell Endocrinol 2006;246: Yen PM. Physiological and molecular basis of thyroid hormone action. Physiol Rev 2001;81: Zoeller RT, Rovet J. Timing of thyroid hormone action in the developing brain: clinical observations and experimentalfindings. J Neuroendocrinol 2004;16:

128 PUBLICATIONS ON THE DISSERTATION THEME 1. Steiblienė V, Mickuvienė N, Bunevičius R. Effect of treatment with antipsychotics on sex hormone binding globulin concentrations in patients with acute psychosis (Gydymo antipsichotikais poveikis lytinius hormonus surišančio baltymo koncentracijai sergant ūminėmis psichozėmis). Biologinė psichiatrija ir psichofarmakologija=biological Psychiatry and Psychopharmacology 2012; 14(1): Steiblienė V, Mickuvienė N, Prange AJ, Bunevičius R. Thyroid axis hormone concentrations in psychotic patients upon hospital admission: effects of prior drug use (Psichoze sergančių pacientų skydliaukės ašies hormonų koncentracija stacionarizavimo metu: vartotų vaistų poveikis). Medicina. Manuscript accepted for the publication. 3. Steiblienė V, Mickuvienė N, Bunevičius R. Ūminė psichozė, susijusi su skydliaukės funkcijos nepakankamu: klinikinio atvejo aprašymas (Acute psychosis related to insuficient of thyroid function: a case report). Biologinė psichiatrija ir psichofarmakologija=biological Psychiatry and Psychopharmacology 2008;10(2): OTHER PUBLICATIONS AND THE PRESENTATIONS ON THE DISSERTATIONS THEME 1. Steiblienė V, Mickuvienė N, Bunevičius R. Changes in thyroid hormone concentrations during acute psychosis epizode. Biologinė psichiatrija ir psichofarmakologija = Biological psychiatry and psychopharmacology : Kauno medicinos universiteto Psichologijos ir reabilitacijos instituto VIII-osios metinės konferencijos tezės. 2008; 2(10): Bunevičius R, Steiblienė V, Mickuvienė N. Effects of treatment with antiosychotic medications on thyroid hormone concentrations. European neuropsychopharmacology : Papers of the 21st ECNP Congress : 30 August-3 September 2008, Barcelona, Spain. Amsterdam : Elsevier. (Posters. P.3.c: Psychotic disorders and antipsychotics - Antipsychotics (clinical)). 2008; 18, suppl. 4, August, p. S412-S413, no. P.3.c Steiblienė V, Mickuvienė N, Bunevičius R. Thyroid axis functioning in psychotic patients during admission to mental hospital. The international journal of neuropsychopharmacology : official scientific journal of the Collegium Internationale Neuropsychopharmacologicum (CINP) : Abstracts from the XXVI CINP Congress: Munich, July Cambridge : Cambridge University Press. (P-02 - Poster Session. Schizophrenia, clinical) 2008:. 11, suppl. 1:150, no. P

129 4. Steiblienė V, Mickuvienė N, Bunevičius R. Relationship between thyroid hormone concentrations and severity of mental symptoms in acute psychoses. 9th World Congress of Biological Psychiatry : 28 June - 2 July 2009, Paris, France : abstracts / World Federation of Societies of Biological Psychiatry (WFSBP) Paris : WFSBP, 2009; (Poster Presentation. Session title: Psychotic Disorders VIII.): 316, no. P Steiblienė V, Mickuvienė N, Bunevičius R. Ūmine psichoze sergančiųjų skydliaukės ašies funkcija bei sąsajos su psichozinių simptomų išreikštumu. Biologinė psichiatrija ir psichofarmakologija=biological Psychiatry and Psychopharmacology : KMU Psichofiziologijos ir reabilitacijos instituto IX-oji metinė konferencija. Kaunas : Sveikatingumo ir medicinos reklamos centras. (Tezės. 2009;2(11): Steiblienė V, Mickuvienė N, Bunevičius R. Effects of treatment with quetiapine and with other antipsychotics on thyroid axis function in acute psychotic inpatients. 10 th World Congress of Biological Psychiatry: 29May - 2 June 2010, Prague, Czech Republic: abstracts / World Federation of Societies of Biological Psychiatry (WFSBP) Praha: WFSBP, 2010; (Poster Presentation. Session title: Psychopharmacology V.): 118, no. P Steiblienė V, Mickuvienė N, Bunevičius R. Skydliaukės ašies hormonų koncentracijų pokyčiai gydant skirtingais antipsichotikais. Biologinė psichiatrija ir psichofarmakologija=biological Psychiatry and Psychopharmacology: LSMU Psichofiziologijos ir reabilitacijos instituto X-oji metinė konferencija. Kaunas: Sveikatingumo ir medicinos reklamos centras. 2011; 1(13):

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