Prevalence and correlates of overweight and obesity in patients with major depression accompanied by abnormal TSH levels

Abstract

Background

Abnormal thyroid function is common in patients with major depressive disorder (MDD), which may be closely associated with metabolic disturbances, especially overweight and obesity. This study aimed to examine the prevalence of overweight and obesity and their related factors in MDD patients with elevated thyroid stimulating hormone (TSH) levels.

Methods

A total of 1718 patients with MDD were recruited in this study. Hamilton Anxiety Rating Scale (HAMA), Hamilton Depression Rating Scale (HAMD), and Positive and Negative Syndrome Scale (PANSS) positive subscale were used to assess clinical symptoms. In addition, free triiodothyronine (FT3), free thyroxine (FT4), thyroid stimulating hormone (TSH), anti-thyroglobulin (A-TG), body weight, height, and blood pressure were measured.

Results

MDD patients with elevated TSH levels had a higher rate of obesity and overweight compared to those without abnormal TSH levels. Among patients with elevated TSH levels, those who were overweight and obese had an older actual age and age of onset, lower A-TG levels, and higher systolic blood pressure than those who were not overweight and obese. Further logistic regression analysis showed that being married (OR: 1.582, 95% CI: 1.191–2.102) and having no suicidal behavior (OR: 1.444, 95% CI: 1.079–1.934) were independently associated with overweight and obesity in patients with elevated TSH level (p < 0.05).

Conclusion

Patients with MDD who have elevated TSH levels are more likely to be obese and overweight. Actual age, age of onset, systolic blood pressure, A-TG levels, marital statusand and suicidal behavior were associated with obesity and overweight in MDD patients with elevated TSH levels.

Introduction

Major Depressive Disorder (MDD) is one of the most common psychiatric disorders characterized by low mood, lack of pleasure, and suicidal thoughts or plans [1]. Patients with MDD usually have abnormalities of thyroid-stimulating hormone (TSH), which plays a vital role in regulating growth, development, metabolism, and reproduction [2, 3]. The neuropathological hypothesis of depression posits that reduced serotonin levels within the brain may trigger the release of thyrotropin-releasing hormone, subsequently leading to increased secretion of TSH [4]. Elevated serum TSH levels may interact with TSH receptors on adipocyte surfaces, thereby inhibiting triglyceride lipase activity within adipose tissue. This promotes triglyceride storage, ultimately contributing to obesity or overweight states [5]. Overweight and obesity not only affect patients’ quality of life but also further exacerbate symptoms of depression and thyroid dysfunction [6, 7].

Previous studies have reported the prevalence of obesity and overweight in MDD patients, the rates of overweight, obesity, and severe obesity among depressed individuals in the United States are 27.9%, 34.3%, and 10.4%, respectively [8]. In Europe, 30.9% of depressed patients are overweight and 21.2% are obese [9]. However, no such studies have been specifically reported the incident rates of overweight and obesity in MDD patients with abnormal serum TSH levels.

The prevalence of overweight and obesity in MDD patients with abnormal serum TSH levels has been associated with several factors. First, abnormal thyroid function may directly affect the metabolic levels of patients, leading to decreased energy expenditure and increased fat storage [10]. In addition, patients with MDD experience more difficulties in coping with stress and maintaining a positive mindset,so social discrimination, stress, and family status lead to binge eating and emotional eating [11]; Also, MDD patients tend to have poor lifestyle habits, such as sleep disorders, insufficient exercise, and an unbalanced diet, thereby increasing the risk of overweight and obesity [12]. Changes in hormone levels also affect body weight in MDD patients with abnormal serum TSH levels [13].

In the present study, we investigated the prevalence of overweight and obesity and their associated factors in MDD patients with abnormal serum TSH levels, which few studies have reported.

Methods

Participants

The study is a cross-sectional design, collected sociodemographic data and clinical data, including thyroid hormone levels and body mass index (BMI) levels in patients with depression at a specific time point, and analyze the relationship between them. The study conducted by the Department of Psychiatry, First Clinical Medical College, Shanxi Medical University, Taiyuan, China. The study received ethical approval from the Institutional Review Board (IRB) of the First Clinical Medical College of Shanxi Medical University. It All participants signed the informed consent form and had the right to decide whether to withdraw at any time.

A total of 1,718 first-episode drug-naive MDD patients，aged 18–60 years, Han Chinese,were recruited in outpatient clinics between 2015 and 2017,and they met the following inclusion criteria: (1) MDD diagnosed by two trained psychiatrists using the Structured Clinical Interview for DSM-IV (SCID-IV) [14]; (2) willing to participate in the study and able to understand the instructions of the clinical psychiatrist. Exclusion criteria: (1) Neurodegenerative or psychiatric disease; (2) Substance abuse/dependence (including alcohol, excluding tobacco); (3) Pregnant or breastfeeding females; (4) Refusal to consent.

Observation indicators

Among 1,718 participants 1,044 had elevated TSH levels. The Chinese Working Group on Obesity recommends that BMI ≥ 24.0 kg/m² and < 28.0 kg/m² be defined as overweight and BMI ≥ 28.0 kg/m² as obese [15, 16]. In this study, participants who meet the above-mentioned definition of obesity or overweight were selected as the observation group; and the others were assigned to the control group.

Two independent psychiatrists interviewed patients using the SCID-IV. Trained researchers collected data via a self-designed questionnaire (for sociodemographic variables including age, sex, marital status, education level, age of onset, and illness duration) as well as clinical measures. Height (in centimeters) and weight (in kilograms) were measured with participants wearing light clothing; body mass index (BMI) was then calculated based on these standardized measurements. Additional clinical data collected included systolic blood pressure (SBP) and diastolic blood pressure (DBP).

SBP and DBP were recorded on the left arm using an Omron Hem digital monitor while the patient sat. The mean of the two consecutive measurements was taken as the final blood pressure value of the individual.

Fasting blood glucose (FBG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides (TG), and indicators of thyroid function such as TSH, free triio- dothyronine 3 (FT3), free thyroxine 4(FT4), thyroid peroxidase antibody (TPOAb) and anti-thyroglobulin (A-TG) were measured to assess the metabolic status and hormone levels of the study participants. Serum concentrations of TSH, FT3, FT4, TPOAb and A-TG were determined by electrochemiluminescence immunoassay (Roche Diagnostics, Indianapolis, IN, USA).The normal range for TSH is 0.27–4.20 mIU/L, 3.10–6.8 pmol/L for fT3, and 10–23 pmol/L for fT4. The glucose oxidase method is used to detect fasting blood glucose levels. Detection of lipid profiles using enzymatic colourimetric assays.

Depression symptoms were assessed using the 17-item Hamilton Depression Scale (HAMD-17) [17], with the total score reflecting the severity of the disorder; a total score ≥24 indicates severe depression [18]. Anxiety symptoms were evaluated via the 14-item Hamilton Anxiety Scale (HAMA-14) [19], and a total score ＞18 was considered indicative of anxiety symptoms [19]. The presence and severity of psychotic symptoms were assessed using the positive subscale of the Positive and Negative Syndrome Scale (PANSS) [20], where a total score ＞15 indicated the presence of psychotic symptoms [20, 21]. The overall severity of the illness was measured using the Clinical Global Impression-Severity (CGI-S) Scale. Suicidal behavior was assessed through face-to-face interviews. All the aforementioned scales have been widely used in scientific research in China [18, 22], and the assessors underwent training and passed consistency and reliability evaluations prior to the study.

Statistical analysis

The statistical analysis of the data was carried out using SPSS 20.0 software. The chi-square test was applied to the categorical variables. For continuous variables, we first used the Kolmogorov-Smirnov test to examine whether each variable followed a normal distribution. The results showed that all variables were non-normally distributed. Subsequently, we attempted to perform a log transformation on all variables, with the expectation that some data would become normally distributed after this process. The result of this step was that fasting blood glucose conformed to a normal distribution.so the independent samples t-test was used for analysis; the other indices remained non-normally distributed (p < 0.05). So, for these continuous variables that still failed to follow a normal distribution after such transformation, we employed the non-parametric (Mann-Whitney U) test to analyse them. Pearson correlation was used to analyze the relationship between BMI and the variables. Binary logistic regression was also used to investigate independent risk factors for overweight and obesity in MDD patients with abnormal serum TSH levels. p < 0.05 indicates statistical significance. All values were consistent with a two-tailed p value < 0.05.

Results

Comparison of the incidence of overweight and obesity in patients

Table 1 compares the prevalence of obesity between the normal and abnormal TSH groups. A chi-square test revealed a significant difference (p < 0.05) in the obesity rate between the TSH normal and the TSH abnormal groups, and the prevalence of overweight and obesity was higher in the TSH abnormal group.

Table 1.

Comparison of obesity incidence between the TSH normal group and TSH abnormal group

		TSH normal group (N = 674)	TSH abnormal group (N = 1044)	χ2	p
Obesity	no	664(98.5%)	990(94.8%)	15.539	< 0.001
	Yes	10(1.5%)	54(5.2%)
Overweight and obesity	no	349(51.8%)	343(32.9%)	60.989	< 0.001
	Yes	325(48.2%)	701(67.1%)

Note: TSH = Thyroid Stimulating Hormone. Obesity = BMI ≥ 28.0 kg/m². Overweight and obesity = BMI ≥ 24.0 kg/m². The significance of bold emphases in the table is p < 0.05

Socio-demographics for overweight and obesity in MDD patients with abnormal TSH

Table 2 shows that the prevalence of overweight and obesity was higher among those who were married and those without suicidal behavior.

Table 2.

Socio-demographics for overweight and obesity in MDD patients with abnormal TSH

		Overweight and obesity		X2	p
		No	Yes
Gender	male	113	245	0.411	0.521
	female	230	456
Academic degree	junior school	76	187	4.408	0.221
	high school	155	296
	university	86	181
	postgraduate	26	37
Marital status	no	115	169	10.318	0.001
	Yes	228	532
Suicidal behaviour	No	240	541	6.343	0.012
	Yes	103	160
Anxious	No	291	593	0.011	0.917
	Yes	52	108
Psychotic symptoms	No	297	611	0.067	0.796
	Yes	46	90

Note: MDD = major depression disorder; TSH = Thyroid Stimulating Hormone. The significance of bold emphases in the table is p < 0.05

There were no significant differences between the observation group and control group in terms of gender, education level, anxiety, and psychiatric symptoms.

In terms of marital status, there were 169 (59.5%) overweight and obese unmarried persons. Among married patients, 532 (70.0%) were overweight and obese. In terms of suicidal behavior, 541 (69.3%) participants without suicidal behavior were overweight and obese. Of the patients with suicidal behavior, 160 (60.8%) were overweight and obese.

Clinical characteristics and biochemical parameters for overweight and obesity in MDD patients with abnormal TSH

As can be seen in Table 3, overweight and obesity were found to be associated with actual age, age of onset, A-TG, and systolic blood pressure by Mann-Whitney U test (p < 0.05).

Table 3.

Clinical characteristics and biochemical parameters for overweight and obesity in patients with major depressive disorder with abnormal TSH

	Overweight and obesity		Z/t	p
	No	Yes
Physical age (years)	32 (22, 45)	36 (25.5, 47)	−2.643	0.008
Course of disease (month)	6 (3.125, 9)	6 (3.5, 9)	−0.654	0.513
Age of onset (years)	32 (22, 45）	36 (25, 46.5)	−2.650	0.008
HAMD	32 (30, 33)	31 (29, 33)	−1.570	0.116
HAMA	21 (19, 23)	21 (18, 23)	−1.372	0.170
CGI-S	6 (5, 7)	6 (5, 7)	−0.529	0.597
A-TG (IU/L)	23.87 (15.24, 126.1)	22.29 (15.32, 79.47)	−1.989	0.047
A-TPO (IU/L)	22.95 (12.85, 65.54)	19.77 (12.43, 51.62)	−1.905	0.057
FT3 (pmol/L)	4.88 (4.27, 5.44)	5.01 (4.42, 5.46)	−1.319	0.187
FT4 (pmol/L)	16.5 (14.21, 18.6)	16.52 (14.42, 18.66)	−0.459	0.646
FBG (mmol/L)	5.58 ± 0.64	5.60 ± 0.62	−0.603	0.547
TC (mmol/L)	5.6 (4.87, 6.29)	5.61 (4.98, 6.32)	−0.443	0.658
HDL-C (mmol/L)	1.2 (0.91, 1.42)	1.16 (0.89, 1.33)	−1.593	0.111
TG (mmol/L)	2.01 (1.46, 2.86)	2.04 (1.46, 2.82)	−0.092	0.927
LDL-C (mmol/L)	3.22 (2.6, 3.7)	3.23 (2.63, 3.82)	−0.639	0.523
TSH (μIU/L)	6.41 (5.17, 8.25)	6.23 (5.24, 7.55)	−0.938	0.348
SBP (mmHg)	122 (116, 128)	124 (118, 130)	−2.116	0.034
DBP (mmHg)	76 (72, 80)	78 (74, 81)	−1.909	0.056

Note: HAMD = Hamilton depression rating scale; HAMA = Hamilton anxiety rating scale; CGI-S = Clinical Global Impression of Severity Scale; TSH = Thyroid Stimulating Hormone; A-TG = anti-thyroglobulin; A-TPO = thyroid peroxidases antibody; FT3 = free triiodothyronine; FT4 = free thyroxine; TC = total cholesterol; HDL-C = high density lipoprotein cholesterol; TG = triglycerides; LDL-C = low density lipoprotein cholesterol; SBP = systolic blood; DBP = pressure; diastolic blood pressure. The significance of bold emphases in the table is p < 0.05

The median actual age was 32 years in the control group and 36 years in the observation group (p < 0.05); the same median ages (32 vs. 36 years, p < 0.05) were observed for onset age.

Regarding A-TG, the median was 23.87 for patients without overweight and obesity and 22.29 for patients with overweight and obesity, with a p-value of 0.047. These results suggest that A-TG levels are also a factor for overweight and obesity. Patients with low A-TG levels will have an increased prevalence of overweight and obesity.

For systolic blood pressure, the median values were 122(116,128) mmHg for normal-weight patients, compared to 124(118,130) mmHg for overweight and obese patients, with p-values of 0.034.

Regression analysis of the factors influencing overweight and obesity in patients

The results of the binary logistic regression analysis of the factors affecting overweight and obesity in MDD patients with TSH abnormalities are shown in Table 4. A binary logistic regression model was employed to assess BMI, with TSH as a covariate and marital status, history of suicidal behaviour, age, age at onset of depression, A-TG levels, and systolic blood pressure as independent variables. The regression results showed that being married(OR: 1.582, 95% CI: 1.191–2.102) and having no suicidal behavior (OR: 1.444, 95% CI: 1.079–1.934)were independent risk factors for overweight and obesity.

Table 4.

Regression analysis of factors influencing overweight and obesity in MDD patients with abnormal TSH

	B	Std. error	Wald	p	OR	95% CI
						Lower	Upper
Constant	0.116	0.162	0.514	0.473	1.124
Married	0.459	0.145	10.021	0.002	1.582	1.191	2.102
No suicidal behaviour	0.368	0.149	6.092	0.014	1.444	1.079	1.934

Note: MDD = major depression disorder; TSH = Thyroid Stimulating Hormone. The significance of bold emphases in the table is p < 0.05

Correlation between the indexes of patients and BMI

There was a significant correlation between LDL-C and systolic blood pressure and BMI (p < 0.05) but no significant correlation between the other indicators. Specifically, patients’ BMI was weak positively correlated with LDL-C (r = 0.065, p < 0.05) and systolic blood pressure (r = 0.087, p = 0.005), indicating that higher BMI was associated with higher LDL-C and systolic blood pressure. Other indicators (including actual age, age at onset, A-TG, fasting glucose, TC, HDL-C, TG, FT3, FT4, and TSH) were not significantly correlated with BMI (p > 0.05).

Discussion

To the best of our knowledge, this study is the first to examine the prevalence of overweight and obesity in a Chinese population of first-episode drug-naïve MDD patients with abnormal TSH levels and the associated influencing factors. The main findings of our study were as follows: (1) the prevalence of overweight and obesity was higher in Chinese MDD patients with abnormal TSH levels than in those with normal TSH; (2) suicidal behavior, systolic blood pressure, marital status, and age at onset were associated with overweight and obesity.

The present study found that the rate of overweight far exceeded the rate of obesity in patients with major depression who had abnormal TSH levels (67.1% vs. 5.2%), which is inconsistent with previous findings, especially in North America and Europe [9, 23–27]. These findings suggest that in Europe and the United States, the prevalence of obesity is significantly higher in patients with major depression than in patients who are overweight, normal weight, or underweight. Ethnic factor may play a key role. According to Flegal’s study [28], the average obesity rate among U.S. adults is 35.7% and the overweight rate is 33.1%, while according to Zhang’s study [29], the average obesity rate among Chinese adults is only 5.2% and the overweight rate is 28.1%.

Studies have shown that long-term use of mood stabilizers, antidepressants and various antipsychotics can lead to weight gain [30]. Unlike many previous studies, we selected patients who had not previously taken any medication to avoid the effect of medication on BMI. Therefore, our findings may reflect the inherent BMI characteristics of Chinese depressed patients without any pharmacological intervention.

This study found that among patients with MDD and elevated TSH levels, the prevalence of overweight and obesity was significantly higher than in MDD patients with normal TSH levels. TSH is a hormone that regulates thyroid function and can affect metabolic rate and energy expenditure by regulating the synthesis and release of thyroxine [31]. When the metabolic rate is reduced, the body is more likely to accumulate fat, leading to overweight and obesity [32]. Thyroid hormones promote oxidative metabolism and thermogenesis, increasing basal metabolic rate (BMR) [33]. BMR is the body’s minimum level of energy expenditure in a quiet and starved state, and it is also an essential factor in weight control [34]. In addition, thyroid hormones can affect insulin secretion and sensitivity by regulating postprandial glucose levels and affect glucose metabolism and fat metabolism [35]. The relationship between TSH abnormalities and overweight and obesity may involve the role of neurotransmitters. In patients with depression, levels of certain neurotransmitters may be altered, such as norepinephrine and 5-hydroxytryptamine. These neurotransmitters play a crucial role in regulating appetite and metabolic rate, which may contribute to the development of overweight and obesity [4].

In this study, T-AG levels were reduced in MDD patients with abnormal thyrotropin levels. In Li’s study, obese MDD patients with earlier onset of the disease also had reduced T-AG levels [36], which is similar to the results of this study. Several studies have also shown that obese patients with abnormal thyroid-stimulating hormone levels have a significantly lower rate of thyroid antibody positivity compared with normal-weight patients with hypothyroidism [37–39]. The reason for this result may be that thyroid autoimmunity is not associated with changes in thyrotropin and free thyroid hormones [37]. In addition, different study enrollment populations, as well as different patient statuses (e.g., medication use and disease duration) may affect study results and should be considered.

Previous studies have shown that BMI is positively associated with depression severity in patients with MDD in the United States and Europe [9, 40–42], but there have been no such studies in Asia for patients with MDD. In Europe and Korea, BMI has a U-shaped relationship with depression severity in the general population [43, 44]. However, our study did not find a significant linear or nonlinear correlation between disease severity and BMI. Possible reasons for this discrepancy are heterogeneity in drug use, disease duration, ethnicity, and inclusion criteria in previous studies [41, 45–52]. Alternatively, this outcome may stem from the comorbidity of MDD and elevated TSH levels within the study population, a comorbidity that could lead to metabolic disturbances and consequently produce such results.

Actual age is a key factor in overweight and obesity prevalence [53]. With aging, metabolic rate decreases, reducing energy needs, so older people require less energy for basal metabolism and must adopt careful diets and lifestyles to avoid obesity risks [54]. Additionally, aging patients experience declining physical functions, such as reduced muscle mass, bone mass loss, and increased body fat, making them more prone to obesity [55]. In patients with MDD, age at onset significantly correlates with overweight and obesity prevalence. Late-onset depression patients show increased obesity risk [56], similar to this study. Conversely, early-onset patients are more likely overweight/obese [36], possibly due to adverse medication effects on metabolism and weight regulation. Treatments for early-onset depression may disrupt metabolism, leading to weight gain [57]. Married individuals have higher overweight and obesity rates, likely due to marital status, lifestyle, dietary habits, and more [58] frequent meals and snacks, increasing total energy intake [59, 60].

This study shows that systolic blood pressure is higher in MDD patients with abnormal TSH levels who are overweight and obese. Hypertension, overweight, and obesity are prevalent chronic diseases that exhibit a clear interrelationship [61]. Obesity leads to an increased cardiovascular and cardiac workload, which increases susceptibility to cardiovascular disease, hypertension, and heart-related disorders [62]. The increased fat associated with obesity increases circulating blood volume, which places additional stress on the cardiovascular system. These factors increase the risk of developing cardiovascular diseases [63]. Conversely, hypertension can also promote the development of obesity. Elevated blood pressure levels can disrupt fluid balance and promote fluid retention, increasing body fluids and fibrin accumulation. This interrelationship between hypertension and obesity exacerbates the deleterious effects of both conditions [63]. Depressive symptoms can exacerbate the development and progression of chronic diseases such as hypertension and obesity by affecting the autonomic nervous system, the hypothalamic-pituitary-adrenal axis, and the immune system. Also, depressive symptoms may accelerate the progression of hypertension and obesity by affecting physiological systems such as the autonomic nervous system and the immune system [64].

The present study demonstrated that suicidal behavior was significantly associated with the prevalence of overweight and obesity in MDD patients with abnormal TSH levels. The absence of suicidal behavior was an independent risk factor for overweight and obesity. The conventional wisdom is that there is an inverse relationship between depression and obesity [45, 65]. Suicidal behavior is a severe clinical symptom in patients with major depressive disorder, and patients with major depressive disorder may experience a loss of appetite, leading to weight loss. Some studies have shown that the more severe the depressive symptoms, the higher the risk of suicide [66]. In adolescents with depression, the coexistence of overweight or obesity and depression exacerbates the inflammatory state, which may lead to increased severity of depression and risk of suicide [6], contrary to the findings of the present study. Another study found no significant correlation between the severity of depression and suicidal ideation [67], which may be related to differences in cultural background or age distribution.

This study showed that LDL-C levels are associated with BMI in MDD patients with abnormal TSH levels. Previous studies have found a positive correlation between BMI, waist circumference, and LDL-C. In other words, higher BMI and waist circumference are linked to higher LDL-C levels.This may be due to metabolic disturbances in adipose tissue caused by obesity or overweight, which in turn lead to abnormal lipid metabolism [68]. In patients with hypothyroidism, cholesteryl ester transfer protein activity is reduced. This further lowers hepatic lipase activity, decreasing cholesteryl ester transfer. As a result, LDL-C levels rise. Additionally, reduced HDL-C levels and changes in chymotrypsin levels contribute to elevated overall lipid levels [69].

Limitations

This study has several limitations. First, the cross-sectional design does not demonstrate a direct causal relationship between BMI and other factors. Second, suicidal behavior was assessed using a screening question rather than a validated scale, resulting in self-reported suicidal ideation and the absence of data on the severity of suicide attempts. Secondly，the number of male participants in the study group was smaller than that of females, and no association was found between gender and overweight and obesity, so the study results need to be validated by further research with a gender-balanced sample. Fourthly, visceral fat content is a significant factor in metabolic syndrome; however, this study did not measure indicators of visceral fat content (such as waist circumference). Fifthly, our findings show low r-values. Future studies will use stricter designs with longitudinal data to investigate associations between LDL-C, systolic blood pressure, and BMI. Finally, no healthy control group was included in this study, and all MDD patients were recruited from the outpatient department of a general hospital in Shanxi, China, so the generalizability of the findings to other regions of China requires further investigation.

Conclusion

In summary, this study found a 5.2% prevalence of obesity and a 67.1% prevalence of overweight and obesity among MDD patients with abnormal TSH levels. Overweight and obesity were associated with higher actual age and age of onset, lower A-TG, and higher systolic blood pressure. The absence of suicidal behavior was an independent risk factor for overweight and obesity.

Abbreviations

MDD

Major Depressive Disorder

TSH

Thyroid Stimulating Hormone

HAMA

Hamilton Anxiety Rating Scale

HAMD

Hamilton Depression Rating Scale

PANSS

Positive and Negative Syndrome Scale

FT3

Free Triiodothyronine

A-TG

Anti-Thyroglobulin

BMI

Body Mass Index

IRB

Institutional Review Board

SCID-IV

Structured Clinical Interview for DSM-IV

SBP

Systolic Blood Pressure

DBP

Diastolic Blood Pressure

FBG

Fasting blood glucose

TC

Total Cholesterol

HDL-C

High-Density Lipoprotein Cholesterol

LDL-C

Low-Density Lipoprotein Cholesterol

TG

Triglycerides

TPOAb

Thyroid Peroxidase Antibody

HAMD-17

17-item Hamilton Depression Scale

HAMA-14

14-item Hamilton Anxiety Scale

CGI-S

Clinical Global Impression-Severity

Author contributions

Dayu Cao: Writing - original draft. Hongjia Liu: Writing - original draft. Dazhi Li: Writing - original draft. Xiaoli Wang: Writing - review & editing. Hongyu Zhang: Writing - review & editing. Zhenni Huang Writing - review & editing. Yonghui Zhang: Data curation, Investigation. Xiangyang Zhang: Project administration, Supervision, Writing - review & editing.

Funding

This work was supported in part by Tianjin Key Medical Discipline (Specialty) Construction Project (TJYXZDXK-033A).

Data availability

The authors declare that all relevant data from this study are available within the article or from the corresponding author upon reasonable request.

Declarations

Ethical approval

The protocol for the research project had been approved by the Institutional Review Board (IRB) of the First Hospital of Shanxi Medical University (ID number: 2016-Y27) and had therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. All informed consent forms of patients were obtained, and their anonymity was protected.

Consent for publication

The authors declare no conflicts of interest and agree to publish.

Role of the sponsors

The supporters had no role in the design, analysis, interpretation, or publication of this study.

Competing interests

The authors declare no competing interests.