Thyroid function testing in an inpatient mental health unit

Thyroid-Stimulating Hormone Levels and Depression in Older Adults: Cross-Sectional and Longitudinal Analyses in a Community-Dwelling Population

OBJECTIVE

To investigate the association between thyroid-stimulating hormone (TSH) levels and depression in older adults.

DESIGN

Prospective cohort study with an 11-year follow-up period.

SETTING

Community-dwelling participants from the ASPirin in Reducing Events in the Elderly (ASPREE) randomized controlled trial and its follow-up observational study in Australia.

PARTICIPANTS

About 9,050 adults aged ≥70 years with baseline TSH measurements and depression assessments. Participants with thyroid cancer, baseline depression, or thyroid-altering medications were excluded.

MEASUREMENTS

Depression was assessed annually using the Center for Epidemiological Studies Depression Scale (CES-D-10) using a cut score of 12, and hospital admission records. TSH was measured at baseline and year 3, categorized as low (<0.34 mU/L), normal (0.34-3.75 mU/L), or high (>3.75 mU/L).

RESULTS

Cross-sectional analyses found no significant association between TSH levels and depression at baseline (p = 0.79) or year 3 (p = 0.054). Longitudinal analyses revealed no relationship between baseline or time-varying TSH levels and incident depression over the follow-up period (HR = 1.0, 95% CI: 0.96-1.05).

CONCLUSIONS

TSH levels are not associated with prevalent or incident depression in older community-dwelling adults. These findings should guide screening approaches for depression in older adults.

Recommendations for the medical work-up of first episode psychosis, including specific relevance to Indigenous Australians: A narrative review

AIMS

To collate existing literature for busy practicing psychiatrists about the medical work-up for first-episode psychosis (FEP). Therefore, (a) to review current guidelines for the medical work-up of first episode psychosis. (b) To examine whether any specific recommendations for Indigenous Australians exist. (c) To produce an easy reference table of evidence based investigations.

METHOD

A multi-part narrative review process was undertaken. Step 1 "Source identification and summary": identified key existing national and international guidelines and expert opinions related to the medical work-up of FEP and summarised these suggestions. Step 2 "Exploration of each investigation": examined each of the identified investigations for its importance. Step 3 "Relevance to Indigenous Australians": reviewed any particular relevance to the Indigenous Australian population. Step 4 "Clinician guide": involved presenting recommended investigations in a simple table.

RESULTS

Multiple guidelines were identified. There was clear consensus for many aspects. However, there were also differences in the approach for some investigations. Clinical reasoning for the proposed investigations was commonly absent. There were limited specific recommendations for Indigenous Australians. Evidence and importance was explored for each investigation and auseful table for the practicing psychiatrist was constructed. Investigations were stratified into those considered to be "universal," "low yield," or "unecessary."

CONCLUSION

A narrative review of multiple guidelines relating to the medical work-up of FEP identified many similarities and some differences to their approach. Little additional information exists for the Indigenous Australian context. A clinician friendly worksheet for everyday use may be helpful to busy clinicians.

Physical health examination in outpatients with schizophrenia: the cost effectiveness of laboratory screening tests

BACKGROUND

Guidelines on laboratory screening in schizophrenia recommend annual monitoring of fasting lipids and glucose. The utility and the cost effectiveness of more extensive laboratory screening have not been studied.

METHODS

The Living Conditions and the Physical Health of Outpatients with Schizophrenia Study provided a comprehensive health examination, including a laboratory test panel for 275 participants. We calculated the prevalence of the results outside the reference range for each laboratory test, and estimated the cost effectiveness to find an aberrant test result using the number needed to screen to find one abnormal result (NNSAR) and the direct cost spent to find one abnormal result (DCSAR, NNSAR x direct cost per test) formulas. In addition, we studied whether patients who were obese or used clozapine had more often abnormal results.

RESULTS

A half of the sample had 25-hydroxyvitamin D below, and almost one-fourth cholesterol, triglycerides or glucose above the reference range. One-fifth had sodium below and gamma glutamyltransferase above the reference range. NNSAR was highest for potassium (137) and lowest for 25-hydroxyvitamin D (2). DCSAR was below 5€ for glucose, all lipids and sodium, and below 10€ for creatinine and gamma glutamyltransferase. Potassium (130€), pH-adjusted ionized calcium (33 €) and thyroid stimulating hormone (33€) had highest DCSARs. Several abnormal results were more common in obese and clozapine using patients.

CONCLUSIONS

An annual laboratory screening panel for an outpatient with schizophrenia should include fasting glucose, lipids, sodium, creatinine, a liver function test and complete blood count, and preferably 25-hydroxyvitamin D.

Low Yield of Thyroid-Function Tests in Adult Hospitalized Patients - A Retrospective Analysis

BACKGROUND

In the US, serum thyroid-stimulating hormone (TSH) and thyroxine measurements are the fourth- and tenth-commonest laboratory tests ordered, respectively. Diagnosis of thyroid disorder requires clinical suspicion supported by laboratory values. However, in the setting of acute illness, both the clinical and laboratory pictures can be confounded.

OBJECTIVE

To study clinical outcomes and derangement patterns of inpatient thyroid-function tests.

DESIGN

This retrospective study was conducted at an academic center on admissions aged ≥18 years and TSH tests performed over a 1-year period. Admissions with active pregnancy and/or prior thyroid-related diagnosis were excluded.

MAIN OUTCOMES

Clinical outcomes were divided based on new diagnosis of thyroid-related disorder, newly prescribed thyroxine replacement, or antithyroid drugs/ endocrinology referrals, or both. In order to analyze the derangement patterns of abnormal TSH, only the results of the first test ordered were considered (as some admissions had multiple TSH tests ordered).

RESULTS

A total of 7,204 admissions aged ≥18 years had TSH tests done. Of these, 1,912 were excluded. Of the 5,292 admissions with no prior thyroid disorder or active pregnancy, 183 (3.46%) were assigned a new diagnosis of thyroid-related disorder, 54 (1.02%) received treatment/referral, and 46 (0.87%) received both a new diagnosis and treatment/referral. Based on the TSH results (reference range 0.42-4.0 mIU/L) of the 5,292 admissions, 4,312 (81.5%) and 980 (18.5%) admissions were flagged normal and abnormal, respectively. Of the 980 admissions with one or more abnormal TSH results, 21 (2.14%) had first ordered TSH <0.05 mIU/L, 855 (87.25%) admissions had first TSH result between 0.05-10 mIU/L, and lastly 104 (10.61%) were >10 mIU/L.

CONCLUSION

There is low value in testing inpatients for thyroid disorders, and testing comes at significant expense to the health-care system.