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Psychology, Health & Medicine

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The association between depression and thyroid disorders in a regionally representative Canadian sample
Esme Fuller-Thomson , Jasmik Saini & Sarah Brennenstuhl
a a b b

Sandra Rotman Chair, Factor-Inwentash, Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
b

Dalla Lana School of Public Health, University of Toronto, Toronto, Canada Version of record first published: 26 Sep 2011

To cite this article: Esme Fuller-Thomson, Jasmik Saini & Sarah Brennenstuhl (2012): The association between depression and thyroid disorders in a regionally representative Canadian sample, Psychology, Health & Medicine, 17:3, 335-345 To link to this article: http://dx.doi.org/10.1080/13548506.2011.608808

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Psychology, Health & Medicine Vol. 17, No. 3, May 2012, 335345

The association between depression and thyroid disorders in a regionally representative Canadian sample
Esme Fuller-Thomsona*, Jasmik Sainib and Sarah Brennenstuhlb
a Sandra Rotman Chair, Factor-Inwentash, Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada; bDalla Lana School of Public Health, University of Toronto, Toronto, Canada

(Received 28 February 2011; nal version received 25 July 2011) A subsample of six provinces (n 67,621) from the 2005 Canadian Community Health Survey was used to determine the gender-specic prevalence of depression among those with and without thyroid disorders. Information was not available on the type of thyroid disorder. Logistic regression analyses were conducted to determine the odds and socio-demographic correlates of depression among those with and without thyroid disorders. Women had a signicantly higher prevalence of thyroid disorders (9.3%) and depression (6.6%) than men (2.4% and 3.7%, respectively). Thyroid disorders were associated with 22% higher odds of depression in women after adjusting for socio-demographic factors, but no association was found in men. Among women with and without thyroid disorders, younger age, lower income, and limitations in Activities in Daily Living (ADL) were associated with higher odds of depression. Results suggest that women with thyroid disorders are more vulnerable to depression, and sociodemographic correlates of depression are similar among women with and without thyroid disorders. Keywords: depression; thyroid disorders; Canadian Community Health Survey; chronic illness

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Introduction The American Psychiatric Associations (1994) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition states that hyper- and hypothyroidism are among the causes of mood disorders. Indeed, hypothyroidism is often linked with depression. While the relationship between depression and hyperthyroidism is less clear, it is speculated that prolonged hyperthyroidism may wear out noradrenergic transition, and consequently, contribute to depression (Bunevicius & Prange, 2010). Recent evidence also suggests that thyroid autoimmunity, with or without a change in the thyroid state, may be linked with mental symptoms including depression (Bunevicius & Prange, 2010). While evidence supporting the link between thyroid disorders and an elevated rate of depression has been demonstrated in a number of clinical studies (e.g. Cleare, McGregor, & OKeane, 1995; Haggerty & Prange, 1995), the few community-based studies conducted in this area present conicting ndings (for a review see

*Corresponding author. Email: esme.fuller.thomson@utoronto.ca

ISSN 1354-8506 print/ISSN 1465-3966 online 2012 Taylor & Francis http://dx.doi.org/10.1080/13548506.2011.608808 http://www.tandfonline.com

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Bunevicius & Prange, 2010). For example, depression rates have been found to be lower in individuals with untreated biochemical hyperthyroidism (Grabe et al., 2005) or hypothyroidism (Engum, Bjoro, Mykletun, & Dahl, 2002) in comparison to euthyroid respondents. In contrast, increased depression rates have been found among those who report a previous diagnosis of thyroid disorders irrespective of their current thyroid functioning, even when adjusting for age and gender (Engum et al., 2002). Interestingly, a Canadian population-based study found that individuals with self-reported thyroid disease had higher 12-month (4.2%) and lifetime (11.8%) prevalence of major depression than individuals with no chronic conditions (2.4% and 7.5%, respectively) (Patten, Williams, Esposito, & Beck, 2006). However, when analyses were adjusted for age, gender, and other chronic conditions, depression was not associated with thyroid conditions. Patten et al. (2006) suggested that the adjustment for gender weakened the strength of the association due to the fact that females have much higher rates of both thyroid disorders and major depression. This research underscores the importance of genderspecic analyses when assessing the relationship between thyroid conditions and depression. Gender-specic analyses of the thyroid-depression association in population-based studies are rare, and to our knowledge, no such study has been conducted in the Canadian context. This article presents an analysis of the association between self-reported thyroid disorders and current major depression (CIDI-SF) in a large Canadian populationbased sample. In order to develop a prole of those who are at risk of depression among community-dwelling individuals with thyroid disorder, we have investigated the following four research questions: (1) What is the regional prevalence of (a) thyroid disorders and (b) depression by gender? (2) What is the gender-specic socio-demographic prole of adults with and without thyroid disorders? (3) For each gender: (a) What are the age-adjusted odds of depression among those with thyroid disorders in comparison to those without thyroid disorders? (b) What are the odds of depression among those with thyroid disorders compared to those without thyroid disorders, controlling for sociodemographic characteristics (e.g. age, education, income, marital status, and limitations in Activities of Daily Living (ADL)? (4) What socio-demographic characteristics are associated with depression in females with thyroid disorders? Do these dier from the socio-demographic characteristics associated with depression in females without thyroid disorders?

Methods Data source and sample The data reported in this study is based on the Public Use Microdata File of the 2005 Canadian Community Health Survey (CCHS) cycle 3.1 conducted by Statistics Canada (Statistics Canada, 2006). The CCHS provides regionally representative Canadian data using a cross-sectional survey design. The survey collects information

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related to health status, health care utilization, and health determinants for the general Canadian population (Statistics Canada, 2006). The target population for the survey was persons aged 12 years and above, who are living in private dwellings. Excluded were full-time members of the Canadian Forces, individuals living in institutions or certain remote regions, and those residing on Indian reserves or Crown lands. The survey represents approximately 98% of the Canadian population aged 12 and older. The CCHS used a multistage, stratied cluster design to select eligible households and individual respondents from households. The national combined response rate was 78.9%. From the full CCHS sample of 132,947 respondents, a subsample of 71,234 individuals was chosen from the following six Canadian provinces, where questions about depression were included: Alberta, British Columbia, Nova Scotia, Prince Edward Island, Quebec, and Saskatchewan. The provincial-level response rates varied from 76.4% in Quebec to 84.1% in Saskatchewan (Statistics Canada, 2006). Excluding respondents from these provinces with missing or incomplete information on thyroid conditions or depression (n 3613; 5.1% of sample) resulted in a nal sample size of 67,621 (females, n 36,625; males, n 30,996). Data analysis Using the CCHS subsample of the six provinces discussed above, the gender-specic prevalence of thyroid conditions (females, n 4053; males, n 866) and current major depression (females, n 2509; males, n 1241) was computed. Next, the gender-specic age-adjusted odds ratio of depression among those with thyroid conditions in comparison to those without was estimated. Gender-specic odds ratios of depression were also estimated controlling for age in addition to other socio-demographic characteristics known to be associated depression (i.e. household income, education level, marital status, and ADL limitations). Bivariate analyses to determine the association between depression and each of the aforementioned sociodemographic factors were then conducted in the sub-group of women with thyroid disorders (n 4053) and in the sub-group of women without thyroid disorders (n 32,572), and results from each sub-group were compared. Finally, a multivariate logistic regression model predicting the odds of depression was also analyzed for each sub-group of women and then compared across sub-groups. Incomplete data on thyroid conditions, depression, or any of the socio-demographic characteristics resulted in a nal sample size of 4014 and 32,275 for the multivariate analysis of women with and without thyroid disorders, respectively. Due to the complex sampling design of the CCHS, all prevalence data, odds ratios, p-values, and condence intervals reported were weighted to adjust for the probability of selection and non-response. Sample sizes were reported in their unweighted form.

Measures Identication of individuals with thyroid conditions The question about thyroid conditions in the CCHS was nested in a section dealing with chronic health problems. The interviewer began this section by stating: Now Id like to ask about certain chronic health conditions which you may have. We are interested in long-term conditions which are expected to last or have already lasted

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six months or more and that have been diagnosed by a health professional. After being asked about several chronic problems, the respondents were asked, Do you have a thyroid condition? Depression Depression was evaluated using the Composite International Diagnostic InterviewShort Form (CIDI-SF) developed by Kessler, Andrews, Mroczek, Ustun, & Wittchen (1998). The CIDI-SF is a shortlist of items from the fully-structured CIDI interview that measures major depressive episode according to the denitions and the criteria of both the Diagnostic and Statistical Manual (DSM-III-R) and the diagnostic criteria of the International Classication of Diseases (ICD-10). Specically, the short-form used in the CCHS was developed to operationalize DSM-III-R diagnostic criteria A-C for major depressive episode (Statistics Canada, 2006). Well-trained lay interviewers administered the scale, which was used to ascertain respondents as having depression if they had a probability of 90% or greater for a major depressive episode over a period of at least two weeks in the last 12 months. Demographic characteristics In addition to gender, the following demographic characteristics were also investigated among respondents: (1) age (540, 4059, 60 and older); (2) educational attainment; (3) household income; (4) marital status; and (5) ADL status (having ADL limitation versus not having ADL limitation). Respondents level of educational attainment was categorized according to less than high school, high school graduation with/without post-secondary education, and post-secondary graduation. Household income was assessed by ve categories: 5$15,000, $15,000 29,999, $30,00049,999, $50,000 or missing. Results Gender-specic prevalence of thyroid conditions and of depression Of the 67,621 survey respondents, 4919 reported having a medical diagnosis of a thyroid condition. The weighted prevalence was 5.9% [95% condence interval (CI) 5.66.2%] for all respondents. The overall prevalence of thyroid conditions among women was 9.3% (CI 8.79.9%) compared to 2.4% (CI 2.12.7%) in men; women reported signicantly higher rates of thyroid conditions compared to men (p 5 0.001). Females also had a higher prevalence of depression (6.6%; CI 6.27.0%) compared to men (3.7%; CI 3.24.0%) and this dierence was also statistically signicant (p 5 0.001). Gender-specic socio-demographic prole of adults with and without thyroid disorders A higher proportion of females and males with thyroid disorders were younger (females and males: p 5 0.001), had less than high school education (females, p 0.001; males, p 5 0.05), and had lower household incomes (females and males p 5 0.001) compared to those without thyroid disorders. Whereas a greater portion

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of women with thyroid conditions were married or partnered compared to women without thyroid conditions (p 5 0.001), the opposite pattern was true for men (p 5 0.001). Women with thyroid disorders had higher rates of ADL limitations compared to those without thyroid disorders (p 5 0.001); this same comparison could not be made among men due to small sample sizes of males with thyroid conditions and ADL limitations. See Table 1 for the full gender-specic sociodemographic prole of adults with and without thyroid disorders. Gender-specic odds ratio of depression in those with and without thyroid conditions Women with thyroid disorders had signicantly higher age-adjusted and full sociodemographic adjusted odds of depression compared to women without any thyroid condition (ORage 1.26; CI 1.091.46%; ORfull 1.22; CI 1.051.41%). For men, the age-adjusted and full socio-demographic adjusted odds of depression were similar for those with and without thyroid disorders (ORage 0.98; CI 0.63 1.52%; ORfull 0.96; CI 0.611.51%). As a consequence, no further analyses were undertaken for men.

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Socio-demographic characteristics associated with depression among females with and without thyroid conditions Bivariate analysis A signicantly higher proportion of women with thyroid disorders and depression were younger (p 5 0.001), had lower household incomes (p 5 0.001), and were single (p 5 0.001) compared to women with thyroid conditions and no depression. A similar pattern of ndings were found in the sub-group of women without thyroid disorders (Table 2). Indeed, the only important dierence between the two subgroups was related to educational level; while similar portions of those depressed and not depressed fell in each education category among women with thyroid disorders (p 0.16), a signicantly smaller proportion of those depressed had the lowest educational credentials compared to the non-depressed among those without thyroid disorders (p 5 0.001). Unfortunately, data on ADL limitations could not be compared across the sub-groups due to small sample sizes. Multivariate analysis Among women with thyroid conditions, signicantly higher odds of depression were associated with younger compared to older age (540 years: OR 4.54; 4059 years: OR 3.46), lowest household income (5$15,000) compared to the highest ($50,000) (OR 2.01), and having ADL limitations (OR 2.90) (Table 3). In contrast, education and being married or partnered acted as protective factors against depression. Specically, women with high school diplomas compared to those with less education (OR 0.62) and married or partnered women compared to singles (OR 0.58), had signicantly lower odds of depression. As shown in Table 3, similar results were found among those without thyroid conditions. In particular, signicantly higher odds of depression were associated with younger age, lower household income, and having ADL limitations, whereas lower odds of depression were associated with being married or partnered. However, while education seemed

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Table 1. Females (n 36,625) Without thyroid disorders (n 32,572) N1 13,810 10,077 8685 50.001 8778 7516 16,041 3347 5583 6450 12,307 4885 50.001 15,602 16,903 581 31,976 1.3 98.7 43.2 56.8 50.001 554 312 50.001 5.9 12.5 18.3 47.2 16.1 87 182 219 307 71 6.0E 14.3 21.7 50.5 7.5E 59.5 40.5 23.0 24.1 52.9 0.001 293 150 413 26.6 18.8 54.6 46.2 35.2 18.6 109 262 495 13.5 37.2 49.4 13,140 9762 7228 8586 6504 14,801 3535 1968 4229 6164 14,234 15,313 14,782 425 29,680 Weighted2 % p-value3 N1 Weighted2 % N1 With thyroid disorders (n 866) Without thyroid disorders (n 30,130) Weighted2 % 46.5 36.1 17.4 23.6 22.7 53.7 4.1 10.1 17.5 55.7 12.6 78.2 21.8 1.1 98.9 Males (n 30,996)

Gender-specic socio-demographic prole of Canadian adults with and without thyroid disorders.

With thyroid disorders (n 4053)

N1 18.7 39.0 42.3 25.8 23.2 51.0 8.4 18.0 19.9 37.7 15.9 62.9 37.1 3.4 96.6

Weighted2 %

p-value3 50.001

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581 1308 2164

1301 846 1875

50.05

604 972 787 1096 594

50.001

1989 2061

50.001

Age 540 4059 60 Education 5High school High school graduate Post-secondary graduate Income 5$15,000 $15,00029,000 $30,00049,999 $50,000 Missing Marital status Married/common-law Single/divorced or Separated/widowed ADL limitation4 Yes No

158 3980

Notes: 1All sample sizes are reported in their non-weighted form; 2all percentages and p-values are reported in the weighted form. According to Statistics Canada, all prevalence data must be weighted to account for non-response and the probability of selection; 3p-value derived from chi-square tests; 4samples sizes too small to report data for males with thyroid disorders; ADL activities of daily living; E estimate is associated with a high sampling variability.

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Table 2. Bivariate associations between current major depression (CIDI-SF) and socio-demographic variables in Canadian females with and without thyroid disorders. Females without thyroid disorders (n 32,572) Depressed (n 2222) p-value3 50.001 1103 872 247 488 608 1113 341 403 496 740 242 854 1367 93 2127 10.0 13.9 21.0 42.5 12.7 44.8 55.2 3.4E 96.6 18.9 27.8 53.3 55.3 37.8 7.0 12,707 9205 8438 8290 6908 14,928 3006 5180 5954 11,567 4643 14,766 15,536 488 29,849 N1 Weighted2 % N1 Not depressed (n 30,350) Weighted2 % 45.6 35.0 19.4 23.3 23.8 52.9 5.6 12.4 18.1 47.5 16.3 57.7 42.3 1.2 98.8 p-value3 50.001

Females with thyroid disorders (n 4053) Not depressed (n 3766) N1 507 1176 2083 1,218 786 1,733 544 903 732 1025 562 50.001 1879 1884 135 3626 3.1 96.9 63.8 36.2 50.001 7.9 17.9 20.0 37.8 16.4 25.8 23.5 50.7 0.16 18.0 38.4 43.6 Weighted2 %

Depressed (n 287)

N1 29.2E 47.4 23.4E 25.8E 18.7E 55.5 15.4E 19.2E 19.4E 36.2 49.7 50.3

Weighted2 %

74 132 81

83 60 142

50.001

60 69 55 71

50.001

110 177

50.001

Age 540 4059 60 Education 5High school High school graduate Post-secondary graduate Income 5$15,000 $15,00029,000 $30,00049,999 $50,000 Missing4 Marital status Married/common-law Single/divorced or Separated/widowed ADL limitation5 Yes No

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Notes: 1All sample sizes are reported in their non-weighted form; 2all percentages and p-values are reported in the weighted form. According to Statistics Canada, all prevalence data must be weighted to account for non-response and the probability of selection; 3p-value derived from chi-square test; 4sample sizes too small to report missing data for females with thyroid disorders; 5samples sizes too small to report data for females with thyroid disorders; ADL activities of daily living; E estimate is associated with a high sampling variability.

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Table 3. Logistic regression of current major depression (CIDI-SF) in Canadian females with and without thyroid disorders.1 With thyroid disorders (n 4014) OR Age 540 4059 60 Education 5High school High school graduate Post-secondary graduate Income 5$15,000 $15,00029,000 $30,00049,999 $50,000 Missing Marital status Married/common-law Single/divorced or Separated/widowed ADL limitation Yes No 4.54 3.46 1.00 1.00 0.62 0.81 2.01 1.38 0.92 1.00 0.42 0.58 1.00 2.90 1.00 95% CI (3.07, 6.71) (2.42, 4.94) Reference Reference (0.41, 0.94) (0.57, 1.15) (1.25, 3.24) (0.92, 2.06) (0.76, 1.58) Reference (0.51, 1.32) (0.44, 0.78) Reference (1.71, 4.90) Reference Without thyroid disorders (n 32,275) OR 3.88 3.87 1.00 1.00 1.44 1.35 2.14 1.47 1.33 1.00 0.91 0.61 1.00 3.82 1.00 95% CI (3.23, 4.65) (3.14, 4.56) Reference Reference (1.26, 1.64) (1.19, 1.53) (1.81, 2.53) (1.28, 1.70) (1.18, 1.50) Reference (0.79, 1.06) (0.55, 0.68) Reference (2.91, 5.01) Reference

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Notes: 1All odds ratios and condence intervals are reported in the weighted form. According to Statistics Canada, all prevalence data must be weighted to account for non-response and the probability of selection. Reference Reference category used in analysis.

to be protective in the sub-group of women with thyroid disorders, higher education was associated with higher odds of depression in the sub-group without thyroid disorders. Discussion The prevalence of thyroid disorders reported here of 5.9% (CI 5.66.2%) is consistent with a previous Canadian estimate of 5.6% (CI 5.35.9%) reported by Patten et al. (2006). The gender-specic prevalence of thyroid disorders is similarly corroborated by previous research; the prevalence of 9.3% (CI 8.810.0%) and 2.4% (CI 2.12.7%) in women and men, respectively, is consistent with the prevalence of 9.0% (CI 8.49.5%) and 2.2% (CI 1.92.5%) reported by Patten et al. (2006). As expected, the prevalence of thyroid disorders was signicantly higher in women than in men. Our ndings also indicate that Canadian women have a higher prevalence of depression (6.6%; CI 6.27.0%) than men (3.7%, CI 3.24.0%). These numbers are slightly higher than another study by Patten et al. (2006) where the reported prevalence was 5.0% (CI 4.55.4%) in women compared to 2.9% (CI 2.63.3%) in men. It is important to note that Patten et al. (2006) use data from a nationally representative Canadian sample, whereas our sample is only representative of six provinces where questions about depression were asked in the 2005 CCHS.

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We found that women with thyroid disorders had signicantly higher ageadjusted odds of depression than women without thyroid problems (OR 1.26; CI 1.091.46%). However, among men, the odds of depression did not dier signicantly between those with and without thyroid disorders. After making adjustments for relevant socio-demographic characteristics such as age, education, household income, marital status, and ADL limitations, the odds ratio of depression for women with thyroid disorders declined very slightly but remained signicant (OR 1.22; CI 1.051.41%) indicating that thyroid conditions are associated with depression over and above other known risk factors for depression. The ndings reported here may shed new light on previous population-based studies on thyroid disorders and depression. Grabe et al. (2005) conducted a study in a community sample having no previously known thyroid disorder. Using biochemical methods to conrm thyroid cases and a complaint scale to assess a variety of mental and physical complaints, including depression, the authors found hypothyroidism was not associated with increased symptomatic complaints and that hyperthyroidism was associated with a lower frequency of some symptoms, but they did not report any gender dierences in their ndings. Another large-scale epidemiological study by Engum et al. (2002) obtained symptom ratings for depression from a community sample who were asked questions about their thyroid history. The authors found that subjects who self-reported a history of thyroid disease had higher levels of depressive symptoms irrespective of their current thyroid functioning, but they did not assess any gender-specic dierences. It is possible that the inconsistencies in the prior community-based literature could be, in part, due to the lack of gender-specic analysis. Indeed, our results suggest that there may be no relationship between self-reported thyroid conditions and depression among men; although future research is needed to corroborate this nding. A comparison of the socio-demographic factors associated with depression among women with and without thyroid disorders suggests that similar factors are associated with depression in each sub-group. That is, the factors which are known to be predictive of depression in the general population (e.g. age, income, marital status, and ADL limitations) seem also to be associated with depression among women with thyroid disorders. The only dierence may be education level which was negatively associated with depression among women with thyroid disorders but positively associated with depression among women without thyroid disorders. Future research will have to determine if this nding is reliable. Several important limitations in this study were present. First, the data used in our analysis relied on self-report of a previous health care professional diagnosis of any thyroid condition and could not be medically veried. Although biochemical tests measuring thyroid hormone levels and/or the use of chart reviews would have been preferable, data gathered using these methods are not often available in large, population-based datasets such as the CCHS. For this reason, it is not surprising that self-report measures of thyroid conditions have also been used in previous population-based studies (e.g. Bjoro et al., 2000; Patten et al., 2006). It should be noted that self-report of a previous diagnosis of thyroid conditions has been shown to be relatively accurate when compared to medical records (Brochmann, Bjoro, Gaarder, Hanson, & Frey, 1988). Second, due to the way in which individuals with thyroid conditions were identied, there was no possibility of determining what type of condition the

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respondent had. Consequently, we could not dierentiate between hyperthyroidism or hypothyroidism, or other types of thyroid conditions such as nodules which are relatively common, but may not aect the production of thyroid hormones. The American Association of Clinical Endocrinologists (2003) reports that approximately 80% of those diagnosed with thyroid disease have hypothyroidism, which suggests that the majority of those reporting thyroid conditions in our sample were probably diagnosed with hypothyroidism. Moreover, we had no information on the severity of symptoms. These are important considerations because the inability to dierentiate between dierent types of thyroid conditions, and the severity of their presentation, means that we cannot speculate on the specic mechanism linking thyroid abnormality to depression in this sample of Canadians. Third, because data on depression was only available in six provinces, this study cannot be generalized to the Canadian population as a whole. Moreover, although the response rate in each of the provinces fell within an acceptable range (i.e. 76.484.1%), it is still important to consider systematic sources of non-response bias. For example, it is possible that community members with more severe mental health problems were less likely to participate in the survey. Such selective processes may lead to the over- or underestimation of the association between thyroid conditions and depression. Finally, given the cross-sectional nature of the CCHS survey design, it is not possible to determine the direction of the association between thyroid conditions and depression. The above-mentioned limitations underscore the need for further gender-specic and community-based studies which can replicate our ndings. In particular, gender-specic research using prospective data is highly warranted. Conclusion To our knowledge, this study provides the rst population-based, gender-specic analysis of the association between thyroid disorders and depression in the Canadian context. The results of this study suggest that women with self-reported thyroid disorders are more vulnerable to depression than women without thyroid conditions and that the socio-demographic factors associated with depression (e.g. younger age, lower income, single status, and ADL limitations) are similar among women with and without thyroid disorders.

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