Association between panic disorder, major depressive disorder and celiac disease: A possible role of thyroid autoimmunity

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Abstract

Objective: To evaluate the association between celiac disease and specific anxiety and depressive disorders and to identify potential common pathogenetic links, with particular regard to thyroid function and autoimmunity. Methods: Cases included 36 adult celiac patients, 25 females and 11 males, aged 18–64 years. Controls comprised 144 healthy subjects matched by sex and age with no clinical evidence or family history of celiac disease. Diagnosis of celiac disease was made on the basis of clinical history and serological criteria. Psychiatric diagnoses were formulated using the International Composite Diagnostic Interview, according to DSM-IV criteria. Thyroid was evaluated by palpation, echography and measurement of serum-free thyroid hormones (FT4, FT3), thyroid-stimulating hormone (TSH) and antithyroid autoantibodies (anti-TPO). Results: Compared to controls, a significantly higher number of celiac patients met criteria for lifetime [15 (41.7%) versus 30 (29.8%), P<.01] and 6-month [7 (19.4%) versus 9 (6.2%), OR=3.2, χ2=5.2, P<.05] major depressive disorder (MDD) and lifetime [5 (13.9%) versus 3 (2.1%), P<.001] and 6-month [3 (8.1%) versus 2 (1.4%), P<.05] panic disorder (PD). Anti-TPO prevalence was significantly higher in celiac patients than in the control group (11/36=30.5% versus 14/144=9.7%, P<.001). A higher frequency of PD and MDD was found in celiac patients with positive anti-TPO when compared to negative anti-TPO patients (4/11=36.4% PD in TPO+ versus 1/25=4% PD in TPO−, P<.01; 9/11=81.8% MD in TPO+ versus 6/25=9.5% MD in TPO−, P<.01). Conclusion: Patients affected by celiac disease tend to show a high prevalence of PD and MDD and association with subclinical thyroid disease appears to represent a significant risk factor for these psychiatric disorders.

Introduction

Patients with celiac disease often show depressive and anxiety symptoms [1], [2], [3]; however, the frequency of the cooccurrence of affective and anxiety disorders in celiac disease is still unknown, and the role of potential risk factors needs to be further elucidated.

Wheat gluten has been considered as a potential pathogenic factor for psychiatric disorders [4], [5], although, to date, no univocal evidence has been provided that gluten withdrawal may interrupt the course of depressive symptoms [2].

The increased prevalence of affective disorders in celiac patients might also be related to other conditions known to be associated to celiac disease. Interestingly, the prevalence of thyroid diseases (particularly autoimmune thyroid disorders) appears to be increased in celiac patients [6], [7]. Several previous investigations have suggested that subclinical autoimmune hypothyroidism may represent a risk factor for the development of affective disorders [8], [9]. Moreover, recent evidence seems to indicate high levels of thyroid antibodies in depressive disorders [10] and an increased risk of major depressive disorder (MDD) and panic disorder (PD) in patients with thyroid disease [11], [12].

The purpose of the present investigation therefore was to evaluate the relationship between celiac disease and psychiatric disorders, using international standardized psychiatric diagnostic criteria and standardized psychiatric assessment tools, and to measure the relevance of associated thyroid disease in the development of psychiatric illnesses in celiac patients.

Section snippets

Methods

A case–control rectrospective design was used in this study. Cases were 36 adult celiac outpatients attending the Internal Medicine Department of the University of Cagliari, 27 females and 9 males, age 18–64 years (mean±S.D.=41.1±15.3), on a 6-month gluten-free diet, and duration of celiac disease symptoms range from 6 months to 52 years (mean±S.D.=14.0±8.3). Controls were 144 subjects (36 males, 108 females) aged 18–64 years (mean±S.D.=41.3±14.9) who were obtained by matching each “celiac

Lifetime prevalence of mental disorders

When compared to controls, a higher lifetime prevalence of DSM-IV MDD, dysthymic disorder (DD), adjustment disorder (AD) and PD was observed in celiac patients; no differences were found for generalized anxiety disorder, specific phobia and social phobia (Table 1).

Onset of depressive symptoms in 3 (20%) of the 15 cases affected by MDD had occurred subsequent to commencing gluten-free diet. Five (33.3%) of the 15 MDD cases had presented a particularly severe depressive episode after starting

Discussion

The first evidence of a relationship between adult celiac disease and psychiatric disorders was reported in 1982, when Hallert and Derefeldt [1], using the MMPI, first described an increased prevalence of depressive symptoms in celiac patients. These authors also suggested a potential linkage between psychopathology and generalized malabsorption. Subsequent studies have also shown a significant association between adult celiac disease and anxiety or depressive symptoms [2], [3], [4]. Depressive

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