Myxedema Psychosis: Systematic Review and Pooled Analysis

Mouhand FH Mohamed,1,2 Mohammed Danjuma,1,3 Mohammed Mohammed,4 Samreen Mohamed,4 Martin Siepmann,5 Kristian Barlinn,6 Salah Suwileh,1 Lina Abdalla,1 Dabia Al-Mohanadi,7 Juan Carlos Silva Godínez,8,9 Abdel-Naser Elzouki,1,3 Timo Siepmann2,6 1Department of Medicine, Hamad Medical Corporation, Doha, Qatar; 2Department of Health Care Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany; 3College of Medicine, Qatar University, Doha, Qatar; 4Department of Psychiatry, Hamad Medical Corporation, Doha, Qatar; 5Department of Psychotherapy and Psychosomatic Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; 6Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; 7Department of Endocrinology, Hamad Medical Corporation, Doha, Qatar; 8Department of Surgery, National Medical Center Siglo XXI, Mexican Social Security Institute, Mexico City, Mexico; 9Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USACorrespondence: Mouhand FH Mohamed Email Dr.m.oraiby@hotmail.comBackground and Objective: The term myxedema psychosis (MP) was introduced to describe the occurrence of psychotic symptoms in patients with untreated hypothyroidism, but the optimal assessment and treatment of this condition are unclear. We aimed to synthesize data from the literature to characterize the clinical presentation and management of MP.Methods: We performed a systematic review according to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines in PubMed (Medline), Embase, Google Scholar, and Cochrane databases, including observational studies, case series, and case reports published from 1/1/1980 to 31/12/2019 in the English language. Descriptive statistics along with univariate and multivariate analysis were used for data synthesis.Results: Out of 1583 articles screened, 71 case reports met our inclusion criteria providing data on 75 MP cases. The median age at diagnosis was 42 years [32– 56]. About 53% had no prior hypothyroidism diagnosis. Delusions occurred in 91%, with a predominance of persecutory ideas (84%), while hallucinations occurred in 78%. Physical symptoms and signs of hypothyroidism were absent in 37% and 26%, respectively. If symptoms occurred, nonspecific fatigue was seen most frequently (63%). The median thyroid-stimulating hormone value was 93 mIU/L [60– 139]. Thyroid peroxidase antibodies were found positive in 75% (23/33) of reported cases. Creatinine kinase was reported abnormal in seven cases. Cranial imaging (CT or MRI) and electroencephalogram were normal in 89%, 75%, and 73% of the cases reported. The majority of patients were treated orally with thyroxine in combination with short-term antipsychotics. More than 90% of them showed complete recovery. Univariate analysis revealed a trend towards a shorter duration of psychosis with IV thyroid hormone therapy (p= 0.0502), but the effect was not consistent in a multivariate analysis.Conclusion: While we identified a substantial lack of published research on MP, our pooled analysis of case observations suggests that the condition presents a broad spectrum of psychiatric and physical symptoms lending support to the value of screening for thyroid dysfunction in patients with first-ever psychosis.Prospero Registration Number: CRD42020160310.Keywords: psychosis, hypothyroidism, madness, myxedema, depression, neuropsychiatri