i

PREVALENCE OF DEPRESSIVE SYMPTOMS AND ANXIETY

AMONG PATIENTS WITH THYROID DYSFUNCTION

ATHIRA K.

Govt. College of Nursing, Kozhikode

DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT

OF THE REQUIREMENTS FOR THE DEGREE

OF MASTER OF SCIENCE IN NURSING

KERALA UNIVERSITY OF HEALTH SCIENCES

2023
 ii

PREVALENCE OF DEPRESSIVE SYMPTOMS AND ANXIETY

AMONG PATIENTS WITH THYROID DYSFUNCTION

By

ATHIRA K

Dissertation submitted to the

KERALA UNIVERSITY OF HEALTH SCIENCES

Thrissur

In partial fulfilment of the requirements for the Degree of

MASTER OF SCIENCE IN NURSING

in

MENTAL HEALTH NURSING

Under the guidance of

Prof (Dr.) JAYANTHI M.R.

Govt. College of Nursing

Palakkad

and

Dr. SHAMEER V. K.

Govt. Medical College Hospital, Kozhikode

2023
 iii

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled Prevalence of depressive

symptoms and anxiety among patients with thyroid dysfunction is a

bonafide and genuine research work carried out by me under the guidance

of Prof (Dr.) Jayanthi M.R., Govt. College of Nursing, palakkad and

Dr. Shameer V. K., Assistant Professor, Govt. Medical College Hospital, Kozhikode.

ATHIRA K.

10/11/2023

Kozhikode
 iv

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled Prevalence of depressive

symptoms and anxiety among patients with thyroid dysfunction is a bonafide

research work done by Athira K. in partial fulfilment of the requirements for the

degree of Master of Science in Nursing.

Prof (Dr.)JAYANTHI M.R., MSc (N),Ph.D

Principal

Govt. College of Nursing

Palakkad

Dr. SHAMEER V. K., MBBS, MD

Assistant Professor

Department of Medicine

Govt. Medical College Hospital

Kozhikode

10/11/2023

Kozhikode
 v

ENDORSEMENT BY THE PRINCIPAL

This is to certify that the dissertation entitled Prevalence of depressive

symptoms and anxiety among patients with thyroid dysfunction is a bonafide

research work done by Athira K. in partial fulfilment of the requirements for the

degree of Master of Science in Nursing.

Prof (Dr.) RAJALAKSHMY.K ., MSc (N) Ph.D(N)

Principal

Govt. College of Nursing

Kozhikode

10/11/2023

Kozhikode
 vi

COPY RIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that the Kerala University of Health Sciences, Thrissur shall

have the rights to preserve, use and disseminate this dissertation in print or electronic

journal format for academic/ research purpose.

ATHIRA K.

10/11/2023

Kozhikode
 vii

ACKNOWLEDGEMENT

The investigator owes a deep sense of gratitude to all those who have

contributed for the successful completion of this dissertation. It is a pleasure to

mention gratitude to them all in this humble acknowledgement.

The investigator takes this opportunity to earnestly thank

Prof (Dr.)Rajalakshmy K., Principal, Govt. College of Nursing, Kozhikode for her

constant support for the successful completion of the study.

The investigator expresses her gratitude to Prof (Dr.) Geethakumary V.P.,

former principal, Govt. College of Nursing, Kozhikode for the generous support,

valuable ideas and timely advice for completing this dissertation.

The present study has been completed under the guidance of

Prof(Dr.)Jayanthi M.R., Govt. College of Nursing, Palakkad. The investigator whole

heartedly expresses her sincere gratitude for her excellent and timely guidance,

criticism, scholarly advice, encouragement and immense support throughout the

study.

The investigator is deeply obliged to her external guide Dr Shameer V. K.,

Assistant Professor, Govt. Medical College, Kozhikode, under whose guidance this

work has been carried out. She expresses her profound gratitude and exclusive thanks

for his innovative and expert guidance, suggestions, encouragement, and support,

which helped her in accomplishing this task successfully.

The investigator deeply thank Prof. Seenath K. P., Govt College of Nursing

Manjeri for her immense guidance, support, encouragement, constant support for the

study.
 viii

It is the investigators unavoidable duty to express the heartiest gratitude to

Dr.Biju George., Associate Professor, Department of Community Medicine, Medical

College, Kottayam, for their enormous guidance and priceless support rendered in the

statistical analysis of the study.

The investigator acknowledges her heartiest gratitude and indebtedness to

Mr. Saleem T.K., Assistant Professor, Govt. College of Nursing, Kozhikode, for

scholarly corrections, critical guidance, constant support and valuable help rendered

in the statistical analysis of data.

The investigator is extremely thankful to the members of scientific review

committee and institutional ethics committee for permitting her to conduct the study.

She also extends her gratitude to all the faculties of Govt. College of Nursing,

Kozhikode, for their suggestions, critical observations and encouragement.

She expresses her sincere thanks to all the experts who willingly helped her

through content validation as well as translation and re-translation of the tools. The

investigator expresses her sincere gratitude to all the participants for their willingness

and for their whole hearted co-operation during the study.

The investigator owes sincere thanks to Dr. Rony Sebastian, Librarian,

Mrs. Renuka K. K, Library Assistant, Mrs Rajila Malesh, DTP operator, Govt.

College of Nursing, Kozhikode for their generous support and co-operation

throughout the study.

The investigator thankfully remembers the members of Prayag DTP center,

Medical College, Kozhikode for their kind co-operation and sincere concern offered

for shaping the thesis.

 ix

Words fail to express her sincere gratitude to her classmates, seniors and

juniors for their constant encouragement and positive criticism.

The investigator is obliged to her parents, and other family members for their

great support and encouragement throughout the study.

She also expresses her profound gratitude to all the participants who willingly

participated and co-operated with this study. Moreover, the investigator is obliged to

her family members for their boundless love, moral support, and encouragement.

The investigator is obliged to all the members involved directly or indirectly in

this study for their kind help and support in successful completion of this study.

ATHIRA K.

10/11/2023

Kozhikode
 x

ABSTRACT

Thyroid dysfunction is known to cause a myriad of neuropsychiatric

symptoms. Depression and anxiety are the commonest psychiatric disorder in patients
with thyroid disorders, it continues to be significantly under recognized and under
treated and it may affect the quality of life. The present study was aimed to assess the
prevalence of depressive symptoms and anxiety among patients with thyroid
dysfunction. The main objectives were to assess the prevalence of depressive
symptoms and anxiety among patients with thyroid dysfunction and to find out the
association between the depressive symptoms and anxiety among patients with
thyroid dysfunction and selected variables. The conceptual framework was based on
Betty Neuman’s System model. A non experimental descriptive design was used and
sample selected from outpatient department of Medicine, Surgery, Endocrinology of
Govt Medical College Hospital by using purposive sampling technique. Sample
consisted of 110 patients with thyroid dysfunction. The tools used were a semi
structured interview schedule to assess the socio personal and clinical variables of
patients with thyroid dysfunction, Beck Depression inventory to assess the depressive
symptoms among patients with thyroid dysfunction and Generalized Anxiety Disorder
Questionnaire to assess the prevalence of anxiety among patients with thyroid
dysfunction. The findings revealed that 40 % had mild mood disturbance, 30 % had
moderate depression, 20% had borderline clinical depression and 3.6% had severe
depression. The study reported that 67.3% had mild anxiety, 17.3% had minimal
anxiety, 14.5 % had moderate anxiety and 0.9 % had severe anxiety. There was
significant association between marital status (p=0.048) and regularity of treatment
(p=0.008)of patients with thyroid dysfunction and anxiety and there is no significant
association between depressive symptoms and selected variables among patients with
thyroid dysfunction. These findings have implications in the nursing practice,
education, administration and research.

Keywords: depressive symptoms, anxiety, patients with thyroid dysfunction.

 xi

TABLE OF CONTENTS

List of tables

List of figures/graphs

List of appendices

Chapters Title Page No

1 INTRODUCTION 1-17

2 REVIEW OF LITERATURE 18-33

3 METHODOLOGY 34-47

4 ANALYSIS AND INTERPRETATION 48-73

5 RESULTS 74-78

6 DISCUSSION. SUMMARY, AND CONCLUSION 79-95

REFERENCES 96-104

APPENDICES 105-134
 xii

LIST OF TABLES

Sl No Title Page No

1 Distribution of participants based on age in years 50

2 Distribution of participants based on type of family and 53

marital status

3 Distribution of participants based on education and 54

occupation

4 Distribution of participants based on source of support and 56

problems experiencing in daily life

5 Distribution of participants based on age at diagnosis, 58

duration of diagnosis, medications for thyroid dysfunction

and regularity of treatment

6 Distribution of participants based on the level of 62

depressive symptoms reported by patients with thyroid

dysfunction

7 Mean, standard deviation, maximum and minimum score 63

obtained in Beck Depression Inventory

8 Distribution of participants based on level of anxiety 65

reported by patients with thyroid dysfunction

9 Mean, standard deviation, maximum and minimum score 66

obtained in Generalized Anxiety Disorder Questionnaire

10 Association between depressive symptoms among patients 68

with thyroid dysfunction and selected variables

 xiii

11 Association between anxiety among patients with thyroid 70

dysfunction and selected variables

12 Association between marital status and anxiety among 72

patients with thyroid dysfunction

13 Association between regularity of treatment and anxiety 73

among patients with thyroid dysfunction

 xiv

LIST OF FIGURES

Sl No Title Page No

1 Conceptual framework based on Betty Neuman’s system 17

model to assess the prevalence of depressive symptoms and

anxiety among patients with thyroid dysfunction.

2 Schematic representation of the study to assess the 37

prevalence of depressive symptoms and anxiety among

patients with thyroid dysfunction.

3 Distribution of participants based on sex 51

4 Distribution of participants based on place of residence 52

5 Distribution of participants based on socio economic status 55

6 Distribution of participants based on diagnosis 57

7 Distribution of participants based on co morbidities 59

8 Distribution of participants based on history of thyroid 60

dysfunction in the family

 xv

LIST OF APPENDICES

Sl No Title Page No

Section A- English

A Approval letter from Scientific Review Committee 105

B Approval letter from Institutional Ethics Committee 106

C Permission letter from superintendent of Govt 107

Medical College, Kozhikode.

D List of experts for content validity 109

E Informed consent – English 110

F Tool 1- Semi structured interview schedule for socio 111

personal and clinical variables

G Tool 2- Beck Depression Inventory to assess the 115

depressive symptoms among patients with thyroid

dysfunction

H Tool 3- Generalized Anxiety Disorder Questionnaire 121

to assess the anxiety among patients with thyroid

dysfunction

Section B –Malayalam

I Informed consent- Malayalam 122

J Tool 1- Semi structured interview schedule for socio 123

personal and clinical variables

K Tool 2- Beck Depression Inventory to assess the 126

depressive symptoms among patients with thyroid

dysfunction
 xvi

L Tool 3- Generalized Anxiety Disorder Questionnaire 132

to assess the anxiety among patients with thyroid

dysfunction

M List of abbreviations 134

 1

CHAPTER 1

INTRODUCTION

Introduction

Background of the problem

Need and significance of the study

Statement of the problem

Objectives

Operational definitions

Assumptions

Hypothesis

Conceptual framework
 2

CHAPTER 1

INTRODUCTION

The human body is an amazing creation and also a biological machine made

up of body systems that work together to produce and sustain life. Health is

considered as basic parameter of life. Each system in the human body will affect the

health of the living organism, including the physical state of the body as well as the

mental state and mind. Any of the organs or organ systems do not function properly,

giving rise to signs and symptoms of not being well, then it is said that the state of

health is not good.1 The organ system that will be affected by the disease includes the

nervous system, respiratory system, cardiovascular system, endocrinology system etc.

Among these, endocrine diseases have a considerable impact on public health, and

they may cause long-term disability and alteration in the quality of life and are the

fifth leading cause of death.2 Thyroid disorders are one of the endocrine diseases that

create disease burden in our population.

Mental health is an integral part and essential component of health indeed;

there is no health without mental health. The World Health Organization defines

health as a state of complete physical, mental, and social wellbeing and not merely the
3
absence of disease or infirmity. The WHO describes mental health as a state of

wellbeing in which the individual realises his or her own abilities, cope with the

normal stresses of life, can work productively fruitfully, and is able to make a

contribution to his or her community. 4 Mental health is more than the absence of

mental disorders or disabilities.5

Mental health and illness are relative concepts, which are defined and

described in relation to a person's ability to do his duties properly and basically will
 3

have a positive review.6 Physical illness will lead to mental health issues such as

psychological distress, depression, and anxiety.

In recent years, there has been increasing acknowledgement of the important

role of mental health for achieving development goals, as illustrated by the inclusion

of mental health in sustainable development goals. Depression is one of the leading

causes of disability. Mental health conditions now cause 1 in 5 years to live with a

disability. Mental health conditions have a substantial effect on all areas of life, such

as school or work performance, relationship with family and ability to participate in

the community. Two of the common mental health conditions, including depression

and anxiety, cost the global economy US$ 1 trillion each year.7

Depression is a common and serious illness that negatively affects how feel

and act. Depression causes feelings of sadness or a loss of interest in activities that

once enjoyed. It can lead to a variety of emotional and physical problems and can

decease the ability to function at work and at home. Some medical conditions (thyroid

problems, vitamin deficiency) can mimic symptoms of depression; thereby it is

important to rule out general medical causes. Depression affects an estimated 1 in 15

adults (6.7 %) in a year. And one in 6 people (16.6 %) will experience depression at

some time in their life. Women are more likely than men to experience depression. 8

Anxiety disorders are characterised by excessive fear and worry and related

behavioural disturbances. Symptoms are enough to result in significant distress or

significant impairment in functioning. 9 An estimated 275 million people suffer from

anxiety disorders. That’s around 4 % of the global population, with a spread of

between 2.5 % and 6.5% of the population per country. Around 62% of those

suffering from anxiety are female (170 million) compared with 105 million male
 4

suffers.10Globally, the incidents of anxiety disorders and DALYS were increasing

continuously, about 45.82 million.11

The load of non-communicable diseases is so high, nearby 40 million deaths

each year, equivalent to 70 % of all deaths globally. Thyroid disorders are one among

all, and the global burden was estimated to be more than 2 billion, and in India, it was

expected to be more than 40 million.12

Problems with the thyroid include a variety of disorders that can result in the

gland producing too little thyroid hormone (hypothyroidism) or too much

(hyperthyroidism).13In the developed world, hypothyroidism prevalence is

approximately 4-5%, and that of subclinical hypothyroidism is about 4-15 %. 15 In

India, the prevalence of hypothyroidism is 10.9 % and the prevalence of

hyperthyroidism ranges from 4.8- 25.8% in women and 0.9 -7.9 % in men.14 Thyroid

disorders can affect heart rate, mood, energy, metabolism and many other functions.

Thyroid disorders have a noticeable impact on the energy level and mood.

Hypothyroidism tends to make people feel tired, sluggish, and depressed.

Hyperthyroidism develops symptoms like n anxiety, problems with sleep,

restlessness, irritability, mood swings, weight loss, palpitation and an enlarged thyroid

gland.16They may lead to disturbance in emotion and cognition. Both increase and

decrease in thyroid function cause mood abnormality.

Psychiatric comorbidities are common in thyroid disorder patients and

complicate patient's life quality as well as disease management. Health professionals

should look for early signs of depression and anxiety for effective patient care. Early

diagnosis and treatment are essential for depression and anxiety, in delaying or

reducing further complications and improving their quality of life. During clinical
 5

experience the researcher noticed the relationship between thyroid disorder and

psychiatric comorbidity. This incident motivate the researcher to study about

prevalence of depressive symptoms and anxiety among patients with thyroid disorder

and this will help the researcher to gain knowledge and apply it on the future.

Background of the study

Thyroid hormone (TH) has important actions in the adult brain. A varying

degree of psychiatric symptoms/disorders is common in patients with thyroid

dysfunction, both hypo- and hyperthyroidism. Many studies have revealed that there

are significantly deranged levels of T3, T4, and thyroid-stimulating hormone (TSH) in

patients with depression. Thyroid dysfunctions have been recognized to cause

significant manifestations in mental health and lead to disturbances in emotions and

cognition. Both increase and decrease in thyroid function can cause mood

abnormalities. Vice versa, depression can also go hand in hand with subtle thyroid

dysfunctions.17

Thyroid dysfunction was found to be associated with a variety of

neuropsychiatric disturbances like depression, mania, acute psychosis and cognitive

disorders.18overt hypo and hyperthyroidism are associated with increased risk of

depression.19Commonly documented abnormalities are elevated thyroxine (T4), low

tri iodothyronine(T3), blunted thyroid stimulating hormone (TSH)response to

thyrotropin-releasing hormone .20 Disorders are usually diagnosed and categorized on

the basis of serum hormonal levels of the hypo-thalamo-pituitary-thyroid axis

(namely – thyrotropin-releasing hormone, TRH; thyroid stimulating hormone,

TSH; tetra-iodothyronine, T4; and tri-iodothyronine, T3).

 6

The relationship between mood disorders and thyroid dysfunction has been

long described, firstly about two hundred years ago. Later, the term myxedema

madness was introduced to describe mental status in patients with hypothyroidism.

Today, it has been well established that thyroid dysfunction, especially

hypothyroidism, may significantly impact mental status, especially mood state and

cognitive conditions in hypothyroid patients. Various psychiatric disorders have been

associated with hyperthyroidism. Over 150 years ago, Basedow had already described

a manic psychosis illness in a patient with exophthalmic goitre .21 Psychotic disorders,

symptoms of anxiety, depression and suicidality also seem to be more common in

people with hyperthyroidism.22

There is a common relationship between thyroid hormone levels and anxiety-

23
depression in hypothyroid patients. It is known that anxiety disorder, major

depression, and psychosis are seen in an average of 30%, 40%, and 5% of patients

with hypothyroidism. 24It has also been reported that thyroid dysfunction may affect

mood and the progression of mood disorders. Initially, nonspecific symptoms are

seen. However, depression, forgetfulness, deceleration in thought, and concentration

problems may be seen in the later stages of hypothyroidism. In severe clinical

conditions, psychotic symptoms may appear.25 A depressive mood is the most

common psychiatric symptom in patients with thyroid dysfunction. In addition,

anxiety and sleep disorders are common in these patients.

Depression is a serious illness that has a life time risk of occurrence of 20 % in

26
the United States. Many factors increase a person’s risk of developing depression,

and these include both modifiable and non-modifiable factors such as genetics,

hormonal disturbances and association with other medical disorders. 27One such
 7

common association exist between hypothyroidism and depression. Both increase and

decrease in the thyroid hormones results mood disorders like depression and anxiety,

which can easily resolved by addressing the thyroid imbalances. 28

Thyroid dysfunction is very common, with an estimated 20 million people

having some type of thyroid disorder. Hypothyroidism is a common endocrinological

problem worldwide and the global burden of hypothyroidism is significant. In the

29
developed world, hypothyroidism prevalence is approximately 4-15 %. Worldwide

prevalence of hyperthyroidism is estimated between 0.2% and 1.3 % of the

population.30 About 42 million people in India suffer from thyroid diseases.31 The

prevalence of thyroid dysfunction in India reports that hypothyroidism is about 24%

and hyperthyroidism is 2.1 %.32 In the population-based study done in Cochin on 971

adult subjects, the prevalence of hypothyroidism and subclinical hypothyroidism was

3.9% and 9.4% respectively. The prevalence of hyperthyroidism and overt

hyperthyroidism was 1.6% and 1.3%.33

Psychiatric symptoms or disorders are common in patients with thyroid

dysfunction. A cross-sectional study was conducted at Ambala among 100 patients

with hypothyroidism, and the results show that females constituted 70 % of the

sample. A total of 60 % reported some degree of depression, and 63 % out of the total

patients showed some degree of anxiety. In India, various studies were done on

prevalence of depression and anxiety among patients with thyroid dysfunction.In

studies conducted on 147 patients with thyroid disorders, the results show that there

was a significantly high prevalence of depression (59.2 %)and anxiety (21.8%).

 8

WHO reports that depression is a common mental disorder that affects people

of all ages. Depression affects a person's ability to function on a day-to-day basis,

including their ability to live independently in the community and work. Depression

in young people tends to be chronic and recurrent. Untreated depression can prevent

people from working and participating in family and community life. At worst,

depression can lead to suicide. Depression can be effectively prevented and treated. If

depression is left unchecked and untreated, it can cause many negative effects. This

can cause a never-ending circle of frustration and disappointment for the person. 35

This information and findings help the researcher to know more about the

existence of relationship between thyroid disorders and psychiatric co morbidity. The

aim of the present study helps to explore information regarding prevalence of

depressive symptoms and anxiety among patients with thyroid dysfunction and its

association with selected variables.

Need and significance of the study

Mental health is the foundation for emotions, thinking, communication,

learning, resilience, hope and self-esteem. Mental health is also key to relationships,

personal and emotional well-being and contributing to community or society. Mental

health is a component of overall well-being. It can influence and be influenced by

physical health. Mental illnesses can be related to or mimic a medical condition. For

example, depressive symptoms can relatedto a thyroid condition. Mental illnesses can

be associated with distress and/or problems functioning in social, work or family

activities.36Prompt diagnosis and early intervention in the initial stages of a mental

illness can have significant and life-changing consequences for a person’s mental
 9

health. Early intervention can lead to improved diagnosis and treatment and more

timely and targeted referrals to specialist services.37

Thyroid dysfunction in adults is commonly associated with a host of cognitive

and psychiatric problems. Both an increase and decrease in thyroid function can cause

mood abnormalities. Cognitive decline, dysphoria, and depression are common

manifestations of overt hypothyroidism, while hyperthyroidism can cause agitation,

acute psychosis, and apathy, especially in older people. Untreated thyroid dysfunction

will cause physical as well as mental complications.38

Anxiety disorders can severely impair a person's ability to function at work,

school, and in social situations. Anxiety can also interfere with a person's
39
relationships with family members and friends. Early identification of anxiety is

important because, when ignored, it can affect grades, school performance, social and

interpersonal skills, and life outcomes.40

According to a World Health Organisation report, India has the highest

number of depressed individuals in the world. This means that one out of three

individuals in India suffers from depression. It is estimated that 300 million people

worldwide experience depression.41 WHO reports that depression is the second most

common reason for disability in the world and develops feelings of sadness, loss of

interest in pleasurable activities and a variety of physical and emotional problems. In

other cases, it might interfere with the work, leading to less productivity, and it can

also lead to some chronic health conditions. The treatment of depression is important

because people with untreated depression have a lower quality of life, a higher risk of

suicide, and worse physical outcomes if they have any medical conditions besides

depression. In fact, people with depression are almost twice as likely to die as people
 10

without the condition. If left untreated, depression can severely impact one's sleep

patterns, leave one feeling hopeless and irritable, and could even result in weight gain

or loss. Treatment, which can include medication, talk therapy, alternative treatments

or a combination of these, can help to minimize these symptoms.

A descriptive cross sectional study was conducted in Saudi Arabia regarding

the prevalence of depression among hypothyroid patients in 395 participants. Among

the participants 321 cases were females. Result shows that depression was recorded

among 341 hypothyroid cases (86.3%) and 33.7% had a major depressive disorder. 63

A descriptive, cross-sectional study was conducted in the endocrinology

outpatient clinic of the tribhuwan university hospital, Nepal about the prevalence of

anxiety and depression among 129 patients with thyroid disorder. Results showed that

Patients' mean age was 38.09±12.68 years; most were females (102, 79.1%) and

hypothyroid (90, 69.8%). The overall prevalence of anxiety and depression were

50.4% and 42.6% respectively. 42

Psychiatric comorbidities are common in thyroid disorder patients and

complicate patient’s life quality as well as disease management. The investigator

aimed to explore the prevalence of anxiety and depression and identify associated

characteristics among patients with thyroid function disorder. The investigator feels

that identifying the symptoms of depression at an early stage is an important step to

prevent the worsening of the condition. To the best of the researcher's knowledge, no

study regarding the prevalence of depressive symptoms and anxiety among patients

with thyroid dysfunction has been conducted in Kerala.

Depressive symptoms and anxiety in patients with thyroid dysfunction are

identified at the earliest and managed scientifically; they can lead a very successful
 11

life. These above experiences, thoughts and studies motivated the investigator to

conduct a research study to assess the prevalence of depressive symptoms and anxiety

among patients with thyroid dysfunction.

Purpose of the study

The purpose of the study is to find out the prevalence of depressive symptoms

and anxiety among patients with thyroid dysfunction. Identifying the prevalence of

depressive symptoms and anxiety in earlier periods will help to prevent complications

and further progress of psychiatric problems. Identifying the prevalence will help to

give special care to those people and the focus area of the treatment can be extended.

Statement of the problem

A study to assess the prevalence of depressive symptoms and anxiety among

patients with thyroid dysfunction attending Government Medical College Hospital,

Kozhikode.

Objectives

 Assess the prevalence of depressive symptoms among patients with thyroid

dysfunction.

 Assess the prevalence of anxiety among patients with thyroid dysfunction.

 Find out the association between depressive symptoms among patients with

thyroid dysfunction and selected variables.

 Find out the association between anxiety among patients with thyroid

dysfunction and selected variables.

Operational definition

 Prevalence - refers to the number of cases of depressive symptoms and

anxiety among patients with known cases of thyroid dysfunction during the
 12

period of study and expressed as frequency and percentage out of the persons

studied.

 Depressive symptoms–refers to the depressive symptoms consist of depressed

mood, loss of interest and enjoyment, reduced energy leading to increased

fatigability, diminished activity, reduced attention and concentration, reduced

self-esteem and self-confidence, ideas or acts of self-harm, disturbed sleep,

diminished appetite among patients with thyroid dysfunction as measured by

Beck depression inventory.

 Anxiety- refers to the psychological fear experienced by the person with

thyroid dysfunction as measured by the Generalised Anxiety Disorder

Questionnaire.

 Patients with thyroid dysfunction-refers to the known case of thyroid

dysfunction is that the body produces too much or too little thyroid hormones,

which is clinically diagnosed thyroid dysfunction after a blood test by the

treating physician from Government Medical College Hospital Kozhikode.

 Selected variables-refers to socio-personal variables and clinical variables of

patients with thyroid dysfunction.

Socio-personal variables- includes age, sex, religion, education, marital status,

place of residence, type of family, occupation, socio-economic status, source

of income, source of support, and problems in daily living.

Clinical variables- includes diagnosis, age at the time of diagnosis, duration of

diagnosis, medications for thyroid dysfunction, duration of treatment, co-

morbidities, if any, regularity of treatment, and family history of thyroid

dysfunction.
 13

Hypotheses

H1: There is a significant association between depressive symptoms and selected

variables among patients with thyroid dysfunction.

H2: There is a significant association between anxiety and selected variables among

patients with thyroid dysfunction.

Assumptions

 Patients with thyroid dysfunction experience anxiety and depressive

symptoms.

 Socio-personal variables will influence anxiety and depressive symptoms

among patients with thyroid dysfunction.

Conceptual framework

In this study, the conceptual framework is developed on the basis of a review

of literature, discussion with the experts, and the clinical experience of the

investigator, and it is based on Betty Neuman’s system model theory (1972).

The conceptual framework is a structure which the researcher believes can

best explain the natural progression of the phenomenon to be studied. It provides an

integrated way of looking at a problem under study. The conceptual framework of this

study is based on the concepts of the health care system model by Betty Neuman. In

this study the researcher aims at assessing the depressive symptoms and anxiety

among patients with thyroid dysfunction.

The Neuman’s System model is a unique, open system based perspective that

provides a unifying focus of approaching a wide range of health concerns. The model

is open to creative interpretation and is widely used throughout the world as a

 14

multidisciplinary, holistic and comprehensive structure and as a guidance for

excellence in nursing practice, education, research and administration. The Neuman

system model presents a system based framework for viewing individuals, families or

communities. Neuman model focuses on the response of the client as an open system

to actual or potential environmental stressors and the use of primary, secondary and

tertiary nursing interventions for retention, attainment and maintenance of optimal

client system wellness.

In this model human being is a total person as a client system and the person is a

layered multidimensional being who is constantly interacting with the internal and

external stressors. Each layer of the client system consists of five variable or

subsystems. The variables are

1. Physiological: refers to bodily structures and function.

2. Psychological: refers to mental processes, functioning and emotions

3. Socio-cultural refers to system functions that relate to social and cultural

expectations and activities

4. Spiritual: refers to the influence of spiritual beliefs

5. Developmental: refers to life developmental process, age-related processes

and activities

Stressors are environmental factors that are intrapersonal, interpersonal and extra-

personal in nature and have the potential to disrupt system stability.

1. Intrapersonal stressors occur within the client system boundary and

correlate with the internal environment. It included a person’s emotions

and feelings.
 15

2. Interpersonal stressors that occur outside the client system boundary are

proximal to the system and have an impact on the system. eg, role

expectations

3. Extra personal stressors occur outside the client system boundary.e.g.,

social policy, job and financial concerns.

Betty Neuman believes nursing as a unique profession that is concerned with

all the variables which influence the response of a person to a stressor, and nursing

actions should assist individuals, families and groups to maintain a maximum level of

wellness. The primary aim is the stability of the client system through nursing

interventions to reduce stressors and the use of primary, secondary and tertiary

interventions.

Primary prevention consists of interventions initiated before an encounter with

the stressor. Secondary prevention focuses on early detection of symptoms and

interventions once a reaction has occurred. Tertiary prevention occurs after the system

has been treated through secondary prevention and offers support to the client and

attempts to regain the system equilibrium and facilitate reconstitution.

In the present study, patients with thyroid dysfunction in an open system have

continuous interaction with stressors from the internal and external environment,

these stressors are interpersonal, intrapersonal and extra personal in nature. The

intrapersonal stressors include age, sex, marital status, co morbidities if any, duration

of treatment. Extra personal stressors include education, occupation, socio economic

status, place of residence, family history of mental illness, and religion. Interpersonal

stressors include problems experienced in daily living as a source of support system.

 16

The client system is represented by a series of solid and broken circles. Here,

the client system is the patients with thyroid dysfunction. The central circle is the

basic structure or energy source, which includes basic survival factors. The outer most

solid circle is referred to as the normal line of defence and represents the client's

normal state of wellness or the usual state of adaptation, which the person has

maintained over time. The broken line outside of the normal line of defence is the

flexible line of defence, which acts as a protection against the normal line of defence.

Ideally, it prevents stressors from invading the client system by blocking or defusing

stressors before they are able to attack the normal line of defence. The broken circles

surrounding the basis structure are the line of resistance, which is defined as the

reactions that occur within the client system when a stressor succeeds in penetrating

the normal line of defence. Their function is to restore equilibrium and protect the

basic structure. When the lines of resistance are ineffective, the client system adapts

to the stress by reconstitution.

This study focuses on primary prevention by assessing the prevalence of

depressive symptoms and anxiety among patients with thyroid dysfunction. Early

identification helps in the management of depressive symptoms and anxiety

associated with thyroid dysfunction and the maintenance of healthy behaviour.

The conceptual framework of the study is shown below.

 17

STRESSORS
LEVELS OF
N
PREVENTION
INTRAPERSONAL U
PRIMARY
STRESSORS
PREVENTION R
Assessment of
Age, sex, marital
prevalence of S
status, co morbidities
depressive symptoms SECONDARY
if any, duration of I
and anxiety among PREVENTION
illness, duration of
patients with thyroid N
treatment. Assessment of
Patients with dysfunction measured
by Beck depression prevalence of G
INTERPERSONAL thyroid
inventory and depressive
STRESSORS dysfunction I
generalized anxiety symptoms and
Problems disorder anxiety N
experiencing in daily questionnaire. T
living, source of
support. LINE OF RESISTANCE E
EXTRAPERSONAL NORMAL LINE OF DEFENSE TERTIARY R
STRESSORS PREVENTION
FLEXIBLE LINE OF DEFENSE V
Education, occupation,
E
socio economic status,
place of residence, N
religion, family history Reconstitution
of mental illness, type T
of family. I
O
Figure 1. Conceptual framework to assess depressive symptoms and anxiety among patients with thyroid dysfunction based on N
Betty Neuman’s system model theory (1972).

17
 18

CHAPTER 2

REVIEW OF LITERATURE

Prevalence of depressive symptoms and anxiety

Prevalence of depressive symptoms

Prevalence of anxiety

Summary
 19

CHAPTER 2

REVIEW OF LITERATURE

Review of literature is an evaluative report of information found in the

literature related to selected area of the study. Review of literature refers to an

extensive and systematic examination of publication relevant to required search.

A review of literature is an essential, supportive and informative evidence of

scientific research. It is a systemic identification, location, scrutiny and summary of

written material that contain information relevant to the problem under the study.

The review of literature for the present study has been organized under the following

headings

 Prevalence of depressive symptoms and anxiety

 Prevalence of depressive symptoms

 Prevalence of anxiety

Prevalence of depressive symptoms and anxiety

A cross sectional study conducted in endocrinology clinic in university

Malaysia medical centre about the prevalence of depression and anxiety among

thyroid patients and associates. The study was conducted among 160 patients. The

patients were interviewed by using MINI international neuropsychiatry inventory for

diagnostic assessment, socio personal and clinical data were obtained by interviewing

the patients and from the case notes, quality of life was assessed by using short form

health questionnaire. The result shows that the prevalence was 9.4% for major

depressive disorder and 22.5% for anxiety disorder. The score for quality of life was

lower in those with major depressive disorder and anxiety disorder.43

 20

A study conducted in two university hospitals in Denmark regarding the

prevalence of anxiety and depression symptoms in patients with Graves' disease

compared to patients with another chronic thyroid disease, nodular goitre and to

investigate determinants of anxiety and depression in Graves' disease. 157 cross-

sectionally sampled patients with Graves' disease, 17 newly diagnosed, 140 treated,

and 251 controls with nodular goitre completed the Hospital Anxiety and Depression

Scale (HADS). In Graves' disease levels of anxiety and depression were significantly

higher than in controls. The prevalence of depression was 10% in Graves' disease

versus 4% in nodular goitre, anxiety was 18% versus 13%.Symptoms of anxiety and

depression increased with comorbidity. Anxiety symptoms increased with duration of

Graves' disease.44

A cross sectional study conducted at Maharshi Markandeshwar Institute of

Medical sciences and Research, Ambala about the prevalence of anxiety and

depressive symptoms among patients with hypothyroid. A total of 100 patients

diagnosed as hypothyroidism were evaluated using Hamilton depression rating scale

(HDRS) and Hamilton scale for anxiety (HAM-A). Females constituted 70% of the

sample. The findings were suggested that a total of 60% reported some degree of

depression based on HDRS (males – 56.63% and females – 64.29%) whereas about

63% out of the total patients screened showed some degree of anxiety (males –

56.66% and females – 65.72%) based on HAM-A. The most common depressive

symptom among the males was depressed mood (73.33%) and among females was

gastrointestinal somatic symptoms (68.54%). The most common anxiety symptom

among the males was depressed mood (70.0%) and among females was anxious mood

(92.85%).17
 21

A cross sectional study was conducted in a teaching hospital Punjab regarding

the nature and extent of psychiatric co morbidity in patients suffering from thyroid

dysfunction. The study was conducted among 50 patients having thyroid dysfunction

by consecutive sampling method. The patients were assessed with a self -structured

questionnaire for recording the socio demographic variables, Hamilton rating scale for

depression, Amritsar depressive inventory and the Hamilton rating scale for anxiety.

The result of their study suggested that among the total patients 68% were diagnosed

as hypothyroidism and 32 % had hyperthyroidism. 47.1 % patients were found to

have significant depression and 47.1 % were found to have moderate to severe

anxiety.45

A study conducted on patients attending a medical outpatient department

regarding the prevalence and proportion of depression, anxiety,and somatization

symptoms and compare the same between two groups of patients. The sample

consisted of 34 patients with CHT and 36 patients with SCHT. The patients were

assessed by using Hamilton Rating Scale for Depression, Patient Health

Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 Questionnaire, and PHQ-

15 for somatization. The result suggests that on assessing the severity of depression

and anxiety, more cases of mild depression were reported in the subclinical

hypothyroid group compared to moderate and severe depression being higher in the

clinical hypothyroid group (P = 0.0001). Anxiety was well matched in both groups

while somatization was higher in the subclinical hypothyroid group (P = 0.0001). 46

A systematic review and meta- analysis to provide meta analytic data on the

association of depression and anxiety with autoimmune thyroiditis. Data sources used

were Google scholar, the EBSCO Host databases, the web of knowledge and the
 22

Pubmed. Data extraction was performed by multiple observers following the

PRISMA guidelines. Twenty studies comprising 22 independent samples were

included with a total of 44388 participants. Patients with AIT, Hashimoto thyroiditis

or sub clinical or overt hypothyroidism had significantly higher scores on

standardised depression instruments and anxiety instruments. This meta- analysis

establishes the association between AIT and depression and anxiety disorders.47

A cross sectional and observational study was conducted in North Bengal

about the correlation between anxiety, depression and cognitive function with

subclinical hypothyroidism. The study participants were collected from patients

attending department of biochemistry with the age group of 20-50 years and the

sample size was 120. The results suggest that the extent of anxiety was mild

(p<0.001), whereas depression was moderate (p<0.07) among the cases of subclinical

hypothyroidism. The executive function was normal in most of the cases. Correlation

between anxiety and SCH was found to be statistically significant (p=0.000), also

between depression and SCH (p=0.027).48

A cross sectional study conducted in Neuro Psychiatry Clinic of Uskudar

University in Istanbul, Turkey about the relationships between the serum levels of

TSH and mood disorders, including depression and anxiety. A total of one hundred

and fifty patients aged 18 to 79 years old were included in the study. The patients

mood were evaluated for the presence of depression and anxiety via Beck Depression

Inventory II and Beck Anxiety Inventory. The data showed a significantly higher

TSH level in the females when compared to their male counterparts in the severe

depression subgroup (p = 0.011).49

 23

A case control study was conducted regarding the prevalence of anxiety and

depression in levothyroxine treated hypothyroid women and in women without

hypothyroidism. The study was performed among 393 women by convenient

sampling technique. In the case group 153 levothyroxine treated hypothyroid women

and in the control group 240 women without hypothyroidism were included. The tool

used for the study was Hamilton hospital anxiety and depression scale and a

sociodemographic questionnaire. The findings were suggested that the prevalence of

anxiety in levothyroxine treated hypothyroid women was higher than in women

without hypothyroidism (29.4% versus 16.7%). The prevalence of depression in the

case group was higher than in the control group (13.1% versus4.6%). 50

A descriptive, cross-sectional study was conducted in the endocrinology

outpatient clinic of the tribhuwan university hospital, Kathmandu, Nepal about the

prevalence of anxiety and depression among patients with thyroid disorder. 129

thyroid disorder patients were participated in this study. A semi-structured

questionnaire, Beck Anxiety Inventory, and Beck Depression Inventory were used for

socio demographic characteristics, anxiety, and depression respectively. The results

shows that the patients' mean age was 38.09±12.68 years, most were females (102,

79.1%) and hypothyroid (90, 69.8%). Overall prevalence of anxiety and depression

were 50.4% and 42.6% respectively. Anxiety was more prevalent in females (54.9%

vs 33.3% in males, p=0.046), low economic status (73.9% vs 35.5% in higher status,

p=0.019), and hyperthyroid (64.1% vs 44.4% in hypothyroid, p=0.040). Depression

was more prevalent in females (47.1% vs 25.9% in males, p=0.048), Janajati ethnic

group (54.8% vs 31.1% in Brahmin-Chhetri, p=0.002), lower economic status (69.6%

vs 35.5% in higher status, p=0.016), and hyperthyroid (56.4% vs 36.7% in

 24

hypothyroid, p=0.037). Associations with occupation, marital status, family type,

religion, and duration of illness were not significant.51

A study was conducted in family medicine outpatient clinic regarding the

anxiety and depression levels of patients treated for hypothyroidism who assumed

euthyroid status. The study was conducted on 76 euthyroid volunteer participants

(patient groups) who were treated for hypothyroidism and followed-up and 22 healthy

volunteers (control group). This study was conducted as a prospective and

randomised controlled study. The Beck Depression Inventory (BDI) and Beck

Anxiety Inventory (BAI) were applied to all the groups. Results show that mild

depression was detected in 54.5% of the first group, 41.7% of the second group, and

33.3% of the third group. When the BDI and BAI total scores of the participants in

different groups were compared, statistically significant differences were determined.

Statistically significant results were detected related to different BAI sub-parameters

between the patient groups and in comparison to the fourth group. 52

A comparative study conducted in Shri Maharaja Hari Singh Hospital in

Kashmir, India regarding the presence of psychiatric disorders in people with

hyperthyroidism and euthyroid patients. Seventy-five patients with hyperthyroidism

and an equal number of euthyroid patients participated in the study. Participants were

selected using stratified random sampling. There was no significant difference

between the two groups in terms of demographic features. For the mental health

assessment, the Mini-International Neuropsychiatric Interview (MINI), Hamilton

Depression Rating Scale [HAM-D], and Hamilton Anxiety Rating Scale [HAM-A]

were used. All the studied subjects were females. The result shows that 60% of the

participants with hyperthyroidism showed signs of a psychiatric disorder, against

34.7% of participants in the control group.53

 25

A cross sectional epidemiological study was conducted in Burdan Medical

College to evaluate the impact of thyroid hypofunction on anxiety and depression in

females of reproductive age group. A total of 175 hypothyroid were included in the

study and 75 controls were also enrolled for the study. Patients were assessed for

depression and anxiety using Hospital Anxiety and Depression Scale. The computer

software SPSS version 16.0 was used for analyzing the data. Study suggested that

among hypothyroid patients 28 % had anxiety and 22.28 % had depression whereas 8

% anxiety and 5.33 % depression found out of controls. Significant difference was

found between controls and hypothyroid. Occurrence of anxiety and depression was

significantly more in hypothyroid subjects as compared to control group. 54

A comparative study was conducted in Ukraine, regarding the anxiety and

depression in women of reproductive age group with thyroid disease. The study was

conducted among 176 women of reproductive age with subclinical hypothyroidism

and euthyroidism with autoimmune thyroiditis compared with healthy women.

Anxiety and depression were assessed using the Hamilton Anxiety and Depression

Scale. The study says that out of the 176 women surveyed, 37.5% of them had anxiety

syndrome,13.6 % had depression,10.8 % had co morbid anxiety disorder and

depression and 38.1% of those surveyed had normal results. The study conclude that

anxiety depressive syndrome is 3.5 times more common in patients with thyroid

disease than in healthy women.55

A cross sectional study was conducted in south India, regarding the prevalence

of anxiety and depression among patients with thyroid disorder. The study was

conducted among 132 patients by purposive sampling technique. Data were collected

by using Hamilton depression rating scale and Hamilton anxiety rating scale. The

results shows that the overall prevalence was higher among patients with thyroid
 26

disorder compared to the general population, with half of the patients having atleast

one psychiatric illness. The most common illness were depressive disorder/dysthymia

and generalized anxiety disorder, present in 20 % and 13% of the patients. The

number of patients developing the major depressive disorder and generalized anxiety

disorder was similar between hypothyroid and hyperthyroid category. 56

A descriptive cross sectional study was conducted at chitwan medical college

on anxiety, depression and self care management among hypothyroid patients. A total

of 258 samples were collected by using convenient sampling techniques. The tools

used for the study was semi structured interview schedule for collecting socio

demographic data and the two instruments used for the assessment of depression and

anxiety is PHQ and GAD questionnaire respectively. The data was analysed in SPSS

version 20. The study concluded that out of 258 participants female constituted 64 %

of the sample. A total of 72.1% of the respondents had different level of anxiety and

60.1% had different levels of depression and 50 % of the respondents had different

level of self care management. Anxiety was significantly associated with sex(0.044),

marital status(0.00) and family history of mental illness(0.009) whereas depression

was significantly associated with educational status(0.009) and duration of illness

(0.002).72

Prevalence of depressive symptoms

A cross sectional study was carried out at one of the non-profit hospital at

central region of Peninsular Malaysia. 153 thyroid patients were selected by using

simple random sampling technique. Several tools were used in this study including

Depression Anxiety Stress Scale-42 (DASS-42), list of Life Threatening Experiences

(LTE), Multidimensional Scale of Perceived Social Support (MSPSS); and Thyroid

 27

Function Test including TSH and fT4 were reviewed from the patient’s file. Study

results shows that about 15% (n=23) out of 153 thyroid disorder patients had varies

degree of depression (males - 7.8% (n=3) and females – 17.3% (n=20)). Also, there

were positive correlation between depression and TSH (r=0.235, p=0.03), stressful

life events (r=0.264, p=0.001) and negative correlation (r=-0.068, p=0.402) with

perceived social support from family. 57

A cross-sectional study was conducted in endocrine clinics of KFHU in Al

Khobar about the prevalence of depression among hypothyroid patients. A total of 56

patients were included in the study by convenient sampling technique. Patients were

screened for depression using Patient Health Questionnaire-9 screening tool, in

addition to obtaining their socio demographic data, details of their thyroid function

status, and other risk factors for depression. The study results shows that 33.9% of

patients were depressed with varying degree of depression,10.7 % moderately

depressed, 19.6 %moderately severely depressed,3.6 % were severely depressed. 58

A systematic review and meta-analysis aimed to evaluate the risk of

depression in persons with SCH. The pubmed, Embase and Web of Science databases

were searched up to august 2018. The primary outcome was the prevalence of

depression as evaluated by various types of self reporting depression scales.21 studies

were included in the systematic review, with a total of 103,375 subjects from 7 studies

being pooled for the meta analysis to evaluate the risk of depression. The meta

analysis showed that persons with SCH had a significantly elevated risk of depression

than persons with euthyroidism. The meta analysis reported that SCH was positively

associated with the risk of depression, especially in persons with age above 50

years.59
 28

A meta-analysis and systematic review to evaluate the association between

SCH and depression including the prevalence of depression in SCH (with a sub-

analysis of the geriatric cohort) and the effect of levothyroxine therapy among

patients with SCH and coexistent depression. The result suggests that in a pooled

analysis of 12,315 individuals, those with SCH had higher risk of depression than

euthyroid controls (relative risk 2.35, 95% confidence intervals [CI], 1.84 to 3.02; p <

0.001). Geriatric cohort with SCH had a 1.7- fold higher risk of depression compared

with healthy controls (odds ratio 1.72, CI, 1.10 to 2.70; p = 0.020). There was no

difference in the mean TSH level between individuals with depression and healthy

controls (2.30 ± 1.18 vs. 2.13 ± 0.72 mIU/L, p = 0.513). In individuals with SCH and

coexistent depression, levothyroxine therapy was neither associated with

improvement in the Beck Depression Inventory scoring (pooled d + = − 1.05, CI -2.72

to 0.61; p = 0. 215) nor Hamilton Depression Rating Scale (pooled d + = − 2.38, CI -

4.86 to 0.10; p = 0.060).60

A cross-sectional study was conducted in Immamain alkadymain teaching

hospital at baghdad city, regarding the prevalence of depressive symptoms among

patients with hypothyroid disease. A total of 50 patients diagnosed as hypothyroidism

were evaluated using DSM-V criteria for depressive disorders. The results shows that

females constituted 84% of the sample and 58% reported depression based on Dsm –

V criteria. The most common symptoms were decrease energy, change appetite and

weight, feeling of sadness, loss of interest; change of activity and over sleep .61

A study conducted on Subclinical hypothyroidism and symptoms of

depression, evidence from the National Health and Nutrition Examination Surveys

(NHANES).Participants (N = 7683 adults) were from the National Health and

 29

Nutrition Surveys of 2007–2008, 2009–2010, and 2011–2012. The study included

participants who had data on their thyroid profile and depressive symptoms were

measured using Patient Health Questionnaire, and excluded those with overt

hypothyroidism or hyperthyroidism, and those on thyroid hormone replacement

therapy. Of all the participants, 208 (2.7%) had subclinical hypothyroidism and of

them only six had depression. Subclinical hypothyroidism was not associated with

depression (OR = 0.61, 95% CI 0.20–1.87) nor with the specific depression

symptoms.62

A descriptive, cross-sectional study was conducted in Aseer region, southern

Saudi Arabia, regarding the prevalence of depression among hypothyroid patients

attending endocrinology clinics in Armed Forces Hospital. A total of 395 participants

were included in the study. Data were collected using a direct interview questionnaire

which covered patients’ personal, clinical, and medication data and Depression

assessment was done based on the Patients Health Questionnaire (PHQ-9). Among the

participants 321 (81.3%) cases were females. Result shows that depression was

recorded among 341 hypothyroid cases (86.3%) whose 33.7% had a major depressive

disorder.63

A cross sectional study conducted in tertiary care hospital in Pakisthan about

the prevalence of depression among thyroid patients. A total of 341 patients were

enrolled for the study. The tools were used are data collection form for the assessment

of socio personal and clinical data and the depression level was assessed by 21 items

of Hamilton rating scale for depression. Data were analysed by SPSS 20. The result

concluded that the prevalence of depression in thyroid patients was high. All patients
 30

were depressed, most of them had very severe depression (46%), 36.4% had severe

depression, 17.6% had moderate depression.64

A descriptive cross-sectional study was conducted in National Guard Health

Affairs, Riyadh, Saudi Arabia regarding the prevalence and levels of depression

among patients with hypothyroidism, who were being treated with levothyroxine. The

Patient Health Questionnaire-9 was used. The study included 130 patients using

consecutive sampling, whom 89% were female. The prevalence of depression among

hypothyroid patients was 70%, 30% had no/mild depression, 27% had moderate

depression, and 43% had moderately severe/severe depression. There was a

significant association between the prevalence of depression and lower levels of

education up to high school (68%), patients older than 30 years of age (85%), and

married/widowed patients (83%). Patients with moderately severe/severe depression

had more difficulties in performing daily-life activities (91%), as well as higher levels

of thyroid-stimulating hormone (TSH) of 2.91 mIU/l (Interquartile range: 1.60-

7.05).34

A cross-sectional study was conducted in Al Mouwasat University Hospital,

Damascus, Syria, regarding the prevalence of depression among a sample of clinical

and subclinical hypothyroid patients, and correlation between thyroid-stimulating

hormone and depression severity. A total of 114 patients diagnosed with

hypothyroidism were evaluated by interview using the Diagnostic and Statistical

Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. The study concluded that

the prevalence of depression among patients with hypothyroidism (either clinical or

subclinical) was 31.57%. Higher depression rates were observed in clinical

hypothyroidism patients compared with subclinical hypothyroidism patients. In

 31

addition, depression severity was also higher in the clinical hypothyroidism group.

Increased rate and severity of depression with increased TSH levels. The rate and

severity of depression are inversely proportional to the duration of the diagnosis of

hypothyroidism.65

A descriptive cross sectional study was conducted at medical OPD of

BPKIHS, Dharam, Nepal regarding prevalence of depression and identify associated

characteristics among patients with thyroid function disorder. A total of 210 patients

were included in the study by using purposive sampling technique. Semi-structured

questionnaire and Beck Depression inventory scale were used to collect data

regarding socio demographic characteristics and prevalence of depression

respectively. The results shows that mean age was 38.60 years, 79.5 % were females,

48.6 % had clinical hypothyroidism and 51.4 % had subclinical hypothyroidism.

There is a significant association between depression and socio personal variables

including age, marital status, type of hypothyroidism and duration of illness. 66

A narrative review on hypothyroidism and depression, studies have

demonstrated that somatostatin and serotonin influence the hypothalamus-pituitary-

thyroid axis, which links hypothyroidism to depression. Multiple studies concluded

that undiagnosed, untreated, undertreated patients with hypothyroidism are at

increased risk of developing depression. Autoimmune thyroiditis is also associated

with an increased risk of depression. Elevated thyroid-stimulating hormone (TSH),

antithyroglobulin (TgAb), and thyroid peroxidase antibodies (TPOAb) levels have all

been linked to depression and an increased risk of suicide. Moreover, hypothyroidism

is known to be one of the leading causes of treatment-resistant depression. Treating

 32

underlying hypothyroidism with thyroid replacement therapy could significantly

improve mood disorders such as depression.67

A systematic review and meta-analysis (registered in PROSPERO:

CRD42020164791), until May 2020, Medline (via PubMed), PsycINFO, and Embase

databases were systematically searched for studies on the association of

hyperthyroidism and clinical depression, without language or date restrictions. Two

reviewers independently selected epidemiological studies providing laboratory or

ICD-based diagnoses of hyperthyroidism and diagnoses of depression according to

operationalized criteria (e.g. DSM) or to cut-offs in established rating scales. All data,

including study quality based on the Newcastle-Ottawa Scale, were independently

extracted by two authors. Odds ratios for the association of clinical depression and

hyperthyroidism were calculated in a DerSimonian-Laird random-effects meta-

analysis. Out of 3372 papers screened we selected 15 studies on 239 608 subjects,

with 61% women and a mean age of 50. Relative to euthyroid individuals, patients

with hyperthyroidism had a higher chance of being diagnosed with clinical

depression.68

Prevalence of anxiety

A study conducted in department of endocrinology and metabolism, Selcuk

University regarding the prevalence of anxiety in subclinical thyroid disorders. Eighty

five outpatients were enrolled in the study. In the presence of normal t3 and t4

patients were grouped as subclinical hyperthyroid and subclinical hypothyroid. Beck’s

Anxiety inventory was administered to all patients. Results shows that both of the

subclinical hyperthyroid and subclinical hypothyroid groups had significantly higher

anxiety scores than euthyroid group (F:11.4,p>0.001). The study concluded that
 33

subclinical thyroid dysfunction increases the anxiety of patients whether hyperthyroid

or hypothyroid.69

Summary

It is evident from the detailed review of research and non research literature

that the anxiety and depression is closely related to the patients with thyroid

dysfunction and the literature review has also made with investigator to grab the

significance of providing attention to mental health aspects of patients with thyroid

dysfunction.
 34

CHAPTER 3

METHODOLOGY

Research approach

Research design

Schematic representation of the study

Setting of the study

Population

Sample and sampling technique

Inclusion criteria

Exclusion criteria

Tools

Development and selection of the tools

Description of the tools

Content validity

Translation of tool

Pre testing of tool

Reliability of the tools

Pilot study

Data collection process

Plan for data analysis

 35

CHAPTER 3

METHODOLOGY

The research methodology involves the steps, procedures and strategies for

gathering and analysing data in research investigation. This chapter deals the research

approach, design, variables, setting of the study, population, sample, sampling

technique, research tool and technique, pilot study, data collection process and the

plan for data analysis.

Research approach

The research approach is an overall plan or blue print chosen to carry out the

study. A quantitative research approach has been adopted to assess the prevalence of

depressive symptoms and anxiety among patients with thyroid dysfunction.

Research design

The research design consists of the blue print for the collection, measurement

and analysis of the data. The primary objectives of the study to assess the prevalence

of depressive symptoms and anxiety among patients with thyroid dysfunction. In view

of nature of the problem selected for the study and the objectives to be accomplished,

a non-experimental descriptive survey design was adopted.

Variables

Depressive symptoms and anxiety among patients with thyroid dysfunction is

the research variable. Extraneous variables are socio personal variables and clinical

variables. Socio -personal variables include age, gender, place of residence, type of

family, marital status, education, occupation, socio economic status, source of

support, problem experiencing in daily living. Clinical variables include, diagnosis,

 36

age at diagnosis, duration of diagnosis, medication for thyroid dysfunction, regularity

of treatment, co morbidities and family history of thyroid dysfunction.

Schematic representation of the study

Schematic representation of the study is given in figure

 37

Variables and tools Outcome

Variables Socio personal variables

Population
Depressive symptoms and anxiety  Age
Patients with thyroid dysfunction among patients with thyroid  Sex
Setting dysfunction.  Place of residence
 Age
Tools  Type of family
Medicine, Surgery, Endocrinology
 Marital status
Outpatient department of Govt. Tool – 1 semi structured  Education
Medical College Hospital Kozhikode interview schedule  Occupation
Sampling technique To assess socio personal variables  Socio economic status
Identification of
and clinical variables.  Source of support
Purposive sampling depressive symptoms
and anxiety among  Problem experiencing in
Sample Tool – 2 Beck Depression daily living
Inventory patients with thyroid
Patients with thyroid dysfunction dysfunction. Clinical variables
attending medicine, surgery, To assess the depressive symptoms
endocrinology outpatient department among patients with thyroid  Diagnosis
of Govt. Medical College Hospital dysfunction.  Age at diagnosis
Kozhikode and between the age  Duration of diagnosis
Tool – 3 Generalized Anxiety
group of 25-55 years. Disorder questionnaire  Co morbidities
 Medication for thyroid
Sample size To assess the anxiety among dysfunction
110 patients with thyroid dysfunction. patients with thyroid dysfunction.  Regularity of treatment
 Family history of thyroid
dysfunction

Figure 2: Schematic representation of the study to assess the prevalence of depressive symptoms and anxiety

37
among patients with thyroid dysfunction.
 38

Setting of the study

The study was conducted at outpatient department of medicine, surgery and

endocrinology of Government Medical College Hospital, Kozhikode. Government

Medical College Hospital, Kozhikode is also known as Calicut Medical College and

is a school of medicine in Kozhikode in the Indian state of Kerala. It is a tertiary

reference Center which was established in 1957 as the second medical college in

Kerala. The foundation stone of the college was laid down on May 29 1957 by the

governor of Kerala, Dr Ramakrishna Rao. The main hospital was commissioned in

1966 with 1183 beds it was later supplemented by Institute of Maternal and Child

Health,the Savithri Devi Saboo Memorial Cancer Institute and chest hospital. It is

located in north east of the Kozhikode city that serves 40% of the population of

Kerala. Bed strength of this hospital is 3025, it is currently the largest hospital in India

and tenth largest in the world. Calicut Medical College is located with an area

covering more than 270 acres of land in the outskirts of Calicut city. The OPD’s

within the New Medical College Hospital (NMCH) block, it is a 3-floor building and

has an average census of 2387 patients coming from different areas of Malabar

region, for consultation and treatment. There are 8 medical wards and 6 surgical

wards in Government Medical College Hospital, Kozhikode.

Population

The population is the set of people or entities to which the results of the study

are to be generalized. The population of the study were patients with thyroid

dysfunction.
 39

Sample and Sampling technique

Sample is the subset of population that is selected for a particular study. In the

present study the sample consists of 110 patients with thyroid dysfunction attending

medicine, surgery, and endocrinology outpatient departments of Government Medical

College Hospital, Kozhikode who fulfilled the inclusion criteria. The researcher used

purposive sampling technique for obtaining participants for the present study.

Sample size calculation

p=4pq/d2

p=50.4

q=49.6

d=9.9

p=4x50.4x49.6/9.9x9.9

p=102

Sample size selected for the study is 110

The sample size was calculated based on a descriptive study conducted on 129

thyroid disorder patients. The overall prevalence of anxiety and depression were 50.4

% and 42.6 % respectively. 51

Inclusion criteria

Patients with thyroid dysfunction who are:

 known case of hypo and hyperthyroidism.

 between the age group of 25- 55 years.

 40

 willing to participate in the study.

 able to read Malayalam or English.

Exclusion criteria

Patients with:

 Mental illness.

 Critical illness.

 Physical and functional disabilities.

Tools and technique

In the present study the investigator used the following tools

Tool 1: Semi structured interview schedule to collect socio personal and clinical

variables

Section 1a - Socio personal variables of patients with thyroid dysfunction

Section 1b – Clinical variables of patients with thyroid dysfunction

Tool 2: Beck Depression Inventory

To assess the depressive symptoms among patients with thyroid dysfunction.

Tool 3: Generalized Anxiety Disorder questionnaire

To assess the anxiety among patients with thyroid dysfunction

Technique -self report, interview, record review.

 41

Development of tool

Based on objectives of the study the tools were prepared and selected by

reviewing the related literature and with the guidance of the experts. The following

steps were taken.

 Reviewed research and non-research literature related to children with special

needs.

 Formal discussion with experts in nursing,

 Formal discussion psychologists and experts in Medicine, Surgery and

Endocrinology

 Observation and personal experience of research

 Clinical experience of the investigator

 Informal discussion and interview among patients with thyroid dysfunction

 Final tool was prepared under the valuable suggestions and guidance of guide

Description of the tool

Tool 1: semi structured interview schedule for socio personal and clinical

variables

It includes two sections 1a, 1b respectively.

Section 1a- Socio personal variables of patients with thyroid dysfunction.

It includes 10 questions age, sex, place of residence, type of family, marital

status, education, occupation, socio economic status, source of support, problems

experiencing in daily living.

 42

Section 1b-clinical variables of patients with thyroid dysfunction

It includes 8 questions Diagnosis, age at diagnosis, duration of diagnosis,

medication for thyroid dysfunction, regularity of treatment, duration of treatment, co

morbidities, family history of thyroid dysfunction.

Tool 2: Beck Depression Inventory

The Beck Depression Inventory was developed in 1961 by Beck et al.A

second version of the inventory was developed in 1996 to reflect revisions in the

fourth edition text revision of the diagnostics and statistical manual of mental

disorders. The BDI is a self -rating scale for depression. The BDI has been widely

used as an assessment instrument in gauging the intensity of depression in patients. It

consist of 21 items such as mood, pessimism, sense of failure, dissatisfaction, guilt,

sense of persistent, self- hate, self- accusation, self- punitive wishes, crying spells,

irritability, social withdrawal, indecisiveness, body image, work inhibition, sleep

disturbances, fatiguability, loss of appetite, weight loss, somatic pre- occupation, loss

of libido. Each of the items is rated on a scale of 0-3, thus the total score range is 0-

63. The authors have provided this estimate of the severity of depression based on the

total score. Normal 1-10,mild mood disturbances 11-16, borderline depression 17-

20,moderate depression 21-30, severe depression 31-40,extreme depression >40. The

tool shows a high internal consistency. The reliability of the tool is measured by

cronbachs alpha ranges from 0.76 to 0.95. The BDI administration is straightforward

and it can be given as an interview by the clinician or as a self - report instrument.

 43

Scoring and interpretation

Score range

Items Normal Mild mood Borderline Moderate Severe Extreme

disturbances depression depression depression depression

21 items 1-10 11-16 17-20 21-30 31-40 >40

Tool 3: Generalized Anxiety Disorder questionnaire

The Generalized Anxiety Disorder scale 7 is a 7 item, self rated scale

developed by spritzer and colleagues (2006) as a screening tool and severity indicator

for generalized anxiety disorder. The GAD -7 is normally used in outpatient and

primary care settings for referral to a psychiatric pending outcome. GAD-7 has seven

items, which measure severity of various signs of GAD according to reported

response categories with assigned points. The GAD-7 items include: 1) nervousness;

2) inability to stop worrying; 3) excessive worry; 4) restlessness; 5) difficulty in

relaxing; 6) easy irritation; and 7) fear of something awful happening. Assessment is

indicated by the total score, which is made up by adding together the scores for the

scale of all seven items. The GAD-7 had a sensitivity value of 0.89 and a specificity

value of 0.82. Each of the items is estimated by, Not at all (0 points), Several days (1

point), More than half the days (2 points), Nearly every day (3). The authors have

provided this estimate of the severity of depression based on the total score points.

Normal 0-4, mild anxiety 5-9, moderate anxiety 10-14, >15 severe anxiety.
 44

Scoring and interpretation

Score range

Item Normal Mild anxiety Moderate anxiety Severe anxiety

7 items 0-4 5-9 10-14 >15

Content validity of the tool

Validity of the tool refers to whether the measuring instrument accurately

measures what it is supposed to measure. After receiving preliminary corrections from

guide, the tools were given to 11 expert faculties from different fields to ensure the

content validity. The experts included six from the field of Psychiatric Nursing, two

psychiatrists, one psychiatric social worker, and one clinical psychologist, one from

department of medicine. The experts were requested to give their opinions and

suggestions regarding the relevance, adequacy and appropriateness of the tools. The

tools were finalized based on the suggestions and modifications given by the experts

and research guide.

Translation of tool

The tools were translated to Malayalam and then retranslated to English with

the help of language and subject experts to validate the language.

Pre testing of the tool

The tools were pretested by administering it to 5 patients with thyroid

dysfunction similar to study population and it was found that the questions and

language used are clear, understandable and unambiguous.

 45

Reliability of the tool

Reliability of an instrument is the degree of consistency with which it

measures the attributes it is supposed to measure. The reliability of Beck Depression

Inventory was assessed using Cronbach’s alpha. It was 0.82 and for Generalized

Anxiety Disorder Questionnaire it was 0.740, the tool was considered reliable.

Pilot study

The pilot study began after obtaining approval from Scientific Review

Committee, Institutional Ethics Committee and Kerala University of Health Science,

Thrissur. As per the suggestion from Institutional Ethics Committee, included

Dr Shameer V K ,Assistant Professor, Department of Medicine, Govt Medical

College ,Kozhikode as co guide of the present study . Data collection for the study

was conducted from 3.4.2023 to 15.4.2022 and conducted among 15 participants from

Government Medical College Hospital Kozhikode. Data collection started after

explain the purpose and nature of study to the participants, and informed consent will

be obtained from the participants. The socio personal and clinical data were collected

by semi structured interview schedule, depressive symptoms assessed using Beck

Depression Inventory and anxiety assessed by using Generalized Anxiety Disorder

Questionnaire. During pilot study investigator does not feel any difficulty. The study

was found to be feasible.

Data collection process

After obtaining approval from Scientific Review Committee, Institutional

Ethics Committee of Government college of nursing, Kozhikode, Kerala University of

Health Science, Thrissur and concerned authority from Government Medical College

Hospital Kozhikode. As per the suggestion from Institutional Ethics Committee,

 46

included Dr Shameer V K, Assistant Professor, Department of Medicine, Govt

Medical College, Kozhikode as co guide of the present study. The data collection for

the study was conducted from 22.04.2023 to 27.05.2023. The investigator daily

visited the selected Center and personally met the participants and obtained

willingness of the participants in the study. After explaining the purpose of the study

and ensuring confidentiality, a written informed consent was obtained from the

subjects who fulfilled the inclusion criteria and the questionnaire was given to the

samples. The socio personal and clinical data were collected from the patients using

semi structured interview schedule each participants taken the average 10-15 minutes

to complete the questions. Beck Depression Inventory and Generalized Anxiety

Disorder Questionnaire it taken an average time of 10-15 minutes. Daily 6-8

participants interviewed and each participant taken average 20-30 minutes to

complete the questions. After 20-30 minutes of interview data sheet is collected and

gathered. The participants were co-operative, it helps to complete the data collection

on time.

Plan for data analysis

Data collected would be analysed based on the objectives of the study using

descriptive and inferential statistics. The following methods of analysis is planned to

perform with the help of expert.

 Socio personal and clinical variables would be analysed using frequency and

percentage.

 Prevalence of depressive symptoms and anxiety would be analysed using

frequency, percentage.
 47

 Association between depressive symptoms with selected variables would be

analysed using chi square test.

 Association between anxiety with selected variables would be analysed using

chi square test.

Summary

This chapter deals with research approach, research design, schematic

representation of the study, description of the setting, population, sample, sampling

technique, development and description of the tool used for data collection, content

validity and reliability of the tool, details of the pilot study, data collection and plan

for data analysis.

 48

CHAPTER 4

ANALYSIS AND INTERPRETATION

Section I Sample characteristics based on socio personal variables and

clinical variables

Section I a Socio personal variables of patients with thyroid dysfunction

Section I b Clinical variables of patients with thyroid dysfunction

Section II Depressive symptoms among patients with thyroid dysfunction

Section III Anxiety among patients with thyroid dysfunction

Section IV Association between the depressive symptoms among

patients with thyroid dysfunction and selected variables

Section V Association between the anxiety among patients with

thyroid dysfunction and selected variables

 49

CHAPTER 4

ANALYSIS AND INTERPRETATION

This chapter deals with analysis and interpretation of the results of the study.

The study was intended to assess the prevalence of depressive symptoms and anxiety

among patients with thyroid dysfunction. The study data were collected from 110

samples at Government Medical College Hospital Kozhikode. The data collected

were organized, tabulated and subjected to descriptive and inferential statistical

analysis with the help of 18th version of SPSS package software. Analysis data were

organised under the following headings.

Section I Sample characteristics based on socio personal variables and

clinical variables

Section I a Socio personal variables of patients with thyroid dysfunction

Section I b Clinical variables of patients with thyroid dysfunction

Section II Depressive symptoms among patients with thyroid dysfunction

Section III Anxiety among patients with thyroid dysfunction

Section IV Association between the depressive symptoms among patients

with thyroid dysfunction and selected variables

Section V Association between the anxiety among patients with thyroid

dysfunction and selected variables.

 50

Section I: Sample characteristics based on socio personal variables and clinical

variables

This section deals with socio personal variables and clinical variables of

patients with thyroid dysfunction includes age, sex, place of residence, type of family,

marital status, educational status, occupation, socio economic status, source of

support, problems in daily living, diagnosis, age at diagnosis, duration of diagnosis,

medication for thyroid dysfunction, regularity of treatment, co morbidity, family

history of thyroid dysfunction. Findings are presented in the tables 1-6 and figures 3-

7.

Section I a –Socio personal variables of patients with thyroid dysfunction

Table 1

Distribution of participants based on age in years

(n=110)

Age in years f %

26-35 35 31.9

36-45 45 40.9

46-55 30 27.2

Table 1 shows that 40.9 % participants were belonged to the age group of 36-

45 years and 31.9 % of participants belonged to the age group of 26-35 years.
 51

4%

Male
Female

96%

Figure 3. Distribution of participants based on sex

Figure 3 depicted that 96 % of participants were females and 4 % were males

males.
 52

90 84.5%
80

70

60
percentage

50
Panchayath
40 Municipality
30 Corporation

20
8.2%
10 7.3%

0
Panchayath Municipality Corporation

Place of residence

Figure 4. Distribution of participants based on place of residence

Figure 4 depicts that 84.5% of participants were residing in panchayath area,

8.2 % were residing in municipality and 7.3 % were residing in corporation.

 53

Table 2

Distribution of participants based on type of family and marital status

(n=110)

Variables Category f %

Type of family

Nuclear family 105 95.5

Joint family 5 4.5

Extended family 0 0.0

Marital status

Married 93 84.5

Unmarried 11 10.0

Widow/widower/divorced/separated 6 5.5

Table 2 shows that 95.5% of participants belonged to nuclear family and

84.5% of participants were married.

 54

Table 3

Distribution of participants based on education and occupation

(n=110)

Variables Category f %

Education

Primary education/Secondary education 68 61.8

Higher secondary/Degree 39 35.5

Post graduate/Professional/technical 3 2.7

Occupation

Government employee 6 5.5

Private employee/manual labour/self 44 40.0

employed

Unemployed/Home maker 60 54.5

Table 3 reveals that 61.8 % of participants were attained primary /secondary

education and 54.5 % of participants were home maker or unemployed.

 55

13%

APL
BPL

87%

Figure 5. Distribution of participants based on socio economic status

Figure 5 depicted
ed that 87 % of participants were belonged to Below Po
Poverty

Line category and 13 % were belonged to Above Poverty Line category

 56

Table 4

Distribution of participants based on source of support and problems

experiencing in daily life

(n=110)

Variables Category f %
Source of support Partner/Children/Siblings/Parents 104 94.5

Friends/ Any others 60 5.5

No support system 0.0 0.0

Problem

experiencing in No 78 70.9

daily life Yes 32 29.1

Table 4 shows that 94.5 % of participants received support from partner,

children, siblings and parents and 70.9 % of participants were not experiencing any

problems in daily living.

 57

Section I b: Distribution of participant

participants based on clinical variables

16%

Hypothyroidism
Hyperthyroidism

84%

Figure 6. Distribution of participants based on diagnosis.

Figure 6 depicts that 84.0 % of participants were diagnosed as hypothyroidism

and 16.0% of participants were diagnosed as hyperthyroidism.

 58

Table 5

Distribution of participants based on age at diagnosis, duration of diagnosis,

medications for thyroid dysfunction and regularity of treatment.

(n=110)
Variables Category f %
Age at diagnosis
26-35 58 52.7
36-45 46 41.8
46-55 6 5.5
Duration of diagnosis
Below 6 month 18 16.4
6month to 1 year 16 14.5
Above 1 year 76 69.1
Medication for thyroid
dysfunction No 51 46.4
Yes 59 53.6
Regularity of
treatment Regular 38 34.5
Irregular 72 65.5

Table 5 shows that 52.7% of participants were diagnosed between age group

of 26-35, 69.1% of participants had the duration of diagnosis of above 1 year, 59.0 %

of participants were had medication for thyroid dysfunction, 72.0% of participants

were taken irregular treatment.

 59

100 93.6%
90
80
70
60
Percentage

50 No
40 Yes
30
20
6.4%
10
0
Yes NO
Co morbidities

Figure 7.Distribution of participants based on co morbidities

Figure 7 shows that 93.6 % of participants had no any co morbidities and 6.4%

of participants had co morbidities.

 60

30%
family history of
thyroid dysfunction
no family history of
thyroid dysfunction
70%

Figure 8.. Distribution of participants based on history of thyroid dysfunction in

the family

Figure 8 depicts that 70 % of participants had the family history of thyroid

dysfunction.
 61

Section II

Depressive symptoms among patients with thyroid dysfunction

This section deals with the subject characteristics based on the depressive

symptoms among patients with thyroid dysfunction. Depressive symptoms are

measured using Beck Depression Inventory. This scale consists of total of 21 items

such as mood, pessimism, sense of failure, dissatisfaction, guilt, sense of persistent,

self- hate, self- accusation, self- punitive wishes, crying spells, irritability, social

withdrawal, indecisiveness, body image, work inhibition, sleep disturbances,

fatiguability, loss of appetite, weight loss, somatic pre- occupation, loss of libido.

Each of the items is rated on a scale of 0-3, thus the total score range is 0-63. Severity

of depression was assessed based on the total score. Data is presented in table 6 is

depressive symptoms measured using beck depression inventory.

 62

Table 6

Distribution of participants based on the level of depressive symptoms reported

by patients with thyroid dysfunction

(n=110)

Depressive symptoms Score range f %

Normal 1-10 7 6.4

Mild mood disturbance 11-16 44 40.0

Borderline clinical depression 17-20 22 20.0

Moderate depression 21-30 33 30.0

Severe depression 31-40 4 3.6

Extreme depression Over 40 0 0.0

Table 6 shows 40% of participants had mild mood disturbance, 30 % had

moderate depression, 20% had borderline clinical depression and 3.6% had severe

depression when measured by Beck Depression Inventory.

 63

Table 7

Mean, standard deviation, maximum and minimum score obtained in Beck

Depression Inventory

The mean, standard deviation, maximum and minimum score obtained in Beck

Depression Inventory is shown in table 7.

(n=110)

Total score Minimum Maximum Mean score SD

score score

Beck

Depression 7 39 18.68 6.36

Inventory score

(in 63)

Data presented in table 8 shows that, the mean score of total Beck Depression

Inventory was 18.68 with a standard deviation of 6.36.

 64

Section III

Anxiety among patients with thyroid dysfunction

This section deals with participants characteristics based on the anxiety among

patients with thyroid dysfunction. Anxiety is measured using Generalised Anxiety

Disorder Questionnaire. This questionnaire consist of total 7 items such as

nervousness, inability to stop worrying, excessive worry, restlessness, difficulty in

relaxing, easy irritation and fear of something awful happening. Assessment is

indicated by the total score, which is made up by adding together the scores for the

scale of all seven items. The severity of depression was based on the total score

points.

Data is presented in table 8 for anxiety measured using Generalized Anxiety

Disorder questionnaire.
 65

Table 8

Distribution of participants based on level of anxiety reported by patients with

thyroid dysfunction

(n=110)

Anxiety Score range f %

Minimal anxiety 0-4 19 17.3

Mild anxiety 5-9 74 67.3

Moderate anxiety 10-14 16 14.5

Severe anxiety >15 1 0.9

Table 8 shows that 67.3% of participants had mild anxiety, 17.3% had

minimal anxiety, 14.5% had moderate anxiety and 0.9% had severe anxiety when

measured using GAD questionnaire.

 66

Table 9

Mean, standard deviation, maximum and minimum score obtained in

Generalized Anxiety Disorder Questionnaire

The mean, standard deviation, maximum and minimum score obtained in Generalized

Anxiety Disorder Questionnaire is shown in table 9.

(n=110)

Total score Minimum Maximum Mean score SD

score score

Generalized

Anxiety
3 15 6.94 2.26
Disorder

Questionnaire

(in 21)

Data presented in table 9 shows that, the mean score of total Generalized

Anxiety Disorder was 6.94 with a standard deviation of 2.26.

 67

Section IV

Association between depressive symptom among patients with thyroid

dysfunction and selected variables.

This section deals with analysing the association between the depressive symptoms

among patients with thyroid dysfunction and selected variables which includes age,

sex, place of residence, type of family, marital status, education, occupation, socio

economic status, source of support, problems experiencing in daily living, diagnosis,

age at diagnosis, duration of diagnosis, medication for thyroid dysfunction, regularity

of treatment, duration of treatment, co morbidities, family history of thyroid

dysfunction . In order to find out the association between depressive symptoms

among patients with thyroid dysfunction and selected variables the following null

hypothesis was stated and tested at 0.05 level.

H0: there is no significant association between depressive symptoms among patients

with thyroid dysfunction and selected variables.

In order to test the hypothesis data were subjected to chi square test at 0.05 level of

significance and the findings are presented in table 10

 68

Table 10

Association between depressive symptoms among patients with thyroid

dysfunction and selected variables.

(n=110)
χ2
Socio personal and clinical variable df p – value

Age 9.095 9 0.429

Sex 8.90 4 0.064

Place of residence 4.39 8 0.820

Type of family 4.88 4 0.299

Marital status 7.87 8 0.446

Educational status 14.84 8 0.062

occupation 3.41 8 0.906

Socio economic status 3.87 4 0.423

Source of support 4.37 4 0.350

Problems in daily living 8.56 4 0.073

Diagnosis 5.43 4 0.245

Age at diagnosis 7.53 8 0.480

Duration of diagnosis 4.45 8 0.814

Medications for thyroid dysfunction 7.13 4 0.129

Co morbidities 3.71 4 0.446

Regularity of treatment 7.02 4 0.135

Family history of thyroid dysfunction 2.27 4 0.685

From the table 10 its evident that there is no significant association between

depressive symptoms and socio personal variables of patients with thyroid

dysfunction. The null hypothesis stated was accepted for this socio personal variable.
 69

Section V

Association between anxiety among patients with thyroid dysfunction and

selected variables.

This section deals with analysing the association between the anxiety among patients

with thyroid dysfunction and selected variables which includes age, sex, place of

residence, type of family, marital status, education, occupation, socio economic status,

source of support, problems experiencing in daily living, diagnosis, age at diagnosis,

duration of diagnosis, medication for thyroid dysfunction, regularity of treatment,

duration of treatment, co morbidities, family history of thyroid dysfunction . In order

to find out the association between the anxiety among patients with thyroid

dysfunction and selected variables following null hypothesis was stated and tested at

0.05 level.

H0: There is no significant association between anxiety among patients with thyroid

dysfunction and selected variables.

In order to test the hypothesis data were subjected to chi square test at 0.05 level of

significance and the findings are presented in table 11-13.

 70

Table 11

Association between anxiety among patients with thyroid dysfunction and

selected variables.

(n=110)

χ2
Socio personal and clinical variable df p – value

Age 8.07 9 0.527

Sex 1.18 3 0.756

Place of residence 6.62 6 0.357

Type of family 2.54 3 0.467

Marital status 12.71 6 0.048*

Educational status 10.77 6 0.090

Occupation 6.70 6 0.340

Socio economic status 1.07 3 0.783

Source of support 1.92 3 0.580

Problems in daily living 3.30 3 0.347

Diagnosis 5.38 3 0.162

Age at diagnosis 2.06 6 0.914

Duration of diagnosis 3.58 6 0.732

Medications for thyroid dysfunction 7.23 3 0.065

Co morbidities 2.39 3 0.496

Regularity of treatment 11.90 3 0.008**

Family history of thyroid dysfunction 2.02 3 0.568

*significant at 0.05 level **significant at 0.01

 71

Table 11 shows that there is significant association between marital status and

regularity of treatment of patients with thyroid dysfunction and anxiety, as the

obtained p value ≤0.05 for marital status[ χ2(df)=12.71.,p<0.05] and regularity of

treatment[χ2(df)=11.90.,p<0.01] of patients with thyroid dysfunction. The null

hypothesis stated was not accepted for the marital status and regularity of treatment.

Null hypothesis was accepted for other variables and there is no significant

association between other variables such as place of residence, age, sex, type of

family, educational status, occupation, socio economic status, problems in daily

living, diagnosis, source of support, age at diagnosis, duration of diagnosis,

medications for thyroid dysfunction, co morbidities and family history of thyroid

dysfunction.
 72

Table 12

Association between marital status and anxiety among patients with thyroid

dysfunction

(n=110)

Marital status n Anxiety χ2 p–

value

Minimal Mild Moderate Severe

Married 93 12 65 15 1

Unmarried 11 6 5 0 0 12.71 0.048*

Widow/widower/ 6 1 4 1 0

Divorced/Separated

*significant at 0.05 level

Table 12 shows that there is significant association between marital status

[χ2(df)=12.71.,p<0.05]and anxiety among patients with thyroid dysfunction, as the

obtained p value ≤0.05 for marital status. The null hypothesis stated was not accepted

for the marital status, severe levels of anxiety present among the participants were

married.
 73

Table 13

Association between regularity of treatment and anxiety among patients with

thyroid dysfunction

(n=110)

Regularity n Anxiety χ2 p – value

of treatment

Minimal Mild Moderate Severe

Regular 38 3 24 11 0

Irregular 72 16 50 5 1 11.90 0.008**

**significant at 0.01 level

Table 13 shows that there is significant association between regularity of

treatment [χ2(df)=11.90.,p<0.01] and anxiety among patients with thyroid dysfunction,

as the obtained p value ≤0.05 for regularity of treatment. The null hypothesis stated

was not accepted for the regularity of treatment, severe levels of anxiety present

among the participants were taken irregular treatment.

Summary

This chapter dealt with analysis and interpretation of data collected from

patients with thyroid dysfunction. This chapter helps the investigator to interpret the

study findings that equipped the investigator for further discussion.

 74

CHAPTER 5

RESULTS

Objectives

Hypotheses

Results
 75

CHAPTER 5

RESULTS

This chapter deals with the brief description of the study including the

objectives, hypothesis and major findings of the study. The present study was

conducted to assess the prevalence of depressive symptoms and anxiety among

patients with thyroid dysfunction. This finding of the study was discussed in terms of

objectives and hypothesis.

Objectives

 Assess the prevalence of depressive symptoms among patients with thyroid

dysfunction.

 Assess the prevalence of anxiety among patients with thyroid dysfunction.

 Find out the association between depressive symptoms among patients with

thyroid dysfunction and selected variables.

 Find out the association between anxiety among patients with thyroid

dysfunction and selected variables.

Hypotheses

 H1: There is a significant association between depressive symptoms and

selected variables among patients with thyroid dysfunction.

 H2: There is a significant association between anxiety and selected variables

among patients with thyroid dysfunction.

 76

Results

Section I- sample characteristics based on socio personal and clinical variables

 Among the patients 40.9% participants were belonged to the age group of 36-

45 years and 31.9 % of participants belonged to the age group of 26-35 years,

96 % of participants were females and 4 % were males.

 Regarding the place of residence 84.5% of participants were residing in

panchayath. Among the participants 95.5% were belonged to nuclear family,

84.5% of participants were married.

 Regarding the educational status 61.8 % of participants were attained primary

/secondary education and 54.5% of participants were home maker or

unemployed.

 Among the participants 87% were belonged to Below Poverty Line and 13 %

were belonged to Above Poverty Line.

 Regarding the source of support 94.5% of participants received support from

partner, children, siblings and parents and 70.9 % of participants were not

experiencing any problems in daily living.

 Among the patients 83.6 % of participants were diagnosed as hypothyroidism

and 16.4 % of participants were diagnosed as hyperthyroidism.

 Regarding the age at diagnosis 52.7% of participants were diagnosed at the

age group of 26-35 and 69.1% of participants had the duration of diagnosis of

above 1 year.

 Among the participants 59 % had medication for thyroid dysfunction and 72%

of participants were taken irregular treatment.

 Among the participants 93.6 % had no any co morbidities.

 77

 Regarding the family history of thyroid dysfunction 70 % of participants had

the history of thyroid dysfunction in the family.

Section II - Depressive symptoms among patients with thyroid dysfunction

 Among the participants 40% of had mild mood disturbance, 30 % had

moderate depression, 20 % had borderline clinical depression and 3.6 % had

severe depression when measured by Beck Depression Inventory.

 Among the participants the mean score of total Beck Depression Inventory

was 18.68 with a standard deviation of 6.36.

Section III – Anxiety among patients with thyroid dysfunction.

 Among the participants 67.3 % had mild anxiety, 17.3 % had minimal

anxiety, 14.5 % had moderate anxiety and 0.9 % had severe anxiety when

measured using GAD questionnaire.

 Among the participants the mean score of total Generalized Anxiety

Disorder was 6.94 with a standard deviation of 2.26.

Section IV - Association between depressive symptoms and selected variables

using beck depression inventory

 There is no significant association between depressive symptoms among

patients with thyroid dysfunction and variables such as age, place of

residence, sex, type of family, marital status, occupation, educational status,

socio economic status, problems in daily living, source of support,

diagnosis, age at diagnosis, duration of diagnosis, medications for thyroid

 78

dysfunction, regularity of treatment, co morbidities and family history of

thyroid dysfunction.

Section V - Association between anxiety and selected variables when measured

using GAD questionnaire.

 There is significant association between marital status and regularity of

treatment of patients with thyroid dysfunction and anxiety.

 The computed ‘p’ value for association between anxiety among patients with

thyroid dysfunction and selected variables such as marital status and regularity

of treatment was lesser than 0.05.

 There is no significant association between other variables such as age, place

of residence, sex, type of family, educational status, occupation, socio

economic status, problems in daily living, source of support, diagnosis,age at

diagnosis, duration of diagnosis, medications for thyroid dysfunction, co

morbidities and family history of thyroid dysfunction.

 79

CHAPTER 6

DISCUSSION, SUMMARY AND CONCLUSION

Discussion

Summary

Conclusion

Nursing implication

Recommendation
 80

CHAPTER 6

DISCUSSION, SUMMARY AND CONCLUSION

This chapter deals with the major findings of the present study, including

summary of the study, conclusion drawn from the findings, discussion and limitations

of the study, nursing implications and recommendations for future research. The

present study was undertaken to assess the prevalence of depressive symptoms and

anxiety among patients with thyroid dysfunction attending outpatient department of

Government Medical College Hospital Kozhikode. A quantitative descriptive research

design was used and data were collected from 110 participants through purposive

sampling technique. The present study was conceptualized using Betty Neuman’s

system model.

Discussion

The finding of the study was discussed with observation made in other study

findings which the investigator reviewed.

Socio personal variables of patients with thyroid dysfunction

The present study revealed that 40.9 % subjects were belonged to the age

group of 36-45 years. This finding is in concordance with a study a study to assess the

prevalence of anxiety and depression among patients with thyroid disorder. The

results shows that the mean age of population was 40 years, with a majority (38%) of

the patients from the age group of 35-49 years.58

The present study revealed that among the total participants 96 % of subjects

were females and only 4 % were males. These findings are supported by a cross

sectional study on patients with thyroid dysfunction to determine the prevalence of

 81

depressive symptoms. The results showed that a that among the total participants 84

% of the sample were females and only 16 % were males.61 These findings are also

supported by a cross sectional study to estimate the prevalence of depression among

patients with thyroid dysfunction. The study findings reported that 81.3 % were

females.63The female preponderance for the prevalence of thyroid disorders is

globally recognized.

The present study showed that among the total patients 83.6 % of subjects

were diagnosed as hypothyroidism and 16.4 % of subjects were diagnosed as

hyperthyroidism. These findings are consistent with the findings of a cross sectional

study conducted on 129 thyroid disorder patients. The result suggested that among the

total patients 69.8 % had hypothyroidism.51These findings are also consistent with a

cross sectional study was conducted regarding the nature and extent of psychiatric co

morbidity in patients suffering from thyroid dysfunction. Among the total patients

68% were diagnosed as hypothyroidism and 32 % had hyperthyroidism. 45

The present study revealed that among the total patients 84.5 % were married.

These findings are supported by a descriptive study to explore the prevalence of

depression and identify associated characteristics among patients with thyroid

disorder. The study findings reported that among the total sample 94.8% were

married.66

The present study shows that 61.8 % of participants were attained primary

/secondary education and 54.5 % of participants were home maker or unemployed

and 84.5% of participants were residing in panchayat. The findings were

contradictory with the results of a study conducted on prevalence of depression

among a sample of clinical and subclinical hypothyroid patients, and correlation

 82

between thyroid-stimulating hormone and depression severity. The results shows that

69.3% were living in cities and 30.7% were living in rural areas, 43% of participants

were did not attend university and 57% were completed their university study, 45.6%

of participants were unemployed 28.9%were employees, 8.8% were students and

16.7% were other careers.65

Depressive symptoms among patients with thyroid dysfunction

The present study revealed that among the patients with thyroid

dysfunction40% had mild mood disturbance, 30 % had moderate depression, 20 %

had borderline clinical depression and 3.6% had severe depression when measured by

Beck Depression Inventory. These findings are consistent with the findings of a

descriptive study which revealed that 33.9% of patients were depressed with varying

degree of depression, 10.7% moderately depressed, 19.6% moderately severely

depressed, 3.6% were severely depressed.58 The findings are also supported by a

study conducted to investigate the prevalence of depressive symptoms and anxiety

among patients with thyroid dysfunction, 100 were completed the HDRS. A total of

60 % reported some degree of depression.17The findings are also supported by a cross

sectional study to assess the prevalence of depression among thyroid patients. Among

the total patients 46% had very severe depression, 36.4% had severe depression, and

17.6% had moderate depression. 64

The present study reveals that symptoms of thyroid dysfunction resemble the

clinical presentation of mental health disorder includes depression and anxiety. The

findings were supported by a study conducted on thyroid disease and mental

disorders. The study concluded that Characteristic symptoms of hyperthyroidism may

resemble the clinical presentation of a mental health disorder. The relationship

 83

between the clinical presentation and anxiety as well as its precipitating role in the

development of an anxiety disorder. Despite their potential casual relationship it is

important to assess and address both the thyroid dysfunction and mental health

symptoms.70

Anxiety among patients with thyroid dysfunction

The current study showed that 67.3% had mild anxiety, 17.3 % had minimal

anxiety, 14.5 % had moderate anxiety and 0.9 % had severe anxiety when measured

using GAD questionnaire. These findings are supported by a descriptive study

conducted to assess the prevalence of depression and anxiety among patients with

thyroid dysfunction. The study result showed that 50.4 % had anxiety when measured

by GAD questionnaire.51The findings are also supported by a cross sectional study

conducted to assess the prevalence of depression and anxiety among patients with

thyroid dysfunction. The study findings suggested that 63 % had some degree of

anxiety.17

Association between depressive symptoms and selected socio personal variables

The present study showed that there was no significant association between

depression and socio personal variables of patients with thyroid dysfunction. The

result is contradictory with the findings of a cross sectional descriptive study

conducted on patients with thyroid dysfunction. The result shows that there was

significant association between depression and socio personal variables like gender,

socio economic status, occupation, education and family type.66

The present study shows that there is no significant association between

depression and problems in daily living (p =0.07). These findings are consistent with

a study conducted to assess the prevalence of depression and anxiety among

 84

hypothyroid patients. The result shows that patients were met among those who

experienced stressful life events such as family problems (e.g. death of relative or

marital separation), economic, social and emotional problems, educational obstacles it

showed no statistical significant association between stressful life events

and depression. This indicates that patients who were found to have depressive

symptoms are more likely to be due to hypothyroid-related causes rather than other

confounders such as stressful life events48.

The present study reveals that there is no significant association between

depression and socio personal variables among patients with thyroid dysfunction. The

findings were contradictory with a study conducted to assess the depression among

patients with thyroid disorder. In simple linear regression, the factors significantly

associated with higher scores on HAM-D scale were patients’ age of more than 45

years, urban residence, married, illiteracy, drug abuse, thyroid’s disease duration for

>10 years and presence of other co morbidity. Whereas, patients’ age of 18-30 years,

unmarried, and employment were significantly associated with lower score on HAM-

D scale. Upon multiple linear regression, patients’ age of 18-30 years (P=0.001,

B=2.629), illiteracy, drug abuse, thyroid disease for >10 years and presence of co

morbidity were significantly associated with higher scores on HAM-D scale.

Whereas, education level of intermediate and above were significantly associated with

comparatively lower score on HAM-D scale 49.

The present study reveals that there is no association between depression and

source of support. A study conducted on depression level among thyroid patients and

its correlate shows proved that there was inverse correlation between depression and

social support from family. The findings suggested that the depression were likely

reduced when the patients received high support from their family. This study also
 85

showed that the thyroid patients received high support from their friends, however

there was no statistical significance (p=0.402, r=0.068).71

The present study revealed that there is no significant association between

depression and problems in daily living and source of support. The findings were

contradictory with a study conducted on depression level among thyroid disorder

patients and its correlation. The results shows that the stressful life events had

positive correlation with depression (p=0.001, r=0.264). It showed that the stress full

life events had influence depression presentation. Most of the patients who had

depression reported at least one moderate to severe stressful life events in a six month

period.71

The present study reveals that there was no significant association between

depression and socio personal variables, the computed p value is >0.05 for the socio

personal variables. The findings were contradictory with a study conducted on

anxiety, depression and self care management among hypothyroidism. The results

shows that depression was significantly associated with educational status (p=0.009)

and duration of illness (p=0.002). 72

Association between anxiety and selected socio personal variables

The present study shows that there was significant association between anxiety

and selected variables such as marital status (p=0.048) and regularity of treatment

(p=0.008). The findings were supported by a study conducted on anxiety, depression

and self care management among hypothyroidism. The result shows that anxiety was

significantly associated with marital status (p=0.00). And the findings were not

supported for the association between anxiety and selected variables such as family

history of mental illness (p=0.009) and sex (p=0.044).72

 86

The present study revealed that there was a significant association between

anxiety and selected variables including marital status and regularity of treatment. The

result is contradictory with the findings of a cross sectional descriptive study

conducted on 129 patients with thyroid function disorder. The results suggest that

there was significant association between anxiety and socio personal variables

includes female gender, low socio economic status, occupation, education and family

type. The findings are consistent with the association between marital status and

anxiety among patients with thyroid dysfunction.51

Summary

The present study was conducted to assess the prevalence of depressive

symptoms and anxiety among patients with thyroid dysfunction in Government

Medical College Hospital Kozhikode. The study aims to assess the prevalence of

depressive symptoms and anxiety among patients with thyroid dysfunction and to find

out the association between depressive symptoms and anxiety with selected variables.

The conceptual framework was based on Betty Neuman’s System Model. The

literature reviewed were organized under the following headings like prevalence of

depressive symptoms and anxiety among patients with thyroid dysfunction,

prevalence of depressive symptoms among patients with thyroid dysfunction,

prevalence of anxiety among patients with thyroid dysfunction. The study adopted a

non-experimental descriptive study approach. Sample consisted of 110 patients with

thyroid dysfunction selected by purposive sampling technique. Semi structured

interview schedule for socio personal and clinical data of patients with thyroid

dysfunction. Beck Depression Inventory to assess the prevalence of depressive

symptoms among patients with thyroid dysfunction. Generalized anxiety disorder

questionnaire to assess the anxiety among patients with thyroid dysfunction. The
 87

content validity of the tools were ensured with the help of experts from nursing and

related fields. Pretesting was done by administering the tool to patients with thyroid

dysfunction. Psychometric property of Beck Depression Inventory and Generalized

anxiety disorder questionnaire has been reported by various studies that are the

reliability of tool is ensured. Pilot study was conducted from 3.4.2023 to 15.4.2023 by

interviewing 15 patients with thyroid dysfunction. Pilot study revealed the

appropriateness of the methodology used. The main study data collection was done

from 21.4.2023 to 27.5.2023. The investigator visited the outpatient department of

Government Medical College Hospital Kozhikode and patients with thyroid

dysfunction. The investigator identified sample with the help of doctors and record

review. The data collection process was started with the identification of patients with

thyroid dysfunction who met the criteria. The investigator met the patients personally

at OPD and participants were instructed about the purpose and nature of the study and

cleared their doubts. Confidentiality assured and informed consent obtained. An

average of 30 minutes is taken for the data collection from each participant. The

details of socio personal data were recorded with the help of the interview. Data

related to prevalence of depressive symptoms and anxiety were collected with the

help of Beck Depression Inventory and Generalized anxiety disorder questionnaire.

Data collected were analysed by descriptive statistics and inferential statistics. After

analysis following major results were obtained.

 Among the patients 40.9% participants were belonged to the age group of 36-

45 years and 31.9 % of participants belonged to the age group of 26-35 years,

96 % of participants were females and 4 % were males.

 Regarding the place of residence 84.5% of participants were residing in

panchayath..
 88

 Among the participants 95.5% were belonged to nuclear family, 84.5 % of

participants were married.

 Regarding the educational status 61.8 % of participants were attained primary

/secondary education and 54.5 % of participants were home maker or

unemployed.

 About the participants 87% were belonged to Below Poverty Line and 13 %

were belonged to Above Poverty Line.

 Regarding the source of support 94.5% of participants received support from

partner, children, siblings and parents and 70.9 % of participants were not

experiencing any problems in daily living.

 Among the patients 83.6 % of participants were diagnosed as hypothyroidism

and 16.4 % of participants were diagnosed as hyperthyroidism.

 Regarding the age at diagnosis 52.7% of participants were diagnosed at the

age group of 26-35 and 69.1% of participants had the duration of diagnosis of

above 1 year.

 Among the participants 59 % had medication for thyroid dysfunction and 72%

of participants were taken irregular treatment.

 Among the participants 93.6 % had no any co morbidities.

 Regarding the family history of thyroid dysfunction 70 % of participants had

the history of thyroid dysfunction in the family.

 Among the participants 40% of had mild mood disturbance, 30 % had

moderate depression, 20 % had borderline clinical depression and 3.6 % had

severe depression when measured by Beck Depression Inventory.

 Among the participants the mean score of total Beck Depression Inventory

was 18.68 with a standard deviation of 6.36.

 89

 Among the participants 67.3 % had mild anxiety, 17.3 % had minimal anxiety,

14.5 % had moderate anxiety and 0.9 % had severe anxiety when measured

using GAD questionnaire.

 Among the participants the mean score of total Generalized Anxiety Disorder

was 6.94 with a standard deviation of 2.26.

 There is no significant association between depressive symptoms among

patients with thyroid dysfunction and variables such as age, place of residence,

sex, type of family, marital status, occupation, educational status, socio

economic status, problems in daily living, source of support, diagnosis, age at

diagnosis, duration of diagnosis, medications for thyroid dysfunction,

regularity of treatment, co morbidities and family history of thyroid

dysfunction.

 There is significant association between marital status and regularity of

treatment of patients with thyroid dysfunction and anxiety.

 The computed ‘p’ value for association between anxiety among patients with

thyroid dysfunction and selected variables such as marital status and regularity

of treatment was lesser than 0.05.

 There is no significant association between other variables such as age, place

of residence, sex, type of family, educational status, occupation, socio

economic status, problems in daily living, source of support, diagnosis, age at

diagnosis, duration of diagnosis, medications for thyroid dysfunction, co

morbidities and family history of thyroid dysfunction.

 90

Conclusion

The study was aimed to assess the prevalence of depressive symptoms and

anxiety among patients with thyroid dysfunction in Government Medical College

Hospital Kozhikode. In the present study shows that patients with thyroid dysfunction

were experienced psychological problems like depression and anxiety. The depressive

symptoms mainly manifested was sadness, pessimism, sense of failure,

dissatisfaction, guilt, sense of persistent, self- hate, self-accusation, self- punitive

wishes, crying spells, irritability, social withdrawal, indecisiveness, body image, work

inhibition, sleep disturbances, fatiguability, loss of appetite, weight loss, somatic pre-

occupation,loss of libido. Anxiety symptoms mainly demonstrated was nervousness,

inability to stop worrying, excessive worry, restlessness, difficulty in relaxing, easy

irritation and fear of something awful happening. Patients with thyroid dysfunction

self report revealed that 40 % had mild mood disturbance, 30 % had moderate

depression, 20% had borderline clinical depression and 3.6% had severe depression.

The study reported that 67.3% had mild anxiety, 17.3 % had minimal anxiety, 14.5 %

had moderate anxiety and 0.9 % had severe anxiety. There is significant association

between age, marital status, source of support and regularity of treatment of patients

with thyroid dysfunction and anxiety.

Nursing implication

The findings of the study have implications in nursing practice, nursing

education, nursing administration and nursing research.

Nursing practice

Nurses are in every community –large and small- providing expert care from

birth to the end of life. Nurses role ranges from direct patient care and case
 91

management. They care for individuals and families of all ages in homes, hospitals,

schools, long term care facilities and outpatient clinics. Nurses work to provide

education, promote healthy practices, share their expertise, and help patients heal.

Guiding patients and their families, nurses can provide people in a community with

referral to other services resources and classes.

The role of nursing professionals in wellness, promotion, prevention of

mental health problems, standardised care and treatment of hospitalised patients and

in taking up a good interpersonal relationship has immense importance. Apart from

that stabilization of psychological condition such as anxiety and depressive symptoms

in hospitalized patients is a routine part of nursing care, the psychology of patients

can be easily overlooked by nurses through maintaining a therapeutic rapport.

Present study shows that majority of patients with thyroid dysfunction had

depressive symptoms and anxiety. Proper identification and managing them by

adopting suitable measures is the prime responsibility of the nurse. Adequate training

programme should be given to staff nurses, student nurses, and community nurses

regarding in view of management of patients with thyroid dysfunction. Early

identification and managements of these symptoms helps to improve the quality of

life in patients with thyroid dysfunction.

Nursing education

Nursing encompasses autonomous and collaborative care of individuals of all

ages, families, groups and communities, sick or well and in all settings. Nurses

continue to play an important role in helping patients and family. Learning about the

disease and knowing what to expect can help caregivers feel more in control and

better able to plan ahead. The nursing education should give significance to the

development of knowledge, skill and attitude among nursing students in conducting

 92

health surveys, project studies, and health awareness programme on depression,

anxiety and thyroid dysfunction. Nurse educators should provide awareness regarding

depression, anxiety and thyroid dysfunction. Nurses should be equipped with

adequate knowledge and necessary skill in providing psychological interventions for

patients with thyroid dysfunction. The student should recognise the importance of

early identification of depressive symptoms, anxiety and should become part of its

practice. Students should familiarise with various tools to assess depression and

anxiety. The nurse should recognize its importance and should become part of its

practice. Present study emphasizes the relationship between the anxiety and

depression the aspect should be highlighted in the psychiatric nursing curriculum by

providing opportunities to students to practice the skills.

The study findings project a greater insight towards the psychological

distress like anxiety and depression among patients with thyroid dysfunction. Nurse

educator must emphasize nursing students through curriculum so that they could

focus on psychological aspects among patients with thyroid dysfunction.

Nursing administration

The nurse administrator systematically enhances the quality and

effectiveness of nursing services and nursing practices. The findings of the study

could be utilised as a basis for in service education programme for nurses.

Administrative support can be given to nurses to conduct awareness programme at

various levels. There should be in service education programmes workshops and

seminar for the nurses and nursing students regarding importance of early

identification of depression and anxiety in order to improve the quality of life.

Planning and organizing individual and group teaching will ensure quality

patient care. The in service department of the hospital should do activities in updating
 93

the knowledge of staff nurses and making them competent in early identification and

management of depressive symptoms and anxiety among patients with thyroid

dysfunction. The staff should be equipped to provide counselling and referral services

for patients with depressive symptoms and anxiety. The administrator should take

steps to provide sufficient man power, money and material. Nursing administrators

can arrange counselling programmes to patients with thyroid dysfunction having

psychological problems. Administrative support can be given to nurses to conduct

counselling programmes and patient care conferences.

Nursing research

The aim of nursing research is to facilitate the development of clinical nursing

interventions which will improve health outcomes and contribute to the optimal

delivery of care. Nursing research has a tremendous influence on current and future

professional nursing practice, thus rendering it an essential component of the

educational programme. Nursing research is to contribute the knowledge to the body

of nursing to expand and broaden the scope of nursing. Nurses need research because

it helps them advance their field, stay updated and offer better patient care.

Information literacy skills can help nurses use information more effectively to

develop their own conclusions. The field on research on depressive symptoms and

anxiety among patients with thyroid dysfunction is still in its infancy, because there

are only few studies conducted in this topic.

Early identification of depression and anxiety among patients with thyroid

dysfunction have great importance in improving quality of living, and there is little of

studies are conducted in this area. Nursing research develops knowledge about health

and the promotion of health over the full lifespan, care of persons with health
 94

problems and disabilities and nursing actions to enhance the ability of individuals to

respond effectively to actual or potential health problems. Today’s education is giving

more importance to evidence based practices. The nurse researcher should be

motivated enough to conduct among psychological aspects of thyroid dysfunction.

Hence more studies are to be conducted in the area, prevalence of psychiatric

problems among patients with thyroid dysfunction.

Limitations

 The findings of the study can only be generalized to limited population due

to small sample size.

 Generalization was not possible since the study was done in one setting.

 Only single instrument was used for data collection.

Recommendations

 A similar study can be replicated on a larger sample and different study

settings.

 This study can be conducted as a qualitative study to assess the prevalence

of depressive symptoms and anxiety among patients with thyroid

dysfunction.

 A comparative study can be conducted to assess the prevalence of

depressive symptoms and anxiety among patients with hypothyroidism and

hyperthyroidism.

 A comparative study can be conducted to assess the prevalence of

depressive symptoms and anxiety among patients with newly diagnosed

thyroid dysfunction and patients on thyroid hormone replacement therapy.

 95

 A prospective study can be undertaken to assess the prevalence of

depressive symptoms and anxiety among patients with thyroid dysfunction

 96

REFERENCES

1. TOPPR. Toppr: The better learning app [Internet]. Toppr.com. 2018. Available

from: https://www.toppr.com

2. Crafa A, Calogero A E, Cannarella R, Mongioi L M,Condorelli R A,Greco E

A,Aversa A, Vignera S L.The burden of hormanal disorders:A worldwide

overview.Front Endocrinol.2021 June;12.

3. Mental health:strengthening our response[internet].WHO.int. Available

from:https://www.who.int/news.room/fact-sheets/detail/mental- health-

strengthening-our-response.

4. Galderissi S, Heinz A, Kastrup M, Beezhold J, Sartorious N. Toward a new

definition of mental health.world psychiatry.2015;14(2):231-3.Available

from:https://www.ncbi.nlm.gov/pmc/articles/PMC4471980.

5. EMERGING EVIDENCE .Promoting mental health[internet]Who .int

AVcailable from:https://www.who.int/mental health/evidence/en/promoting

mhh.pdf

6. Malla A, Jobber R, Garcia A.Mental illness like other medical illness:a critical

examination of the statement and its impact on patient care and society.J

Psychiatry Neuroscience .2015;40(3):147-50.

7. Home │ psychiatry.org [Internet]. www.psychiatry.org. Available from:

https://www.psychiatry.org.

8. American Psychiatric Association. https://www.psychiatry.org.

9. Mental disorders world health organisation. Available from:https:// www.who.org

10. The World Economic Forum [Internet]. World Economic Forum. Available from:

https://www.weforum.org.

11. https://www.the zebra .com

 97

12. Pokkarel BM, Chaudary M.Prevalence of thyroid problems .Rupendehi Campus

Journal .2022;3.

13. Johns Hopkins Medicine, based in Baltimore, Maryland [Internet]. www.hopkins

medicine.org. Available from: https://www. Hopkins medicine.org.

14. Kumar P, Mukherji A, Roy A. Prevalence of hypothyroidism in the population of

west bokaro coal mine area ,jharkand.Cureas.2022;14(9).

15. Hollowell JG, Staehling NW, Flanders WD, Hannon WH, Gunter EW, Spencer

CA, Braverman LE: Serum TSH: T(4), and thyroid antibodies in the United

States population (1988 to 1994): National Health and Nutrition Examination

Survey (NHANES III). J Clin Endocrinol Metab. 2002, 87:489-99.

10.1210/jcem.87.2.8182 2.

16. https://www.nhs.uk.com

17. Bathla M,Singh M, Relan P.Prevalence of anxiety and depression among patients

with hypothyroidism .Indian Journal of Endocrinology and Metabolism.2016

Aug;20(4):468-474.

18. Davis J, Tremont G. Neuropsychiatric aspects of hypothyroidism and treatment

reversibility. Minerva Endocrinol. 2007;32(1):49–65. [PubMed] [Google

Scholar]

19. .Medici M, Direk N, Visser WE, Korevaar TI, Hofman A, Visser TJ, et al.

Thyroid function within the normal range and the risk of depression: a

population-based cohort study. J Clin Endocrinol Metab. 2014;99(4):1213–9. doi:

10.1210/jc.2013-3589. [PubMed] [CrossRef] [Google Scholar]

20. Hage MP, Azar ST. The link between thyroid function and depression. J Thyroid

Res. 2012;2012 doi: 10.1155/2012/590648. [PMC free article] [PubMed]

[CrossRef] [Google Scholar]

 98

21. Greer S,Parsons V.Schizophrenia like psychosis in thyroid crisis.British Journal

of Psychiatry.1968;114(516):1357-1362.

22. Zader SJ, WilliamsE, Burky M A.Mental health conditions and

hyperthyroidism.2019;144(5):2018-2874.

23. Fischer S, Ehlert U. Hypothalamic-pituitary-thyroid (HPT) axis functioning in

anxiety disorders. A systematic review. Depress Anxiety. 2018;35(1):98-110.

24. Ahmed R. Developmental thyroid diseases and monoaminergic dysfunction.

Adv Appl Sci Res. 2017;8(3):1-10.

25. Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, et al.

Guidelines for the treatment of hypothyroidism: prepared by the American

Thyroid Association task force on thyroid hormone replacement. Thyroid.

2014;24(12):1670-751

26. Kessler RC. Lifetime and 12-Month Prevalence of DSM-III-R Psychiatric

Disorders in the United States. Archives of General Psychiatry. 1994 Jan

1;51(1):8.

27. Haggerty Jr. JJ, Prange Jr. AJ. BORDERLINE HYPOTHYROIDISM AND

DEPRESSION. Annual Review of Medicine. 1995 Feb;46(1):37–46.

28. Bhagwat N, Tayde P, Sharma P, Sharma B, Dalwadi P, Sonawane A, et al.

Hypothyroidism and depression: Are cytokines the link? Indian Journal of

Endocrinology and Metabolism. 2017;21(6):886.

29. Bemban D A, Hamm R M,Morgan L,Winn P,Davis A,Barton E.Thyroid disease

in the elderly,predictability of of subclinical hypothyroidism.J Fam

Pract.1994;38:583-588.
 99

30. Madariaga G,Palacios S,Grima G,Galofre J C.The incidence and prevalence of

of throid dysfunction in the Europe:a meta analysis.Journal of clinical

endocrinology and metabolism.2014;99:923-931.

31. http://www.ias,ac,in.2011 april.

32. Usha menon V,Sundaram K R,Unnikrishnan A G,Jayakumar R V,Nair V,Kumar

H.High prevalence of undetected thyroid disorders in an iodine sufficient adult

south indian population.Journal indian medical association.2009;107:72-77.

33. Kumar P, Mukherji A,Roy A.Prevalence of hypothyroidism in the population of

west bokaro.cureus.2022 Sep;14(9).

34. Alfaifi J S,Alshehri B H,Alamri F A,Alshehri A A,Alfaifi A S.Prevalence and

Determinants of Depression among Hypothyroidism.Arch Pharma

Pract.2020;11(4):109-14.

35. What is mental illness.American psychiatric association.available from:

https://www.psychiatry .org.

36. Early intervention in mental illness.2021 Nov. available

from:https://www.health.vic.gov.au

37. Thyroid disease.2020 Nov.Available from:https://my.cleveland clinic.org.

38. American Psychological Association (APA). https://wwwapaorg [Internet]. 2021;

Available from: https://www.apa.org

39. The importance of early intervention for anxiety.2015. Nov. Available from:

https://news.asu.edu.arizona state university.

40. Pioneer T. English News Paper | Breaking News | Latest Today News in English |

News Headlines India [Internet]. The Pioneer. Available from:

https://www.dailypioneer.com
 100

41. Depression and its effect on your life.2020.Gateway to Mental Health Services |

Resources to Recover [Internet]. Available from: https://www.rtor.org

42. Gulseren S, Gulseren L,Hekimsoy Z,Cetinay P,Ozen C ,Tokatlioglu

B.Depression , anxiety,health related quality of life and disability in patients with

overt and subclinical thyroid dysfunction.Archives of medical

research.2006.jan1;37(1):133-9

43. Zainal N, Yaacob S, Kaur A, Pendek R. P01-314 - Prevalence of depression and

anxiety disorders among thyroid disorder patients in a teaching hospital in

Malaysia. European Psychiatry. 2010;25:527.

44. Bové KB, Watt T, Vogel A, Hegedüs L, Bjoerner JB, Groenvold M, et al.

Anxiety and Depression Are More Prevalent in Patients with Graves’ Disease

than in Patients with Nodular Goitre. European Thyroid Journal [Internet]. 2014

Sep 1 [cited 2020 Mar 27];3(3):173–8. Available from:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4224229/

45. Bali K. A Study of Psychiatric Co-Morbidity in Patients Suffering from Thyroid

Dysfunction. Journal of Medical Science And clinical Research. 2017 Dec

14;5(12).

46. Kale K, Baviskar B. Depression, anxiety, and somatization in patients with

clinical and subclinical hypothyroidism: An exploratory study. Thyroid Research

and Practice. 2018;15(1):10.

47. Siegmann EM, Müller HHO, Luecke C, Philipsen A, Kornhuber J, Grömer TW.

Association of Depression and Anxiety Disorders With Autoimmune Thyroiditis.

JAMA Psychiatry. 2018 Jun 1;75(6):577.

 101

48. Mani K, Ray A, De S. Assessment of anxiety depression and executive function

in cases of subclinical hypothyroidism attending in a tertiary care centre. National

Journal of Physiology, Pharmacy and Pharmacology. 2018 march ;1.

49. Koner S,Chaunduri A.Impact of thyroid hypofunction on Anxiety and

Depression.International Journal of Research and Review.2019 June;6(6):341-

346.

50. Romero-Gómez B, Guerrero-Alonso P, Carmona-Torres JM, Notario-Pacheco B,

Cobo-Cuenca AI. Mood Disorders in Levothyroxine-Treated Hypothyroid

Women. International Journal of Environmental Research and Public Health.

2019 Nov 28;16(23):4776.

51. Gorkhali B, Sharma S, Amatya M, Acharya D, Sharma M. Anxiety and

Depression among Patients with Thyroid Function Disorders. Journal of Nepal

Health Research Council. 2020 Nov 13;18(3):373–8.

52. Gunes NA. Evaluation of anxiety and depression in patients with thyroid function

disorder. Revista da Associação Médica Brasileira. 2020 Jul;66(7):979–85.

53. Gulseren S, Gulseren L, Hekimsoy Z, Cetinay P, Ozen C, Tokatlioglu B.

Depression, Anxiety, Health-Related Quality of Life, and Disability in Patients

with Overt and Subclinical Thyroid Dysfunction. Archives of Medical Research

[Internet]. 2006 Jan [cited 2019 Nov 26];37(1):133–9. Available

from:https://www.sciencedirect.com/science/article/abs/pii/S0188440905002286

54. Subedi A, Bhandari P.prevalence of depression in hypothyroidism. International

journal of science and research. June 2021;10(6):284-288.

55. Pasyechko N V,Kulchinsika V M. Anxiety and depression in women of

reproductive age with thyroid disease. International Journal of

Endocrinology.2022;18(3).
 102

56. Raj S, Prabhu P, Devasia A. Prevalence of depression and anxiety among patients

with thyroid disorder. International journal of medical reviews and case

reports.2023;7(5):15-18.

57. Lllani N,Azlina D,Sanisash S,Ramli M,Niknoor A.Depression symptoms level

among thyroid disorder patients.Malaysian Journal of Psychiatry.2017

June;26(1):0-0.

58. Mohammad MYH, Bushulaybi NA, AlHumam AS, AlGhamdi AY, Aldakhil HA,

Alumair NA, et al. Prevalence of depression among hypothyroid patients

attending the primary healthcare and endocrine clinics of King Fahad Hospital of

the University (KFHU). Journal of Family Medicine and Primary Care [Internet].

2019 Aug 28 [cited 2021 Mar 6];8(8):2708–13. Available from:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6753820/

59. Sham S Y,Umar N A,Hambali Z,Razali R,Manaf M R.Subclinical

hypothyroidism among patients with depressive disorders.Malaysian Journal of

Medicine and Health Sciences.2014.june ;10(2):71-78

60. Loh HH, Lim LL, Yee A, Loh HS. Association between subclinical

hypothyroidism and depression: an updated systematic review and meta-analysis.

BMC Psychiatry. 2019 Jan 8;19(1).

61. Mohammad A H.Prevalence of depression among patients with

hypothyroidism.college of medicine Al Nahrain University.2019:1-13.

62. Tang R, Wang J, Yang L, Ding X, Zhong Y, Pan J, et al. Subclinical

Hypothyroidism and Depression: A Systematic Review and Meta-Analysis.

Frontiers in Endocrinology. 2019 Jun 4;10.

 103

63. Alfaifi J S,Alshehri B H,Alamri F A,Alshehri A A,Alfaifi A S.Prevalence and

Determinants of Depression among Hypothyroidism.Arch Pharma

Pract.2020;11(4):109-14.

64. Rehman S,Ahmed N,Wahid A,Khan A,Iqbal Q.Level and factors associated with

depression among thyroid patients at a tertiary care hospital.World Journal of

Depression and Anxiety.2020 Mar;2(1):1005.

65. Almalki A,Alosail A,Almalki M,Mal R,Albacker A,Alredbi A,Ismail A,Omair

A,Alshahrani A.Prevalence of Depression among hypothyroid patients being

treated with levothyroxine.International Journal of Medicine in Developing

Countries.2020 Oct;4(11):1918-1923.

66. Hamed A, Nme N,Alhalabi N,Tayfour R,Latifeh Y.Prevalence of depression in

group of hypothyroid patients and its relationship with the level of

hypothyroidismBiomedical research.2021Jan;32(2).

67. Nugura S,Rachakonda S,Sripathi S,Khan M,Patel N,Meda R.Hpothyroidism and

Depression ;A Narrative Review.PubMed Central .2022 Aug;14 (8):e28201.

68. Bode H, Ivens B,Bschor T,Schwarzer G,Henseller J,Baethge C.Hyperthyroidism

and clinical depression:a systematic review and meta analysis.Translational

Psychiatry.2022 Sep;12(362).

69. Sait Gonen M, Kisakol G, Savas Chilli A, Dikbas O, Gungor K, Inal A, et al.

Assessment of Anxiety in Subclinical Thyroid Disorders. Endocrine Journal

[Internet]. 2004 [cited 2020 Feb 15];51(3):311–5. Available from:

https://www.jstage.jst.go.jp/article/endocrj/51/3/51_3_311/_pdf/-char/ja

70. Bunevicius R, Prange Aj. Thyroid disease and mental disorders:cause and effect

or only co morbidity.Curr opin psychiatry.2010;23(4):363-368.

 104

71. Daud A, Saidi S, Musa R, Jaafar S.depression level among thyroid disorder

patients and its correlation.International journal of scholars.2021;4(1):52-58.

72. Khanal D,Chapagain S, Thapa S. Anxiety, depression and self care management

among hypothyroidism.Journal of Diabetes and Endocrinology of Nepal.2022

December;6(2):1-7.
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APPENDIX A

APPROVAL LETTER FROM SCIENTIFIC REVIEW

COMMITTEE

APPENDIX B

APPROVAL LETTER FROM INSTITUTIONAL ETHICAL

COMMITTEE
 106

APPENDIX B

APPROVAL LETTER FROM INSTITUTIONAL ETHICAL

COMMITTE
 107

APPENDIX C

PERMISSION LETTER FROM GOVT MEDICAL COLLEGE

HOSPITAL, KOZHIKODE
108
 109

APPENDIX D

LIST OF EXPERTS FOR CONTENT VALIDITY

1 Dr.Mithun Sidharth 7 Dr. Vimal Kumar S V

Assistant professor Clinical psychologist
Department of psychiatry IMHANS,
Govt Medical college, Kozhikode
Kozhikode
2 Dr. Vineeth 8 Dr. Jobin Tom
Assistant professor Psychiatric Social Worker
Department of Medicine IMHANS, Kozhikode
Govt Medical college, Kozhikode

3 Mr. Saleem T K 9 Mr. Ullekh P G

Assistant professor Assistant professor
Govt College of Nursing JDT Islam college of Nursing
Kozhikode Kozhikode
4 Mr. Nabeel P 10 Mrs. Shiji Joseph
Assistant professor Assistant professor
Govt College of Nursing Govt College of Nursing
Kozhikode Thrissur
5 Mr. Vipin 11 Mrs Alka Raju
Assistant professor Nursing tutor
Govt College of Nursing Department of psychiatry
Kozhikode IMHANS Kozhikode
6 Dr. Reena George
Assistant Professor
Department of psychiatry
IMHANS Kozhikode
 110

APPENDIX E

INFORMED CONSENT

In signing the document, I am giving consent to be a subject for the study

conducted by Ms. ATHIRA.K, MSc Nursing student, Govt. College of Nursing,

Kozhikode. I understand that I will be a part of research study to Assess the

‘Prevalence of depressive symptoms and anxiety among patients with thyroid

dysfunction’.

I have been informed that my willingness to participate in the study is entirely

voluntary. I am vested with full right to resolve my consent and terminate the

partnership at any point of time during the study. I have been told that my answers to

the question will be confidential. I also have been informed that I have no financial

commitments for the study and there is nothing that will adversely affect the services

that may receive from the public health care institutions.

If I have any questions about the study or about my rights as study participant

Mrs. Athira K (8921684317) is the person whom I contact.

Will honor all agreement

Respondent signature:

Name &address :
Investigators name & address:
Name: Athira k
Address: MSc Nursing
Govt. College of Nursing , Kozhikode
Place :

Date :
 111

APPENDIX F

TOOL I

SEMI STRUCTURED INTERVIEW SCHEDULE TO COLLECT SOCIO

PERSONAL AND CLINICAL VARIABLES OF PATIENTS WITH THYROID

DYSFUNCTION

Instructions for the interviewer

 Introduce yourself and explain purpose of the study

 Ask questions in the interview schedule using one to one interview schedule

 No unnecessary explanation/comment to answer would be given

 Put a tick mark (√) on appropriate column according to the response of the

participant.

 Section B, Item number 1- verification of records

Section A

Socio personal variables

1. Age (years) :

2. Sex

a. Male ( )

b. Female ( )

c. Transgender ( )

3. Place of residence

a. Panchayath ( )

b. Corporation ( )

c. Municipality ( )
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4. Type of family

a. Nuclear family ( )

b. Joint family ( )

c. Extended family ( )

5. Marital status

a. Married ( )

b. Unmarried ( )

c. Widow/Widower/Divorced/Separated ( )

6. Education status

a. Primary ( )

b. Secondary ( )

c. Higher Secondary ( )

d. Degree ( )

e. Post graduate ( )

f. Professional/Technical ( )………

7. Occupation

a. Government employees ( )

b. private employee/Self employee/ ( )

Manual labour

c. Unemployed /Home maker ( )

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8. Socio economic status

a. APL ( )

b. BPL ( )

9. Source of support

a. Partner ( )

b. Children ( )

c. Siblings ( )

d. Friends ( )

e. Parents ( )

f. Any others ( )

g. No support system ( )

10. Do you experience problems in your daily life?

a. Yes: ( )

b. No ( )

If yes specify ……………………..

Section B

Clinical variables

1. Diagnosis ---------------------------

2. Age at the time of diagnosis ---------------------------

3. Duration of diagnosis
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a. Below 6 months ( )

b. 6 month to 1 year ( )

c. Above 1 year ( )

4. Medications for the treatment of thyroid dysfunction

a. No ( )

b. Yes ( )

If yes ,……………………….

5. Duration of treatment

a. below 6 months ( )

b. 6 month to 1 year ( )

c. Above 1 year ( )

6. Co morbidities if any -----------------------------

7. Regularity of treatment

a. Regular ( )

b. irregular ( )

8. History of hyper or hypo thyroid dysfunction in the family

a. No ( )

b. Yes ( )

if yes specify ……………………………

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APPENDIX G

TOOL II

SELF REPORT BECK’S DEPRESSION INVENTORY TO ASSESS THE

DEPRESSIVE SYMPTOMS ANONG PATIENTS WITH THYROID

DYSFUNCTION

BECK DEPRESSION INVENTORY

Instructions : please read each statement and put tick mark a number 0,1,2,3 which

indicates how much the statement applied to you over the past month .There are no

right or wrong answers. Do not spend too much time on any statement.

Si No item score

1 mood

I do not feel sad. 0

I feel sad 1

I am sad all of the time and I can’t snap out of it. 2

I am so sad and unhappy that l can’t stand it. 3

2 pessimism

I am not particularly discouraged about the future. 0

I feel discouraged about the future. 1

I feel I have nothing to look forward to. 2

I feel the future is hopeless and things cannot improve. 3

3 Sense of failure

I do not feel like a failure. 0

I feel I have failure more than a average person 1

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As I look back on my life, all I can see is a lot of failures. 2

I feel I am a complete failure as a person. 3

4 Self dis-satisfaction

I get satisfaction out of things as I used to. 0

I don’t enjoy things the way I used to. 1

I don’t get real satisfaction out of the anything anymore. 2

I am dissatisfied or bored with anything. 3

5 Guilt

I don’t feel particularly guilty. 0

I feel guilty of a good part of the time. 1

I feel quite guilty most of the time. 2

I feel guilty all of the time. 3

6 Punishment

I am don’t feel I am being punished 0

I feel I may be punished 1

I expected to be punished 2

I feel I am being punished. 3

7 Self dislike

I don’t feel disappointed myself 0

I am disappointed myself 1

I am disguised with myself. 2

I hate myself 3

8 Self accusation

I don’t feel I am any worse than anybody else. 0

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I am critical of myself for my weakness or mistakes 1

I blame myself all the time for my faults. 2

I am blame myself for everything bad that happen. 3

9 Suicidal ideas

I don’t have any thought of killing myself. 0

I have thoughts of killing myself but I would not carry them 1

out self.

I would like to kill myself. 2

I would kill myself if I had the chance 3

10 crying

I don’t cry any more than usual 0

I cry more now than I used to 1

I cry all the time now. 2

I used to be able to cry, but now I can’t cry even though I want 3

to.

11 Irritability

I am no more irritated by things than I never was 0

I am slightly more irritated by things that I never was. 1

I am quite annoyed or irritated a good deal of the time. 2

I feel irritated all the time 3

12 Social withdrawal

I have not lost interest in other people. 0

I am less interested in other people than I used to. 1

I have lost most of interest in other people. 2

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I have lost all of my interest in other people. 3

13 In decisivenesss

I make decision about as well as I ever could 0

I put off making decision more than I used 1

I have greater difficulty in making decision more than I used 2

to.

I can’t make decision at all anymore. 3

14 Body image change

I don’t feel that I look any worse than I used to. 0

I am worried that I am looking old or unattractive 1

I feel there are permenant changes in my appearance that 2

make me look unattractive

I believe that I look ugly. 3

15 Work difficulty

I can’t work about as well as before. 0

I takes an extra effort to get started t at doing something. 1

I have to push myself very hard to do anything. 2

I can’t do any work at all 3

16 Insomnia

I can sleep as usual. 0

I don’t sleep as well as I used to. 1

I wake up 1-2 hour earlier than usual and find it hard to get 2

back to sleep.
 119

I wake up several hours earlier than I used to and cannot get 3

back to sleep.

17 Fatiguability

I don’t get more tired than usual. 0

I get more tired easily than I used to 1

I am get tired from doing almost anything. 2

I am too tired to do anything. 3

18 Loss of appetite

My appetite is not worse than the usual. 0

My appetite is not as good as it used to be. 1

My appetite is much worse now 2

I have no appetite at all anymore 3

19 Weight loss

I have not lost much weight if any lately 0

I have lost more than 5 pounds(2.26kg) 1

I have lost more than 10 pounds(4.53kg) 2

I have lost more than 15 pounds(6.80kg) 3

20 Somatic preoccupation

I am no more worried about my health than usual 0

I am worried about physical problems like aches, pain, upset 1

stomach, constipation

I am very worried about physical problems and it’s hard to 2

think of much else.

 120

I am so worried about my physical problems that I cannot 3

think of anything else.

21 Loss of libido

I have not noticed any recent changes in my interest in sex. 0

I am less interested in sex than I used to be. 1

I have almost no interest in sex. 2

I have lost interest in sex completely 3

 121

APPENDIX H

TOOL III

SELF REPORT GENERALIZED ANXIETY DISORDER QUESTIONNAIRE

TO ASSESS THE ANXIETY AMONG PATIENTS WITH THYROID

DYSFUNCTION

GENERALIZED ANXIETY DISORDER QUESTIONNAIRE

Instructions : please read each statement and put tick mark a number 0,1,2,3 which

indicates how much the statement applied to you over the past week .There are no

right or wrong answers. Do not spend too much time on any statement.

How many days have you been Not at Several More than Nearly
all days half of the everyday
bothered by any of the following
days
problems

1 Feeling nervous anxious or an edge 0 1 2 3

2 Not able to stop or control worrying 0 1 2 3

3 Worrying too much about different 0 1 2 3

things

4 Trouble relaxing 0 1 2 3

5 Being so restless it is so hard to sit 0 1 2 3

still

6 Becoming easily annoyed or irritable 0 1 2 3

7 Feeling afraid as if something awful 0 1 2 3

might happen
 122

APPENDIX I
 123

APPENDIX J


124
125
 126

APPENDIX K

√
127
128
129
130
131
 132

APPENDIX L


133
 134

APPENDIX M

LIST OF ABBREVIATION

GAD Generalized Anxiety Disorder Questionnaire

OPD Outpatient Department

WHO World Health Organization

DALYS Disability Adjusted Life Years

TSH Thyroid Stimulating Hormone

T3 Tri- iodo thyronine

T4 Tetra iodo thyronine

TH Thyroid hormone

TRH Thyroid Releasing Hormone

BDI Beck Depression Inventory