How Myo-inositol Can Improve Hashimoto’s Symptoms

As an avid researcher, I am always struck by the many inter-relationships between diseases of the body and the mind. A good example of this is the anxiety, mood swing and OCD (obsessive-compulsive disorder) symptoms that can often be clues that a person may be having underlying issues with their thyroid.

As a pharmacist, I’ve been frequently dismayed that our modern medical solution to these mind-body connections is to throw completely different prescription medications at the two. Not only does this often mean neglecting to “fix” the real root causes of both conditions, but many medications meant to address psychiatric symptoms often have unwanted side effects that make the physical health situation worse.

Looking for root causes is so important. In many cases, people find out that something as relatively straight-forward as a nutrient deficiency or a blood sugar imbalance may be causing both their anxiety symptoms as well as their worsening thyroid condition.

Once you identify your root causes, you can usually feel better pretty quickly. For example, having people take therapeutic dosages of two nutrients, selenium and myo-inositol, as well as working to balance their blood sugar, can work wonders at both reducing their anxiety and OCD symptoms as well as reducing their thyroid antibodies and thyroid symptoms. Some people have even seen their TSH level drop or have gone into remission after supplementing with selenium and myo-inositol.

Blood sugar imbalance can be a root cause of Hashimoto’s and anxiety, and is also a co-occurring symptom of another condition that affects many women, polycystic ovary syndrome (PCOS). Myo-inositol has been found to improve symptoms of PCOS. It has also been found to be effective in increasing insulin-sensitivity, which results in improvements in reproductive health, including enhanced fertility.

As you can see, myo-inositol can be greatly beneficial for Hashimoto’s!

In this article, you’ll discover:

• What myo-inositol is and how it supports our health
• How myo-inositol can improve Hashimoto’s symptoms
• The connection between PCOS, Hashimoto’s and blood sugar levels
• The anxiety, depression, OCD and mood connection to Hashimoto’s
• Recommended dosage and precautions

What Myo-inositol Is and How It Supports Our Health

Myo-inositol is an important nutrient in our bodies that serves key functions relating to hormone signal transduction throughout our endocrine system. As such, myo-inositol plays an important regulatory role relating to thyroid health (regulating the thyroid-stimulating hormone, or TSH) and reproductive health (regulating the follicle-stimulating hormone, or FSH). It also regulates glucose uptake and may be involved in serotonin uptake (our happy and calming hormone) (1).

Myo-inositol has been found to provide many valuable health effects, including anti-inflammatory, anti-oxidant, anti-diabetic and anticancer effects (2).

Research has shown that myo-inositol supplementation reduces thyroid antibody and TSH levels, as well as improves symptoms associated with anxiety, mood swings, depression and OCD. Research has also found that myo-inositol improves PCOS symptoms such as menstrual irregularities, acne, insulin resistance and weight (3). More will be discussed about each of these further in this article.

So what exactly is myo-inositol? And why might you be deficient?

Myo-inositol is a form of inositol, a type of natural sugar alcohol that’s present in mammalian cells. Inositol was previously known as vitamin B8, as it used to be thought of as an essential nutrient, but it was later learned that it is actually made within our bodies, so it lost its official vitamin designation. However, just because we can make it internally, does not mean that we can’t be deficient!

There are actually 9 forms (referred to as isomers) of inositol, with the two most common being myo-inositol and D-chiro-inositol. These two forms are seen in much of the research relating to inositol, and in fact, they have been studied as a combination treatment relating to PCOS.

Myo-inositol is found in many plants and in the tissues of animals. Foods with the highest concentration of myo-inositol are fruits, beans, corn, and nuts. Blueberries, one of my favorite superfoods, are an especially rich source!

Research has shown that although it is synthesized in the body, some individuals may not be able to meet their body’s metabolic needs through its own synthesis alone (4).

While the human body (via the liver and kidney) can produce up to 4 g/day of inositol, it has been found that the overly processed, high glucose (and low fiber) Western diets that many people follow only provide about 1 g/day of the compound (5).

People can be deficient due to their diet, poor nutrient absorption (common in Hashimoto’s), or perhaps even a genetic predisposition (such as having poor glucose metabolism) (6).

High glucose levels hinder inositol availability by increasing its degradation and by inhibiting both myo-inositol biosynthesis and absorption (7).

How Myo-Inositol Can Improve Hashimoto’s Symptoms

Blood sugar imbalance is a potential root cause of Hashimoto’s, and I’ll talk more about that in the next section. But first, let me talk about the importance of myo-inositol relating to thyroid stimulating hormone (TSH) signaling.

As I mentioned earlier, due to its key role in TSH signaling, myo-inositol supplementation has been shown to reduce thyroid antibodies, reduce TSH levels, and even achieve remission in people with Hashimoto’s.

TSH signaling is a very complex process, and there are two different branches of signaling that have an impact on TSH levels. One of these branches is inositol dependent, so too little inositol causes TSH resistance, causing too much TSH to be produced (8). Myo-inositol improves TSH sensitivity, which in turn results in a reduction of TSH levels.

Think of it this way. If someone has earplugs in their ears, they can’t hear well, so you have to yell for them to hear you. But if they remove the earplugs, they can hear you without you having to speak at a loud volume. It is similar with TSH. Without adequate myo-inositol, the body has to be “louder” and generate greater levels of TSH. In my first book Hashimoto’s: The Root Cause, I discussed how an elevation of TSH, for whatever reason, may result in triggering or exacerbating the autoimmune process of Hashimoto’s. Providing myo-inositol in clinical studies appears to “remove the earplugs”, so to speak… resulting in less TSH being produced.

There have been a number of studies focused on myo-inositol relating to Hashimoto’s, PCOS and OCD. Let’s first focus on Hashimoto’s.

In most of the studies relating to Hashimoto’s, myo-inositol has been evaluated in conjunction with selenium, likely because the research has already proven selenium to be effective at reducing thyroid antibodies. This is not surprising, as selenium deficiency is one of the most common nutrient deficiencies that I see in people with Hashimoto’s, and over 50 percent of them are likely deficient in it.

Selenium supplementation has been tied to a reduction in thyroid antibodies, improvements in thyroid symptoms, and a reduction in anxiety. I routinely recommend that my clients and readers try selenium to see if it helps them feel better. You can read much more about selenium here.

Given selenium’s well understood benefits for Hashimoto’s, studies have evaluated the incremental benefit of taking both selenium and myo-inositol over simply taking selenium alone. And the findings have shown there are benefits to taking both.

In one study done in 2013, patients with autoimmune thyroiditis were split into two groups, with one group being treated with 600 milligrams of myo-inositol and selenium (selenomethionine) per day for 6 months, and the other being treated with just selenium. While both groups showed a decrease in thyroid antibodies, the group treated with myo-inositol also experienced a 31 percent reduction in TSH levels. The selenium group showed no change in TSH levels (9).

The group taking the myo-inositol and selenium also showed a 44 percent reduction of thyroid antibodies, while the group taking selenium alone showed a 42 percent reduction in antibodies. Thyroglobulin was reduced by 48 percent with the myo-inositol/selenium combination versus 38 percent with just selenium alone.

Some people actually went into remission after starting the myo-inositol. Improvements were seen in people’s assessment of their personal wellbeing. The authors of this study also pointed out that these two compounds were safe, with no side effects seen as part of their data collection.

In a more recent follow-up study in 2017, these results were confirmed and then expanded upon. Thyroid antibodies, TSH and quality of life were all significantly improved after administration of both myo-inositol and selenium. Interestingly, there was one case of hyperthyroidism included in this study, and in that single case, the supplementation increased TSH levels up to normal concentrations (10).

My own clinical results also support the improvements that may be seen when taking myo-inositol with selenium. I recommend this combination as a first step for people with mild elevations in TSH and thyroid antibodies, and sometimes it’s just enough to do the trick. I often recommend using myo-inositol powder instead of sweetner in tea!

The Connection Between PCOS, Hashimoto’s and Blood Sugar

In at least one study, it was found that up to 50 percent of people with Hashimoto’s have an impaired tolerance to carbohydrates, causing issues with blood sugar imbalances and insulin surges. I have found that many of my clients suffer from these types of surges, which can cause nervousness, anxiety, lightheadedness and fatigue.

In a 2017 study on insulin resistance and Hashimoto’s, the authors concluded that high thyroid antibody levels are related to high fasting blood glucose levels and high insulin levels. Their findings indicated a possible relationship between insulin resistance, autoimmune thyroiditis and TSH levels. They also concluded that patients testing with positive thyroid antibodies should be followed closely for diabetes mellitus and cardiovascular events (11). (Learn more in my article about blood sugar imbalances and Hashimoto’s.)

Blood sugar and insulin resistance are also a problem commonly seen in women with PCOS (12).

PCOS is an endocrine, reproductive and metabolic disorder, affecting at least 5 to 10 percent of reproductive-age women, worldwide (13). Women with PCOS are found to have a 50 to 70 percent incidence of insulin resistance, independent of body size and build (14). In those who are obese, the prevalence of insulin resistance rises to 80 percent (15).

Given these statistics, a common treatment for PCOS includes the insulin-sensitizing drug metformin. It has been shown to improve insulin sensitization and ovulatory function. Metformin does, however, have a number of negative side effects.

Remember when I said myo-inositol was involved in hormone signal transduction and helped regulate TSH, FSH and glucose uptake? Well, due to its similar regulatory role relating to addressing glucose intolerance, myo-inositol was identified as being a potential substitute for metformin in improving PCOS symptoms. Subsequently, there has been research focused on this, with that research confirming the positive results of myo-inositol supplementation.

Myo-inositol is the most abundant inositol form found within the ovary, with approximately 99 percent of the ovarian intracellular inositol being myo-inositol (16). Studies have shown that a high concentration of myo-inositol is required to ensure healthy oocyte (immature egg) maturation in the ovary (17).

So it is no wonder, then, that research has found myo-inositol to be beneficial to women with PCOS! One study found that after just 12 weeks of myo-inositol supplementation, there were improvements to insulin levels and LH/FSH levels, with both being significantly reduced. (These markers can be a potential signal of fertility challenges when elevated.) Menstrual cycles also normalized (18).

In another study, myo-inositol supplementation was found to improve the number of good quality oocytes, clinical pregnancies, and delivery rates in overweight women with PCOS. Insulin sensitivity improved as well (19).

Additionally, there are many studies that have focused on the benefits of pairing myo-inositol and D-chiro-inositol to reduce insulin resistance and improve ovarian function in women with PCOS.

In one of these studies, a myo-inositol and D-chiro-inositol combination therapy was found to improve oocyte quality, embryo quality and pregnancy rates during in vitro fertilization (20).

In another study, the combined myo-inositol and D-chiro-inositol treatment was found to be better than myo-inositol alone at improving ovulation, endocrine and metabolic parameters (21). An additional study showed a significant improvement in insulin sensitivity as well as lipid profile in PCOS patients (22).

Besides metformin, myo-inositol is now considered a further insulin-sensitizing supplement which could benefit women with PCOS (23). Side effects that can occur with metformin have not been seen.

Interestingly, there is also a connection seen between women with PCOS as well as hypothyroidism. Perhaps this can be partly explained by shared root causes, such as both having blood sugar imbalances as well as having deficiencies in myo-inositol (resulting in a less than optimal inositol-dependent signaling pathway).

In one study, it was found that 22.5 percent of women with PCOS also had hypothyroidism, compared to just 8.75 percent in controls (24). The same authors also found TPO antibodies present in 27 percent of patients with PCOS versus 8 percent in controls. More recently, a study found a higher prevalence of Hashimoto’s, higher antibody levels and elevated TSH levels in PCOS patients (25).

In view of its recognized insulin-sensitizing activity, myo-inositol is used today to prevent and/or treat a number of metabolic disorders related to insulin resistance, such as metabolic syndrome, gestational diabetes mellitus and PCOS.

The Anxiety, Depression, OCD and Mood Connection to Hashimoto’s

Research has shown that anxiety, depression, mood fluctuations, OCD behaviors and a general feeling of being “unwell” are early signs of an autoimmune attack on the thyroid, and can be correlated to thyroid antibodies, even when the TSH level is still “normal”.

Many new clients come to me after being prescribed anxiety and mood related medications, including SSRIs (Selective Serotonin Reuptake Inhibitors), lithium, antipsychotics, dopamine, and benzodiazepines. They don’t feel well, and may have other thyroid symptoms, but in many cases are still being told their TSH level is normal, so their thyroid is fine (oh, and “just keep taking those anxiety meds!”). Sometimes the term hypochondriac is thrown about. I’ve had way too many clients who were told they were bipolar, when in fact the thyroid was out of balance.

Yet, there is research that concludes with the recommendation that people presenting with these types of psychiatric symptoms be initially screened for underlying thyroid issues (26).

Anxiety and mood disorders are very common thyroid symptoms. A study in 2004 found that there is an association between the presence of an anxiety or mood disorder and the presence of TPO antibodies. (You can read more about mood disorders and Hashimoto’s.)

The most common type of anxiety disorder reported in people with thyroid antibodies is obsessive-compulsive disorder (OCD).

I myself used to have issues relating to OCD (which interestingly is very common in pharmacists and those with Type A personalities like yours truly!) and anxiety, which seemed to rear their ugly heads when my Hashimoto’s was least controlled by diet and other interventions.

But, I have seen the positive effects of successful interventions (like removing reactive foods, reducing stress, and treating streptococcal based gut imbalances which have been tied to OCD — but this is a post for another day), as well as addressing various nutrient deficiencies. Two that I recommend most often, relating to OCD, are selenium and myo-inositol.

Several studies have found that daily treatment with inositol resulted in improvements to OCD (measured as a reduction on the Yale-Brown Obsessive-Compulsive Scale) (27).

In one small study, thirteen patients with obsessive-compulsive disorder were given either 18 g of inositol or a placebo, daily, for 6 weeks. The subjects had significantly lower scores on the Yale-Brown Obsessive-Compulsive Scale when taking inositol. The authors concluded that inositol is effective for depression, panic, and obsessive-compulsive disorders, a spectrum of disorders responsive to selective serotonin reuptake inhibitors (28).

Just like myo-inositol regulates TSH, FSH and glucose uptake, research has shown that it may be involved in the modulation of serotonin uptake, too (29). I think it is a much more natural solution to anxiety and OCD behaviors versus some of the psychiatric prescription medications that so many people are on today!

Along with anxiety and OCD, depression is also associated with Hashimoto’s.

In a meta-analysis done comprised of 19 studies, with a total of 36,174 participants (34,094 for anxiety and 35,168 for depression), patients with AIT (autoimmune thyroiditis), subclinical hypothyroidism, or overt hypothyroidism had significantly higher scores on standardized depression and anxiety tests. The authors concluded that patients with AIT exhibit an increased chance of developing symptoms of depression and anxiety or receiving a diagnosis of depression and anxiety disorders (30).

The study found that approximately 23.8 percent of patients with AIT experience depression, and approximately 41.6 percent of patients with AIT experience anxiety disorders.

To learn more about depression and Hashimoto’s, please see my article.

It makes sense that mood swings, anxiety, OCD and even depression can be so intertwined with Hashimoto’s. Fluctuating thyroid hormone levels (due to any number of root causes), stressed out adrenals, and even the autoimmune process itself can be common culprits. The good news is there are a lot of interventions that can help, including addressing the nutrient deficiencies and blood sugar balancing issues we’ve been discussing.

One other strategy that I often discuss with clients having these types of anxiety and mood related symptoms is changing up their thyroid medication to a T3-containing medication like Nature-Throid, WP Thyroid, Armour, or compounded T4/T3. In my survey of Root Cause readers, around 60 percent reported improved mood after switching to a T3-containing medication.

Recommended Dosage and Precautions

Given the research and the results in my own clinical practice, I typically recommend that people with Hashimoto’s try supplements such as selenium and myo-inositol. Generally, you do not need to test your own levels of these nutrients. They have been shown to be safe (with noted precautions) in the research, so my philosophy is to try them and see if they result in improvements.

I recommend taking 700 mg daily of the Rootcology Myo-Inositol Powder, which contains the myo-inositol form, for reducing TSH and thyroid antibodies (ideally, in conjunction with selenium). As a side bonus, if you are trying to replace sugar or other sweeteners in your tea or coffee, myo-inositol has half of the sweetness of table sugar and may just do the trick for you. However, varying doses may be needed for helping to address other conditions.

Myo-inositol should not be taken by people who have kidney disease or who may be already taking supplements such as Cleavers (a diuretic herb) that can affect the kidneys or the lymphatic system. Myo-inositol may not be properly cleared when the kidneys are overworked, such as in kidney disease or while taking diuretics.

Myo-inositol is also not recommended if you are pregnant or lactating. People with diabetes taking myo-inositol should watch for signs of low blood sugar (hypoglycemia), as myo-inositol may lower blood sugar and hemoglobin A1c levels.

Rarely, myo-inositol has been associated with nausea, headaches, dizziness or fatigue. If you experience these effects, then I’d discontinue taking it.

As always, I suggest you work with a good functional medicine practitioner and consult with him or her before trying myo-inositol. If you are on psychiatric medications, please do not go off of them without working with the prescribing practitioner.

What You Can Do Today

If you have Hashimoto’s, you likely have one or more nutrient deficiencies. And while it’s important to investigate and correct any underlying root causes (such as food sensitivities, blood sugar imbalances or gut issues), in the meantime, myo-inositol supplementation could help you feel better.

Remember, much of the research relating to Hashimoto’s has shown myo-inositol can increase the effectiveness of selenium. Both have been found to reduce thyroid antibodies and help reduce anxiety. Myo-inositol has also been shown to reduce TSH levels and balance blood sugar, as well as help with depression, mood swings and OCD. It can encourage a healthy mood, emotional wellness and less stressful behaviors.

For those with PCOS, myo-inositol may help to support a healthier reproductive system, as well as improve ovulatory function.

Even those who haven’t yet been diagnosed with thyroid disease, due to having a “normal” TSH level, could still have thyroid antibodies, and I recommend testing for those. It is easy and inexpensive, and antibody testing provides you with “early warning” information that can help you prevent further damage to your thyroid. Remember, you can have thyroid antibodies for years – even a decade – prior to testing abnormal for TSH.

I hope this helps you on your healing journey! Let me know how taking myo-inositol and selenium together works for you.

Looking for more info? Supplements can help or hurt your thyroid! Download my FREE eBook to learn about safe and effective supplements that can help your thyroid symptoms naturally.

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References

1. Unfer V, Facchinetti F, Orrù B, Giordani B, Nestler J. Myo-inositol effects in women with PCOS: a meta-analysis of randomized controlled trials. Endocrine Connections. 2017;6(8):647-658. doi:10.1530/EC-17-0243.
2. Dinicola S, Minini M, Unfer V, Verna R, Cucina A, Bizzarri M. Nutritional and Acquired Deficiencies in Inositol Bioavailability. Correlations with Metabolic Disorders. International Journal of Molecular Sciences. 2017;18(10):2187. doi:10.3390/ijms18102187.
3. Formuso C, Stracquadanio M, Ciotta L. Myo-inositol vs. D-chiro inositol in PCOS treatment. Minerva Ginecol. 2015 Aug;67(4):321-5.
4. Berdanier C. Is Inositol an essential nutrient? Nutrition Today. 1992.
5. Dinicola S, Minini M, Unfer V, Verna R, Cucina A, Bizzarri M. Nutritional and Acquired Deficiencies in Inositol Bioavailability. Correlations with Metabolic Disorders. International Journal of Molecular Sciences. 2017;18(10):2187. doi:10.3390/ijms18102187.
6. De Leo V, Musacchio M, Cappelli C, et al. Genetic, hormonal and metabolic aspects of PCOS: an update. Reproductive Biology and Endocrinology. 2016;14:38. Doi: 10.1186/x12958=016-0173-x.
7. Dinicola S, Minini M, Unfer V, Verna R, Cucina A, Bizzarri M. Nutritional and Acquired Deficiencies in Inositol Bioavailability. Correlations with Metabolic Disorders. International Journal of Molecular Sciences. 2017;18(10):2187. doi:10.3390/ijms18102187.
8. Nordio M, Pajalich R. Combined Treatment with Myo-Inositol and Selenium Ensures Euthyroidism in Subclinical Hypothyroidism Patients with Autoimmune Thyroiditis. Journal of Thyroid Research. 2013;2013:424163. doi:10.1155/2013/424163.
9. Nordio M, Pajalich R. Combined Treatment with Myo-Inositol and Selenium Ensures Euthyroidism in Subclinical Hypothyroidism Patients with Autoimmune Thyroiditis. Journal of Thyroid Research. 2013;2013:424163. doi:10.1155/2013/424163.
10. Nordio M, Basciani S. Treatment with Myo-Inositol and Selenium Ensures Euthyroidism in Patients with Autoimmune Thyroiditis. International Journal of Endocrinology. 2017;2017:2549491. doi:10.1155/2017/2549491.
11. Ceyhun V, Tezcan K, Perihan V, et al. Insulin resistance in the patients with euthryroid Hashimoto thyroiditis. Biomedical Research. 2017;28(4).
12. Unfer V, Nestler JE, Kamenov ZA, Prapas N, Facchinetti F. Effects of Inositol(s) in Women with PCOS: A Systematic Review of Randomized Controlled Trials. International Journal of Endocrinology. 2016;2016:1849162. doi:10.1155/2016/1849162.
13. Unfer V, Facchinetti F, Ora B, Giordani B, Nestler J. Myo-inositol effects in women with PCOS: a meta-analysis of randomized controlled trials. Endocrine Connections. 2017;6(8):647-658. doi:10.1530/EC-17-0243.
14. DeUgarte CM, Bartolucci AA, Azziz R. Prevalence of insulin resistance in the polycystic ovary syndrome using the homeostasis model assessment. Fertil Steril. 2005 May;83(5):1454-60.
15. Nestler JE. Role of hyperinsulinemia in the pathogenesis of the polycystic ovary syndrome, and its clinical implications. Seminars in Reproductive Endocrinology. 1997;15(2):111–122. doi: 10.1055/s-2007-1016294.
16. Unfer V, Carlomagno G, Papaleo E, Vailati S, Candiani M, Baillargeon JP. Hyperinsulinemia alters myoinositol to d-chiroinositol ratio in the follicular fluid of patients with PCOS. Reproductive Sciences. 2014;21(7):854–858. doi: 10.1177/1933719113518985
17. Kalra B, Kalra S, Sharma JB. The inositols and polycystic ovary syndrome. Indian Journal of Endocrinology and Metabolism. 2016;20(5):720-724. doi:10.4103/2230-8210.189231.
18. Genazzani AD, Lanzoni C, Ricchieri F, et al. Myo-inositol administration positively affects hyperinsulinemia and hormonal parameters in overweight patients with polycystic ovary syndrome. Gynecol Endocrinol. 2008 Mar:24(3):139044 doi: 10.1080/09513590801893232.
19. Kalra B, Kalra S, Sharma JB. The inositols and polycystic ovary syndrome. Indian Journal of Endocrinology and Metabolism. 2016;20(5):720-724. doi:10.4103/2230-8210.189231.
20. Colazingari S, Treglia M, Najjar R, Bevilacqua A. The combined therapy myo-inositol plus D-chiro-inositol, rather than D-chiro-inositol, is able to improve IVF outcomes: Results from a randomized controlled trial. Arch Gynecol Obstet. 2013;288:1405–11.
21. Nordio M, Proietti E. The combined therapy with myo-inositol and D-chiro-inositol reduces the risk of metabolic disease in PCOS overweight patients compared to myo-inositol supplementation alone. Eur Rev Med Pharmacol Sci. 2012;16:575–81.
22. Minozzi M, Nordio M, Pajalich R. The combined therapy myo-inositol plus D-Chiro-inositol, in a physiological ratio, reduces the cardiovascular risk by improving the lipid profile in PCOS patients. Eur Rev Med Pharmacol Sci. 2013 Feb;17(4):537-40.
23. Unfer V, Facchinetti F, Ora B, Giordani B, Nestler J. Myo-inositol effects in women with PCOS: a meta-analysis of randomized controlled trials. Endocrine Connections. 2017;6(8):647-658. doi:10.1530/EC-17-0243.
24. Sinha U, Sinharay K, Saha S, Longkumer TA, Baul SN, Pal SK. Thyroid disorders in polycystic ovarian syndrome subjects: A tertiary hospital based cross-sectional study from Eastern India. Indian Journal of Endocrinology and Metabolism. 2013;17(2):304-309. doi:10.4103/2230-8210.109714.
25. Singla R, Gupta Y, Khemani M, Aggarwal S. Thyroid disorders and polycystic ovary syndrome: An emerging relationship. Indian Journal of Endocrinology and Metabolism. 2015;19(1):25-29. doi:10.4103/2230-8210.146860.
26. Heinrich TW, Grahm G. Hypothyroidism Presenting as Psychosis: Myxedema Madness Revisited. Primary Care Companion to The Journal of Clinical Psychiatry. 2003;5(6):260-266.
27. Carey PD, Warwick J, Harvey BH, et al. Single photon emission computed tomography (SPECT) in obsessive-compulsive disorder before and after treatment with inositol. Metab Brain Dis. 2004 Jun;19(1-2):125-34.
28. Fux M, Levine J, Aviv A, Belmaker RH. Inositol treatment of obsessive-compulsive disorder. American Journal of Psychiatry. 1996;153:1219-1221. https://doi.org/10.1176/ajp.153.9.1219
29. Mukai T, Kishi T, Matsuda Y, et al. A meta-analysis of inositol for depression and anxiety disorders. Hum Psychopharmacol. 2014 Jan;29(1):55-63. doi: 10.1002/hup.2369.
30. Siegmann E, Müller HHO, Luecke C, Philipsen A, Kornhuber J, Grömer TW. Association of Depression and Anxiety Disorders With Autoimmune Thyroiditis A Systematic Review and Meta-analysis. JAMA Psychiatry. 2018;75(6):577–584. doi:10.1001/jamapsychiatry.2018.0190