It tears hearts to read of medics saying that TSH is too low, and allowing T4 and T3 levels to be low when the consequences can be so dreadful. Not just the end-point, but the painful road that has been followed.
Medicina (Kaunas). 2021 Jul 15;57(7):714.
doi: 10.3390/medicina57070714.
Association of Thyroid Function with Suicidal Behavior: A Systematic Review and Meta-Analysis
Thyroid disease is a very common condition that influences the entire human body, including cognitive function and mental health. As a result, thyroid disease has been associated with multiple neuropsychiatric conditions. However, the relationship between thyroid dysfunction and suicide is still controversial. We conducted a systematic review and meta-analysis to describe the association of thyroid function with suicidal behavior in adults. We searched four data bases (MEDLINE, EMBASE, PsycINFO, and Scopus) from their inception to 20 July 2018. Studies that reported mean values and standard deviation (SD) of thyroid hormone levels [Thyroid-stimulating hormone (TSH), free thyroxine (FT4), free triiodothyronine (FT3), total thyroxine (TT4), and total triiodothyronine (TT3)] in patients with suicidal behavior compared with controls were included in this meta-analysis. The abstracts and papers retrieved with our search strategies were reviewed independently and in duplicate by four reviewers for assessment of inclusion criteria and data extraction, as well as for evaluation of risk of bias. Random-effects models were used in this meta-analysis to establish the mean difference on thyroid function tests between groups. Overall, 2278 articles were identified, and 13 studies met the inclusion criteria. These studies involved 2807 participants, including 826 participants identified with suicidal behavior. We found that patients with suicide behavior had lower levels of FT3 (-0.20 pg/mL; p = 0.02) and TT4 (-0.23 µg/dL; p = 0.045) compared to controls. We found no differences in either TSH, FT4, or TT3 levels among groups. With our search strategy, we did not identify studies with a comparison of overt/subclinical thyroid disease prevalence between patients with and without suicide behavior. The studies included in this meta-analysis had a low-to-moderate risk of bias. In the available literature, the evidence regarding the association of thyroid disorders and suicidal behavior is limited. We found that patients with suicidal behavior have significantly lower mean FT3 and TT4 levels when compared to patients without suicidal behavior. The clinical implications and pathophysiologic mechanisms of these differences remain unknown and further research is needed.
Very good point you make Helvella. So important that how a person FEELS physically and mentally should be what dictates treatment as well as test results
".. further research is needed" Meanwhile hypothyroidal people suffer terrible angst and some decide they've had enough.It seems to me that this "resesrch" is b.... y urgent and failure to a start prescribing on T3 results is at least negligent and probably reckless (we now have research evidence that there is a serious and obvious risk)
I'm surprised they could find enough cases who'd had their fT3 measured to do one study on ..let alone a systemic review and meta-analysis.
Looks like they must measure thyroid function much more thoroughly in Psychiatry departments than than they do in Endocrinology departments....
And it seems to provide yet another example of TSH alone being no use whatsoever for assessing the real state of a patient , and fT3 shedding much more light onto what it's really like for the patient to live in that body.
From the full text;
4. Discussion
In this systematic review and meta-analysis, we found that patients with suicidal behavior have lower levels of FT3 and TT4 compared with controls, but we found no difference in TSH, FT4, or TT3 levels. Furthermore, the subgroup of patients with history of suicide attempt had lower FT3 and FT4 levels, and higher TSH levels compared to controls.
This study represents the first summary about the relationship between suicidal behavior with thyroid function.
Our results are in line with previously published evidence regarding the risk/association of thyroid disorders with suicide behavior [10,30,31]. Heiberg-Brix et al. found that patients with Hashimoto’s thyroiditis had an increased frequency of death by suicide (HR = 1.31; 95% CI, 1.04–1.65, p = 0.024) compared to euthyroid controls in a register-based Danish study [10]. In contrast, this frequency is not increased in patients with Graves’ disease compared to controls without Graves’ disease or euthyroid controls from the general population [32,33]. According to these findings, suicide possibly has a stronger association with autoimmune hypothyroidism rather than autoimmune hyperthyroidism. Similar results have been reported for suicidal attempt/ideation and thyroid disorders. A cross-sectional study showed that the prevalence of hypothyroidism in a group of 31 patients with bipolar disorder and suicide attempt was higher (25.8%) compared with a prevalence of 15.9% in a group of 63 patients with bipolar disorder with no suicide attempt [30]. Sanna et al. reported a 6.5% prevalence of thyroid disorders in males with history of suicidal ideation, compared with a 1.9% prevalence in males without history of suicidal ideation [31]. Nevertheless, these results should be analyzed carefully as all these studies are observational with relatively small sample size and analyses are not adjusted for confounders.
The development of suicide, depression, and other affective disorders has been previously associated with autoimmune diseases, including thyroid-specific diseases [10,34,35,36]. In a meta-analysis published by Siegmann et al., patients with Hashimoto thyroiditis and either subclinical or overt hypothyroidism showed significantly higher scores on standardized depression instruments compared to euthyroid controls [37]. A second meta-analysis published in 2019, found that patients with subclinical hypothyroidism had higher risk of depression than euthyroid controls. However, there was no difference in the mean TSH level between individuals with depression and healthy controls [38].
Although the majority of patients with depression and other mood disorders have completely normal thyroid function tests, several test abnormalities have been described including elevated TT4 levels, low TT3 and FT3 levels, blunted TSH response to thyrotropin-releasing hormone, and positive antithyroid antibodies [36,39,40,41,42,43,44,45].
Interestingly, thyroid hormone in the form of liothyronine has been used for the treatment of depression, mainly as an augmentation therapy in severe forms of depression [46,47,48,49].
In addition, in the setting of suicidal behavior, there is evidence suggesting that thyroid hormones might have a role in the regulation of the neurotransmitters involved in suicide pathogenesis, such as serotonin and norepinephrine [50,51,52,53].
As demonstrated by our results, where most of the participants had concomitant affective disorders (depression or bipolar disorder) or schizophrenia, patients with suicidal behavior had significantly lower levels of FT3 and TT4, albeit not clinically meaningful, when compared with the control group.
To our knowledge, this is the first systematic review and meta-analysis of available evidence evaluating the relationship between suicide and thyroid function tests. There were some limitations to our study. First, due to the observational nature of all the studies included in this meta-analysis, it was not possible to establish causality. Second, although we used clear and standardized inclusion criteria and comprehensive search strategies, there remains possible sources of bias such as incomplete searching, publication bias, and the influence of confounding factors (current therapies, psychiatric comorbidities, environmental factors, etc.) in our results. Third, there was heterogeneity of the criteria used to define suicide behavior in the included studies (based on clinical records, psychiatric assessment, self-reported, etc.) and the presence of other concomitant psychiatric diseases which can affect the risk of suicidal behavior. Importantly, suicide is a very complex phenomenon related to many mental health diagnoses and with a multitude of biological, psychological, and social variables which should be considered when interpreting our findings.
In my desperation and reading I found you could be prescribed T3 for depression more so than for thyroid probs. This didn’t seem fair. After all you will end up with psychiatric probs if you’ve got thyroid probs, they’ll just prefer to give you antidepressants though.
Am wondering if there’s some health misogyny going on here. We know men are far more likely to receive appropriate treatments for other conditions, such as clot busters for stroke etc. Are men more likely to get T3 for thyroid or depression? Also, re suicidal tendencies/thoughts - I think it would be good if the research looked at the wider family as well as the thyroid patient.
We know thyroid probs run in families. My 20 year old sister was never diagnosed with thyroid probs but she was a victim of untreated depression and suicide. Her death has been the main deterrent for myself when I have felt like giving up.
as i understand it, it's not at all easy to get T3 from psychiatrists... it's only allowed for what's termed 'treatment resistant depression' .. which presumably means you must have tried every other psychoactive drug (and not improved) first, and probably had some in-patient admissions etc. If it is actually prescribed more for that , than for thyroid , then i suspect it is a reflection of the massive scale of the mental health problems in the world.
The figures for male suicide (particularly 'young' men) are, i believe horrifyingly worse than female's, so perhaps that would explain it if there is more T3 used for males .. but a diagnosis of 'depression' won't get them any T3 .
I'm very sorry to hear about your sister... i've been close myself, a few years ago. but wouldn't do it for the same reasons .. i know only too well the lifelong impact suicide has on close friends /relatives left behind.
the following is not aimed specifically at you . it's a general observation, so please don't be offended..
..I think it must already be difficult enough for male thyroid patients who find their way to this forum... given that we are mostly female ....without having to keep reading posts that make them feel like we think they don't suffer as much as us , or have an easier time at the doctors. These things are very individual and none of us like being put in a box.
In my experience Doctors are just as capable of gaslighting/fobbing off men, as they are women and i'd like to think if i ended up with a predominently 'male' disease and went to a forum for help i wouldn't have to keep dealing with opinions about it being 'easier for a woman'
Thanks for posting helvella and I'm sure that quite a number of people may have taken their own life as they could no longer continue as their symptoms didn't resolve.
I assume, too, that doctors/endocrinologists could not restore the thyroid hormones to optimum - or did not want to - and told patients 'your tests are ok without checking the FT4 and FT3, especially if they were on levo alone.
This woman's life (as you know) was saved as she just had posted on the forum of her intent but she was able to consult with Dr Gordon Skinner in Glasgow as he also consulted in Glasgow as well as Birmingham.
This is very interesting. It accords with my experience, with increasing depression and suicidal thoughts as my undiagnosed thyroid disorder galloped out of control. These got even worse with treatment on Levothyroxine I never felt well on it, I was hugely disappointed to still feel terrible after two years of taking it, yet close relatives had made rapid and remarkable recoveries on it, it was utterly devastating to me, I knew there must be something wrong for it not to be working properly in my case. I began to search for help, as the suicidal thoughts began to swamp me. I felt my life was not worth living, I did not even feel human I felt like a thing, a miserable two dimensional waste of space the spark totally lost from life, it was dreadful. I came upon some interesting info. I discovered I still had options for treatment which really annoyed me as I had been told nothing of them by the NHS. I decided to try NDT because I felt had nothing to loose life was so utterly devoid of joy of any kind and I had formulated serious plans to kill myself. The forum here really helped and offered fantastic support, in fact I believe people on here saved my life . So I gave NDT a go, to miraculous result. The depression was banished and the suicidal thoughts evaporated, colour came back into my life and I felt whole again. There is no other explanation than the T3 in the NDT rectifying the serious lack of free T3 I had. I was told my levels were still abnormal, that one hormone was very low and I would just have to learn to live with feeling unwell by the thyroid nurse who sadly replaced the care of the consultant endocrinologist on my rocky road to “optimisation” and discharged me from their care, despite my complaints that I still did not feel at all well. They did aim for TSH of 0.2 - 0.5 but what good is that if your free T3 is rock bottom? What makes me mad is the total lie that that woman told me, they could have helped me but they or she chose not to. At that time one could get T3 on the NHS. I was lucky, I am glad I took control of my health and listened to wise people here. It’s awful to think that people do kill themselves because of poor management of thyroid disorder, which is completely avoidable. It’s shameful.
I’m taking this to the endo man in September. More ammo. I suspect he is thinking that I am better with low fT3 than a liothyronine prescription. 2 days off lio and back to levo only and I am exhausted after a 5 mile walk, generally more tired than previously and my mood has dropped. If I say this to endo man, no doubt he’ll reassure me that it’s my age and sex. I’m a 45 year old woman so that means I’m supposed to feel cr@p? Or he will suggest it is psychosomatic. Everyone knows that thyroid patients make it all up because self medicating, trying to obtain T3 on the dark web and arguing with endos and doctors is a great hobby and a fantastic way to make friends and meet people. To be fair, whilst I’m glad they’ve done the meta analysis, it is straight from The University of the Blinking Obvious…
Considering that levothyroxine (T4) is an inactive hormone and has to convert to liothyronine (T3), It is T3 that is the active thyroid hormone and is required by our millions of T3 receptor cells (brain and heart containing the most). Why don't the medical professionals know the very basic way of prescribing for us.
It seems that many GPs - even if they want to prescribe other than levothyroxine seem to be afraid that they will be reprimanded if they do so. Or they don't understand at all the purpose of a thyroid gland! That it permits our whole body to function as normal, from head to toe. Best of all we can be symptom-free and feel well again. It is great to feel well again.
The professionals seem afraid and I suspect they think they'd be pursued if something untoward happens to the patient. More likely it would be with too low a dose, rather than too high a dose.
I have to say I have had suicidal thoughts and this is with Graves and high T3 over range. The thoughts of killing myself have come and gone as my levels have fallen closer to range. To complicate matters I have PTSD so this mixed with feeling depressed and at points severe Graves has put my mental health at risk. To anyone reading these posts there is hope for u. Do not give up but reach out to the forum for advice on your levels and know there is always hope. NIKEGIRL
I don't know if it's " just " the treatment for hypothyroidism that sees many of us contemplating cancelling ourselves out.
I just feel totally disillusioned by the lack of understanding and deeply disappointed by the lack of concern shown when I was very unwell.
With some effort on my part and the help of this forum I have been able to get back on track for myself and now source my own full spectrum thyroid hormone replacement.
The " old " me is back, I now recognise myself in the mirror, and know what the electric kettle is for, and for want of better description, I am " back in the room " most of the time.
I was never " this ill " even when diagnosed with Graves Disease - which is said to be a life threatening disease, if not treated.
I was well on the AT drug but told it was too dangerous to stay on long term and that I would be having RAI the following year.
The whole treatment plan for Graves is back to front, there is no follow up after drinking the RAI - so having been through the system it hasn't solved anything for me other than make me more unwell.
Hypothyroidism is insidious by nature, slowly rubbing out the person's ability to function independently and when current thinking is closed to anything other than monotherapy with T4 - Levothyroxine and, likely, anti depressants shows a serious under valuation of people's health.
The restrictive treatment and guidelines for hypothyroidism are not fit for purpose and do not work for around 15% of those of us dealing with hypothyroidism.
Is it too much to ask that there is a rethink or a further guideline added, for those with AI thyroid disease and those who have lost their thyroid gland through surgery or RAI :
I now manage lingering Graves, thyroid eye disease and hypothyroidism :
But then maybe restoring a patient's health is not the main priority anymore.
I need to download and give to the last gp who asked if I felt like harming myself when I needed an increase in levo. Tsh was at the time 3.5 and I felt awful. All he wanted to do was give me antidepressants
The replies so far have been very much on point and moving.
I don't want to reply individually to every one of them - most of the replies stand on their own. But I do want to tell you how much I appreciate them.
Before posting, I'd had been unsure how it would be received. It is a tough read and a hard subject. Thank you.
Sometimes the hardest issues are the most important ones and all it takes is for someone to be brave enough to open up the subject matter for discussion. I have found this site to be amazing and this site and people here have embraced the difficult issues people face and i think that’s what makes it so amazing. I have felt nothing but live and support here so thank u to everyone in my Thyroid Family.
Helvella thank you for another and so very important points . Personally with my thyroid journey I found that Dr's have a hang up with numbers and TSH when it comes to thyroid dosing. Why doesn't it accure to Dr to take the patients well-being foremost into account?
Are you going to believe Lab results over over patients symptoms????
I was a recipient of being treated by lab results and ignored what my symptoms where .Only to end up having to have my thyroids removed for papilary cancer.
I fit the criteria as I have low t3 t4 and tsh one below range the other rock bottom indicating hypopituarism or secondary hypothyroidism...not getting taken seriously all tests come back by my doctors surgery as normal no action despite doing 3 private tests too...i am so ill and suffer depression and after a breakdown 6 years ago tried to end my life...still feel on the brink purely due to not being believed and my doctor won't refer me to an endo as even though my results are bottom of the range or below I'm apparently fine...quality of life is rubbish so suicide can seem a way out I can understand that
While good to see research into hypothyroidism and it’s effects, it is concerning to see a desktop study with no control group of healthy thyroid, but not in perfect health, people in such a sensitive area as suicidal tendency. In short is the hypothyroid community at greater risk than any other group of people with a complex chronic illness? We don’t need stigmatising, or indeed legislating against as high risk people.
Indeed. As their conclusions make clear: Future large, well conducted studies are needed to increase our confidence in the findings presented here, especially studies reporting the specific association of hypothyroidism/hyperthyroidism in this population, which can provide a better understanding, evaluation, and follow-up of patients with thyroid dysfunction and suicidal behavior.
This is a tough one. Everyone is different and has different needs, as we all know on this forum - what works for me might not work for the next person. I suspect some people with hypo may feel suicidal or depressed from the crappy treatment available from most doctors. I remember my first meeting with a new doctor. He knew I had hypo and I expressed that I was tired all the time. His response - ask me if I wanted SSRIs! I said, "I'm tired, not depressed!" My former brother-in-law took anti-depressants for over 20 years (not even really knowing what he taking) and ended up in a terrible state of health. It took him over three years, tons of tests and doctors to figure out what was going on and even longer to begin the return to health. Doctors hand them out like candy. Be very careful about taking them. While some people do need them - I would suspect most don't. Let's take care of ourselves (and each other here) as best we can! Bless you all.
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