|Year : 2016 | Volume
| Issue : 2 | Page : 63-66
Serum thyroid stimulating hormone levels and suicidal tendency in patients with first-episode schizophrenia: An exploratory study
Amresh Shrivastava1, Vidya Jadhav2, Sagar Karia3, Nilesh Shah4, Avinash De Sousa4
1 Consultant Psychiatrist, University of Western Ontario, Ontario, Canada
2 Research Assistant, Desousa Foundation, Mumbai, Maharashtra, India
3 Specialty Medical Officer; Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Sion, Mumbai, Maharashtra, India
4 Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Sion, Mumbai, Maharashtra, India
|Date of Web Publication||1-Jun-2016|
Dr. Avinash De Sousa
Carmel, 18, St. Francis Road, Off SV Road, Santacruz West, Mumbai - 400 054, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Neuroendocrine hormones play an important role in emotional regulation in normal individuals and those suffering from mental disorders. The objective of the study was to examine levels of thyroid stimulating hormone (TSH) and the severity of psychopathology and suicidality in patients suffering from first episode schizophrenia (FES). Materials and Methods: In 60 patients of FES, the level of TSH was measured. The level of psychopathology was assessed using the positive and negative symptoms scale for schizophrenia (PANSS) while suicidal tendency was measured using The Scale for Impact of Suicidality-Management, Assessment, and Planning of Care (SIS-MAP). Results: We found that 21% patients were hospitalized with a suicide attempt within preceding 5 days. Mean TSH level was 5.7 mIU/L, which was slightly higher than cut-off point. There was no significant difference in TSH levels between those who had attempted suicide before the admission into the hospital and those who did not. Further, the level of TSH was not found to correlate with total PANSS score, positive symptoms or negative symptoms score but with global psychopathology scale. There was a positive correlation with TSH score and SIS-MAP score. Conclusions: The present study shows the presence of higher level of TSH in FES and an inverse correlation with suicide potential in patients suffering from schizophrenia. Further, it shows the presence of high suicide risk and possibility of hypothyroid state. The study argues more careful screening for suicide in patients with FES among patients who are admitted without and the attempt of suicide.
Keywords: First episode schizophrenia, suicidal, thyroid, thyroid stimulating hormone
|How to cite this article:|
Shrivastava A, Jadhav V, Karia S, Shah N, De Sousa A. Serum thyroid stimulating hormone levels and suicidal tendency in patients with first-episode schizophrenia: An exploratory study. Thyroid Res Pract 2016;13:63-6
|How to cite this URL:|
Shrivastava A, Jadhav V, Karia S, Shah N, De Sousa A. Serum thyroid stimulating hormone levels and suicidal tendency in patients with first-episode schizophrenia: An exploratory study. Thyroid Res Pract [serial online] 2016 [cited 2019 Oct 23];13:63-6. Available from: http://www.thetrp.net/text.asp?2016/13/2/63/183277
| Introduction|| |
Schizophrenia is a complex neurobiological disorder with involvement of the neurochemical and neuroendocrine system in its pathogenesis. However, exact role of thyroid hormone in the pathophysiology of schizophrenia is not well known. High, low as well as normal levels of thyroid hormone are well documented in both drugs naïve and medicated patients with schizophrenia, particularly those on antipsychotics and antidepressants drugs. Elevated and normal total T4 levels are seen in drug-naive and acute schizophrenia and are known to normalize or decrease, respectively, response to treatment with different drugs.,, Some other studies have reported a positive correlation between circulating free T4 and free T3 with the severity of schizophrenia. Some studies show that thyroid levels may have predictive value for future attempts of suicide. Unusually, high rates of suicide (8–13%) are seen in the early phase of schizophrenia, its prodromal phase and in ultrahigh-risk candidates for psychosis.,,
Thus, it appears that thyroid hormone is intricately related to the neurobiology of psychosis-depression and suicide. However, the nature of the relationship remains quite obscure. This study examines the role of thyroid hormones in the early phase of schizophrenia, particularly in relation to suicide attempt based on the hypothesis that low level of thyroid stimulating hormone (TSH) observed is associated with psychosis and the relationship between suicidal behavior and hypothalamic-pituitary-thyroid axis abnormalities.
| Materials and Methods|| |
This was a cross-sectional cohort study carried out at a Mental Health Care Centre wherein consenting patients were recruited as per the inclusion criteria of age between 18 and 30 years, diagnosis of the first episode schizophrenia (FES) as per Diagnostic and Statistical Manual for the Classification of Psychiatric Disorders IV criteria. The exclusion criteria consisted of the presence of any endocrinal, neurological, cardiovascular, preexisting thyroid dysfunction, diabetes, head trauma or any other organic factor, presence of polysubstance abuse (patients having a history of cannabis abuse were not excluded) and pregnancy and lactation, and postpartum phase.
Levels of TSH were done after the patients' florid state of psychosis had subsided. TSH level was obtained from routine blood work, and a cut-off of 5 ng/ml was taken to define abnormal and normal values. Psychopathology was assessed by positive and negative symptoms scale for schizophrenia. The severity of suicide was assessed by a suicide assessment scale, which was locally developed and validated (The Scale for Impact of Suicidality-Management, Assessment, and Planning of Care [SIS-MAP]). This scale classifies severity into three categories, depending upon the total score of 0–17 which is mild, 18–32 which is moderate, and more than 33 which is severe.
| Results|| |
Patients' characteristics of those participating in the study are described in [Table 1]. It was found that 13 (21%) patients of 60 were hospitalized with a suicide attempt within preceding 5 days. Mean TSH level was 5.7 ng/ml which was slightly higher than cut-off point. There was no significant difference in TSH levels between those who had attempted suicide and those who did not, before the admission into the hospital. The patients had meant suicidality score of 26.9, which is within the range of mild to moderate severity of suicidality. Interestingly, there was no significant difference in the severity of suicidality between those who had attempted suicide and those who did not [Table 1] and [Table 2]. A further level of TSH was not found to correlate with positive symptoms, or negative symptoms score but only with global psychopathology scale [Table 3].
|Table 2: Scale for Impact of Suicidality-Management, Assessment, and Planning of Care score in sample|
Click here to view
|Table 3: Correlations between disease severity and thyroid stimulating hormone|
Click here to view
TSH level which was higher than normal in the sample of FES and showed a positive correlation with total suicidality score indicating that more the TSH level, suicidality increased [Figure 1].
|Figure 1: Correlation between Scale for Impact of Suicidality-Management and thyroid stimulating hormone levels|
Click here to view
| Discussion|| |
This study showed three important findings the first being that though thyroid value has poor statistical significance there is a definite difference between the two groups. Second that there was a trend between suicidality and thyroid levels and that those patients who did not attempt suicide have several characteristics of risk for suicide and, therefore, should be managed with caution. Though there was no significant correlation with severity of psychosis, positive or negative symptoms, there is a difference between TSH levels among those who did not attempt suicide and those who attempted. Similarly, more subjects have abnormal TSH among those who attempted suicide (69.6%) than among these who did not (59.6%).
The severity of psychopathology in patients without a suicide attempt was similar to the severity among those who attempted suicide. Further, TSH was also not significantly different between the two groups of attempted and nonattempted suicide. The second important finding was the presence of a mild level of suicidality. SIS-MAP score of about 28 which represents the moderate severity of risk in the patients of early psychosis. SIS-MAP score was also relatively higher (score of 28) though without statistical significance, among the patients who were admitted without any suicide attempt than among those who made an attempt. This indicates that patients who did not attempt suicide also had a moderately higher level of risk for suicide.
Though suppressed thyroid hormone in psychosis has been documented earlier,, it is difficult to make this inference for the present study whether it was due to florid psychosis or an effect of antipsychotic drugs. The possibility of a hypothyroid state in prepsychotic state also cannot be ruled out. Though apparently this finding does not appear to be of much significance, in about 40% patients TSH was normal, and a significant number of patients did not attempt suicide, if these are the same patients who had normal TSH without a suicide attempt in early psychosis, then it would be an argument to investigate this relationship further to examine where normal or high TSH level can indicate presence of risk for suicide in early psychosis.
Elevated TSH in 60% subjects also indicates the possibility of depression in psychosis which is widely known in schizophrenia in about 30–70% subjects. The presence of mild suicidality in a group of hospitalized patients of psychosis is understandable in view of significant suicide risk in the early phase of schizophrenia admitted with attempted suicide. It is interesting to note that, though statistically insignificant, suicidality score was mildly lower among those who were admitted with attempted suicide. Relief in mental pain after an attempt is one of the known processes for relieving the stress of self-harm. Moderately high risk of suicide (P = 0.436) suggested the presence of suicide risk in the inpatients who did not attempt suicide. Overall suicide rate remains high in this phase. Our study shows 44 out of 60 in the total sample, 36 out of 47 who did not attempt suicide and 8 out of 13 who attempted suicide with a high risk of suicide. This suggests the need for more careful screening for suicide potential among the early psychosis group of patients.
A trend of lower TSH, i.e., a hypothyroid state correlated with high suicidality seen in our study confirms the observation of link of thyroid hormone with mood state and depression. In literature, this has been well explained. Relationship of thyroid hormone and melancholia is known since a long time. It is also been explained neurologically. Though in our study there was no statistical correlation between gender and TSH, generally hypothyroid state is more common among females. This again supports the assertion that there may be a relationship between TSH-depression-suicide and psychosis possibly because of the involvement of TSH in emotional regulation.
| Conclusion|| |
To conclude, the present study shows the presence of higher level of TSH in early psychosis and an inverse correlation with suicide potential in patients suffering from schizophrenia. Further, it shows the presence of high suicide risk and possibility of hypothyroid state. The study argues more careful screening for suicide in patients with early psychosis among patients who are admitted without and the attempt of suicide.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bauer M, Whybrow PC. Thyroid hormone, neural tissue and mood modulation. World J Biol Psychiatry 2001;2:59-69.
Duval F, Mokrani MC, Monreal-Ortiz JA, Fattah S, Champeval C, Schulz P, et al.
Cortisol hypersecretion in unipolar major depression with melancholic and psychotic features: Dopaminergic, noradrenergic and thyroid correlates. Psychoneuroendocrinology 2006;31:876-88.
Bunevicius R. Thyroid disorders in mental patients. Curr Opin Psychiatry 2009;22:391-5.
Valdivieso FS, Kripper C, Ivelic JA, Fardella C, Gloger S, Quiroz D. High prevalence of thyroid dysfunction among psychiatric inpatients. Rev Med Chil 2006;134:623-8.
Sim K, Chong SA, Chan YH, Lum WM. Thyroid dysfunction in chronic schizophrenia within a state psychiatric hospital. Ann Acad Med Singapore 2002;31:641-4.
Othman SS, Abdul Kadir K, Hassan J, Hong GK, Singh BB, Raman N. High prevalence of thyroid function test abnormalities in chronic schizophrenia. Aust N
Z J Psychiatry 1994;28:620-4.
Hor K, Taylor M. Suicide and schizophrenia: A systematic review of rates and risk factors. J Psychopharmacol 2010;24 4 Suppl: 81-90.
Siris SG. Suicide and schizophrenia. J Psychopharmacol 2001;15:127-35.
Rich CL. Endocrinology and suicide. Suicide Life Threat Behav 1986;16:301-11.
American Psychiatric Association. Diagnostic and Statistical Manual for the Classification of Psychiatric Disorders – 4th
edition (DSM-IV). Washington DC. American Psychiatric Publishing; 1994.
Kay SR, Fiszbein A, Opler LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull 1987;13:261-76.
Nelson C, Johnston M, Shrivastava A. Improving risk assessment with suicidal patients: A preliminary evaluation of the clinical utility of The Scale For Impact Of Suicidality – Management, Assessment and Planning of Care (SIS-MAP). J Clin Psychol Pract 2010;1:19-26.
Baumgartner A, Pietzcker A, Gaebel W. The hypothalamic- pituitary-thyroid axis in patients with schizophrenia. Schizophr Res 2000;44:233-43.
Kelly DL, Conley RR. Thyroid function in treatment-resistant schizophrenia patients treated with quetiapine, risperidone, or fluphenazine. J Clin Psychiatry 2005;66:80-4.
Palha JA, Ruano D, Santos NC. Circulating thyroid hormones in schizophrenia. San Diego, California, USA: Society for Neurosciences; 2010.
Strawn JR, Ekhator NN, D'Souza BB, Geracioti TD Jr. Pituitary-thyroid state correlates with central dopaminergic and serotonergic activity in healthy humans. Neuropsychobiology 2004;49:84-7.
Dean B, Boer S, Gibbons A, Money T, Scarr E. Recent advances in postmortem pathology and neurochemistry in schizophrenia. Curr Opin Psychiatry 2009;22:154-60.
Nordentoft M. Crucial elements in suicide prevention strategies. Prog Neuropsychopharmacol Biol Psychiatry 2011;35:848-53.
Esposito S, Prange AJ Jr., Golden RN. The thyroid axis and mood disorders: Overview and future prospects. Psychopharmacol Bull 1997;33:205-17.
[Table 1], [Table 2], [Table 3]