Thyroid anxiety and depression

Have Depression or Anxiety? Get Your Thyroid Checked

Six weeks ago I woke up tired and depressed, as I have so often in the last year. All I wanted to do was go back to bed.

The negative intrusive thoughts began before my feet touched the floor.

You are so lazy, I thought to myself. You could never hold a REAL job. You can barely string together three sentences.

All I had to do that day was to crank out one quality blog before getting the kids from school, but every few paragraphs I needed to lie down.

Since I hadn’t been sleeping well for months and was used to feeling fatigued, I assumed my exhaustion and concentration problems were merely symptoms of my chronic depression.

But there was actually something more going on than depression.

“Your thyroid is not making enough thyroid hormone,” a new doctor told me over the phone that day. “That’s the first thing we have to work on, because low thyroid levels can affect a lot of things and make you feel very tired and depressed.”

As a physician who practices “functional medicine,” a science that engages the entire body to address the underlying causes of disease, she had taken a dozen vials of blood from me the week before as part of a comprehensive consultation.

What Are the Symptoms of a Thyroid Disorder?

The thyroid is a butterfly-shaped gland in the front of your neck that produces hormones that control how your body uses energy and a lot of other things, like body temperature and weight. When your thyroid is underactive (hypothyroidism), your symptoms might include:

  • Fatigue
  • Weight gain
  • Constipation
  • Fuzzy thinking
  • Low blood pressure
  • Bloating
  • Depression
  • Slow reflexes

When your thyroid is overactive (hyperthyroidism), symptoms include:

  • Anxiety
  • Insomnia
  • Weight loss
  • Diarrhea
  • High heart rate
  • High blood pressure

What Role Do Thyroid Levels Play in Mood Disorders?

The interesting thing is that I’ve had my thyroid levels checked for eight years now, ever since an endocrinologist spotted a tumor in my pituitary gland. However, not until a comprehensive lab test was done did a doctor suggest treatment for low levels of both T3 and T4 hormones.

According to the American Thyroid Association, more than 12 percent of the American population will develop a thyroid condition. Today an estimated 20 million Americans have some form of thyroid disease; however, 60 percent are unaware of their condition.

Many of those people will visit their primary care physician or a psychiatrist and report symptoms of depression, anxiety, fatigue, insomnia, and fuzzy thinking. They might receive a diagnosis of major depression, general anxiety, or bipolar disorder, and leave the doctor’s office with prescriptions for antidepressants, mood stabilizers, sedatives, or all three.

The drugs might help some of the symptoms abate, but the underlying illness will remain untreated.

Dana Trentini, a mother of two, was diagnosed with hypothyroidism the year following the birth of her first son in 2006. She was overwhelmed with fatigue. Her pregnancy weight was impossible to lose. Her hair began to fall out. And kidney stones landed her in the emergency room. She was treated by a leading endocrinologist and became pregnant again; however, her thyroid stimulating hormone (TSH) reached levels far above the recommended reference range for pregnancy, and she miscarried.

In October of 2012, she launched her blog, Hypothyroid Mom, to help educate others about thyroid disease. “The mission of Hypothyroid Mom is clear — to drive awareness,” she writes on her blog. “The Thyroid Federation International estimates there are up to 300 million people, mostly women, with thyroid dysfunction worldwide, yet over half are unaware of their condition.”

In January 2014, Everyday Health featured Hypothyroid Mom for Thyroid Awareness Month: “How Mom’s Thyroid Problems Can Hurt Baby.” It is Dana’s life mission to bring about universal thyroid screening in pregnancy. “I will save babies in memory of my lost child,” she writes.

A friend led me to her fascinating post “Mental Disorder or Undiagnosed Hypothyroidism?” In this post, she features a letter from one of her readers who was diagnosed with bipolar disorder and pumped full of meds, ready to undergo electroconvulsive therapy (ECT). The woman, Jana, writes: “Finally after four years of bipolar medications to the max, a close family member was diagnosed with hypothyroidism so my doctor tested me too. I have a family history of thyroid disease. I was diagnosed with hypothyroidism.”

And then Jana says something that makes me think all persons taking antidepressants and mood stabilizers should have their thyroid checked: “Every single time I attend a bipolar support group, I ask everyone if they are hypothyroid and every time half the people raise their hand and the other half have no clue what it is and they don’t know if they have been tested.”

Dana then highlights a few studies linking bipolar disorder, depression, and thyroid disease. As she mentions, the use of lithium to treat bipolar disorder complicates matters because the medication can itself cause thyroid problems. However, plenty of research points to the connection between bipolar disorder and thyroid disease even in those who aren’t medicated with lithium, as well as the connection between different kinds of mood disorders and hypothyroidism. Dana mentions these:

A study published in Biological Psychiatry found that Hashimoto’s thyroid antibodies were highly prevalent in a sample of outpatients with bipolar disorder as compared with a control group.

Another study in Biological Psychiatry compared bipolar twins with healthy twins and found that autoimmune thyroiditis is related not only to bipolar disorder itself, but to the genetic vulnerability to develop the disorder.

A study published in BMC Psychiatry found a link between thyroid autoimmunity, specifically the presence of thyroid peroxidase antibodies, and anxiety and mood disorders.

Another study published in BMC Psychiatry found that subjects with Hashimoto’s disease displayed high frequencies of lifetime depressive episodes, generalized anxiety disorders, social phobia, and primary sleep disorders.

For some people, thyroid treatment is straightforward and brings fast relief of symptoms. Mine has been more complicated because I take lithium for my bipolar disorder and I have a pituitary tumor. I’m extremely sensitive to medications that stimulate thyroid production: What should be a therapeutic dose for me causes insomnia. I am hopeful, however, that I will eventually find a solution.

If you suffer from depression, anxiety, or both, please get your thyroid checked. Read Dana’s post “Top 5 Reasons Doctors Fail to Diagnose Hypothyroidism.”

An underactive thyroid can make you feel depressed, fatigued, and fuzzy-brained. An overactive thyroid can cause anxiety and insomnia. If you fluctuate between the two, you will have symptoms similar to those of bipolar disorder.

Thyroid disease may very well be at the root of your problem.

Do you have one or more of the following symptoms?

  • Unexplained weight gain or loss
  • Swelling, puffiness
  • Low energy, depressed mood
  • Racing heart, anxiety
  • Lethargy, sleeplessness
  • Digestive disturbances, constipation or loose stools
  • Brain fog, forgetfulness
  • Aching muscles, cramps
  • Hair loss, thinning
  • Dry skin, brittle nails

If so, you could be among the nearly 200 million people worldwide1 (the majority of whom are women) who have some type of thyroid problem. If you also suffer from symptoms of depression, did you know that a normal thyroid test can be masking a critical link between these two conditions?

The Quiet Regulator

Most of us never think about our thyroids. Yet this butterfly-shaped, master gland regulates some of the most critical functions of the human body. From the production of hormones to regulating metabolism, the thyroid helps maintain healthy weight, overall immunity, and even regulates mood and memory functions. When one or more of these systems is disturbed, we must explore a possible connection to thyroid to avoid treating the symptoms while neglectinga the root cause.

Hyperthyroidism is a condition in which the thyroid gland produces too much thyroid hormone. Characterized by feelings of anxiety, a racing heart, bouts of insomnia, diarrhea, and weight loss, this is more rare than underactive thyroid, and has the potential to trigger heart and bone problems.

An underperforming thyroid, or hypothyroidism, is a condition in which the thyroid gland doesn’t produce enough thyroid hormone. Despite being incredibly common, hypothyroidism is one of the most under-diagnosed conditions in America. At least 20 percent of all women have an under responsive thyroid – yet only half of those women get diagnosed.

And the other half? For reasons I will explain, too many of these patients are given a clean bill of physical health, and a prescription for an antidepressant.

Are You Really a Mental Patient?

As a holistic psychiatrist, I often refer to psychiatric pretenders: physiological conditions that masquerade as symptoms of mental illness. In my experience, a vast majority of psychiatric symptoms are actually driven by thyroid dysfunction.

I’m not alone in these observations. Scientists like Dr. Mark S. Gold, a world-renowned addiction expert, have long known about the relationship between a dysfunctional thyroid and symptoms of depression.2 Through ongoing research, this correlation continues to be validated.3 So why the staggering number of missed diagnoses?

Missing the Diagnostic Mark

Symptoms of thyroid dysfunction can vary broadly, and unfortunately, are not easily pinpointed in the standard diagnostic exam. Complaints of low energy, flat mood, poor sleep, and appetite disturbance, are too easily hung on the nail of “depression”, for which an easy fix is applied – a prescription for antidepressant medication.

The standard medical test for thyroid, called TSH, measures thyroid stimulating hormone levels. Even when doctors perform this test, their interpretation of the clinical picture is limited by their biases. I speak from experience when I say that most physicians are simply not trained to diagnose thyroid imbalance properly. Where It Goes Wrong

TSH measures only one hormone in the blood, rather than the entire range of thyroid-produced hormones (of which there are five identified). And doctors rarely look at free hormone levels – levels of thyroid hormones in the blood that aren’t bound to proteins.

They also miss screening for thyroid antibodies, which would demonstrate an autoimmune component to the imbalance, distinguishing it from nutrient-deficiency thyroid dysfunction, for example. They apply a one-size-fits-all “fix” in the form of a synthetic hormone called Synthroid. The “gold-standard” thyroid treatment, Synthroid is the most prescribed drug on the market today.4

Thanks to growing awareness among sufferers, what constitutes a normal thyroid test result has come under scrutiny. Results may fall within normal range even when thyroid autoantibodies are grossly elevated and data suggests that this is relevant to those suffering from mood, anxiety, and cognitive complaints.

Current standards allow for a normal result within the range of 0.5 to 5.0. However, variations in laboratory testing as well as deviations by age, pregnancy, and other health factors, have allowed many patients at the fringes (and well beyond) to go undiagnosed.5

Thyroid’s Relationship with Adrenals

Any effort to resurrect thyroid function cannot afford to ignore the adrenal glands. Adrenals are small glands that sit over our kidneys. Through the production of hormones and neurochemicals, adrenals help us respond to life’s everyday demands.

When signalled by the brain, adrenals produce the stress hormone cortisol, which is intrinsically tied to thyroid functionality. This is key to why stress has a direct impact on thyroid and mood. Whether through overactive cortisol production (a state of chronic fight or flight), or the brain essentially shutting down cortisol secretion, patients who suspect thyroid dysfunction must test cortisol output throughout the day to see the big picture. When properly tested, thyroid patients often show abnormal adrenal output. The next question to ask is “Why?”

Adrenal Stress Factors

When we consider the potential stressors affecting adrenals, the following offenders stand out:

  • Birth control pills – Even with normal test readings, these synthetic hormones lower available thyroid hormone in the body by elevating thyroid-binding globulin. This protein binds to thyroid hormone in the bloodstream. When thyroid-binding globulin goes up, your thyroid levels go down.
  • Gluten – The thyroid contains proteins that resemble those found in gluten, confusing the immune system, which pounces on the thyroid like a foreign invader. Studies show people with celiac disease have three times the risk of thyroid dysfunction, as well as a strong association between untreated celiac disease and depression.
  • Fluoride – Once used to suppress overactive thyroid, fluoride interferes with multiple aspects of the thyroid’s tissues, disrupts normal hormone physiology, displaces iodine and depletes selenium, two critically essential elements for thyroid function. Recent research shows that fluoride in water increases risk of thyroid illness by 30 percent.6
  • Endocrine disruptors – Industrial and agricultural chemicals such as phthalates, flame retardants, and PCBs interfere with the thyroid’s biology. The resultant disruption can present as immune system hyperactivity, as well as disturbances in mood.

The Canary in the Coalmine

Connecting the dots between these physiological functions and mental health may seem convoluted and difficult at first, but not after you come to appreciate the direct, intimate relationship shared between these networks in the body.

The thyroid is a canary in the coalmine. In our fast-paced, nutrient-depleted world that’s filled with toxic substances, your thyroid gland may be the first to come under siege. While you may not feel the attack in your thyroid per se, you’ll feel it in your mood and cognition.

How to Test Effectively

If you suspect thyroid may be at the root of your depressed mood and physical symptoms, it’s important to be empowered by facts. The idea of your physiology working in tandem with your mental health isn’t something most doctors agree on, so be prepared to guide the process – or find a new doctor.

For starters, insist on testing (or order your own) beyond the standard TSH. The following breaks down my own testing protocol:v

  • Measure the full range of thyroid hormones in the blood, including thyroid antibodies. Test for TSH, T4, free T3 (FT3), reverse T3 (RT3).
  • Screen for the autoimmune disease, Hashimoto’s thyroiditis, by ordering thyroid peroxidase antibodies (TPOAb) and thyroglobulin antibodies (TgAb).
  • For optimal thyroid functioning, the pattern of cortisol output must be optimized. You may choose to test your salivary cortisol although this is why I don’t typically do this test with my own patients.

For help interpreting the results of these tests, I recommend connecting with an experienced functional medicine doctor or naturopath who has experience working with thyroid patients.

Safeguard Your Glands to Improve Your Mood!

I share the protocol that I have used to support hundreds of patients through their mental/health challenges in my book, A Mind of Your Own. This protocol includes the comprehensive testing I have outlined here, which goes far beyond the standard employed by traditional doctors. But these tests are just the beginning. The next steps are a series of diet and lifestyle adaptations that will begin to bring these critical systems back into balance.

Supporting a healthy thyroid is an exercise in holistic medicine. It starts with supporting the immune system so it doesn’t attack the body’s own tissues and manifest as symptoms of depression – and autoimmune disease. The healing journey continues with the awareness of what’s really going on in your body, and deepens as you become empowered by choices that support your vitality – mind, body and soul.

To learn more, check out A Mind of Your Own. For hands-on support with these lifestyle changes, explore the Vital Mind Reset.

  • 1 http://www.thyroid.ca/thyroid_disease.php
  • 2 https://www.researchgate.net/publication/16572953_Hypothyroidism–or_is_it_depression
  • 3 https://www.hindawi.com/journals/jtr/2012/590648/abs/
  • 4 http://www.webmd.com/drug-medication/news/20150508/most-prescribed-top-selling-drugs
  • 5 https://thyroidresearchjournal.biomedcentral.com/articles/10.1186/1756-6614-8-S1-A17
  • 6 https://medicalxpress.com/news/2015-02-fluoridation-england-linked-higher-underactive.html#nRlv
  • TSH cut off point based on depression in hypothyroid patients

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    Identifying hyperthyroidism’s psychiatric presentations

    Ms. A experienced an anxiety attack while driving home from work, with cardiac palpitations, tingling of the face, and fear of impending doom. Over the following 3 months she endured a “living hell,” consisting of basal anxiety, intermittent panic attacks, and agoraphobia, with exceptional difficulty even going to the grocery store.

    A high-functioning career woman in her 30s, Ms. A also developed insomnia, depressed mood, and intrusive ego-dystonic thoughts. These symptoms emerged 10 years after a subtotal thyroidectomy for hyperthyroidism (Graves’ disease).

    Hyperthyroidism’s association with psychiatric-spectrum symptoms is well-recognized (Box 1).1-4 Hyperthyroid patients are significantly more likely than controls to report feelings of isolation, impaired social functioning, anxiety, and mood disturbances5 and are more likely to be hospitalized with an affective disorder.6

    Other individuals with subclinical or overt biochemical hyperthyroidism self-report above-average mood and lower-than-average anxiety.7

    Ms. A’s is the first of three cases presented here to help you screen for and identify thyrotoxicosis (thyroid and nonthyroid causes of excessive thyroid hormone). Cases include:

    • recurrent Graves’ disease with panic disorder and residual obsessive-compulsive disorder (Ms. A)
    • undetected Graves’ hyperthyroidism in a bipolar-like mood syndrome with severe anxiety and cognitive decline (Ms. B)
    • occult hyperthyroidism with occult anxiety (Mr. C).

    These cases show that even when biochemical euthyroidism is restored, many formerly hyperthyroid patients with severe mood, anxiety, and/or cognitive symptoms continue to have significant residual symptoms that require ongoing psychiatric attention.6

    Ms. A: Anxiety and thyrotoxicosis

    Ms. A was greatly troubled by her intrusive ego-dystonic thoughts, which involved:

    • violence to her beloved young children (for example, what would happen if someone started shooting her children with a gun)
    • bizarre sexual ideations (for example, during dinner with an elderly woman she could not stop imagining her naked)
    • paranoid ideations (for example, “Is my husband poisoning me?”).


    She consulted a psychologist who told her that she suffered from an anxiety disorder and recommended psychotherapy, which was not helpful. She then sought endocrine consultation, and tests showed low-grade overt hyperthyroidism, with unmeasurably low thyroid stimulating hormone (TSH) concentrations and marginally elevated total and free levothyroxine (T4). Her levothyroxine replacement dosage was reduced from 100 to 50 mcg/d, then discontinued.

    Without thyroid supplementation or replacement, she became biochemically euthyroid, with TSH 1.47 mIU/L and triiodothyronine (T3) and T4 in mid-normal range. Her panic anxiety resolved and her mood and sleep normalized, but the bizarre thoughts remained. The endocrinologist referred her to a psychiatrist, who diagnosed obsessive-compulsive disorder. Ms. A was effectively treated with fluvoxamine, 125 mg/d.

    Discussion. Many patients with hyperthyroidism suffer from anxiety syndromes,8-10 including generalized anxiety disorder and social phobia (Table 1). “Nervousness” (including “feelings of apprehension and inability to concentrate”) is almost invariably present in the thyrotoxicosis of Graves’ disease.11

    Hyperthyroidism-related anxiety syndromes are typically complicated by major depression and cognitive decline, such as in memory and attention.9 Thus, a pituitary-thyroid workup is an important step in the psychiatric evaluation of any patient with clinically significant anxiety (Box 2).3

    Box 1

    Excess thyroid hormone’s link to psychiatric symptoms

    The brain has among the highest expression of thyroid hormone receptors of any organ,1,2 and neurons are often more sensitive to thyroid abnormalities—including overt or subclinical hyperthyroidism and thyrotoxicosis, thyroiditis, and hypothyroidism3—than are other tissues.

    Hyperthyroidism is often associated with anxiety, depression, mixed mood disorders, a hypomanic-like picture, emotional lability, mood swings, irritability/edginess, or cognitive deterioration with concentration problems. It also can manifest as psychosis or delirium.

    Hyperthyroidism affects approximately 2.5% of the U.S. population (~7.5 million persons), according to the National Health and Nutrition Examination Survey (NHANES III). One-half of those afflicted (1.3%) do not know they are hyperthyroid, including 0.5% with overt symptoms and 0.8% with subclinical disease.

    NHANES III defined hyperthyroidism as thyroid-stimulating hormone (TSH) <0.1 mIU/L with total thyroxine (T4) levels either elevated (overt hyperthyroidism) or normal (subclinical hyperthyroidism). Women are at least 5 times more likely than men to be hyperthyroid.4

    CNS hypersensitivity to low-grade hyperthyroidism can manifest as an anxiety disorder before other Graves’ disease stigmata emerge. Panic disorder, for example, has been reported to precede Graves’ hyperthyroidism by 4 to 5 years in some cases,12 although how frequently this occurs is not known. Therefore, re-evaluate the thyroid status of any patient with severe anxiety who is biochemically euthyroid. Check yearly, for example, if anxiety is incompletely resolved.

    Table 1

    Psychiatric symptoms seen with hyperthyroidism

    Anxiety

    Apathy (more often seen in older patients)

    Cognitive impairment

    Delirium

    Depression

    Emotional lability

    Fatigue

    Hypomania or mania

    Impaired concentration

    Insomnia

    Irritability

    Mood swings

    Psychomotor agitation

    Psychosis

    Causes of hyperthyroidism

    Approximately 20 causes of thyrotoxicosis and hyperthyroxinemia have been characterized (see Related resources).11,13-15 The most common causes of hyperthyroidism are Graves’ disease, toxic multinodular goiter, and toxic thyroid adenoma. Another is thyroiditis, such as from lithium or iodine excess (such as from the cardiac drug amiodarone). A TSH-secreting pituitary adenoma is a rare cause of hyperthyroidism.16

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