Understanding Graves’ Disease and Depression

If you have Graves’ disease, you’re at higher risk of developing depression. Graves’ disease is a common form of hyperthyroidism, where your thyroid produces too much thyroid hormone. Your thyroid gland controls several hormones that are involved in metabolism, the process of turning food into energy.

Depression, also called major depressive disorder, causes ongoing feelings of sadness and loss of interest in usual activities. Graves’ disease and depression are believed to be linked because hormones affect the brain and body. Some research estimated that about 69% of people diagnosed with hyperthyroidism have depression.

This article explores the connections between these conditions, possible complications, and options for diagnosis and treatment, plus how to cope when you have both Graves’ disease and depression.

The Connection Between Graves’ Disease and Depression

The thyroid releases thyroid hormones, including triiodothyronine (T3) and thyroxine (T4). One of T3's jobs is to control both levels and actions of two key neurotransmitters (chemical messengers in the brain) involved in depression: serotonin and norepinephrine. So an imbalance of thyroid hormones can directly lead to depression.

Research also shows that taking T3 hormone supplements can improve the effectiveness of antidepressants.

Cortisol, a stress hormone, is believed to play a role as well. In people with depression, cortisol levels are high. Research has shown that cortisol inhibits thyroid hormones' activity, so depression may lead to thyroid dysfunction.

Risk Factors

Several things can increase your likelihood of developing Graves’ disease, depression, or both. Risk factors for Graves’ disease include:

• Being between the ages of 30 and 50
• Being female
• Having a family member with the disease
• Having other autoimmune conditions, including rheumatoid arthritis, lupus, and type 1 diabetes
• Extreme physical or emotional stress
• Infection
• Pregnancy
• Smoking

Risk factors for depression include:

• Serious or chronic medical illness
• Family history of depression
• Previous bouts of depression
• Trauma, stress, or major life changes
• Being female, likely due to hormonal fluctuations
• Poor nutrition
• Using alcohol or other depressant drugs, recreational or prescription

Additionally, if you have Graves’ disease, your depression risk is higher if you have: 

• Graves’ ophthalmopathy (eye disease)
• High levels of an enzyme called thyroid peroxidase (TPO)
• Thyroid antibodies (immune cells that attack the thyroid gland)

Complications of Graves’ Disease and Depression

When you have both Graves’ disease and depression, the primary complication is suicidal thoughts and behaviors. In a 2019 study on kids ages 10 through 18, those with hyperthyroidism were almost five times more likely to think about or attempt suicide.

Graves’ ophthalmopathy also contributes to this risk. A 2017 study found a small risk increase of suicide in Graves’ disease overall but a significantly increased risk in people who also had Graves’ eye disease. Another study found the risk of death by suicide in people with Graves’ ophthalmopathy was triple that of healthy people.

Sexual dysfunction is also possible in both thyroid disease and depression, likely due to hormonal imbalances. So having both conditions may increase your chances of developing it yourself.

Diagnosis of Graves’ Disease and Depression

Typically, if you have symptoms that may be due to one or both of these conditions, you’ll start with your primary care provider. They can give you a diagnosis or a tentative one, rule out other physiological causes of your symptoms, prescribe medicine, and, if necessary, refer you to a specialist.

For Graves’ disease, the specialist would be an endocrinologist (doctor specializing in hormones). For depression, it would be a mental health professional such as a psychiatrist.

To diagnose Graves’ disease, doctors rely on:

• Symptoms: Unintended weight loss, heart palpitations, insomnia, thinning hair, dizziness, and high blood pressure are key symptoms.
• Physical exam: Goiter (enlarged thyroid gland in the front of your throat) and over-responsive reflexes are common.
• Blood tests: Low thyroid-stimulating hormone (TSH), high T3 and/or T4 point to hyperthyroidism. TPO antibodies distinguish Graves’ from non-autoimmune hyperthyroidism.
• Radioactive iodine scan: You swallow radioactive iodine, which is then monitored by X-ray. An overactive thyroid will take in more iodine than usual. (Your body uses iodine to produce thyroid hormones.)

Mental disorders like depression are diagnosed with the DSM-5. That’s the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

The diagnostic criteria for depression are based on symptoms. You must have feelings of sadness, poor mood, and loss of interest in your usual activities for at least two weeks.

Additionally, you must also have at least five other symptoms from this list that cause significant distress or impairment:

• Change in appetite and related weight changes
• Disrupted sleep or sleeping too much
• Fatigue and low energy on most days
• Feelings of worthlessness, guilt, and hopelessness
• Inability to focus and concentrate that may interfere with your daily tasks
• Slow or agitated movement
• Thoughts of death, dying, or suicide, or suicide attempts

It may be difficult to diagnose depression if you also have untreated Graves’ disease. You and your doctor may not recognize that you’re depressed until depression symptoms persist despite thyroid treatment.

Treatment of Graves’ Disease and Depression

Treatment for Graves’ disease depends on whether you keep your thyroid gland or have it surgically removed. 

After thyroidectomy (surgical removal of the thyroid), your body can’t produce any thyroid hormones. So instead of having hyperthyroidism, you have hypothyroidism (underactive thyroid). This requires treatment with thyroid hormone medicine.

Depression is generally treated with antidepressants and psychotherapy.

Medications

Antithyroid medications and antidepressants are considered safe to take together. However, other combinations may result in problems.

Thyroid hormone drugs are generally safe to take with antidepressants. They may even make tricyclic antidepressants more effective.

While that may be a good thing, your doctor should keep a close eye on you if you’re taking both drugs. It’s possible that the thyroid medication could exaggerate the heart-related side effects of tricyclics.

Tricyclic antidepressants include:

• Amitriptyline
• Asendin (amoxapine)
• Norpramin (desipramine)
• Pamelor (nortriptyline)
• Sinequan (doxepin)
• Surmontil (trimipramine)
• Tofranil (imipramine)
• Vivactil (protriptyline)

Selective serotonin reuptake inhibitors (SSRIs) are another class of antidepressants. They increase the activity of serotonin in the brain. Early research suggests that SSRIs may slightly reduce the amount of T4 in your system. That could make thyroid hormone medications less effective.

SSRIs include:

• Celexa (citalopram)
• Lexapro (escitalopram)
• Luvox (fluvoxamine)
• Paxil (paroxetine)
• Prozac (fluoxetine)
• Viibryd (vilazodone)
• Zoloft (sertraline)

Serotonin-norepinephrine reuptake inhibitors (SNRIs) are similar to SSRIs but newer. They increase the activity of both serotonin and norepinephrine (another neurotransmitter). 

So far, there’s no evidence that SNRIs interfere with thyroid hormones. SNRIs include:

• Cymbalta (duloxetine)
• Effexor (venlafaxine)
• Fetzima (levomilnacipran)
• Pristiq (desvenlafaxine)
• Savella (milnacipran)

Psychotherapy

A few types of psychotherapy are used to treat depression:

• Cognitive behavioral therapy (CBT): Involves correcting unhealthy thoughts and habits that may worsen your condition(s)
• Interpersonal therapy: Focuses on your relationships with others
• Psychodynamic psychotherapy: Deals with conflicts and emotional patterns that may cause problems for you
• Supportive therapy: Mixes multiple types of therapy with the goal of relieving symptoms

Coping With Graves’ Disease and Depression

Dealing with any chronic condition poses challenges. With two, it takes more work to manage things and feel good. Lifestyle changes and a support system are important factors in that.

Lifestyle Changes

Studies have shown that regular physical activity can both treat depression and prevent it from coming back. Over the long term, exercise helps nerve cells grow, form new connections, and help your brain work better.

The hippocampus is a region of your brain that regulates mood. It tends to be smaller than usual in people with depression. Exercise can cause cell growth in the hippocampus, and that’s been shown to alleviate depression.

Research suggests exercise may help with Graves’ disease by:

• Normalizing thyroid activity
• Reducing fatigue 
• Reducing the need for antithyroid medication

While there’s no ideal diet for everyone with Graves’ and depression, both conditions are tied to inflammation. An anti-inflammatory diet rich in antioxidants may help. That includes:

• Fresh vegetables, especially tomatoes and leafy greens
• Berries and other fruits
• Fatty fish, including salmon, tuna, and sardines
• Whole grains
• Nuts and seeds

Both Graves’ disease and depression often follow stressful events. Both can also be made worse by stress. If you’re in psychotherapy, ask your therapist about stress-reduction techniques. You may also want to look into:

• Mindfulness meditation
• Yoga or tai chi
• Relaxation or deep breathing exercises
• Setting realistic goals
• Setting healthy boundaries

Support Groups

Support groups can be a great way to develop a network of people who understand what you’re going through. Many groups are available online and in local communities. 

For Graves' disease, the Graves' Disease and Thyroid Foundation offers an online directory of support groups.

For depression, you may find online and local support groups through Mental Health America, the Depression and Bipolar Support Alliance, and the Anxiety and Depression Association of America.

Summary

Graves' disease and depression are common together. Each may contribute to the development of the other. They also have common risk factors, including being female and having high stress levels.

Beneficial lifestyle changes for both conditions include regular exercise, an anti-inflammatory diet, and stress management. Support groups may be helpful for finding people who understand your illnesses. You can find these online or in your community.

A Word From Verywell

It’s natural to feel overwhelmed by one illness. When you have two, it can seem too hard to take the necessary steps to feel better. By working with your healthcare team and taking it one step at a time, you can get your health better managed. Allow yourself to have setbacks and bad days or weeks, and get back on track when you’re able.