A 57-year-old woman presented to the Casualty department with seven self-inflicted superficial stab wounds to the neck and one to the abdominal wall: a deliberate suicide attempt following 2 years of depression. All wounds were sutured in Casualty, where a thin, transverse scar was noted above the suprasternal notch (fig 1). This scar had been present for 20 years following the removal of a thyroid tumour, yet the patient was not taking thyroid replacement therapy. On reflection, the patient had the classical signs and symptoms of hypothyroidism: dry skin and hair, a “peaches and cream” complexion, slow voice, weight gain, constipation and fatigue. Thyroid function tests showed thyroid-stimulating hormone (TSH) of 14 μU/litre, free T4<5.2 pmol/litre. The patient was given levothyroxine, which resulted in a change of mood and increased activity within 48 h. On later careful history taking, the patient explained she had resigned from her high-flying career due to ill health, feeling unable to cope with the pace of the job.

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Figure 1

Closer inspection of the neck revealed a thyroidectomy scar amongst the stab wounds.

A large number of medical conditions are significantly more common amongst patients with recurrent depression.1 However, when corrected for body mass index (BMI), gender and age, depression remains a predictive factor for six disorders: thyroid disease, gastric ulcer, rhinitis, osteoarthritis, hypertension and asthma.1 Thyroid disorders in particular are more than twice as common.1 Patients discharged with a diagnosis of hypothyroidism have a greater risk of subsequent admission with depression or bipolar disorder.2 This case highlights the importance of investigating medical causes for depression in cases of attempted suicide.