Association of Sexual Dysfunction,Vitamin D,and Thyroid Levels with Suicidal Behavior Among Patients with Depressive Disorder: A Cross-sectional Study

Abstract

Background:

Vitamin D levels, thyroid hormones, and sexual functioning play significant roles in the risk of suicidal behavior. Despite this, there is a paucity of literature on these within the Indian context, particularly among patients with depression and suicidal behavior. The index study aims to assess the association of sexual dysfunction, hypothyroidism, and vitamin D deficiency with suicidal behavior among patients with depressive disorders.

Methods:

One hundred fifty individuals with a diagnosis of moderate-to-severe depressive disorder were enrolled in the study, seventy-five in each of the two groups, with and without suicidal behaviors. The Hamilton Depression Rating Scale, Columbia-Suicide Severity Rating Scale, and Changes in Sexual Functioning Questionnaire were used to assess participants’ severity of depression, suicidal behavior, and sexual functioning, respectively. Vitamin D and thyroid hormone levels were evaluated.

Results:

Upon comparing patients with and without suicidal behaviors, being single, employed, longer duration of illness, earlier age of onset, greater depression severity, presence of sexual dysfunction, and lower vitamin D levels had significant associations with suicidal behavior in depression. Significant predictors of suicidal behavior were greater depression severity and the presence of sexual dysfunction. Greater depression severity emerged as a significant predictor for sexual dysfunction and, additionally, prolonged duration of illness in female sexual dysfunction.

Conclusion:

Greater depression severity and sexual dysfunction were significant predictors of suicidal behavior in depression. Comprehensive assessment of sexual functioning and vitamin D in individuals with depression can help in timely identification and effective intervention.

Keywords

Sexual dysfunction vitamin D levels thyroid hormone levels depression suicidal behavior

Key Messages

This study explored the relationship between sexual dysfunction, vitamin D, thyroid levels, and suicidal behavior in depressed patients.

Greater depression severity and sexual dysfunction were found to be significant predictors of suicidal behavior.

Comprehensive assessment of sexual functioning and vitamin D in individuals with depression can help in timely identification and effective intervention.

Mental disorders, particularly major depressive disorder (MDD), significantly elevate the risk of suicidality.¹ The World Health Organization (WHO) predicts that by 2030, severe depression will be a significant contributor to disability.^2,3 In India, there is a 4.2% rise in the suicide rate from 2021 to 2022, with the current rate standing at 12.4 suicides per 100,000 population.⁴ A complex interplay of biological, genetic, social, cultural, and environmental factors leads to suicidal behavior, which is a multifactorial phenomenon. A meta-analysis by Large and colleagues, which included 29 studies, showed that among patients with depression, a history of intentional self-harm, hopelessness, guilt or inadequacy, low mood, suicidal thoughts, and a family history of suicide were significantly associated with in-patient suicide.⁵ The most important indicator of suicidal behavior is depression and the hopelessness that goes along with it.⁶

Sexual dysfunction is another common symptom that has been associated with suicidal ideation in the general population. Most MDD patients suffer sexual dysfunction, which is linked to poor quality of life, besides the primary symptoms. Even though MDD has been studied extensively, sexual dysfunction has seldom been considered a contributing factor to MDD.⁷ However, there is, yet again, little research on its connection to suicidal thoughts in depressive patients, so there is a need to explore the same. Vitamin D deficiency and hypothyroidism have been found to have a well-established role in depression. Research suggests that decreased vitamin D levels may increase the risk of depression and suicidal thoughts.⁸ Additionally, vitamin D supplementation has been associated with improved clinical depression, impacting proinflammatory cytokines linked to the chronic inflammatory processes in suicide and depression.⁸ While hypothyroidism is well-established as a risk factor for depression, there is a paucity of research exploring this association specifically with suicidal behavior. Due to a minimal number of studies, there is a vital need to evaluate these constructs in patients with depression and to see their association with suicidal behavior in the Indian context. Exploring the relationship between these risk variables and suicidal behavior in depressed patients can help in improving the screening procedure as well as formulating management strategies to reduce the suicidal risk among patients with depression.

Aim

The aim of this article was to study the association of sexual dysfunction, vitamin D, and thyroid levels with suicidal behavior among patients with depressive disorders.

Objectives

To assess the association of sexual dysfunction, vitamin D, and thyroid levels with suicidal behavior among patients with depressive disorder.

To find the association of demographic and clinical variables with sexual dysfunction, vitamin D, and thyroid levels among patients with depressive disorder.

Methods

The Institutional Ethics Committee approved this study on 22/03/2022. This cross-sectional was conducted between March 2022 and July 2023 in the psychiatry outpatient and inpatient settings of a multispecialty tertiary-care hospital in North-Western India after obtaining written informed consent from the participants. Participants with depressive disorder were recruited and divided into two groups: with suicidal behavior and without suicidal behavior. Both the groups comprised patients of either gender aged between 18 years and 60 years, diagnosed with current depressive episodes according to International Classification of Diseases-11(ICD-11),⁹ (single episode depressive disorder or recurrent depressive disorder) with Hamilton Depression Rating Scale (HAM-D),¹⁰ score ≥ 14 (moderate-to-severe depression). Group 1 included patients having suicidal ideation/plans within the current episode or patients who have made suicide attempts within the current episode. Group 2 included patients with no suicidal ideation/plans/attempts in the current episode. Patients with bipolar affective disorders, any other comorbid psychiatric illness (except tobacco dependence), or chronic medical illnesses, that is, neurological disorders (e.g., Alzheimer’s disease and Parkinson’s disease), cardiovascular diseases (e.g., hypertension, heart disease, and stroke), diabetes, chronic respiratory diseases (e.g., asthma and chronic obstructive pulmonary disease), cancer, chronic kidney disease, etc. were excluded. Females who were pregnant or lactating were excluded from the study. Individuals with organic sexual dysfunctions were excluded.

Sample Size Calculation

The sample size was calculated based on a study by Park et al.¹¹ with 75% among patients with suicidal behavior, 60% among those without, a 95% confidence interval, and 80% study power. A total of 150 patients, 75 in each group, were recruited and assessed for their severity of depression, suicidality, sexual dysfunction, vitamin D, and thyroid profile (Reference value—thyroid-stimulating hormone (TSH): 0.48–4.17 mIU/L, free triiodothyronine (T3): 2.3–4.2 pg/mL, and free thyroxine (T4): 0.89–1.76 ng/dL).

Tools

Hamilton Depression Rating Scale

It is a 21-item clinician-report questionnaire for the severity of depression in both the general population and individuals with psychiatric disorders. Scores ranging from 0 to 7 are considered normal, 8 to 13 indicate mild depression, 14 to 18 suggest moderate depression, 19 to 22 signify severe depression, and scores exceeding 23 are indicative of very severe depression (Cronbach’s a = 0.85).¹⁰

Columbia Suicide Severity Rating Scale

The Clinician-Administered Rating Scale for Suicidal Ideation and Behavior (C-SSRS) is for evaluating both past and current suicidal thoughts and actions. It explores various facets of suicidality, encompassing severity, intensity, behavior, and lethality. Cronbach’s coefficient is 0.89.¹²

Changes in Sexual Functioning Questionnaire

This is a self-assessment scale focusing on sexual activity and function, encompassing aspects like sexual intercourse, masturbation, sexual fantasies, and other related activities. The recommended clinical version consists of 14 items; separate male and female questionnaire versions are available. Each item includes five domains, resulting in a total Changes in Sexual Functioning Questionnaire (CSFQ) score of 70. Scores <41 (women) and <47 (men) suggest sexual dysfunction. For the female and male versions of the CSFQ-14, Cronbach’s a coefficient was determined to be 0.89 and 0.90, respectively.¹³

Statistical Analysis

Data coding and analysis were done using Statistical Package for the Social Sciences (SPSS) version 21.0 for Windows (Chicago, Illinois, USA). The normality of data was assessed using the Shapiro–Wilk test. Non-normally distributed continuous data was assessed using the Mann–Whitney U test, while categorical data was evaluated using the chi-square test. The correlation between clinical and demographic factors with CSFQ, vitamin D levels, and TSH levels was determined through Spearman correlation coefficients. After checking essential assumptions, binominal logistic regression was applied for the identification of potential predictors of suicidal behavior. Linear regression was applied for the identification of potential predictors of sexual dysfunction. The P value below .05 was deemed significant.

Results

The patients were divided into two groups (participants with suicidal behavior and patients without suicidal behavior), with each group consisting of 75 individuals.

Demographic and Clinical Profile

As shown in Table 1, among the 150 participants, 57.3% were female. Approximately 34.7% of the participants had attained a graduate level of education. In individuals without suicidal behavior, homemakers accounted for 49.3% of the participants, and a significant portion (80%) were married. The majority of the participants were Hindu in both groups and hailed from nuclear families and urban environments. Upon comparing both groups, there were no significant differences in the distribution of gender, locality, family type, or religion between the two groups. However, a greater percentage of single individuals observed in the group exhibited suicidal behavior (χ² = 4.76, P = .03). Likewise, an increased proportion of employed individuals within the group had suicidal tendencies (χ² = 7.34, P = .03). The mean age and income of the participants were statistically comparable in both groups.

Table 1.

Demographic and Clinical Profile.

Demographic and Clinical Variables	Depression Without Suicidal Behavior (n = 75)	Depression with Suicidal Behavior (n = 75)	Mann–Whitney U Value (P Value)
Demographic and Clinical Variables	Mean ± SD (Mean Rank)		Mann–Whitney U Value (P Value)
Age (years)	35.39 ± 11.53 (82.45)	31.48 ± 9.83 (68.55)	2,291 (.05)
Income per capita (rupees)	7694.38 ± 4158.05 (70.79)	9957.35 ± 7494.73 (80.21)	2,459 (.18)
Duration of illness (months)	20.88 ± 28.39 (66.82)	31.25 ± 41.41 (84.18)	2,161 (.01)
Age at onset of illness (years)	33.40 ± 11.29 (84.39)	28.67 ± 8.73 (66.61)	2,146 (.012)
Severity of depression (HAM-D score)	16.24 ± 1.70 (49.95)	20.36 ± 3.64 (101.05)	896.5 (<.001)
	Frequency (%)		χ² Value (P Value)
Gender Male Female	31 (41.3) 44 (58.7)	33 (44) 42 (56)	0.11 (.74)
Marital status Single Married	15 (20) 60 (80)	27 (36) 48 (64)	4.76 (.03)
Locality Urban/town Rural	39 (52) 36 (48)	42 (56) 33 (44)	0.24 (.62)
Occupation Employed Unemployed Housewife	21 (28) 17 (22.7) 37 (49.3)	32 (42.7) 22 (29.3) 21 (28)	7.34 (.03)
Family type Nuclear Joint/extended	38 (50.7) 37 (49.3)	45 (60) 30 (40)	1.32 (.25)
Religion Hindu Non-Hindu	73 (97.3) 2 (2.7)	71 (94.7) 4 (5.3)	0.69 (.40)
Education years Illiterate 5th pass 8th pass 12th pass Graduate Postgraduate	3 (4.0) 8 (10.7) 17 (22.7) 15 (20.0) 27 (36.0) 5 (6.7)	2 (2.7) 8 (10.7) 8 (10.7) 15 (20.0) 25 (33.3) 17 (22.7)	10.06 (.07)

HAM-D: Hamilton Depression Rating Scale, SD: standard deviation.

Patients with suicidal behavior had onset of illness at a younger age (U = 2146, P = .012) and longer duration of illness (U = 2161, P = .01) compared to those without suicidal behavior. Results were not statistically significant for the number of episodes, current episode duration, and treatment duration. Among individuals with depression without suicidal behavior, 78.7% had single-episode depressive disorder, while 21.3% had recurrent depressive disorder. In the depression with suicidal behavior group, 66.7% had single-episode depressive disorder, while 33.3% had recurrent depressive disorder. This difference was not statistically significant. Regarding depression severity, in the nonsuicidal group, 90.7% had moderate depression, 9.3% had severe depression, and none had very severe depression. In the suicidal behavior group, 32.0% had moderate depression, 45.3% had severe depression, and 22.7% had very severe depression. This difference was statistically significant (χ² = 55.82, P < .001). Approximately half of the participants, around 50%, were prescribed escitalopram 10mg as part of their treatment regimen. Furthermore, 12.7% of participants had a family history of psychiatric illness, with 4.7% reporting a family history of suicidal behavior. Individuals were distributed across various levels of suicidal ideation intensity, with a significant proportion reporting moderate-to-severe ideations. Many individuals reported experiencing such thoughts a few times or more. Nearly half of the individuals reported experiencing nonspecific active suicidal thoughts. Approximately one-third of the individuals report actively contemplating suicide with methods but without the intent to act.

Depression Severity, Sexual Dysfunction, Vitamin D, and Thyroid Profile

Most individuals (93.3%) in the sample had normal thyroid function, while a small percentage (6.7%) exhibited hypothyroidism. Nearly one-fourth of the individuals (23.3%) had normal vitamin D levels, and another three-fourths (76.7%) had decreased vitamin D levels (<30 ng/mL). Out of the total sample size of 150 individuals, 58.7% of the participants reported experiencing sexual dysfunction.

As shown in Table 2, the mean HAM-D score was significantly greater in patients with suicidal behavior (20.36) compared to patients without suicidal behavior (16.24). The scores for each aspect of sexual functioning in both males and females were significantly different between the two groups, suggesting a notable impact of depression with suicidal behavior on male and female sexual function. Individuals with depression and suicidal behavior had significantly lower levels of vitamin D levels (17.48) compared to those without suicidal behavior (24.57). Among 150 participants, 10 (6.7%) were diagnosed with hypothyroidism, of which three were already on thyroid hormonal replacement therapy. The two groups had no significant differences in T3, T4, and TSH levels.

Table 2.

Sexual Dysfunction, Vitamin D, and Thyroid Profile: Comparative Analysis.

	Depression Without Suicidal Behavior (n = 75)	Depression with Suicidal Behavior (n = 75)	Mann–Whitney U Value (P Value)
	Mean ± SD (Mean Rank))		Mann–Whitney U Value (P Value)
CSFQ-M Pleasure Desire/Frequency Desire/Interest Arousal/Erection Orgasm/Ejaculation Total score	3.54 ± 0.85 (41.27) 7.03 ± 1.47 (38.00) 8.61 ± 2.24 (38.19) 10.39 ± 2.29 (37.11) 10.25 ± 2.11 (39.92) 45.45 ± 7.77 (40.45)	2.60 ± 0.99 (24.26) 6.03 ± 1.75 (27.33) 7.24 ± 2.30 (27.15) 9.36 ± 2.69 (28.17) 8.63 ± 2.41 (25.53) 40.84 ± 7.96 (25.03)	239.5 (<.001) 341.0 (.02) 335.0 (.02) 368.5 (.048) 281.5 (.002) 265.0 (.001)
CFSQ-F Pleasure Desire/Frequency Desire/Interest Arousal/Excitement Orgasm/Completion Total score	3.41 ± 0.87 (55.64) 6.59 ± 1.52 (54.11) 8.02 ± 2.00 (53.23) 9.79 ± 1.96 (55.05) 9.91 ± 1.52 (55.49) 43.79 ± 7.18 (55.77)	2.38 ± 0.85 (30.79) 5.11 ± 1.48 (32.38) 6.40 ± 1.88 (33.31) 7.69 ± 1.98 (31.40) 7.71 ± 2.25 (30.94) 35 ± 6.91 (30.64)	390.0 (<.001) 457.0 (<.001) 496.0 (<.001) 416.0 (<.001) 396.5 (<.001) 384.0 (<.001)
Vitamin D	24.57 ± 12.99 (86.79)	17.48 ± 8.48 (64.21)	1966.0 (.001)
T3 T4 TSH	2.24 ± 0.64 (68.77) 1.41 ± 1.09 (76.18) 2.16 ± 1.11 (69.91)	3.51 ± 9.48 (82.23) 1.38 ± 1.15 (74.82) 2.52 ± 1.57 (81.09)	2307.5 (.05) 2761.5 (.85) 2393.5 (.11)

CSFQ-M: Changes in Sexual Functioning Questionnaire-Male, CFSQ-F: Changes in Sexual Functioning Questionnaire-Female, T3: Triiodothyronine, T4: Thyroxine, TSH: thyroid-stimulating hormone.

Association of Sexual Dysfunction with Demographic and Clinical Variables

There was no significant association of socio-demographic variables like gender, marital status, locality, type of family, religion, occupation, or education years with sexual dysfunction. There was no significant association of clinical variables, that is, diagnosis, history of side effects, history of ECT, psychological intervention, faith healing, or family history of psychiatric illness with sexual dysfunction. For female sexual functioning (CSFQ-F), significant negative associations were found with duration of illness (r = −0.37, P = .001), duration of current episode (r = −0.25, P = .02), duration of treatment (r = −0.31, P = .004), and HAM-D (r = −0.43, P = <.001) signifying that with decrease in CSFQ-F score (more female sexual dysfunction); there was a tendency for increased duration of illness, duration of current episode, duration of treatment, and HAM-D. For male sexual functioning (CSFQ-M), a significant negative association was found with HAM-D (r = −0.16, P = .04). Greater severity of depression was associated with sexual dysfunction in males and females.

Association of Vitamin D Levels and Thyroid Profile with Demographic and Clinical Variables

In demographic variables, gender, marital status, locality, family type, religion, education years, and occupation were not significantly associated with vitamin D levels. Clinical variables were not significantly associated with vitamin D levels. Vitamin D levels showed a significant negative correlation with depression severity (HAM-D score, r = −0.16, P = .04), signifying that with decreasing levels of vitamin D3, there was increased severity of depressive symptoms. No statistically significant association was observed between demographic and clinical variables with thyroid profile.

Regression Analysis to Find the Predictors of Suicidal Behavior and Sexual Dysfunction

As indicated in Table 3, the severity of depression (HAM-D score) (odds ratio = 1.95) and sexual dysfunction (odds ratio = 4.44) were identified as significant predictors of suicidal behavior. After applying multiple linear regression, a lower CSFQ-F score was indicative of a higher level of female sexual dysfunction. Duration of illness (B = −0.07, P = .04) and severity of depression (HAM-D score) (B = −1.07, P = < .001) were identified as significant predictors of female sexual dysfunction. A lower CSFQ-M score was indicative of a higher level of male sexual dysfunction. HAM-D (B = −1.35, P = < .001) was identified as a significant predictor of male sexual dysfunction.

Table 3.

Binary Logistic Regression for Suicidal Behavior.

Variables	B	SE	df	Wald	P Value	Odds Ratio	Confidence Interval
Marital status-single	1.08	1.03	1	1.11	.29	2.95	0.39–22.03
Occupation- Employed Unemployed	0.75 0.04	0.65 0.99	1 1	1.32 0.001	.25 .97	2.11 1.04	0.59–7.53 0.15–7.24
Age of onset	−0.03	0.03	1	1.11	.29	0.97	0.90–1.03
Duration of illness	0.02	0.01	1	2.69	.10	1.02	0.99–1.04
Psychological intervention	1.00	0.63	1	2.55	.11	2.72	0.79–9.28
Depression severity	0.67	0.14	1	23.52	<.001	1.95	0.79–9.28
Sexual dysfunction	1.49	0.60	1	6.06	.01	4.44	1.36–14.55
Vitamin D levels	−0.05	0.02	1	3.84	.05	0.95	0.90–1.00

SE, standard error.

Discussion

The interaction between sexual dysfunction, vitamin D levels, thyroid function, and suicidal behavior in depressive patients is complex and multifactorial. In the index study, patients in the suicidal behavior group were significantly associated with sexual dysfunction in both males and females; results were statistically significant for pleasure, desire/frequency, desire/interest, arousal, orgasm, and total score.

This study showed that suicidal behavior was significantly associated with an earlier age of onset. Similarly, a study done by Badrinarayana¹⁴ and Zisook et al.¹⁵ found that the younger age group (15–30) years are more prone to depression and suicide. A study by Bhatia et al. in Punjab found no significant age differences among suicidal ideators, attempters, and completers.¹⁶ Early-onset depression can lead to a longer illness course, causing substantial functional impairment and illness burden over time. The prolonged exposure to depressive symptoms can magnify negative impacts on daily life, relationships, and overall well-being.¹⁵

The index study found a higher prevalence of suicidal behavior in employed individuals in comparison to unemployed and homemakers, aligning with various studies, such as those conducted by Kumar,¹⁷ De Moore and Robertson,¹⁸ and Sato et al.¹⁹ However, conflicting results emerge from studies conducted by Sharma,²⁰ Shrivastava et al.,²¹ and Kumar and Chandrasekaran.²² This association in the index study could be explained by work-related stress, the demands of the workplace, including high expectations, long working hours, job insecurity, and imbalance between work and personal life, with excessive focus on professional commitments, which may lead to strained relationships, isolation contribute to elevated stress levels, potentially increasing the risk of suicide.

Dell’Osso et al. found a significant correlation between reduced sexual activity, suicidal ideation, and a sense of insignificance in unipolar depression patients.²³ Sreelakshmy et al. found elevated scores across all sexual function indicators in females with depression.²⁴ The link between sexual dysfunction and suicidal behavior can be attributed to several factors. People facing sexual dysfunction often express lower emotional and physical satisfaction, as well as reduced happiness with their primary partner.²⁵ Sexual arousal and satisfaction issues are linked to an increased risk of suicidal thoughts, emphasizing the importance of considering sexual health as a marker for assessing depression-related outcomes. In this study, both male and female sexual dysfunction were found to be significantly linked to the severity of depression. This observation aligns with a few studies.^26,27 This study showed a significant association between female sexual dysfunction and the increased duration of depressive disorder, as well as the duration of the current depressive episode. The findings were similar to the studies.^28,29 Various interconnected factors contribute to sexual dysfunction in individuals experiencing prolonged depression. Chronic depression frequently results in persistent fatigue and physical health challenges, particularly diminishing energy levels for sexual activity and overall interest. Furthermore, the strain that depression places on relationships often leads to communication breakdowns and reduced intimacy, contributing to difficulties in sexual function.

The index study found a significant association between suicidal behavior and decreased vitamin D levels. Several studies have investigated the potential link between vitamin D levels and suicidal behavior. However, the findings have been mixed. Kim et al. found a significantly increased risk of suicidal ideation associated with deficient vitamin D levels.³⁰ Lavigne and Gibbons reported a substantial reduction in the risk of suicide attempts and self-harm among veterans treated with vitamin D2 or D3 supplementation in a retrospective cohort study.³¹ Although Park et al.³² and Grudet et al.³³ found no significant associations between vitamin D levels and suicidal behavior or depression. Nebhinani et al.’s longitudinal study of 158 outpatients with depressive disorders found that 85% had vitamin D deficiency, and those deficient in vitamin D took a significantly longer time to achieve remission.³⁴ Vitamin D deficiency is linked to suicidal behavior through neurobiological mechanisms. The distribution of vitamin D receptors in the brain, especially in areas related to emotional processing and impulse control, suggests a role in neuropsychiatric symptoms that increase the risk of suicidal ideation.³⁵

This study investigated the potential link between thyroid profile and suicidal behavior in individuals with depressive disorders. While the analysis did not establish a significant association between thyroid dysfunction and suicidal behavior in depression, this aligns with the findings of a few studies.^36,37 Toloza et al. reported opposing results, revealing that patients with suicidal behavior exhibited significantly lower levels of FT3 and FT4 compared to controls.³⁸ A narrative review conducted by Nuguru et al. in an Indian context unveiled that elevated levels of thyroid-stimulating hormone, antithyroglobulin, and thyroid peroxidase antibodies were correlated with depression and an increased risk of suicide.³⁹ While there is evidence linking thyroid dysfunction to mood changes, the relationship with suicidal behavior is complex and not fully understood.

The index study has comprehensively explored the association of suicidal behavior with various factors, including sexual dysfunction, vitamin D levels, and thyroid hormone levels in adult patients with depression. At the same time, literature is scarce in this area of the world and India. These variables can be used in day-to-day clinical practice to evaluate patients having depression with suicidal behavior, which would ensure a more comprehensive assessment regarding suicidal behavior and other risk factors.

Limitations

This was a cross-sectional study on the hospital-based sample, using a self-reported scale to assess sexual dysfunction, with a possibility of recall bias. The sample was collected from a single site, catering to one region of the country. Hence, our findings cannot be generalized directly to another setting. Coping, personality, and social support-related variables were not assessed, though they might have some association with suicidal behavior. Previous vitamin D supplementation and dietary patterns were not considered. Past instances of deliberate self-harm and the severity of past episodes were not considered.

Conclusion

This study contributes to the research related to sexual dysfunction, vitamin D levels, and thyroid levels in patients with suicidal behavior in depression, which concludes that significant associations of suicidal behavior were being single, employed, longer duration of illness, earlier age of onset, greater depression severity, presence of sexual dysfunction, and decreased vitamin D levels. After applying logistic regression, significant predictors of suicidal behavior were greater depression severity and the presence of sexual dysfunction. Notably, greater depression severity emerged as a significant predictor for sexual dysfunction. Additionally, a prolonged duration of illness was identified as a significant predictor for female sexual dysfunction.

Incorporating sexual health assessments into routine clinical evaluations for individuals with depression can aid in early identification and intervention. Mental health professionals should integrate assessments of vitamin D status for individuals with depression. Future studies should include a cost–benefit analysis of vitamin D with depression. In the realm of depression, the link between thyroid dysfunction and suicidal behavior remains nuanced and inconclusive across different studies. This research underscores the need for a deeper exploration of the intricate relationship between specific thyroid markers and the susceptibility to suicide in individuals contending with depressive disorders. In the future, large-scale, multisite, multicomponent, well-designed, and adequately powered longitudinal studies should be conducted in patients with depression and suicidal behavior in both community and clinical settings to strengthen our knowledge base, comprehensive evaluation, and holistic care.

Supplementary Material

The supplementary material for this article is available online.

Footnotes

Acknowledgements

None.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Declaration Regarding the Use of Generative AI

None used.

Ethical Approval

The study was approved by the Institutional Ethics Committee at AIIMS Jodhpur (Approval number & date: AIIMS/IEC/2022/4074, Date: 22/03/2022).

Permission from the rest of the authors has been taken.

Funding

The author received no financial support for the research, authorship and/or publication of this article.

Prior Presentations

Yes. It was presented for the Solanki Award at the 39th Annual Conference of the Indian Psychiatric Society, Rajasthan Chapter, in September 2024, where we won the award in this category.

Reporting Guidelines

The STROBE checklist has been used and uploaded as “Supplementary online material.”

Simultaneous Submission to Another Journal or Resource

No.

References

Eikelenboom

, Beekman

ATF

, Penninx

BWJH

, . A 6-year longitudinal study of predictors for suicide attempts in major depressive disorder. Psychol Med, 2019; 49(6): 911–921.

Yang

, Zhao

, Wang

, . The effects of psychological stress on depression. Curr Neuropharmacol, 2015; 13(4): 494–504.

Mathers

and Loncar

Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med, 2006; 3(11): e442.

National Crime Records Bureau. Accidental deaths and suicides in India, 2022. New Delhi: Ministry of Home Affairs, 2022.

Large

, Smith

, Sharma

, . Systematic review and meta-analysis of the clinical factors associated with the suicide of psychiatric in-patients. Acta Psychiatr Scand, 2011; 124(1): 18–29.

Jorgetto

and Marcolan

. Risk and protective factors for depressive symptoms and suicidal behavior in the general population. Rev Bras Enferm, 2021; 74(suppl 3): e20201269.

Liu

, Feng

, Galling

, . Gender-specific sexual dysfunction in patients with depression. Front Psychiatry, 2023; 14: 1194228.

Orsolini

, Latini

, Pompili

, . Understanding the complex of suicide in depression: From research to clinics. Psychiatry Investig, 2020; 17(3): 207–221.

World Health Organization. International Classification of Diseases, 11th Revision (ICD11). Geneva: World Health Organization, 2022.

10.

Hamilton

. A rating scale for depression. J Neurol Neurosurg Psychiatry, 1960; 23(1): 56–62.

11.

Park

, Lee

, Hahn

, . Suicidal thoughts/acts and clinical correlates in patients with depressive disorders in Asians: Results from the REAP-AD study. Acta Neuropsychiatr, 2016; 28(6): 337–345.

12.

Posner

, Brown

, Stanley

, . The Columbia-Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry, 2011; 168(12): 1266–1277.

13.

Clayton

, McGarvey

and Clavet

. The Changes in Sexual Functioning Questionnaire (CSFQ): Development, reliability, and validity. Psychopharmacol Bull, 1997; 33(4): 731–745.

14.

Badrinarayana

. Study of suicidal risk factors in depressive illness. Indian J Psychiatry, 1980; 22(1): 81–83.

15.

Zisook

, Lesser

, Stewart

, . Effect of age at onset on the course of major depressive disorder. Am J Psychiatry, 2007; 164(10): 1539–1546.

16.

Bhatia

, Aggarwal

and Aggarwal

. Psychosocial profile of suicide ideators, attempters and completers in India. Int J Soc Psychiatry, 2000; 46(3): 155–163.

17.

Kumar

PNS

. Age and gender-related analysis of psychosocial factors in attempted suicide. Indian J Psychiatry, 1998; 40(4): 338–345.

18.

De Moore

and Robertson

. Suicide in the 18 years after deliberate self-harm: A prospective study. Br J Psychiatry J Ment Sci, 1996; 169(4): 489–494.

19.

Sato

, Takeichi

and Hara

Suicide attempts by agricultural chemicals. Indian J Psychiatry, 1993; 35(4): 209–210.

20.

Sharma

. Attempted suicide in Himachal Pradesh. Indian J Psychiatry, 1998; 40(1): 50–54.

21.

Srivastava

, Sahoo

, Ghotekar

, . Risk factors associated with attempted suicide: A case-control study. Indian J Psychiatry, 2004; 46(1): 33–38.

22.

Kumar

CTS

and Chandrasekaran

A study of psychosocial and clinical factors associated with adolescent suicide attempts. Indian J Psychiatry, 2000; 42(3): 237–242.

23.

Dell’Osso

, Carmassi

, Carlini

, . Sexual dysfunctions and suicidality in patients with bipolar disorder and unipolar depression. J Sex Med, 2009; 6(11): 3063–3070.

24.

Sreelakshmy

, Velayudhan

, Kuriakose

, . Sexual dysfunction in females with depression: A cross-sectional study. Trends Psychiatry Psychother, 2017; 39(2): 106–109.

25.

Blais

, Monteith

and Kugler

Sexual dysfunction is associated with suicidal ideation in female service members and veterans. J Affect Disord, 2018; 226: 52–57.

26.

Deumic

, Butcher

, Clayton

, . Sexual functioning in adolescents with major depressive disorder. J Clin Psychiatry, 2016; 77(7): 957–962.

27.

Reddy

, Saravanan

, Praharaj

, . Sexual dysfunction in women with depression: A hospital-based cross-sectional comparative study. Indian J Psychol Med, 2020; 42(1): 46–51.

28.

Thakurta

, Singh

, Bhattacharya

, . Nature of sexual dysfunctions in major depressive disorder and its impact on quality of life. Indian J Psychol Med, 2012; 34(4): 365–370.

29.

Bonierbale

, Lançon

and Tignol

The ELIXIR study: Evaluation of sexual dysfunction in 4557 depressed patients in France. Curr Med Res Opin, 2003; 19(2): 114–124.

30.

Kim

, Jeon

, Lim

, . Vitamin D deficiency and suicidal ideation: A cross-sectional study of 157,211 healthy adults. J Psychosom Res, 2020; 134: 110125.

31.

Lavigne

and Gibbons

. The association between vitamin D serum levels, supplementation, and suicide attempts and intentional self-harm. PLoS One, 2023; 18(2): e0279166.

32.

Park

, Yang

, Won

Park T

, . Is serum 25-hydroxyvitamin D associated with depressive symptoms and suicidal ideation in Korean adults?. Int J Psychiatry Med, 2016; 51(1): 31–46.

33.

Grudet

, Wolkowitz

, Mellon

, . Vitamin D and inflammation in major depressive disorder. J Affect Disord, 2020; 267: 33–41.

34.

Nebhinani

, Sharma

and Suthar

Role of vitamin D supplementation in patients with depressive disorders and hypovitaminosis D: A Longitudinal Study. J Ment Health Hum Behav, 2017; 22(1): 14.

35.

Cui

, Gooch

, Petty

, . Vitamin D and the brain: Genomic and non-genomic actions. Mol Cell Endocrinol, 2017; 453: 131–143.

36.

Bode

, Ivens

, Bschor

, . Association of hypothyroidism and clinical depression: A systematic review and meta-analysis. JAMA Psychiatry, 2021; 78(12): 1375–1383.

37.

Loh

, Lim

, Yee

, . Association between subclinical hypothyroidism and depression: An updated systematic review and meta-analysis. BMC Psychiatry, 2019; 19(1): 12.

38.

Toloza

FJK

, Mao

, Menon

, . Association of thyroid function with suicidal behaviour: A systematic review and meta-analysis. Med Kaunas Lith. 2021;57(7):714.

39.

Nuguru

, Rachakonda

, Sripathi

, . Hypothyroidism and depression: A narrative review. Cureus, 2022; 14(8): e28201.

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