Depression and suicide

Suicide. I lost my son Bill this way. He was a fine young man.

Bill was working 2,000 miles away when he be came depressed. He showed the classic signs of depression, but I had no chance to see them. Some people suspected that things were not right with Bill, but no one seemed to know what those signs meant or what to do. Bill fought bravely, but silently and alone. Then he took his life.

The day we buried my son, a friend told me at the cemetery that this was the fourth funeral from a suicide he had attended within recent weeks, and all three who died before Bill had consulted their pastor within days of taking their lives. I came to realize that most people know little about the cause of suicide, or how much can be done to prevent it.

The medical perspective

Suicide cuts across all lines--race, education, economics. Some people describe it as a permanent solution to a temporary problem, but regarding it thus overlooks the fact that suicide involves much more than a wrong choice. It is the product of a sick brain that cannot function normally, think clearly, or handle life's daily flow. The sufferers them selves may experience such anguish at the apparent hopelessness of their situation that they turn to death to relieve their awful emotional distress, not knowing there is a cure.

Formulating a workable attitude to ward suicide has been difficult, but after centuries of confusion and shame, there is a new enlightenment. This new perspective is a medical one: almost all suicides, 95 percent of them, are due to a mental illness. ¹ Suicide prevention depends mainly on recognizing and treating this underlying mental illness.

The type of mental illness that causes the most suicides is depressive illness. Paul Wender, professor of psychiatry in the University of Utah, calls depressive illness "one of the most common and most destructive illnesses in the United States today." ² As many as 36 million Americans will have a major depressive illness. Probably 10 to 15 percent of all men, and 20 to 30 percent of all women, will have a serious depression at some time. Apparently anyone can develop depressive illness, at any age, no matter how strong or knowledgeable one is--factory worker, athlete, teacher, secretary, salesperson, pastor.

In depressive illness, it's as if the brain were invaded by some virus, responding in one of the few ways it can--by a disturbance in thinking and emotion. Fortunately, depression is the most treatable of all mental illness. In fact, the World Health Organization calls it "the world's most treatable untreated dis ease." Depression responds to a special kind of medicine, just like other dis eases. It is wonderful to see recovery firsthand, to see someone's sadness and pessimism replaced by a normal mood and normal thinking, often within a few weeks. People look back with disbelief that they could ever think and feel so bad; it's great to feel well once again.

Many people recover without treatment, but about 10 to 15 percent of those who do not take treatment turn to suicide. Recognizing people with depression and treating them correctly not only prevents that fatal ending but also the needless misery that accompanies pro longed depression with its harmful effects on the family and the job.

To make the public aware of how to recognize and treat depression, the National Institute of Mental Health in the United States is presently directing a 10- year "D/ART" program; the initials stand for the program's theme of Depression, Awareness, Recognition, and Treatment.

Causes of depression

Some depressions are mild, while others are severe. Some last for months, others for years, and some last a lifetime. Some come and go, or have ups and downs (manic depressive illness). At times depression is associated with and occasionally confused with schizophrenia and other psychiatric illnesses. At present there is no clear-cut answer as to what causes depressive illness. It seems to be caused by a combination of factors. Social stresses such as failure, loss, and isolation certainly appear to bring on a depressive illness in some people. Genes and body chemistry make some persons and some families exceptionally prone to depression. For reasons that are not clear, many alcoholics and drug abusers experience depression. And sometimes depression shows up even when people are not having any obvious problems.

Research has shown that people with depression have many abnormalities in the chemistry of the brain, its neurotransmitters, and hormones. Something is wrong, but it is an illness rather than a weakness of the will. This implies that blame and shame are no longer appropriate.

Signs of depression

People with depressive illness often look normal, and they can sometimes smile and appear to be having a good time even when seriously depressed. Friends and helpers need not feel personally responsible for making the diagnosis of depression, but they can become alert about depression as a possibility in the people around them.

Probably the most important rule of all for recognizing depression is that one must keep it in mind! As medical students are admonished: "If you don't think of it [whatever illness we were studying], then you will never see a case." By learning to keep depression in mind, to recognize it, and to help the sufferer receive medical care, one relieves a large cloud of misery and possibly even saves a life. Many of us rarely have the chance to be of that much help to our fellow creatures.

Although there are still no reliable laboratory or physical tests for depressive illness, we have excellent warning signals. People who are seriously depressed will usually show several of these signs together, lasting two weeks or longer. The first two signs are the most important ones.

1. A very pessimistic mood.

a. Gloom. The first clue that someone is depressed may be when that person's friends and family feel a little gloomy themselves after talking with him or her. With young people especially, one must pay attention to gloomy themes in the things they choose to read, draw, watch, or collect. Themes of death and suicide are ominous.

b. Crying or smiling. People with depression may cry a lot. Some, how ever, are unable to cry. Others put on a good front, smile, and even seem to be having a good time. This is often called a "smiling depression" or a "hidden depression." c. Nervousness. Some people seem more irritable and anxious than discouraged, which tends to mask the depression. One must avoid being misled, taking care to check for the signs of depression in worried or nervous people.

d. Complaining. Others say they do not feel depressed but act unhappy and irritable, and they complain of problems or medical symptoms such as a headache or stomachache. A surprisingly large number (some say as many as three fourths) of patients who visit pain clinics have a depressive illness and respond well to antidepressant medicine.

e. Other behavior. Some depressed people, especially youth, show their illness in terms of rebellious and risk-taking behavior, such as involvement with alcohol and drugs. They may fail subjects in school or stop attending alto gether.

2. Loss of interest. One of the most important signs of depressive illness is a loss of interest in things previously en joyed, such as gardening, sports, people, sex. The depressed person makes little remarks such as "I really don't care anymore." Friends often ignore these statements, or they answer with some quick reassurance before changing the subject. Saying this would be better: "What do you mean, John? You sound discouraged." A friend's expression of concern doesn't involve assuming responsibility for solving the distress and despair, but it does help the victim to acknowledge the reality of depression before it deepens into withdrawal and isolation.

3. Feelings of hopelessness, loss, and guilt. The distorted pessimistic out look of people with depressive illness seems to underlie everything. A seriously depressed person not only expects the worst but may describe himself or herself as the worst person on earth.

4. Low energy and fatigue. Tiredness and fatigue are more common in depression than any other illness. Lack of vitality is often more evident than sadness and tears. People have trouble getting themselves started doing things. Depression is always a top consideration as a cause of the currently popular "chronic fatigue syndrome." While some people with depression seem to be moving as if they were stuck in molasses, others become nervous and agitated.

5. Difficulty thinking. Remembering, concentrating, and deciding become heavy burdens for someone suffering depressive illness.

6. Change in appetite and weight. Weight loss or gain--more than five pounds when not dieting--is one sign of depression. It gives other signs a little extra significance.

7. Trouble sleeping. Like changes in appetite and weight, disturbed sleeping is another sign of impaired physical functioning. People with depression may sleep too much or too little. Early-morning wakening can be difficult.

8. Recurrent thoughts of death and suicide. The most seriously depressed sometimes show clues that they are contemplating suicide. Such clues include withdrawal from family and friends, the absence of hope, hearing voices, and other signs of disordered thinking. People thinking of suicide may actually talk about it. They may indicate their plans by giving away prized possessions such as trophies, stereo, and sports equipment, at times remarking: "I won't be needing these anymore." Other indications of impending suicide are putting affairs in order, for example, returning long-borrowed items and making final contact (unspoken goodbyes) with important friends and relatives. A sudden improvement in their mood may indicate that they are no longer painfully undecided about suicide; they have sealed their own fate. Tragically, these signs are often recognized only after death has already occurred.

Diagnostic questions

Because not all signs of depressive illness are obvious, checking for depression involves asking a few questions. The information needed is rather personal, so one must ask gently, compassionately, and in private:

"John, you sound kind of down. How are you? Are you worried about some thing?" (We are learning about his mood.)

"What are you doing that you enjoy these days?" (Is there loss of pleasure?)

"Are you disappointed in yourself? Do you blame yourself?" (Self-image and guilt.)

"Do you have trouble getting your self started doing things?" (Low energy.)

"How are you doing at work? How is your social life? How are things at home?" (These don't involve specific signs of depression, but they are easy to ask and likely to bring out important feelings and answers.)

"Are you having trouble concentrating and making decisions?" (Evaluating the thinking process.)

"Any trouble sleeping? Has your weight changed?" (The body as well as the mind is disturbed in depression.)

"Have you ever thought of hurting or killing yourself?" (Thoughts of death and suicide.)

Asking this last question about thoughts of suicide may seem rash and heartless, but when anyone is seriously depressed those feelings are certainly there. It must be determined how strong they are. Contrary to popular belief, people with a depressive illness are greatly relieved to have the subject brought up.

One might not feel qualified to ask these questions, but the stakes are high. Without the risk of doing harm, a friend or family member may be the only one this person will ever see who has guessed what's wrong, and who can help.

Treating depression

Serious depression is more than a counseling matter. Counseling only delays effective medical treatment, and that's dangerous. Direct referral to counseling also eliminates considering the possibility of another medical explanation for the depressive symptoms, such as hypothyroidism, brain tumor, or medication. Actually, I think that almost everyone suffering major depression should receive both talk and medicine, full therapy with medicine and psycho therapy.

If one's heart has a problem, the person to see is a cardiologist. In the same way, for emotional illness, no one is better equipped to help than a good psychiatrist. He or she has been through medical school and knows about illness and how the body and mind work.

Sometimes patients are unwilling to see a psychiatrist but would accept referral to see a physician. Many internists and family physicians are knowledge able in treating depressive illness, using simple psychotherapy along with the antidepressant medicines and frequent follow-up appointments.

Taking the medicine

Too often people have irrational fears about taking medicine that spoil their chances for recovery. I don't particularly like taking medication myself, but I recognize that it's wise to use helpful drugs that control blood pressure, infections, heart disease, diabetes--and depression.

Taking medicine for depression is not simply treating a "down" condition with "uppers." Stimulants are rarely used now. Today's medicines are not habit-forming, not addicting, and they won't make you do anything you would not normally do. They just slowly relieve the depressive symptoms. Nothing much happens if you stop them prematurely, except the dangerous depressive illness returns. It is distressing to see patients on their way to recovery discontinue medication when they feel better only to relapse and become a chronic treatment failure.

Antidepressant medicines may take two to four weeks before improvement begins. The prescription usually requires simply swallowing one or two, some times three pills a day. Side effects such as dry mouth, drowsiness, nausea, and nervousness are common, but these annoyances often subside with time and dosage adjustments while emotional recovery proceeds. Dangerous effects like convulsions or serious impairment of the heartbeat are rarely seen. The most dangerous side effect of the antidepressant medicines is from not taking them--suicide.

A good outcome usually requires a commitment to taking the medicine for six months or more. Long-lasting kinds of depression need longer treatment, just as high blood pressure requires long-term treatment. Good results are not guaranteed, but current studies suggest that early treatment of a depression, and long-term treatment when necessary, not only cuts short the period of misery and risk, but also diminishes the tendency of the illness to recur.

Getting treatment started

People with depressive illness usu ally need help in getting help. They frequently insist that they are all right and don't want to see a doctor. When this happens--if the family situation is favorable³--the family might gather around their sick one and tell the truth. "John, we love you. We are worried about your health, and we insist that you see the doctor. We are going to take you there." Then someone should accompany John to the doctor. Some patients must literally be taken by the arm; even legal commitment is appropriate if there is no other way. Don't underestimate the importance of taking a personal part in arranging the logistics of medical appointment. Giving the doctor a phone call beforehand will ensure that he or she hears the right words: "possible depression."

Whenever depression is suspected and suicide seems possible, action is required. One must not watch and wait for some additional behavior or sign to be convinced, nor let outdated stigma against psychiatry result in the death of a friend or child.⁴ Many sad families can testify that love, kindness, listening, and talking were not enough. It is essential to take the sufferer to a family physician, a psychiatrist, or a hospital right away. It takes a doctor to tell the difference between depression and other medical conditions. Psychotherapy is important, but it will be more effective later. ⁵ First the rescue.

Grief needs sympathy, problems need counseling, and depression needs medical care. In my medical practice, along with our patients with high blood pres sure and other illnesses, we always seem to have a half dozen patients recovering from depressive illness. They are filled with hope to know that we are familiar with their condition, and despite the present gloom the outlook for recovery is usually very good.⁶