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| The Link Between Depression & Suicide |
| Feature Articles - Mental Health | |
| Wednesday, 31 May 2000 | |
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Despondency had come upon her there in the wakeful night, and had never lifted . . . There was no one thing in the world that she desired. There was no human being whom she wanted . . . The children appeared before her like antagonists who had overcome her. But she knew a way to elude them. She was not thinking of these things when she walked down to the beach . . . The water of the Gulf stretched out before her . . . The foamy wavelets curled up to her white feet and coiled like serpents about her ankles. She walked out. The water was deep, but she lifted her white body and reached out with a long sweeping stroke . . . Her arms and legs were growing tired. She did not look back now, but went on and on . . .
More people in American die of suicide than from homicide. According to recent research, in 1996 there were 30,535 deaths and 775,000 attempted deaths by suicide. Suicide was the eighth leading cause of death in America and the third leading cause of death for young people aged 15-24. Unlike Edna, the despondent female protagonist from Kate Chopin's nineteenth-century novel, most people today who commit suicide do not drown themselves, but use a gun.
What triggers people to take that final leap off the brink of despair that ends their life? According to the National Institute of Mental Health, many factors may lead a person to commit suicide, but research shows that depression and substance abuse top the list in almost all cases. Although most people suffering from depression do not kill themselves, suicide is a possible complication of depressive illness in combination with other risk factors, because suicidal thoughts and behavior are common symptoms of moderate to severe depression. Depression: Who gets it? Depression, a serious mental illness, can interfere with a person's ability to function. An estimated 17.5 million Americans suffer from depression. Of that about 9.2 million have major or clinical depression. This debilitating illness can happen to anyone at any time in life, from infancy to old age, although some people are more prone to it than others. Heredity appears to play a role in risk of depression; however, some people with a family history of the disease elude it. Some notable public figures that suffered from depression include Tipper Gore, who became depressed after her son's 1989 car accident. Her mother also had a history of depression. Novelist William Styron survived a near suicidal depression in 1985, and writer Virginia Woolf ended her depression with suicide. According to the American Medical Association (AMA), typical symptoms of major depression are:
The link between depression and suicide Suicide in conjunction with depression can strike children as well as adults. According to the American Medical Association, depressed children as young as five years old have committed suicide, and the highest rates of suicide from depression are for single or widowed males over 55. Wendal Winn, MD, is a psychiatrist in private practice in Anchorage, Alaska. Dr. Winn treats many cases of depression and anxiety cases in a state where the light/dark phenomena causes seasonal affective disorder and amplifies the depression rate. In addition, a high incidence of substance use and comorbidity prevails, Alaska natives (depression and alcohol use and abuse are the most common risk factors for suicide for Native Americans and Alaska natives) are caught up in a cultural transition, and guns in homes are commonplace. These factors might suggest that Alaska could have a higher suicide rate than most other states. However, data from the National Center for Injury Prevention and Control, "Injury Mortality National Summary of Injury Mortality Data 1987-1993," show that Alaska ranked 5th among states with a suicide rate of 17.6, while Wyoming topped the chart at 22.6. "Depression is very common in the types of populations I work with," says Winn. "There is a known association between depression and suicide, less well known, but increasing, as our colleagues are aware, is that people with anxiety disorders have a surprisingly high incidence of suicide." Psychiatrists and psychotherapists that treat severely depressed clients are commonly confronted with clients' suicidal thoughts. "Anybody with depression is at risk to have suicidal feelings," says Harry A. Brandt, MD. Brandt, former Chief of the National Institute of Mental Health Eating Disorders Unit, now heads the Department of Psychiatry and directs the Center for Eating Disorders at St. Joseph Medical Center, Towson, Maryland. As head of psychiatry in a hospital with an inpatient unit, he treats treatment resistant and difficult cases including depressed patients who harbor suicidal thoughts. "It's not an uncommon component of depression for people to move into a stage of despair where they begin to think about killing themselves. However depression is a very treatable illness. And that's why it is very important for them to get help." Cognitive disturbance accompanying depression includes trouble thinking as the mind darts from thought to thought and this is particularly in the case of an agitated depression — and this is where thinking can become constricted," explains Brandt. "A person loses his capacity to see ways out, to see all their options and to see that there are solutions. "My clinical experience is that a person with depression is viewing the world in a very negativistic, limited, narrow way, colored by the depression," says Brandt. "They begin to think that their only way out is through death, or they lose their best judgment and lack insight to the point where their thinking becomes constricted and they see this as their way out." "Studies have found that patients who've had severe episodes of depression or manic-depressive illness, severe enough to ever have been in the hospital, are 15 to 20 times more likely than the general population to die by suicide," says Lucy Davidson, MD, EdS, an Atlanta psychiatrist. "And the risk of dying by suicide is greatest within the week immediately following discharge. So, that means that persons who are in a depressive episode are at greater risk for suicide during the episode of illness. There may be things about people who get the illness, depression, that makes them at greater lifetime risk as well, separate from times when they are obviously ill with that disorder. Many people who end their lives by suicide may have a genetic predisposition towards that, and when you combine an episode of depressive illness, the combination may be what's lethal, because obviously most people who are ill with depression do not commit suicide." The more we can learn about those that do, notes Davidson, who is Clinical Associate Professor of Psychiatry at the Collaborative Center for Child Well-Being at Emory University, Atlanta, the more we can target our efforts in prevention. "It's not just the severity of the episode of illness," says Davidson. "The more depressed you are the more likely you are to be suicidal. But some people are suicidal in conjunction with an episode of depressive illness from the very moment that the illness starts." Treating depression Depression is generally considered eminently treatable, says Winn. Various forms of psychotherapy, such as cognitive therapy and interpersonal therapy are beneficial in treating depression, as are a variety of antidepressant medications and a combination of the two. Winn advocates the use of mixed treatments for depression. Among therapies such as psychotherapy, cognitive behavioral therapy, interpersonal therapy and psychodynamic therapy, Winn favors cognitive behavioral therapy in which the therapist helps a client to recognize the client's negative thought patterns and replace them with positive ones. "It's a lot different than just 'poor me' or holding someone's hand and being supportive, and it's not long-term analytic complex esoteric psychodynamics," says Winn. "It's more here and now practical perceptions and misbeliefs and kind of in a brief treatment model. That subtype of psychotherapy has better hard evidence of efficacy." Medication Winn advocates sometimes using medications in conjunction with psychotherapy as well. "The armamentarium of antidepressants that we have now is wonderful," says Winn. "We have medications that are safe, non-addicting and are effective. Unfortunately, they are all delayed in effect." According to the American Medical Association (AMA), generally, anti-depressant medications must be used for four to six weeks before they begin to cause substantial improvements in mood. Also, determining the right antidepressant and correct dosage is likely to involve a period of trial and adjustment and to continue for several months. "We have to start breaking the stigma. Research has revolutionized diagnosis and treatment, with a new range of drugs. And they're still coming out," Tipper Gore said. Researchers believe that both depression and suicidal behavior can be linked to decreased serotonin in the brain. Four types of antidepressants that work in various ways to correct a chemical imbalance in the brain are:
Should every patient who's suffering from severe depression be evaluated for the use of medication, even if they are suicidal? "All patients with severe depression should be evaluated for treatment with medication. In the modern era we have a great variety of medications and many patients are very responsive to medication," says Brandt. "A person shouldn't be denied medication treatment because they have a severe depression. If one is so afraid that the person is at risk for killing himself or herself with medication, the person needs careful evaluation for necessity of hospitalization." Moreover, Brandt insists that although he feels that every patient with severe depression should be evaluated for the use of medications — not all patients should be on medication. "In most cases a patient with severe depression and suicidal tendencies should be on medication but I would never make a blanket statement that every patient should be. There are some situations where other treatments are indicated, some patients can't tolerate certain kinds of medication," says Brandt. Winn believes that there are negative and positive sides to treating depression with suicidality with medications. "I would see it as a double-edged sword," he says. "On the positive side depression is generally considered eminently treatable and part of treatment interventions would be the use of modern effective antidepressants. To the extent that depression can be ameliorated with treatment including medication, you would have a reduced incidence of suicidality. The other side of the sword is one of the factors in suicide risk is the presence of means. That is a methodology. And one of the most common methods is overdosing. So, to the extent that people have large supplies of pills lying around, be they antidepressants or otherwise, that does create some risk and that needs to be factored in amongst those of us who treat depressives." Brandt says that although prescription drugs may hold some risk, the decision to dispense the drugs rests on a careful assessment of the patient and the setting the patient is in. "Sure, somebody could take an overdose of medication but any patient who could take an overdose of medication certainly has many other means to potentially hurt or kill themselves," says Brandt. "With medication, one needs to think very carefully about prescribing medication to people who are actively suicidal, because they can be used in a deleterious way. It becomes a vicious circle because if you don't treat patients with severe depression appropriately using all the available modalities, they could potentially get more depressed which puts them at a high risk for suicide." Electro-convulsive therapy Somewhat controversial, electro-convulsive therapy (ECT) has gained ground in the field as a treatment for some people who suffer from depression. "There are a lot of myths about ECT and the public doesn't understand it very well," says Brandt. Electro-convulsive therapy is unlike the rudimentary shock treatments of the past. Sedated patients are given electro-convulsive therapy, which sends a low-level electrical signal through the brain that induces a 30- 60-second general seizure. Relief from depression usually occurs within one to two weeks following the procedure, and antidepressant medication and psychotherapy are used as follow-up treatment. A side effect of this form of therapy is temporary memory loss, according to the AMA. "ECT is one of the most effective treatments for severe life-threatening depression, because it works pretty rapidly — and some patients cannot take medication," says Brandt. "With appropriate use of anesthesia and the application of electrical impulse leading to seizure in the brain, this is a very excellent treatment for severe depression." Winn says that a subset of depressives that is treatment resistant require extraordinary means of treatment such as neuroleptics or thyroid medication or ECT. "Sometimes ECT is literally life-saving, but that's in the treatment resistant, or the minority of cases that don't respond to psychotherapy and medication," says Winn. Assessing suicide risk in clients In 1999, Surgeon General David Satcher released a national strategy for suicide prevention, to better prepare healthcare providers to diagnose potential victims and eliminate the stigma that surrounds mental illness. "Too many physicians are coming into contact with people who are at risk for suicide and not asking the right questions," noted Satcher. The strategy, which consists of 81 recommendations including increasing research, expanding insurance coverage of mental health and substance abuse treatment, improving depression screening, and establishing workplace prevention programs, was compiled from input by more than 450 doctors, counselors, educators and victim's family members who met for a four-day conference in Nevada. One professional, who contributed to the strategy is Atlanta psychiatrist Lucy Davidson, MD, EdS. Dr. Davidson says that some clients are referred to her by counselors because the client may be depressed and threatening suicide. It is important, notes Davidson, that the counselor understands the risk factors for suicide and the types of information that attribute to making a risk assessment and collects them as an integrated part of the mental status examination and evaluation. "Ask about impulsive behavior," she suggests." That will let you know whether someone may act on a suicidal idea in a rapid way." Experts agree that a history of impulsive anger is another red flag for suicidality. "Anger is an important element," says Brandt. "It's important for a therapist to look for rage that's been directed outward, because it's when that rage gets directed towards the self that a client might kill him or herself." A client's language can also reveal a death wish or rationalize suicidal behavior. "A morbid sign is when people begin to have reunion fantasies about deceased loved ones," says Brandt. "They might say, 'I'll reunite with them in death — or in heaven.' Those kinds of statements are ominous because the person is moving into a state where they are overriding their fear of death with what they view as benefits of death." Recovery from depression is not necessarily a suicide safety zone. Just because a client is in recovery from depression and seems to be maintaining a healthier state of mind is not enough reason to think they are no longer suicidal, notes Davidson. "A person who has been deeply depressed and suicidal may be at higher risk for suicide when they begin to recover from their depression," says Davidson. "This is a very dangerous time because you may not inquire or assess the person's level of suicidal risk when they start looking better. The rationale that goes behind it is that those who are in the extreme depths of depression are just not able to organize themselves and take this action. As they begin to recover, the pain of their experience and what it will take to come through the other end of it feels overwhelming, and yet they have a little more energy and organization to act in ways that turn out to be lethal." Intervention when a client is suicidal Early recognition and treatment is the key. Suicide threats should always be taken seriously and steps should be taken to directly address them in a firm but gentle way. "Therapists should not be afraid to raise the issue very directly," says Brandt. "There have been concerns that if one brings up the topic of suicide to a patient that it might trigger the thoughts in the patient or put the idea in the person's mind, and that's very misguided." Brandt suggests that therapists ask clients who are depressed if they've had suicidal thoughts in a direct but matter- of-fact manner. Often, he explains, the client is relieved to talk about it and that sets the stage for the therapist to be able to explore in detail the nature of the client's thinking with the goal of figuring out how serious a situation it is. Patients sometimes ask Brandt if thoughts of death are normal. He answers with an emphatic no. "Normal experience is not to think about death or dying," says Brandt. "Theoretically one can think about some of these issues in a normal mood state, but when one who is depressed begins to think about what it would be like to be dead, or begins to wish to be put out of his or her misery, through death, that is not normal. It is very abnormal and needs to be dealt with as a symptom of a serious life-threatening illness." However, the patient needs to get a sense that the therapist is very comfortable exploring the patient's wish to die or suicidal thoughts or feelings. When the therapist is empathic and skilled in communicating with the patient in a way that encourages the patient to talk about his deepest, darkest fears and feelings, he is relieved that the therapist can head into the topic of suicidal feelings and behaviors and doesn't seem afraid to explore these matters in detail. "You don't want to lead someone to feel that they are abnormal," says Brandt. "But you don't want to let patients minimize the significance of suicidal feelings. For some people it can be a slippery slope where the feelings start and then the patient's thinking becomes so constricted and constrained because of depression that they begin to see suicide as their only option, as opposed to the myriad of options available to them to get help, climb out of their depression and move on with their life." Davidson affirms the importance of addressing the issue of suicidal behavior with the client. "You don't want to avoid it for the mistaken fear that if you mention it the person will deny it," says Davidson. "You don't want to come at it from asking the client for their summary of whether they're suicidal or not, you want to collect the range of information and make an informed clinical decision about that." One way to start, notes Davidson, is to inquire into how they've been feeling, and move the conversation into how they feel about their prospects. "For example," she says "ask them if they think that things will change. That gives the therapist an indication of whether the client is hopeless or not. Then ask if they are feeling like it's not worth it to go on. And then ask if they think things would be better off if they were dead, if they've thought about ending their lives, in a passive way. "When you start with that approach you get a sense of where the person is and you obviously don't have to continue with 25 questions if you get into this and they are doing OK," says Davidson. "You've gotten a feel for the degree of psychic pain that they are experiencing and their sense of hopelessness and whether they are thinking about death as a result of these two things." Intervention techniques and strategies Winn offers several strategies and techniques that counselors can use to address clients' suicide threats. "One strategy for the therapist to employ is an openness and a willingness to explore suicide as an issue, a factor, or risk," says Winn. "There is a somewhat common myth/assumption that if you talk about it, it makes it real, and that's not the case at all. You should be readily willing to screen for and ask about suicide." When that comes up as an issue, Winn notes, a therapist should be well balanced in their approach. He or she should not ignore it or confront it, and not panic. The matter, he says, should be dealt with in a professional manner and explored like many other issues that people explore in a psychotherapy relationship. "One key point for clinicians is to not be winging it or evaluating or dealing with suicide by the seat of the pants. The key is to be proactive," says Winn. Winn suggests that clinicians think through the following issues in advance:
"All of these points impact how you deal with suicide, and it isn't something you deal with when the person is in your office," says Winn. "It's all proactive beforehand." Documentation is extremely important for medical — and legal — purposes. Suicide is one of the most common bases for suit, notes Winn. Documentation provides continuity of care if the client moves on to some other arena or clinician. Winn offers counselors the following techniques to employ when treating a suicidal client: Contracting "Once the suicide card has been played and it's under discussion, many patients will agree to make a promise, or commitment or even a written contract with a therapist or clinician that they won't do anything for a certain period of time — or at least until the next session," says Winn. "It's a way to avoid or postpone any overt act. It's not perfect, but many people use it and it can be effective." Connecting Many people who are depressed or suicidal feel isolated, Winn explains. Winn encourages them to seek out their friends, family, neighbors, church congregations and others to decrease their sense of isolation. Activate He also suggests that they increase their activity level. "Most people who are depressed tend to shut down. They become apathetic and sedentary and it's difficult to do, but to the extent the person can, they need to activate across the board," he explains. Areas to focus on include:
Hospitalization The next line of treatment, according to Davidson, is to then decide what is going on to make the client feel this way and what type of intervention will address the underlying cause. The therapist must then decide the type of environment that will best serve the client, so therapist and client can begin work on the underlying issues making the client suicidal. Not everyone with suicidal ideas has to be hospitalized. Part of decision making involves gathering information from other sources besides the patient, because they have additional information that the patient may not be able to provide, and they may see things that aren't as obvious at the moment. The clinician should ask the client for permission to speak with family members and friends to gain a broader viewpoint regarding the client's background. "People in counseling are probably less reluctant to do this perhaps than people in psychiatry but maybe we should learn from each other," says Davidson. Many factors come into play, before a decision is made to place someone suffering from depression in a hospital instead of treating them as an outpatient. These factors include:
Another factor, notes Brandt, is the pervasiveness of the patient's suicidal thoughts. "Does the person have a specific plan and are they moving closer to action?" says Brandt. "Have they been impulsive in other manners? Is substance abuse involved or other factors that could increase a person's impulsivity? "The therapist needs to assess the cognitive state of the depressed patient in an ongoing, careful and methodical way to assess these kinds of factors," Brandt contends. Establish a referral network "Each person who will be in a front-line position to work with potentially suicidal clients needs to know in advance and be comfortable with ways that they would access a next level of help and coordinate care for a suicidal person," says Davidson. "It's very hard to ask these scary questions and to pursue it if you don't already have the mechanism available to you for what to do next with the suicidal patient." It's important for therapists and counselors to have a referral network of professionals from a medical discipline. "Any patient with severe depression should be referred to a psychiatrist for a psychiatric evaluation," says Brandt. "The psychiatric care is so important to these patients because it involves depression and suicidal depression in particular often requires a full evaluation of all of the different factors including the medical factors that are involved."
Jan Marie Werblin is Associate Editor of Professional Counselor magazine.
Ed. note: The American Foundation for Suicide Prevention supports research projects that help further the understanding and treatment of depression and the prevention of suicide. To reach them:              |
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