Further Observations Regarding Major Depression Treatment and Special Issues - Suicide

Rashmi Nemade, Ph.D., Natalie Staats Reiss, Ph.D., and Mark Dombeck, Ph.D.

Improvement of depression symptoms does not happen all at once. Instead, depression tends to turn around slowly and gradually. The first symptoms that tend to improve are problems with sleeping and loss of appetite (or excessive appetite). This early somatic (body) symptom improvement is often followed by improvements in energy levels (e.g., less fatigue) and interest in activities. During this time, people with depression also gradually become more able to think clearly and to function more productively. The last depression symptoms to disappear are the cognitive and emotional symptoms; typically those that have to do with feeling depressed and discouraged. Depressed patients often fail to pay attention to the fact that they have more energy, or discount that this represents an improvement of their condition (as they still feel bad). Still, physical symptom improvements are real improvements, and they are readily noticed by third party observers. Depressed patients are often the last to know that they are getting better. Thus, it is important for depressed people to continue to stay committed to working with their therapists and doctors even if all their symptoms do not go away quickly.

Special Issues - Suicide

In the United States, one person every minute attempts suicide; half a million of them require emergency room treatment. One person every 24 minutes dies from intentional self-injury, totaling about 30,000 people each year. There are numerous risk factors for suicide, but the biggest risk factor is being depressed. Having a mood disorder, specifically Major Depression, significantly increases the likelihood that someone will commit or attempt suicide.

About 2% of people treated for depression in an outpatient setting (e.g., people with milder forms of depression) will die by suicide. Among those treated for more severe depression in an inpatient hospital setting, the rate of death by suicide is 4%. Another way of looking at suicide risk and depression is to examine the lives of people who have died by suicide and see what proportion of them were depressed. From that perspective, about 60% of people who commit suicide have a mood disorder.

Suicide is a particularly unfortunate outcome, because it is a permanent, desperate solution to what is generally a temporary problem. Suicide victims end up dead, and those they leave behind (family and friends, children and parents, etc.) often end up emotionally devastated, and even traumatized thereafter.

White men over the age of 85 have the highest rate of completed suicide. However, teenagers and adults in their early 20s are at the highest risk for suicide since so many more people in this age group contemplate and attempt to harm themselves. It is unclear why teens and young adults attempt suicide at such a high rate. Some authors note that this age is simply the typical average age of onset for mood disorders. It is also true that many young people may not have developed the coping skills necessary for successfully managing depressive symptoms and instead seek an escape from their despair through suicide. In addition, young people living at home may also be coping with drug/alcohol abuse or with family violence and abuse issues that leave them feel trapped and unloved.

Teenagers and young adults are typically more susceptible to the influence of modeling, and more likely to imitate suicidal behavior. For example, the best predictor of suicide among adolescents is a history of attempted suicide by a friend. Newspaper accounts of "epidemics" of teen suicide are a poignant illustration of this copying behavior. Each year, approximately 20% of adolescents contemplate suicide; by the end of high school, 1 in 10 will have attempted it, with almost 2,000 succeeding each year.

True suicide risk is very difficult to predict with any accuracy as suicide is a low frequency event. Many more people think about suicide than actually carry it out. Accordingly, anyone who expresses signs of depression should be considered a potential suicide risk and should be monitored for suicidality across the course of their depressive illness.

Family members and friends who are close to a depressed individual should watch out for signs that are associated with suicide. People who are contemplating suicide may express the following symptoms, according to the National Institute of Mental Health:

They may talk about feeling suicidal or wanting to die
They may express a feeling of hopeless; that nothing will ever change or get better
They may feel helpless; that nothing they do will make any difference
They may feel like they have become a burden to family and friends.
They may start abusing alcohol or drugs (or abuse drugs and alcohol that much harder)
They may begin the process of putting their affairs in order (e.g., organizing finances or giving away possessions) as a way of preparing for their death
They may write a suicide note
They may become impulsive and start taking risks that put them in harm's way, or into situations where there is a danger of being killed

If you think someone has become suicidal, it is appropriate to take the following steps to help keep that person safe:

Call a doctor, emergency room, or 911 (in the United States) right away to get immediate help
Ask the suicidal person directly if he or she is feeling suicidal. If they respond yes, then ask whether they have developed a suicide plan and if they have gathered together the tools they will use to carry out that plan.
Eliminate the suicidal person's access to things they might use to commit suicide. (medication, weapons, knives, etc.)
Stay with the suicidal person until help comes. Make sure the suicidal person is not left alone.

While some suicide attempts are carefully planned over time, others are impulsive acts that have not been terribly well thought out. Thus, a valuable long-term strategy for helping manage suicide risk is to remove ALL tools and items that might be used to commit suicide from the depressed person's environment. It is impossible to remove all items that can be used to commit suicide (people get creative about this sort of thing when they are motivated enough), but you should do all you can nevertheless.

Passing suicidal thoughts are common enough in depression and are not often all that serious. However, as they can become serious should depression worsen, it is important to take all suicidal thinking seriously. If you find yourself taking suicidal thoughts seriously, or if you believe someone you know is seriously considering suicide, seek professional mental health help as soon as possible. Suicidal feelings are usually responsive to treatment and can be successfully overcome.

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