SUICIDE AND DEPRESSION
Suicide and Depression
On August 11, 2014, my spouse said to me, “Have you heard? Robin Williams committed suicide.” My response was, “Who?” She repeated his name and I asked, “Who?” again. It’s not like I don’t know who Robin Williams is. In fact, he has been one of my favorite comedians and actors for decades. My confusion stemmed from my inability to connect my idea of Robin Williams with suicide. I’m a clinical psychologist. I know a lot about depression and suicide both professionally and personally. I know that depression and suicide can strike anyone regardless of gender, ethnicity or race, profession, or income. And yet, for those few moments, my cognitive dissonance was so great that I just could not connect my idea of Robin Williams with suicide. This insight shocked me then lead me to think, “If I don’t get it, how many other people won’t get it either?”
In the days and weeks since then, more information has emerged that “made sense” out of Mr. William’s choice. The reasons people suicide are varied. But, he was apparently experiencing at least three factors that are known to increase the risk of suicide: clinical depression (what psychologists called Major Depressive Disorder/MDD), a chronic illness (in this case, Parkinson’s Disease which never goes away and only gets worse over time), and a history of alcohol or substance abuse/dependence.
While this helped me “make sense” out of his actions, it is obvious from reports of various people’s responses that others do not understand. In the past few weeks, it has been heartening to see that many people have compassion and understanding regarding this tragic event. However, I have also been profoundly disturbed and angered by responses that criticize, blame, or besmirch the character of Mr. Williams for his decision to commit suicide. The former indicates that the stigma of mental illness is decreasing, while the latter is evidence that much more education regarding suicide and depression is needed. These are the things that led me to feel some conversation on the topic of suicide and depression is warranted. Later in this post I will get more specific about statistics and facts about suicide and depression, but I’d like to lead off this article by commenting on specific issues on my mind about this topic.
The first thing I want to address is the question many people raise, “How could they do that to their family and loved ones?” Let me be clear, as the survivor of a close family member who committed suicide in 2001, I will never disregard the horrific pain and suffering family members and loved ones experience, often for years, when someone commits suicide. However, I think the question, “How could they?” (1) profoundly underestimates the severity of suffering and hopelessness that those who choose suicide experience and (2) disregards the fact that they are often “not in their right mind.”
Let’s talk about the severity of suffering and hopeless first. It has become common to hear someone who is having a rough time state, “I’m so depressed” to express they are in emotional pain. This over used phrase, obscures the fact that Major Depressive Disorder (MDD) is categorically and exponentially different than the normative grief and sadness everyone experiences during painful experiences in their life. In fact, unless you have experienced a Major Depressive Episode (MDE) caused by MDD or Bipolar Disorder, it is hard to fully appreciate the difference. I will list the full symptoms of a MDE later, but, in general, things that one could normally cope with or control are suddenly catastrophically overwhelming and out of your control. I know this from what my clients have told me but, more importantly, from personal experience as well. Growing up, I watched my mother battle repeated episodes of clinical depression caused by Bipolar II Disorder. When my mother was well, she did a phenomenal job of caring for my brother and me. But when depressed, doing this, which was her highest priority in life, was completely beyond her reach. I always had compassion for my mother’s struggle, but didn’t really understand how you could want to do something but suddenly be unable to do it (like get up and feed your children) or you could lose interest in something all together for weeks, months, or even years. I finally got it in my early 20s when my first experience of MDD occurred. The pain was excruciating. I had experienced pain in my life already. Just as an example, I watched my best friend die in front of me from a car accident when I was sixteen and was still able to find a way to cope and do daily activities. But the emotional, cognitive (thinking), and behavioral pain of MDD was so many times worse it shocked me. Suddenly, things that meant the world to me were suddenly beyond my ability to do, or I strangely lost interest in them completely. I think the most dangerous part of it all, and others have told me the same, was my lack of ability to believe that things would ever get better. This belief didn’t change even in the face of evidence to the contrary. I literally could not see that the pain would ever end. I think this hopelessness directly feeds into the symptom of depression that can make MDD a fatal illness: recurrent thoughts of suicide (suicidal ideation) or suicide attempts.
I will give you more statistics on suicide and its risk factors in the posting “FACTS, STATS, AND HELPFUL INFO ABOUT SUICIDE AND DEPRESSION”, but let me give you this now. The American Foundation for Suicide Prevention (AFSP) (www.afsp.org) used figures from the Centers for Disease Control and Prevention Data & Statistics Fatal Injury Report for 2011 to calculate the following. “Ninety percent of all people who die by suicide have a diagnosable psychiatric disorder at the time of their death. … Over 60 percent of all people (in other words 6 out of 10) who die by suicide suffer from major depression (MDD). If one includes alcoholics who are depressed, this figure rises to over 75 percent.” And Depression and Suicide are not small problems. “Depression affects nearly 10 percent of Americans ages 18 and over in a given year, or more than 24 million people. … (And) about 15 percent of the population will suffer from clinical depression (MDD) at some time during their lifetime. (Of those,) thirty percent of all clinically depressed patients attempt suicide (that’s roughly one third); half of them ultimately die by suicide.” The good news is “depression is among the most treatable of psychiatric illnesses. Between 80 percent and 90 percent of people with depression respond positively to treatment, and almost all patients gain some relief from their symptoms. But first, depression has to be recognized. … (And finally,) the best way to prevent suicide is through early detection, diagnosis and treatment of depression and other mood disorders.” (http://theovernight.donordrive.com/?fuseaction=cms.page&id=1034, retrieved August 30, 2014).
Now to my second point about those who complete suicide not being in their right mind. This statement is arguably not true for some people who commit suicide. Just as an example, there are those of sound mind with chronic or terminal illness who make the choice to end their suffering. I don’t mean this statement to be pejorative or unnecessarily pathologizing. However, since nine out of ten people who commit suicide have a diagnosable psychiatric disorder, it is not unfair to assume that their cognitions (thinking) and/or emotions are distorted in some way. The example cited above is hopelessness complicated by the cognitive distortion of catastrophic thinking (e.g., it will never get better). In 1972, Aaron Beck proposed the idea that those who are depressed exhibit specific types of cognitive distortions of their negative automatic thoughts (http://mysite.du.edu/~chmorley/Beck.pdf). Thus, in Cognitive Behavioral Therapy (CBT), one approach to treatment for depression is to help people recognize the negative automatic thoughts that are distorting their thinking and then work to correct the distortions. The key is to first get the person to believe that their thoughts are distorted and to trust someone else’s perception of reality (mental health professionals, medical professionals, spiritual counselors, or family and friends) more than their own. In regards to hopelessness, this would mean believing when someone tells us there is hope for symptom relief even though it completely contradicts our own current lived experience of hopelessness. Thus, belief in trusted other’s belief in hope can be a protective factor against suicide and help someone hold on in the face of painful emotions, thoughts and behaviors until treatment can work or symptoms spontaneously remit.
This leads me to what I feel is one of my key roles as a clinician: to hold onto hope for my client and the belief that healing happens even in the face of overwhelming odds or issues. This doesn’t mean that I don’t understand and acknowledge the hard, sometimes devastating, and painful realities that must be faced. But, it reflects my belief and experience in the power of the human mind to heal and the power of psychological techniques and psychotropic medication to bring symptom relief over time. My second role is as an educator, not just of my clients, but also of the people in my client’s life. Information that promotes understanding and teaches needed skills may come from me directly or through my client educating those around them. In the case of depression this could mean family or friends helping a client get out of bed to engage in regular exercise (with a doctor’s approval) which has been shown to be as effective as taking an antidepressant (http://www.apa.org/research/action/fit.aspx, http://www.health.harvard.edu/newsweek/Exercise-and-Depression-report-excerpt.htm). Without this type of support it may be highly unlikely that the person with MDD could engage in this antidepressant behavior regularly on their own. Another example is encouraging the client to stay engaged in treatment and/or take their medication long enough for it to be helpful. In the case of antidepressant medications, they can take weeks for the antidepressant component to take effect. Unfortunately, the client may experience negative side effects immediately. So my and significant others’ role may be to support and encourage the client to deal with the side effects with the help of their medical doctor or psychiatrist while waiting for the antidepressant qualities to take effect. Encouragement to stay and engage in psychological treatment is similar in that treatment may take weeks before improvement occurs and may require the client to stay engaged in an emotionally, cognitively or behaviorally difficult process. In the case of suicidal ideation or attempts, this can mean educating the client and their significant others about the warning signs for suicide and how to access help in case of emergency (which I cover in the entry “FACTS, STATS, AND HELPFUL INFO ABOUT SUICIDE AND DEPRESSION”). While I can have someone hospitalized, even against their will, to get them treatment and keep them safe until the eminent risk of suicide has passed, this only works if my client is willing to let me and others know they are having thoughts, plans, and intent regarding suicide or if their significant others know when to contact me or emergency services. It is a sad truth, however, that if someone is determined to take their life, there may be nothing anyone can do to prevent this. This reinforces why earlier intervention is so important.
Finally, keeping people engaged or reengaged in treatment is important. The first reason I’ve already stated: treatment takes time to work but is effective. The second reason, staying or getting back into treatment is important, especially for those who may have become discouraged and ended treatment. This is because new understandings about depression and treatments for depression are discovered over time.
One example of a very important development is a new understanding that insomnia can precede depression, and treating the insomnia with Cognitive Behavioral Therapy for Insomnia (CBTI) seems to double chances of a full recovery from MDD. A New York Times article published Nov. 18, 2013, (http://www.nytimes.com/2013/11/19/health/treating-insomnia-to-heal-depression.html?pagewanted=all) reported that a team from Ryerson University in Toronto replicated the results of a pilot study done by Stanford University, the VA Medical Center, and Duke University published back in 2008 (http://www.journalsleep.org/ViewAbstract.aspx?pid=27114). Results from 3 other studies are expected sometime in 2014. If the results hold, this would mean CBTI is one of the most promising short-term treatments for depression in years. The following is a quote from the 2008 pilot study describing CBTI and its differences from sleep hygiene.
CBTI include(s) the following components: (a) education about normal sleep, sleep in depression, circadian rhythms, and impact of substances (Session 1); (b) sleep restriction and stimulus control instructions (introduced during Session 2 and adjusted during subsequent sessions); (c) management of stress and of cognitive and somatic arousals (Session 3); (d) cognitive restructuring (provided throughout the intervention); and (e) instructions for continued schedule adjustment and relapse prevention (Session 7). …
…The most recent practice parameters for the psychological and behavioral treatments of insomnia concluded that there is “insufficient evidence” for sleep hygiene education to be an
option as a single therapy. … All participants were instructed to limit caffeine intake to the equivalent of no more than 3 cups of coffee per day and avoid all caffeine consumption in the late afternoon and evening hours. They were also advised not to consume alcohol too close to bedtime, to avoid eating large meals late at night, and to make the bedroom environment adequately dark, temperate, and quiet (http://www.journalsleep.org/ViewAbstract.aspx?pid=27114, retrieved Sept, 23,2014).
Another example of a new development is the creation of a blood test to that can verify MDD in adults. On Sept 16, 2014, Northwestern University News Center reported that Northwestern Medicine® scientists had come up with a test that identifies nine RNA blood markers that at certain levels coincide with MDD (http://www.northwestern.edu/newscenter/stories/2014/09/first-blood-test-to-diagnose-depression-in-adults.html). It also determined which markers would indicate that someone would benefit from Cognitive Behavioral Therapy as a treatment. The study also found three markers that indicate that someone is at risk of developing MDD at some point in their life. This is the first objective, scientific measure to diagnose depression in adults and could prove incredibly beneficial once it is widely available.
In summary, it is important to remember that depression (MDD) is more than being a little blue, but once identified responds well to treatment. This can be the critical difference between those with MDD who suicide and those who do not. If you or someone you know struggles with MDD or thoughts of suicide, please seek professional help.
I hope that this information was interesting and helpful to you, and that you will consider returning in the future. My next post will be more information on Chronic Pain and Depression.
Michelle E. Mason, PhD, Clinical Psychologist, PSY23467
September 29, 2014
If you would like additional information about me or my practice you may find it on my website (www.adiffpath.com), or you can call me at 510-506-50921, or email at mmasonphd@comcast.net.
