For the Severely Depressed Person,
One Question Must be Asked

There is an anecdote from a number of years ago - whether true or not is unknown - about a young man hospitalized for severe depression. One evening he is found lying in the middle of one of the roadways on the hospital's grounds. Asked what he was doing, he said he was waiting to be run over. "Well, the speed limit is only 10 miles an hour here," one of the attendants said, and so his suicide attempt was dismissed and he was sent back to his room. Later that night, he made his way to an interstate, lay down in a middle lane and within a few moments was run over by a truck.

"Any talk about suicide has to be taken seriously," says Dr. Robert W. Guynn, chairman of the psychiatry and behavioral sciences department at The University of Texas-Houston Medical School. "You - the family member, friend or clinician - need to ask questions. Are the thoughts vague and amorphous, such as `I wish I was dead'? This kind of abstract thinking is fairly common in adolescence. But if the answer to a specific question like `Do you have a plan?' is detailed, then it has to be taken very seriously," says Dr. Guynn, who is also director of the UT-Houston Harris County Psychiatric Center.

"In health care, we are dedicated to preservation, and the individual is dedicated to self-preservation," says Dr. Stuart C. Yudofsky, chairman of the department of psychiatry and behavioral sciences at Baylor College of Medicine. "And yet we sometimes see how a mood or an idea can take hold of a person and completely negate that need to stay alive."

The impulse to end one's life comes from the deep feeling that life if no longer worth living. But this very intense and severe depression - hopelessness - has probably not come on suddenly.

In such a case - when the family and the patient's physician suspects suicidal ideation - a thorough medical evaluation is essential. For many chronically depressed people who also may have a concurrent physical illness, their regular physician may be in the best place to see a dangerous situation. In fact, one recent study indicates that 70 percent of people who committed suicide saw a physician within a month of the suicide act, 40 percent within a week.

The presence of a chronic illness, including substance abuse, adds to the risk of suicide. Nearly all people who take their own lives have a diagnosable mental illness, most often depression. Often, too, there is substance abuse.

"We know that depression runs in families," says Dr. Guynn. "And, while we are not sure of the link, suicide probably does also. The important thing is that depression is a treatable illness, and we can see good results quite quickly," he says. Usually, a very depressed patient will go for treatment at the suggestion of a family member or close friend. Depression is not an illness the family should try to treat; it requires experienced professional care.

During a therapeutic intervention, patients need to be reminded that once the thoughts of hopelessness are alleviated, the need to commit suicide will go away.

Dr. Yudofsky says it is important for the clinician to be straightforward. "Asking the person if they are considering suicide is not going to put that idea into their head. It has to be asked. I will want to know if there is access to firearms, and if there is I would say, `Look, we are going to have your family keep these until you are over this period.'" Dr. Yudofsky thinks about the holiday period which has just ended. (Suicide rates rise during holidays, especially at Christmas and New Year's.) "Holidays can be very hard for the depressed person. They're hard on psychiatrists, too, because we are treating those patients."

Dr Guynn points out that there are certain demographics that make a severely depressed person more likely to attempt suicide. "Men seem to be at a greater risk," he says. "Especially as they grow older. They use methods which are very lethal - firearms or jumping from a high place." While women are three times more likely to attempt suicide as men, men are twice as likely as women to actually kill themselves. A person living alone is twice as likely to take his own life. Sixty percent of people who commit suicide have a previous history of attempts. A history of suicide in the family is a very big risk factor. One in five people who commit suicide are legally intoxicated. And, while elderly white men are the single demographic group with the highest risk of suicide, young black males in urban areas form a group with almost as high a risk - and the absolute highest risk for homicide. (Conversely, elderly black males living in a rural setting form the group least likely to end their own lives.) Among adolescents, the rate of suicide has increased between two- and three-fold since 1970.

Perhaps the most startling demographic is that people with a history of depression are 80 times as likely to kill themselves as people with no depression history.

"The numbers can be difficult to pin down," says Dr. Guynn. "There are cultures where suicide is very much looked down upon. Of course nearly all religions frown on it. There is a stigma to it in almost each culture, so in a global sense - in the sense of the World Health Organization - the numbers may be off a bit."

"In truth, the demographics of suicide are very well worked out, because it's a very discreet act," says Dr. Yudofsky. "And yet, the numbers - such as total number of suicides in the U.S., a rate of 12 per 100,000 - may not tell the whole story." Recent figures indicate that at least 31,000 people in the U.S. take their own lives each year - one every 15 minutes. Another 300,000 Americans attempt suicide - and in about 10 percent of those failed attempts, a permanent disability is inflicted. But the number of deaths are of those where there is no question: they are undeniable suicides. There are many more that probably are suicides - such as one-car accidents and what have been called "deaths by mis-adventure." "When there is a pattern of self-destructive behavior that may culminate in a heroin overdose or fatality because of drunk driving, is that more suicide than accident?" asks Dr. Yudofsky.

Clearly, people who lead self-destructive lives need to take a good look at just why they live that way. "There may not be a sense of urgency with the family or friends of the person," says Dr. Yudofsky. "But the compulsive routine of dangerous living, which probably includes substance abuse, needs to be looked into."

Because depression is a treatable illness, many, if not most, suicides should be preventable. A person's family and/or friends may make the initial suggestion to seek professional help - a severely depressed person probably can't do it alone - and may work with the psychiatrist in the therapeutic program to bring the patient back from the mental abyss.

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©2006 Texas Medical Center

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