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Further Observations Regarding Depressive Disorders Treatment and Special Issues - Suicide

Rashmi Nemade, Ph.D., edited by Kathryn Patricelli, MA

image by Marcus Vegas (lic)Improvement of depression symptoms does not happen all at once. Instead, depressive disorders ten to turn around slowly and gradually. The first symptoms that usually improve are problems with sleeping and eating too much or too little. This early body symptom improvement is often followed by improvements in energy levels, such as being less tired and having more 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. People with depression often fail to pay attention to the fact that they have more energy, or discount that this shows an improvement of their condition since they still feel badly. However, physical symptom improvements are real improvements, and they are definitely noticed by others around the person. People with depression are often the last to know that they are getting better. Because of this, it is important for them 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

On average, one person dies by suicide every 40 seconds somewhere in the world. An estimated 804,000 suicide deaths occurred worldwide in 2012, representing an annual global age-standardized suicide rate of 11.4 per 100,000 population. In the United States, depression is the cause of over two-thirds of the 30,000 reported suicides in the U.S. each year. Globally, this number is a very difficult to assess given the cultural taboos associated with mental health issues and reporting accuracy. There are numerous risk factors for suicide, but the biggest risk factor is being depressed. Having a mood disorder, specifically major depressive disorder, significantly increases the likelihood that someone will commit or attempt suicide.

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 afterward.

Worldwide, in richer countries, three times as many men die of suicide than women do. In low- and middle-income countries the male-to-female ratio is much lower at 1.5 men to each woman. Suicides account for 50% of all violent deaths in men and 71% in women. With regard to age, suicide rates are highest in persons aged 70 years or over for both men and women in almost all regions of the world. In some countries, suicide rates are highest among the young, and globally suicide is the second leading cause of death in 15-29-year-olds. 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 the start 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.

For every suicide there are many more people who attempt suicide every year. Significantly, a prior suicide attempt or a friend's suicide attempt is the single most important risk factor for suicide in the general population. 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 person with depression should watch out for signs that are associated with suicide. According to the National Institute of Mental Health, people who are thinking about suicide may:

  • talk about feeling suicidal or wanting to die
  • express a feeling of hopeless and believe that nothing will ever change or get better
  • feel helpless and like nothing that they do will make any difference
  • feel like they have become a burden to family and friends.
  • start abusing alcohol or drugs (or abuse drugs and alcohol that much harder)
  • begin the process of putting their affairs in order. This could include organizing finances or giving away possessions as a way of preparing for their death
  • write a suicide note
  • 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. Because of this, 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 person with depression's environment. It is impossible to remove all items that can be used to commit suicide though because people get creative about this sort of thing when they are motivated enough.† However, doing all you can may be helpful.

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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