Early detection of depression and prevention of suicide

The Charter Bureau

(First of two parts)

The tragic and sensational death of Maria Theresa Carlson by what seemed to be suicide two months ago is still fresh in the minds of many. Knowing little about the facts, it would be unfair for us to make any judgment or conclusion as to what and why an event like that, indeed, happened. We are not in a position to discuss Carlson’s real-life story, but it is likely that many aspects of suicide and depression will apply to her. Hopefully, this article will help laymen and non-psychiatric physicians in particular understand and recognize potentially suicidal individuals and to act promptly and intervene effectively before actual death takes place.

A famous psychiatrist once said that suicide is neither a sign of insanity nor a mark of genius. We now know that suicide is the end-result of a depressive state characterized by an intense, unbearable pain, of intolerable anguish and despair that the sufferer would be better off dead. Suicide may be considered the final common pathway and outcome of a progressive failure of adaptation, with isolation and alienation from the usual network of human relations that support us all and give meaning to our lives, and with the loss of that vital and mysterious force that makes every living creature want to stay alive.

In general, the rate of suicide increases with age (up to about age 75 and then tapers off); women attempt suicide unsuccessfully about three times as often as men while men succeed about three times as often as women. Although the rate for successful suicide increases with age, the maximum rate for attempt peaks in the 18-25 age group.

Recognizing acute suicidal crisis

Suicide has been related to many emotions: hostility, despair, shame, guilt, dependency and hopelessness. If there is one general psychological state commonly assumed to be associated with suicide, it is a state of intolerable emotion or unbearable despair.

The acute suicidal crisis or period of high and dangerous fatality is an interval of relatively short duration – to be counted typically in hours or days, not usually in terms of months or years. A person is at a peak of self-destructiveness for a brief period, and then is helped, cools off, or is dead. The prototypical psychological picture of a person on the brink of suicide is one "who wants to but does not want to." He makes plans for self-destruction and, at the same time, entertains fantasies of rescue or help. The psychodynamic heart of the suicidal act is ambivalence; the characteristic suicidal sound is a cry for help; the prototypical suicidal act is to cut one’s throat and plead for help and fantasy of rescue and intervention – all at the same time.

Most suicidal events are dyadic events – that is, two-person events. Although the suicidal drama takes place within the person’s head, most suicidal tensions are between two people keenly known to each other such as spouse and spouse, parent and child or lover and lover. Some modes of deaths are more stigmatizing to the survivors than are other modes of death and generally speaking, suicide imposes the greatest stigma of all on its survivors.

In an acute suicidal crisis, the family should be told NEVER to leave the patient alone, day or night or even if the patient shows some apparent improvements. He should be promptly assessed or evaluated by a psychiatrist. This simple strategy is perhaps one of the most important deterrent to suicide. Similarly, a patient’s spouse and other people familiar to the patient’s living condition should be instructed to remove all potentially lethal substances or objects within his reach. Sometimes reminders like these are of tremendous help since their anxiety level is too great to even think of the obvious.

Index of suspicion

The most important aspect of suicide detection is a high index of suspicion on the part of the physician. He must automatically try to appraise the risk of suicide in every patient he sees who show any of the signs of depression. He should look carefully for the following signs and symptoms: sadness, loss of interest or pleasure, disturbance in sleep and appetite, including agitation, decrease in every level, sense of worthlessness, difficulty in concentrating and thoughts of suicide. These signs may be quite subtle and indirect and therefore, direct inquiry should be aimed at defining the specific symptoms. In some instances, depressed patients may still maintain sufficient level of function but their lives are without pleasure, lacking in spontaneity and often haunted with obsessional fears and concern over their future and of their own competence.

A past history of suicidal thoughts or attempts, current, direct or indirect suicidal thoughts or wishes, a family history of suicide, etc. should all serve to make the physician assess this area with more certainty. Any suicidal threat should be taken seriously and weighed carefully. The patient who talks about suicide may well be the one who commits it. Since over half of the people who successfully commit suicide have seen their family physician in the months prior to their death, the doctor has the opportunity to play a critical role in suicide prevention. Pay particular attention to evidence of loneliness, isolation and losses of any kind. (To be concluded)

(Dr. Abcede is a past president of the Philippine Psychiatric Association, currently the psychiatry chief at the UST Department of Neurology and Psychiatry and president of the Philippine chapter of the Asian Union Against Depression (AUD). Dr. Castillo heads CHARTER, a non-stock, non-profit research foundation based at the Manila Sanitarium Hospital.)