Early detection of depression and prevention of suicide

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The Charter Bureau
(Conclusion)

Management of suicidal depression

Although the type of treatment will ultimately depend on the basic underlying process, certain general principles regarding the management of the suicidal patient include the following:

• If the physician suspects any significant risk of suicide, he should get prompt psychiatric evaluation if at all possible. Suicide is a psychiatric emergency and requires immediate attention. This may require enlisting the aid of the patient’s family who in any event should be appraised of the risk.

• Occasionally, a psychiatrist may elect to manage a suicidal patient outside of the hospital but this is generally undertaken only when the therapist knows the patient quite well and feels he has enough of a relationship with the patient that he can safely continue to treat him as an outpatient. Even then this is a risky course to follow at best and will still require 24-hour monitoring from relatives.

• The risk of suicide does not automatically diminish as soon as the patient is hospitalized and in fact, may increase as the patient recovers enough from the depression to regain just enough energy to carry out the suicidal impulses which were preceded by his motor retardation. The period following hospitalization is also a dangerous one – particularly if nothing has really changed in his situation. Thus, immediate, regular follow-ups are necessary.

• At home, medication intake should be supervised by family members who should only be given enough pills to last for a week to avoid possible lethal overdose.

Drug treatment of depression

Effective and specific treatments such as the tricyclic drug for major depressive illnesses have been available for some 40 years now. The use of specific drug therapy doubles the chance that a depressed patient will recover within one month. Studies have shown that at least 75 percent of treated patients will improve. All currently available antidepressants may take up from four to six weeks before significant therapeutic effects are noted. It is prudent to advice the patient to continue taking the medication even if no appreciable response is seen especially during the early weeks of treatment. Because the tricyclics have many undesirable side-effects, newer and novel antidepressant drugs now available are slowly replacing their use. The introduction of SSRIs (specific serotonin re-update inhibitors), SNRIs, including Tianeptin (Stablon), offers clinicians drugs that are equally effective but safer and better tolerated than the previous drugs. Tianeptin, in particular, has added anxiolytic properties that make it suitable for depressed, anxious and agitated patients.

Antidepressant therapy should be maintained for at least six months or the length of a previous episode whichever is greater. Several studies show that prophylactic treatment with antidepressants is effective in reducing the number and severity of recurrences. Another factor suggesting prophylactic treatment is the seriousness of previous depressive episodes, especially those that involved significant suicidal indication and impairment of psychosocial functioning.

Suicidal individuals are not always easy to identify with certainty, as frequent as they are. However, they are people who seek death in an attempt to communicate pain and thus, transmit a host of different signals. They are people who are usually depressed and in a state of extreme hopelessness. Depression, however, is a treatable condition and one wherein the individual can return back to their original functional form and thus, can lead a productive life. It is therefore imperative upon the physician to be aware of its possible existence and include depression in the evaluation of all patients who show depressive signs and symptoms. Then and only then can we expect to manage this condition and prevent wasteful loss of lives.

(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.)