The Holiday Blues

Contrary to popular belief, suicides do not increase during the winter holidays. But that doesn’t mean that holiday depression or sadness is not real for some people.

In the Dana Foundation’s new briefing paper, “Holiday Blues: Getting the Facts, Forgetting the Myth,” mental health experts and Dana Alliance members Myrna Weissman and Eric Nestler discuss what factors may contribute to these “holiday blues.”

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From the Archives: Kay Redfield Jamison

At the end of her recent essay in the New York Times, “To Know Suicide: Depression can be treated, but it takes competence,” Dana Alliance member Kay Redfield Jamison mentions, almost in passing, her own suicide attempt. She wrote vividly about her experiences and those of others in her book, Night Falls Fast. Ellen Frank and David Kupfer reviewed the book for us in 2000; the review includes part of the book’s epilogue:

I was naive to underestimate how disturbing it would be to write this book. I knew, of course, that it would mean interviewing people about the most painful and private moments of their lives, and I also knew that I would inevitably be drawn into my own private dealings with suicide over the years. Neither prospect was an attractive one, but I wanted to do something about the untolled epidemic of suicide and the only thing I knew to do was to write a book about it. I am by temperament an optimist, and I thought from the beginning that there was much to be written about suicide that was strangely heartening.

As a clinician, I believed there were treatments that could save lives; as one surrounded by scientists whose explorations of the brain are elegant and profound, I believed our basic understanding of its biology was radically changing how we think about both mental illness and suicide; and as a teacher of young doctors and graduate students, I felt the future held out great promise for the intelligent and compassionate care of the suicidal mentally ill.

All of these things I still believe. Indeed, I believe them more strongly than I did when I first began doing the background research for this book two years ago. The science is of the first water; it is fast-paced, and it is laying down, pixel by pixel, gene by gene, the dendritic mosaic of the brain. Psychologists are deciphering the motivations for suicide and piecing together the final straws—the circumstances of life—that so dangerously ignite the brain’s vulnerabilities. And throughout the world, from Scandinavia to Australia, public health officials are mapping a clearly reasoned strategy to cut the death rate of suicide.

Still, the effort seems unhurried. Every seventeen minutes in America, someone commits suicide: Where is the public concern and outrage? I have become more impatient as a result of writing this book and am more acutely aware of the problems that stand in the way of denting the death count. I cannot rid my mind of the desolation, confusion, and guilt I have seen in the parents, children, friends, and colleagues of those who kill themselves. Nor can I shut out the images of the autopsy photographs of twelve-year-old children or the prom photographs of adolescents who within a year’s time will put a pistol in their mouths or jump from the top floor of a university dormitory. Looking at suicide—the sheer numbers, the pain leading up to it, and the suffering left behind—is harrowing. For every moment of exuberance in the science, or in the success of governments, there is a matching and terrible reality of the deaths themselves: the young deaths, the violent deaths, the unnecessary deaths.

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From the Archives: Suicide Prevention

In this month’s Cerebrum article, “Suicide and the United States Army,” Dr. Elspeth Cameron Ritchie, a retired Army colonel, explains how the U.S. Military now collects data on suicides. She recommends ways to put that data to use through new strategies—like means restriction and service animals—that could bring down the high suicide rate in the military.

In July of 2011, Kay Redfield Jamison wrote the Cerebrum article “Suicide in the Young: An Essay.” She said:

“We know, first, that suicide is a terrible killer of the young. In the United States, suicide is the third major cause of death in 15-to-19-year-olds and the second leading cause of death in college-age students. In 1996, more teenagers and young adults died from suicide than from cancer, heart disease, AIDS, stroke, and lung disease combined. Suicide kills the young dreadfully and disproportionately. And, across the world, in those between the ages of 15 and 44, suicide is the second leading killer of women and the fourth of men.”

These numbers have not changed much. According to the CDC, suicide is still the third leading cause of death for 15-24 year olds, and for every completed suicide in this age range, there are 100-200 unsuccessful suicide attempts.

Dr. Ritchie says in her new article that military suicide differs from civilian suicide in part due to the role of mental illness. Most soldiers who commit suicide have not been diagnosed with a mental illness, although substance abuse issues can be a factor. She writes that an accumulation of stressors, like pain, disability, and estrangement from friends and family are more common risk factors among active duty personnel.

In contrast, in the civilian population, writes Dr. Jamison:

“We have compelling evidence from a large number of studies that the single most important factor in suicide is psychopathology: More than 90 percent of all people who kill themselves suffered from a major psychiatric or addictive illness (depression, manic-depression, schizophrenia, or alcohol and drug abuse), a severe anxiety disorder, or borderline or antisocial personality disorder. Those who are victims of both depression and alcohol or drug abuse are especially at risk. Most people who were depressed will not kill themselves. But of those who do, the majority were profoundly depressed.”

This, too, remains true today.

So what can be done to prevent suicide in the civilian population? The National Institute for Mental Health recommends treating underlying disorders, like depression and substance abuse, while addressing suicide risks. Studies have shown that cognitive behavior therapy can effectively reduce the number of suicide attempts. A combination of medication and therapy may be even more effective. In addition, primary care physicians should be better trained to recognize warning signs of suicide.

If someone you know talks to you about suicide, take him or her seriously. Call 911 or the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).

–Johanna Goldberg

From the Archives: Brainsick

There may not be a Dana Foundation piece as raw and powerful as “Brainsick: A Physician’s Journey to the Brink,” published in 2002.

Leon E. Rosenberg, M.D., a senior molecular biologist at Princeton (and former dean of the Yale School of Medicine and former head of pharmaceutical research for Bristol-Meyers Squibb), describes his experience with mental illness and attempted suicide in an honest, no-nonsense narrative.

It begins:

More than four years ago—on May 26, 1998, to be exact—I awakened during another restless, dreadful night. The clock read 4:15 a.m., so I closed my eyes and tried to be calm. It didn’t work. I got out of bed. “This must end, today,” I thought. “I can’t sleep. I can’t eat. I can’t teach. I can’t even read or write.”  

After taking a walk around our farm, I brewed coffee for my wife, Diane, and me, and then helped get our 16-year-old daughter, Alexa, off to high school. Diane asked if she should cancel her appointment to go horseback riding. “No,” I said. “I’m a little less depressed, and you can’t just sit around here day after day and take care of me like I’m a baby. By the time I get a haircut, you’ll be back.” 

As soon as she had driven away, I put all the antidepressants and sleeping pills I had into a small satchel, added a full quart bottle of vodka, and headed my car toward Highway 95. I didn’t know where I was going, but it certainly was not to the barber.  As I crossed the bridge into Pennsylvania, I vaguely remember seeing the sign for Highway 32, and I exited. The sun was shimmering on the Delaware River, which only made keeping my eyes on the road more difficult. I saw a sign for New Hope (or was it No Hope?) and drove into town. I wandered up one street and down another until I saw a sign for the Wedgewood Inn.  I had never been there before, but I was too agitated to look further. The Wedgewood it would be. 

The proprietress looked askance at the luggage I carried but showed me to a small room anyway. “This will be fine,” I think I said and closed the door. I sat down on the double bed with its chenille spread and put the pills and the vodka on the bedside table. Slowly, almost ritually, I took one or two pills at a time, washed down with a generous swig of vodka. By the time all the pills and more than half the vodka were gone, I started to feel less wired—even quiet.  As I lay down and sank toward what I believed would be death, I found myself thinking of a relative who had committed suicide this way some years earlier. Perhaps I connected with him because my jumbled brain thought he, and only he, might comprehend what I was doing. 

I woke up 12 hours later with a headache, dizziness, nausea, and hiccups. I stumbled out to my car in the darkness, and called my wife from the cell phone. I remember being so relieved to hear her voice. “We’ve been looking all over for you,” she said, “where are you?” I told her what I had done, where I was, and that I wanted to come home. “Stay right where you are,” she said.

The article emphasizes that there are many treatments for depression and bipolar disorder—antidepressants, lithium, therapy, electroconvulsive treatment—that can work; putting off seeking treatment can be deadly. Unfortunately, finding the treatments that work can take time.

One thing is clear. As Dr. Rosenberg wrote, “It makes no sense to allow stigma, whose underlying premise is that people with mental illness are weak, to cow affected people into being unwilling to be diagnosed. It is time that I and other physicians say so.”

–Johanna Goldberg

Dearth of depression treatment

If you’re feeling down and out but struggling to get through
it on your own, you’re not alone.

A large new survey has found that only half of those in the
United States with depression
are receiving any sort of treatment for the condition—many because they have
not been formally diagnosed.

For the study,
which appears in the January issue of Archives
of General Psychiatry,
researchers assessed nearly 16,000 people to study
how commonly depression occurs in the United States and what kinds of treatment
people with the disorder receive. Because the participants were carefully
selected from three large national surveys instead of from hospital records,
the survey represents a snapshot of the U.S. population as a whole, the
scientists say.

“We can talk about population estimates for the whole of the
U.S. Ours is a cross-sectional, nationally representative sample,” says lead
author Hector
González
, an assistant professor of family medicine and public health
sciences at Wayne State University in Detroit. “That’s the beauty of our
study.”

Approximately 9 percent of the participants either met the
criteria for depression or had met them sometime within the past 12 months. Of
those with depression, only half had received any treatment for the condition
and only one-fifth had received treatment that conformed to the American Psychological Association’s recommended
guidelines.

Because the survey team assessed each person independently
for depression based on data and interviews, those numbers include many people
who have not been officially diagnosed by a physician, González says. He does
not have firm numbers on how many people that might be but expects they
represent a significant proportion of the U.S. population.

If the sample is indeed representative, then the country holds
roughly 14 million untreated residents. People with untreated depression are
not only in danger of jeopardizing their jobs, personal relationships, and
general health, but many also have an increased risk of harming or killing
themselves. According to the Dana Guide to Brain
Health
, approximately 20 percent of depressed people will make a suicide
attempt and around 6 percent will ultimately succeed.

The survey also found that therapy is used to treat
depression more often than drugs. Although the study didn’t directly address
the reasons, one cause for the disparity might be that antidepressants seem to
work only for those patients with the most severe cases of depression. A study released
yesterday
in the Journal of the
American Medical Association
found that for mild to moderate cases of
depression, drug treatment was similar to treatment with a placebo pill. “Only
15 percent of people in the U.S. with depression have very severe depression,” González
says. “So 85 percent don’t respond to antidepressants better than placebo.”
This doesn’t mean that the drugs have lost favor, though, he adds; half of the
antidepressant prescriptions doctors now write are for conditions other than
depression.

The scientists also looked at whether incidence and
treatments differed among particular ethnic subgroups. While overall rates of
depression were similar to the national average among all groups, González
says, African and Mexican Americans had a notably reduced chance to receive
both any care at all and the recommended treatment.

The scientists plan to use their results and additional data
to see what kinds of treatments are most effective against depression.
“Depression is a leading cause of disability worldwide,” González says. “We
think we can help meet the health needs of Americans and others, by seeing how
well these people are supported.”

—Aalok Mehta

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