Depression and Suicide

Every 17.3 minutes someone commits suicide in the United States. According to National Institute of Mental Health statistics, suicide is the ninth leading cause of death in Americans and accounts for more than 30,000 deaths every year. More Americans die of suicide than are victims of homicide. Although most people who become depressed do not commit suicide, depression can be a lethal illness. Contrary to popular belief, not everyone who commits suicide is depressed, but the majority of people who commit suicide do so during a severe depressive episode. The suicide risk in people with severe depression ranges between 15 and 30 percent, with approximately seven suicide attempts for every successful suicide. Women are two to three times more likely to attempt suicide, but men are four to five times more likely to be successful in their attempt.

Over 70 percent of all suicides in the United States are committed by white men, and the majority of those deaths involve firearms. The second highest rate in the country is reported in white women, followed by rates for black women. Black men in the United States currently have the lowest suicide rate; unfortunately, it is rising.

Bob T. was a seventy-two-year-old retired government employee who lived alone in a retirement community. He had been the sole caretaker for his wife, who had been bedridden for two years before her death the previous year. Bob was hypertensive and diabetic. Both conditions had been well controlled with diet and medication until the past few months. Despite repeated visits to his physician, Bob did not feel well. He experienced vague stomach discomfort, joint aches, increasing insomnia, and fatigue, which he reported to his doctor on repeated visits. Bob did not discuss with his physician his fear that his memory was failing rapidly and that he might have “old-timer’s disease.” He often thought of his wife in a “happier place” and longed to join her. One Sunday afternoon after attending church services, Bob went home, wrote his name and the current date in the family Bible below the entry noting his wife’s death, and shot himself in the head.

Thoughts of suicide may be intermittent and relatively brief, but they may also be persistent and intrusive, developing into plans for carrying it out. Circumstances that increase the risk for suicide in depressed patients include advancing age, male sex, Caucasian race, living alone, chronic medical illness, a recent major loss, substance abuse, panic attacks, psychotic symptoms, previous episodes of depression, previous suicide attempts, and family history of depression. In addition, people who are depressed and simultaneously have other brain disorders such as schizophrenia, dementia, or brain damage from illness or trauma may be at increased risk for suicide because of impaired judgment and a tendency toward impulsiveness.

Common methods of suicide include gunshot wound to the head or chest, overdose of over-the-counter or prescription medications, overdose of street drugs, laceration of neck or wrists with a sharp object such as a razor blade or a knife or broken glass, asphyxiation by hanging or from the breathing of a toxic gas such as natural gas or carbon monoxide from an automobile exhaust, and purposeful “accidents, ” such as car crashes against trees or off bridges. In the past, women were reported to choose less violent means of suicide, such as overdose or asphyxiation by gas, while men chose more violent means, such as guns. Now, however, suicide by firearms is the most common method for both men and women, accounting for over half of all suicides. Unfortunately, depressed people intent on suicide can be very creative in choosing their method of death, despite the efforts of their doctors and their loved ones to prevent the tragedy.

The risk for suicide, ironically, may be greatest when the sufferers have passed the lowest point in the course of their illness and have begun to recover. The reasons are not clear but may relate to the observation that recovery from depression often begins with an increase in energy level without immediate improvement in mood. When such is the case, depressed people in the early stages of recovery have regained enough energy to plan and carry out a long-desired suicide. It may also be that once seriously depressed individuals finally make the decision to escape the anguish of illness through death, they feel a temporary reprieve from their symptoms.

Suicide may occur without warning, but 80 percent of people who attempt or commit suicide do give some indication of their intent by means such as voicing despair and world-weariness, expressing suicidal thoughts, threatening to harm themselves, increasing the use of alcohol or drugs, or writing suicide notes. Rehearsing suicide or seriously discussing specific methods may also indicate a determination to go forward with it. More often the hints are subtle behavioral changes that may serve as red flags. Such warnings perhaps indicating that the despondent individual is putting his or her house in order may include making out a will, reviewing life insurance coverage, purchasing cemetery plots, giving away valued possessions, or getting in touch with close relatives. Contrary to popular understanding, most people do not leave notes.

Once someone has decided to commit suicide, it may be impossible to prevent the tragedy. Although many suicide attempters are ambivalent about their course of action until the last moment, others are determined to die and give few clues ahead of time.

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