eMedicine Specialties > Emergency Medicine > Psychosocial

Depression and Suicide

Author: Louise B Andrew, MD, JD, Medical-Legal, Risk Management and Trial Consultant, Litigation Stress Counselor
Contributor Information and Disclosures

Updated: Feb 8, 2010

Introduction

Background

Depression is a potentially life-threatening mood disorder that affects up to 12% of the population, or approximately 17.6 million Americans each year. In addition to considerable pain and suffering that interfere with individual functioning, depression affects those who care about the ill person, sometimes destroying family relationships or work dynamics between the patient and others. The economic cost of depressive illness is estimated at $30-44 billion a year in the United States alone. The human cost cannot be overestimated.

As many as two thirds of the people with depression do not realize that they have a treatable illness and do not seek treatment. Persistent ignorance and misperceptions of the disease by the public, including many health providers, as a personal weakness or failing that can be willed or wished away leads to painful stigmatization and avoidance of the diagnosis by many of those affected.

Pathophysiology

The etiology of depression is multifactorial, but depression is thought to involve changes in receptor-neurotransmitter relationships in the limbic system. Serotonin and norepinephrine are the primary neurotransmitters involved but dopamine has also been related to depression.

A family history of depression is common. Bipolar disorder has a prominent depressive component but is a different clinical entity from depression. There is a possible defect on chromosome II or X, but current genetic research is inconclusive.

Frequency

United States

An estimated 11% of the US population will experience depression at some time. Suicide accounts for 32,000 deaths yearly in the US and is the 11th leading of cause of mortality.

International

In Eastern Europe, 10 countries report more than 27 suicides per 100,000 persons. Latin America and Muslim countries report the lowest rates, fewer than 6.5 cases per 100,000.

Mortality/Morbidity

• The morbidity of the depression is difficult to quantify. The lethality of depression, however, is measurable and is the result of completed suicide, which is the ninth leading reported cause of death in the United States.
• In 2005, 1.4% of all deaths worldwide were attributed to suicide. The real number is unknown since underreporting is predictably significant. Suicide is estimated to be the eighth leading cause of death in all age ranges.
• Almost all people who kill themselves intentionally have a diagnosable mental disorder with or without substance abuse, which in itself, is often a result of attempted self-treatment for the symptoms of depression. Approximately two thirds of individuals who complete suicide have seen a physician within a month of their death.

Race

Suicide rates among American Indian and Alaskan natives between 15 and 34 years are almost twice the national average for this age range. Hispanic females make significantly more suicide attempts than their male or non-Hispanic counterparts.

The risk of suicide is increased by concurrent alcohol and drug abuse, access to lethal means, hopelessness, pessimism, and impulsivity, and is reduced by help-seeking behavior, access to psychiatric treatment, and availability of family and other social supports.

Sex

More women than men seek treatment for depression, but this is not necessarily reflective of the true incidence of the disease.

• Although depression is more often diagnosed in women, more men than women die from suicide by a factor of 4.5:1. White men complete more than 78% of all suicides, and 56% of suicide deaths in males involve firearms. Poisoning is the predominant method among females.
• An estimated 8-25 attempted suicides occur for every completion. Many of these are never discovered or never reported. It is important to understand that the majority of suicide attempts are expressions of extreme distress, not merely bids for attention.

Age

The highest suicide rates are found in men older than 75 years. However, suicide is also a selective killer of youth. It is the third leading cause of death among people aged 15-24 years, after unintentional injuries and homicide, and the second leading cause of death in college students. The mean age for successful completed suicides is 40 years.

In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. In September 2004, the results of an FDA analysis suggested that the risk of emergent suicidality in children and adolescents taking SSRIs was real. The FDA advisors recommended the following:

• A "black-box" warning label be placed on all antidepressants, indicating that they increase the risk of suicidal thinking and behavior (suicidality)
• A patient information sheet (Medication Guide) be provided to the patient and their caregiver with every prescription
• The results of controlled pediatric trials of depression be included in the labeling for antidepressant drugs

The committees recommended that the products not be contraindicated in the United States because access was important for those who could benefit from them. For more information, see the FDA Statement on Recommendations of the Psychopharmacologic Drugs and Pediatric Advisory Committees.

Some studies have shown that the FDA warnings regarding suicide in children on antidepressants may have had the unintended result of a decrease in the rates of diagnosis and treatment of depression, as well as dosing adjustments by physicians. It has also been noted that monitoring of these patients did not increase following the warnings.^1,2,3,4

Clinical

History

• Depression is often difficult to diagnose because it can manifest in so many different ways. For example, some depressed individuals seem to withdraw into apathy, while others may become irritable or even agitated. Eating and sleeping patterns can be exaggerated to either extreme, either excessive or almost eliminated. Observable or behavioral symptoms may be minimal despite profound inner turmoil. Depression is a pernicious and all encompassing disorder, generally affecting body, feelings, thoughts, and behaviors to varying degrees. Symptoms of depression include the following:
  • Persistently sad, anxious, or empty moods
  • Loss of pleasure in usual activities (anhedonia)
  • Feelings of helplessness, guilt, or worthlessness
  • Crying, hopelessness, or persistent pessimism
  • Fatigue or decreased energy
  • Loss of memory, concentration, or decision-making capability
  • Restlessness, irritability
  • Sleep disturbances
  • Change in appetite or weight
  • Physical symptoms that defy diagnosis and do not respond to treatment (especially pain and gastrointestinal complaints).
  • Thoughts of suicide, death, or suicide attempts
  • Poor self-image or esteem (as illustrated, for example, by verbal self-reproach)
• To establish the diagnosis of major depression, a patient must express one of the first 2 and at least 5 of the other symptoms listed above. Such disturbances must be present nearly daily for at least 2 weeks. Symptoms can last for months or years.
• Symptoms can cause significant personality changes and changes in work habits, making it difficult for others to empathize with the depressed individual. Some symptoms are so disabling that they interfere significantly with the patient's ability to function. In very severe cases, people with depression may be unable to eat or even to get out of bed.
• Symptomatic episodes may occur only once in a lifetime or may be recurrent, chronic, or longstanding; in some cases they seem to last forever. Occasionally, symptoms appear to be precipitated by life crises or other illnesses; at other times, they occur at random.
• Clinical depression commonly occurs concurrently with or can be precipitated by injury or other medical illnesses, and worsens the prognosis for these illnesses. Even the diagnosis of concurrent illness is made much more difficult by the presence of depression.

Physical

There are no inevitable physical findings of depression, though some manifestations may be seen quite often.

• Signs of depression may include the following:
  • Psychomotor retardation or agitation, such as slowed speech, sighs, and long pauses
  • Slowed body movements, even to the extent of motionlessness or catatonia
  • Pacing, hand wringing, and pulling on hair
  • Appearance of preoccupation
  • Lack of eye contact
  • Tearfulness or sad countenance
  • Self-deprecatory manner, or belligerence and defiance (especially in adolescents)
  • Memory loss, poor concentration, and poor abstract reasoning

Causes

In addition to depression, alcohol/substance abuse (especially opiates and cocaine), impulsiveness, and certain familial factors are highly associated with risk for suicide. These factors include a history of mental problems or substance abuse, suicide in the immediate family, family violence of any type, and separation or divorce.

Other risk factors include prior suicide attempt(s), presence of a firearm in the home, incarceration, and exposure to the suicidal behavior of family members, peers, celebrities, or even highly publicized fictional characters. It is also established that the initiation of treatment for depression with psychotherapeutic agents can temporarily increase the incidence of suicidal ideation and therefore the likelihood of suicide attempts. The incidence of depression in healthcare workers is comparable to that in the general population, though the rate of completion of suicide is higher.

• Alteration in the balance of neurotransmitters and/or their function
  • Impaired synthesis of neurotransmitters
  • Increased breakdown or metabolism of neurotransmitters
  • Increased pump uptake of neurotransmitters
  • Typically, neurotransmitters are passed from neuron to neuron. Subsequently they are (1) reabsorbed into the neuron where they are either destroyed by an enzyme or actively removed by a reuptake pump and stored until needed, or (2) destroyed by monoamine oxidase (MAO) located in the mitochondria.
  • A decrease in the functional balance of these neurotransmitters causes certain types of depression (ie, decreased norepinephrine causes dullness and lethargy, and decreased serotonin causes irritability, hostility, and suicidal ideation).
  • Environmental factors including coexisting illnesses or substance abuse (discussed above) may affect neurotransmitters and/or have an independent influence on depression.

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