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Exploring the link between depression and suicide

From the June 1999 ACP-ASIM Observer, copyright 1999 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maquire

NEW ORLEANS—When working with patients who appear to be suffering from depression, physicians need to be aware of the significant correlation between major depression and mortality, according to Jan Fawcett, MD, a practicing neuropsychiatrist in Chicago, Ill.

Dr. Fawcett, who is also head of the department of psychiatry at Chicago's Rush-Presbyterian-St. Luke's Medical Center, talked about physicians' role in preventing suicide at this year's William C. Menninger Memorial Award Lecture. He acknowledged that the areas of depression and suicide are difficult for primary care physicians for a number of reasons. For one, suicide is a rare event that receives little study. In addition, Dr. Fawcett said, diagnosing depression can be difficult since the illness has so many physical manifestations.

Yet because of cutbacks in mental health care benefits, he explained, primary care physicians are increasingly being called upon to treat depression and prevent suicide. Currently, major depression affects 8% to 12% of the American population, a figure that may run as high as 20% for women. In addition, there are 32,000 suicides in the United States every year.

Dr. Fawcett suggested the following sample questions to help screen patients for depression: "Are you still able to take an interest in things that you like? Are you feeling down or depressed?"

If the answer to either question is yes, he said, ask about core symptoms of depression such as sleep disturbances, changes in appetite, low self-esteem and anhedonia, or loss of a sense of engagement and pleasure.

"If patients have two of those present in addition to the screening question, the sensitivity is now 97% that they have a major depression," Dr. Fawcett said.

Once depression has been diagnosed, he continued, inquire about the patient's history of suicide attempts and present suicidal feelings. He warned, however, that a patient's denial of suicidal tendencies may be an unreliable indicator. Research shows that while 70% of successful suicides admit their intentions to three different people in the six months before their deaths, only 18% confide in a physician. Because patients frequently deny feeling suicidal to doctors, talk to the patient's family if you suspect that someone is suicidal.

Dr. Fawcett said that it's also important to distinguish patients who are acutely—or imminently—suicidal from those who have chronic risk. Patients who exhibit severe anxiety symptoms such as anxious ruminations and agitation are at high acute risk of suicide.

"Acutely suicidal patients require hospitalization, either voluntarily or involuntarily," Dr. Fawcett said. "Every physician is charged with making that decision." Symptoms of severe anxiety are quickly treatable with benzodiazapines.

Hopelessness and anhedonia, on the other hand, usually indicate chronic risk and can signal recurring depressive episodes. "Depression is a recurrent illness," he said. "For many patients, we are advocating constant maintenance. Look at it the way you view hypertension." A history of suicide attempts indicates a chronic rather than an acute risk—except for patients who have lost a spouse or a significant relationship, or recently suffered an onset of alcohol or drug abuse.

Some research points to physiological indicators of suicidal tendencies, Dr. Fawcett said. Patients with low cholesterol levels have greatly increased rates of death from accidents, violence and suicide, while low brain serotonin is associated with marked aggressive and impulsive behavior—other suicide indicators.

Finally, Dr. Fawcett evaluated several therpies commonly used in suicide prevention:

  • Lithium carbonate maintenance in addition to antidepressant therapy significantly reduces suicide attempts over time. However, the patient has to be on the medication for at least six months.
  • Clozapine has been proven to be effective in treating schizophrenia, though it does have significant side effects. Other drugs are being tested as replacement therapies.
  • Cognitive psychotherapy can be effective in treating mild or moderate cases of hopelessness and anhedonia.

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