Dr. Kevin Most: Mental Health
We have talked in the past about depression and suicide in the past, and this past week we are reminded about this terrible disease. Kate Spade and Anthony Bourdain each took their lives last week after fighting with depression. This past week, two days after Kate Spade took her own life, the CDC released some staggering information. Suicide rates increased in every state with the exception of Nevada, between 1999 and 2016. In some states the suicide rate was up more than 50%. In more than half of these suicides the individual was not known to have had depression at the time of the act
It is sad that we have had to use the death of celebrities to hear that these individuals lost their fight with depression. I say it in this way so we all understand, this is a fight against a terrible illness. We say people lost their fight against cancer and this is no different and we need to make all of us more aware of this and eliminate the social stigma associated with depression.
I have heard people say over the past few days, “How could they do that, they were rich and successful, they had great jobs and were famous” Depression is a disease that can strike anyone, just like cancer. We need to understand that depression is not avoided because you are rich and have everything you need or are famous. Depression is an illness in our brain, just like Parkinson’s is, just like Alzheimer’s is, just like brain cancer is.
Each year we lose at least 45,000 individuals to suicide, it is the 10th leading cause of death in the US and rising. That number is actually artificially low as there are many deaths that in fact may have been a suicide but not verified. It is the second leading cause of death among people aged 10-34. Let’s put this in perspective, we have more than twice the number of suicides than we do homicides in this country. Why is it we report on homicides in the news daily but no mention of suicides? Is it the social stigma of weakness or embarrassment that many equate to suicide? Would we make a bigger impact if we discussed the signs and symptoms of depression more regularly? With the recent mass shootings, we are always asking what made the person do that? Yet do we ask that about the 45,000 suicides? The families and friends certainly do after the act, but with 50% of those who died by suicide, did so without a diagnosis of depression. Have we done a poor job of sharing the signs and symptoms? For those individuals without a diagnosis of depression, 90 percent of them will have evidence of a mental health condition as we do a psychological autopsy. This is performed by reviewing not only medical records but discussion with family and friends as well as reviewing work records. Each aspect often shows signs that if we were more aware of what to look for, an intervention may have saved a life. We need awareness to get these individuals the help they need
We do know that suicide is not always associated with depression and in some cases it is associated with stress and serious lifestyle problems. The economic downturn that hit 10 years ago caused a spike in suicides, couple that with the current opioid epidemic we are fighting it is not surprising that we are seeing increases in suicides. Studies have shown that those addicted to opioids do have a 40-60% higher risk of suicidal ideation, so the importance of identifying those individuals is as important as identifying those with depression.
Is this a physician diagnosis issue? I would argue that we need to educate the public more about depression and suicide risk. The chance of a doctor picking this up during a routine office visit is rare. We all know the ABCDE to identify Skin Cancer, we know the FAST symptoms for stroke, yet do we know what to look for in a depressed patient or one considering committing suicide? I bet many don’t
We also need to change how we talk about suicide we often say “committed suicide” this has the image of committing a crime, we should all try to use the terms “died by suicide” in its place. It is difficult for all of us to not be judgmental, we need to view suicide as a part of abnormal human behavior that if identified early can be avoided, just like colon cancer. We need to identify it early and encourage treatment.
The patient who reaches out for help, as they have identified that they personally have concerns about depression is great, but the patient who wants to hide it during an office visit is easy. Now I am not trying to say the physicians and healthcare system have no fault, in fact I think we have a major part in the problem. We don’t have enough treatment facilities, we don’t have enough psychiatrist, and the medications are expensive. A staggering statistic is that 60 % of the counties in the US do not have a single psychiatrist. What is worse is 80% or rural counties do not have a single psychiatrist. This void leads to 40% of those individuals identified with a new onset mental illness go untreated. Need to have a better grasp on that? It equates to 60 million people who have a new onset mental illness will not receive care from a psychiatrist, and many will receive no care at all.
In order to access the opportunities that we have, we must first identify the individual who may need the help.
It is important that we all know the warning signs of both depression as well as suicide risk. Individuals who have major depression have a very high incidence of suicidal ideation, so getting those individuals treated early may save a life.
Here are some of the signs of depression and as you read them you will see that often these would not be captured by a physician during an office visit.
Symptoms of depression
1. Trouble concentrating or making decisions
2. Feelings of guilt or worthlessness
3. Hopelessness or pessimistic attitude
6. Loss of interest in things they once enjoyed
8. Persistently sad or anxious
So who is at Risk for Suicide, there are some common things that we see.
1.) A family history of suicide
2.) Substance abuse or intoxication- these can cause mood swings and cause irrational behavior
3.) Access to fire arms or drugs
4.) Serious or chronic illness or diagnosis of a terminal illness
5.) Prolonged stress
6.) A recent tragedy or loss
7.) Gender, although women attempt suicide more often than men, men are four times as likely to die from suicide.
Warning signs for suicide
1.) Comments about killing themselves, these often begin with harmless thoughts, “ I wish I wasn’t here” or “you would be better off without me”
2.) Increased alcohol or drug use
3.) Aggressive behavior
4.) Social withdrawal from friends and family
5.) Dramatic mood swings
6.) Reckless behavior
These should all concern you to a point of getting help for the individual.
There are signs that show much more concern of imminent danger, these signs need immediate action and monitoring of the individual until you can get them help
1.) Putting their affairs in order and giving away possessions,
2.) Saying goodbye to family and friends, that friend who visits you out of the blue and seems to be saying goodbye should be a concern
3.) Mood shifts that go from despair to calm, this individual has often come to the conclusion that they will commit suicide and they have a plan
4.) Watch for any planning they may be doing, borrowing medication, hoarding medication, borrowing tools or a firearm
These are things you as a friend or family member need to watch for.
What do you do, get the individual to a safe place, like an ER. If you can’t or they refuse, stay with them and call for help, call either 911 or call the National Suicide Prevention Lifeline 800-273- TALK (8255). The suicide hotline is manned 24/7 365 by expert mental health professionals. Other things to do is to minimize the risk, remove firearms from the home, do not leave them alone, remove medications from their isolated control, minimize alcohol use, but most importantly get them professional help.
Treatment for these individuals really varies and is specific to the patient. For the patient with depression, antidepressant medication and therapy will be helpful. For the individual who is undergoing stress or lifestyle issues, medication may be used but often different types of medication as well as therapy to understand why a patient feels the way they do about a stressor and help them understand and deal with the stress.
There are large philosophical debates going on around the world around suicide in some settings. For example, Switzerland has euthanasia clinics where assisted suicide is accepted. Five states have “Death with Dignity” laws that allow for assisted suicide in cases of terminal illness. The argument that is being discussed is how is a chronic mental illness any different from a chronic medical illness.
Locally we all know that the budget cuts made last year impacted mental health in the state of Illinois. The impact it had was felt throughout the state, it is not uncommon for emergency rooms across the state to have patients needing mental health care in their Emergency room for long times sometimes up to days. I do not know but I doubt the new Illinois budget put those services back in place. It is something we need everyone to discuss with their government leaders