Depression and Suicide

Last Updated: June 17, 2004Synonyms and related keywords: depressive illness, mood disorder, suicidal, suicidality, suicide ideation, suicide attempt, suicide attempts, self-destructive acts, self-murder, suicide gesture, major depressive disorder, MDD, unipolar depression, unipolar affective disorder, serotonin, norepinephrine, dopamine, selective serotonin reuptake inhibitors, SSRIs, tricyclic antidepressants, TCAs, norepinephrine, NE, dopamine, DA, suicide, seasonal affective disorder, SAD, antidepressants, lithium, psychotherapy

Background: Depression is a potentially life-threatening mood disorder that affects up to 10% 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 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 phase but is a different clinical entity from depression. There is a possible defect on chromosome II or X.

Frequency:

In the US: An estimated 5-20% of the population experience depression at some time.

Mortality/Morbidity:

The morbidity of the disease is difficult to quantify. The lethality of depression is measurable and is the result of completed suicide, which is the ninth leading reported cause of death in the United States.

In 1994, 1.4% of all deaths were attributed to suicide. It is reported that more than 30,000 Americans commit suicide each year. 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 is often a result of attempted self-treatment for the symptoms of depression.

Race: No racial preponderance exists in reportable depression or suicide.

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 commit over 72% of all suicides, and 78% of suicides use firearms.

It is estimated that 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 persons older than 85 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.

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 holistic disorder, generally affecting body, feelings, thoughts, and behaviors to varying degrees. Symptoms of depression include the following:

o Persistently sad, anxious, or empty moods

o Loss of pleasure in usual activities (anhedonia)

o Feelings of helplessness, guilt, or worthlessness

o Crying, hopelessness, or persistent pessimism

o Fatigue or decreased energy

o Loss of memory, concentration, or decision-making capability

o Restlessness, irritability

o Sleep disturbances

o Change in appetite or weight

o Physical symptoms that defy diagnosis and do not respond to treatment (especially pain and gastrointestinal complaints).

o Thoughts of suicide, death, or suicide attempts

o 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.

Symptom 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 other medical illnesses and worsens the prognosis for these illnesses. Even 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:

o Psychomotor retardation or agitation, such as slowed speech, sighs, and long pauses

o Slowed body movements, even to the extent of motionlessness or catatonia

o Pacing, hand wringing, and pulling on hair

o Appearance of preoccupation

o Lack of eye contact

o Tearfulness or sad countenance

o Self-deprecatory manner; belligerence and defiance (especially in adolescents)

o Memory loss, poor concentration, and poor abstract reasoning

Causes: In addition to depression, alcohol/substance abuse (especially 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, 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.

Alteration in the balance of neurotransmitters and/or their function

o Impaired synthesis of neurotransmitters

o Increased breakdown or metabolism of neurotransmitters

o Increased pump uptake of neurotransmitters

o 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.

o 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 (listed above) may affect neurotransmitters and/or have an independent influence on depression.

Lab Studies:

Depression is a clinical diagnosis. Laboratory tests are primarily used to rule out other diagnoses. Consider the following laboratory tests:

o Complete blood count (CBC)

o Electrolytes, including calcium, phosphate, and magnesium

o BUN and creatinine

o Calcium

o Serum toxicology screen

o Thyroid function tests

o Thyroid-stimulating hormone (TSH) level

Imaging Studies:

CT scan or MRI of brain if OBS or hypopituitarism is included in the differential

Other Tests:

Electrocardiogram (ECG): Diagnosis of arrhythmia, particularly heart block

Electroencephalogram (EEG)

Certain psychometric tests can make a diagnosis of depressive disorders with reasonable clinical certainty; however, these are not generally available in emergency departments.

o Zung Self-Rating Depression Scale

o Beck Depression Inventory (BDI)

o Criteria for Epidemiologic Studies-Depression (CES-D) scale

Studies - Depression scale:

o Children's Depression Inventory (CDI)

o Yesavage Geriatric Depression Scale

Emergency Department Care:

The emergency physician's responsibility in managing a patient with depression is to maintain a high index of suspicion for the diagnosis, especially in populations at risk for suicide.

Although primary at-risk populations include young adults and elderly persons, depression and suicidality can occur in any age group, including children.

Depression should be strongly suspected as an underlying factor in drug abuse or overdose (including alcohol) with self-inflicted injury or even in an intentionally inflicted injury where the assailant is known to the victim. In any such patient, screening for diagnostic symptoms of major depression and suicidality is mandatory.

When a patient has contemplated or attempted suicide, the burden is on the physician to directly explore the situation with the patient in as much detail as possible to determine the current presence of suicidal ideation as well as accessible means and plans. Discussing these is the most important step an ED physician can take in an attempt to prevent suicide in a patient at risk.

If suicidality is present, hospitalization with the patient's consent or via emergency commitment should be undertaken unless clearcut means to assure the patient's safety exist while outpatient treatment is begun. A child who is suicidal or has made an attempt at suicide should be admitted to a protected environment until all medical and social services can be employed.

Psychotherapeutic interventions act synergistically with pharmacologic therapy.

Patients may require additional interventions that can be instituted immediately on transfer from the ED, but never actually in the ED. Electroconvulsive therapy (ECT) is safe and can be quickly effective. It is usually reserved for refractory cases, cases of pharmacologic resistance or adverse effects, and cases in which rapid reversal is indicated. Newer treatment modalities for refractory depression, including electromagnetic transcranial stimulation and repetitive vagal stimulation, are becoming more widely available. For individuals who have previously been given a diagnosis and who have been successfully treated with these modalities, rapid reinstitution can be lifesaving.

Consultations: Consult a mental health clinician after a screening evaluation is complete and all acute medical complications are addressed. The protocol for consultation should be established by the institution and should be the same for every patient.

Antidepressant therapy usually should not be initiated by an emergency physician. A psychiatrist should be consulted for definitive pharmaceutical intervention. After

consultation, it may be appropriate to provide a small amount of the suggested medication to sustain the patient until follow-up.

The variety and forms of antidepressant agents available and indications for each are beyond the scope of this article.

Further Inpatient Care:

When depression is diagnosed, particularly when suicidality is present or reasonably suspected, the physician, often in consultation with a mental health professional, is responsible for designing an intervention appropriate to the diagnosis and degree of risk that is assessed.

o This may require legal certification that the patient is in need of emergency evaluation and protective observation, emergency or short-course medication, contracting for safety with the patient, and/or releasing the patient in the protective custody of the family or law enforcement agency.

o While evaluating and securing an appropriate disposition for the patient, all staff members must maintain measures to ensure the safety and preserve the dignity of the patient.

Transfer:

Transfer is indicated when there is a need for protective custody or intensive intervention that is not available at the present institution.

Complications:

Suicide

Failure to improve

Drug reaction

Prognosis:

The ED can sometimes be the last opportunity for intervention in the downward spiral of depression, which leads to death for a significant number of those affected. Although the clinician may never see the results of protective intervention, this is an opportunity to really make a difference. There are few diseases as lethal yet so reversible as depression. Lives can be and are saved every day as the result of the timely efforts and empathic interventions of skilled and compassionate emergency physicians.

Patient Education:

Patients must be told clearly and convincingly that depression is an eminently treatable illness.

Carefully inform patients about the critical importance of taking any medications that are prescribed, as well as likely adverse effects and their management.

Stress the need for short-term follow-up and continuing treatment.

Recommend reading for patients. A good source of information about depression is the Depression and Affective Disorders Association (http://www.drada.org/), as well as the National Alliance for the Mentally Ill (http://www.nami.org/).

For excellent patient education resources, visit eMedicine's Depression Center. Also, see eMedicine's patient education articles, Depression and Suicidal Thoughts.

Medical/Legal Pitfalls:

Failure to recognize or appropriately hospitalize a suicidal patient

Failure to document historical details demonstrating lack of suicidality

Failure to follow transfer protocols in accordance with the Emergency Medicine Treatment and Active Labor Act (EMTALA) (Note that under current EMTALA interpretations, even a discharge is considered a transfer.)

Failure to prescribe suicide precautions for a possibly suicidal patient who is discharged to an institutional setting (such as correctional facilities) rather than a psychiatric setting.

Failure to warn others of any threat made concerning them by a patient who is not to be admitted to protective custody.

Failure to provide a source of follow-up care or to advise on indications to return to the ED.

Failure to warn patient and significant others about potential signs of deterioration and suicidality and what to do about them.