Depression and Suicide: Amid Harsh Truths, Reasons for Hope

Course Director Stephen M. Strakowski, MD, far right, with, from left: Guest speaker Eric Hipple; special guests Renee Greden and John Greden, MD, Executive Director of the University of Michigan Comprehensive Depression Center and Founding Chair of the National Network of Depression Centers, which includes UC. Photo by Dave Collins / UC Academic Health Center Communications Services.

If 90 percent of suicide victims have a diagnosable depressive illness, and if depression is often treatable, then suicide should be preventable. That was a conclusion one could draw from last weekend’s two-part symposium staged by the newly formed Cincinnati Mood Disorders Consortium, a UCNI affiliate, at the Cintas Center.

Experts from the UC Department of Psychiatry and Behavioral Neuroscience, the Lindner Center of HOPE and Cincinnati Children’s Hospital Medical Center immersed an audience of clinicians (in the morning) and community members (in the afternoon) in statistics, guidelines, illuminating stories and ideas for the future. Guest speakers included former Detroit Lions Quarterback Eric Hipple and Cincinnatians Karen and Dave Troup, who share a tragic bond in having lost a son to suicide.

The statistics were sobering. Of the 14 million U.S. adults who suffer from depression, 6.8 million receive no treatment. Of the 7.2 million who are treated, only 3.2 million are adequately served. Among patients with bipolar disorder, a serious mental illness that includes significant depression, and also the potential for severe and debilitating elevations of mood known as mania, 15 to 19 percent will commit suicide. The suicide rate in America, at 11.5 per 100,000 population, has gone unchanged during the last 40 years and is the 11th leading cause of death, overall and among the top 5 in young people. In 2010 roughly 33,000 people died of suicide, and many more made an attempt but did not die.

Speakers pointed to the following reasons for inadequate care:

  • improper diagnoses; as recently as 2000, 69 percent of patients with bipolar disorder were misdiagnosed as having depression. “Prescribing an antidepressant for a person with bipolar disorder can add gas to the fire,” noted Paul Keck, MD, President and CEO of the Lindner Center of HOPE. A mood stabilizer should always be used in bipolar disorder.
  • improper dosing; primary care physicians who treat mental illness may abandon a medication after prescribing only the lowest acceptable dose. By failing to increase the dose within the FDA-approved range in patients who are tolerating the drug, clinicians lose the opportunity to discover whether the drug actually works for an individual patient.
  • among primary care physicians, failure to refer patients with complex disorders to specialists for optimal management;
  • among people with depression, failure to seek treatment because of stigma or a fear that they will become a burden to family or friends

Other highlights from symposium speakers included:

Henry Nasrallah, MD, Director of the Schizophrenia Research Program and Professor of Psychiatry and Neuroscience: The two primary, idiopathic depressive disorders not associated with an underlying medical illness or substance abuse are: 1) major depressive disorder, which involves depression only; and 2) bipolar disorder, which is divided into bipolar 1 (depressive episodes and episodes of mania, an abnormal elevation of mood) and bipolar 2 (a variant characterized by depressive episodes interspersed with hypomanic symptoms, which are are less severe, or disabling, than mania.)

Stephen M. Strakowski, MD, the Dr. Stanley & Mickey Kaplan Professor and Chair of the Department of Psychiatry and Behavioral Neuroscience at UC and Vice-President of Research for UC Health, said he envisions an evolution toward programmatic treatment of bipolar disorder similar to that of juvenile diabetes. Programmatic treatment involves the patient and family members. It involves tracking mood daily the way a diabetic might keep track of blood sugar. “It’s difficult to treat bipolar,” Dr. Strakowski said. “It’s a complicated, dynamic illness.”

Scott Ries, LISW, Director of the CMDC and Associate Professor of Psychiatry, and Robin Arthur, PhD, Director of Psychology at the Lindner Center, stressed the importance of evidence-based therapy in patients who are depressed or suicidal, including: 1) Cognitive behavioral therapy (CBT), which challenges hopeless automatic thoughts and promotes successful thinking and 2) Dialectical Behavioral Therapy (DBT), which promotes mindfulness (awareness without judgment), emotion regulation skills and self-soothing.

John F. Greden, MD, Executive Director of the University of Michigan Comprehensive Depression Center and Founding Chair of the National Network of Depression Centers, noted that the suicide rate has been flat for 40 years. “We need to get out there screening in the high schools, supporting research projects, achieving — and just as importantly — maintaining wellness, and counteracting stigma,” he said. “The National Network of Depression Centers, which includes the University of Cincinnati as an inaugural member, is a new model that enables us to finally achieve large-sample, important, standardized studies that lead to breakthroughs, comparable to those achieved by America’s Cancer Center Network. To conquer depression and bipolar we need to get the new knowledge to where it is needed, and our goal is to have new advances be within 200 miles of every citizen in the United Sates.”

Melissa DelBello, MD, Professor of Psychiatry, Pediatrics and Psychology, presented statistics relating to the U.S. Food and Drug Administration’s 2004 “black box” warning that antidepressant medications known as selective serotonin reuptake inhibitors (SSRIs) could increase suicidal thoughts and behavior in children and adolescents. After the warning, pediatricians’ diagnoses of depression among children and adolescents dropped 44 percent, and suicide in that population rose 14 percent. The black box warning was implemented after an FDA review showed an increase in suicidal thoughts, though no suicides, among children taking antidepressants, particularly in the first month. Michael Keys, MD, Director of Senior Adult Psychiatry at the Lindner Center of HOPE, said that late-onset depression can be an early precursor of dementia; depression is the third leading predictor of death six months after a heart attack; and depression in the elderly correlates more with an individual’s perception of poor health than with the individual’s actual physical health. Risk factors for suicide among caregivers for the elderly include isolation, depression, being male and having a firearm in the home.

Karen Troup, Field Service Assistant Professor in UC’s Special Education Program and mother of Jake: “If I had a message to share from what I’ve learned today, it would be never to assume that a child would never take his or her own life. Rather, parents should be vigilant and assume that it can happen to anyone. Everyone needs to know what questions to ask and have a plan of response if they learn that any person is struggling with serious depression.”

General statistics: April and May are the worst months for suicide for people who already have depression or are susceptible to depression. White males (see above chart, courtesy of NIMH) are most at risk for completed suicide, although females make many more attempts. Suicide risk is highest in white males over age 65.

— Cindy Starr

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