Category Archives: depression

More on Depression and Suicide

By Dr David Laing Dawson

Let me take my most recent blog a little farther.

For mental health workers: Stop asking the suicide question. It is a question that produces about 50% false positive, 49% genuine negative, and 1% false negative answers. It misleads and distracts. And, clearly, even with thousands of mental health professionals asking that question over and over again, the actual completed suicide rate is increasing (it does not work), while the statement “I want to die” has become legitimized as a replacement for, “I am not happy with my life at this moment.”

The question also distracts and misleads. The answer to this simple question becomes the criteria for holding or not holding, for acting or not acting, for caring or not caring. It also, in hospitals and emergency rooms, becomes a cover-my-ass question before discharging from care.

Rather, spend the time to be with. To look, listen, and attend. Depression is visible. It is not a hidden illness. It is visible. If you don’t believe me watch Anthony Bourdain’s last television special.

Agitated Depression, a combination of despair and high anxiety, is very visible and a high risk for suicide. The pain of agitated depression is hard to sit with, be next to. The diminution of conscious awareness is apparent. Being there and listening one can experience the loss of attachment to others and to a future and to the pain of being in that person’s skin.

Flat, blunted depression is airless. The eyes have no life, the voice no lilt; the entire arousal system is diminished. It is difficult to sit long with this person without feeling his or her lonely shrinking consciousness.

Offer help and treatment in a safe environment. And by treatment I mean medical psychiatric treatment, not a CBT course starting next month. Hospitalization is needed if the risk is severe, and definitely when the person is in a state of agitated depression, or if he or she not once in the course of an hour spoke of anything beyond tomorrow, and no one’s name caused a glimmer of light to appear in his eyes.

Offer treatment, help, hope and hospitalization. Severely depressed people accept help when it is offered.

Do not “contract for safety”. It is, again, a bizarre “cover-my-ass” approach that is obviously paradoxical. It means, at face value, that the counselor believes the risk of suicide is high and at the same time that eliciting a promise to not kill oneself (at least before the next appointment) is a sufficient response to that risk.

We treat heart failure to prevent death.

We should treat depression to prevent suicide.

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Suicide and Depression

By Dr David Laing Dawson

This week, after the suicides of three Ontario Provincial Police officers a heartfelt plea went out from the president of the Union. He implored officers who were suffering to seek help, to talk with someone.

A similar heartfelt message was re posted by my daughter after she learned an old friend had committed suicide.

Broadly, over the last many years, we have seen many “Let’s talk about it” public campaigns.

But over those same years the numbers of completed suicides have gradually increased while the numbers of people taken to the emergency departments for assessment of “suicide ideation” have dramatically increased.

What are we missing?

I think it is this: Most suicides are the product of severe depression. Not all, but most. And often complicated by loss, drugs, alcohol, pain, anxiety, poverty, PTSD, bullying. But still, usually, a state of depression.

And depression, medical depression, is not simply a mood disorder. It is a cognitive disorder as well. Let me explain.

Normally, when we are healthy, our consciousness includes much more than ourselves. Besides being aware of ourselves and our inner state we are aware of (conscious of) our surroundings, the task at hand, our loved ones, our extended family, our colleagues, our friends, our fellow travelers, the citizens of our community, of our country, and, sometimes, far beyond that. All of these things and people float in and out of our consciousness through the waking hours, and may visit us as an eternal puzzle in our dreams.

I assume that awareness, the breadth of that awareness, varies from person to person. For most of us it does not that often go beyond friends, workmates and family, fellow travelers, until we watch the news. Still, it always stretches beyond ourselves.

Not in a severe depression. In a medical depression, the illness depression, our consciousness shrivels. That floating awareness of all around us closes in. We, when suffering from a depression, lose our awareness of others. They simply fall away from our consciousness.

Hence asking a severely depressed person to reach out to others is akin to asking a paralyzed man to walk to the nearest emergency.

The public anti suicide programs and initiatives may even be making the problem worse. They reduce this mental health problem to a dichotomy: thinking about suicide or not thinking about suicide, held in hospital or not held in hospital.

Certainly the statistics tell us the current public initiatives are not working. Not working.

A far better approach would be to talk about depression. Recognizing it in ourselves and others, and helping those others seek treatment. We do have effective treatment for depression.

Dwayne Johnson and Heroic Narratives

By Dr David Laing Dawson

Within the same time frame I was reading Marvin’s blog on the Mental Health Commission and the associated commentary, Dwayne Johnson’s story of depression popped up on multiple news sites. None of the sites gave much detail and I remain unsure if he suffered bouts of what we used to call “clinical depression”, and before that “endogenous depression” or if he simply suffered some difficult discouraging periods in life when his football career and a relationship ended.

In these brief news items Dwayne’s story is shaped as the narrative of an “heroic struggle”.

And I realized that most such stories are shaped and told in that form. It is a classic narrative form, and one we all want to hear.

Facing great odds, our hero, perhaps after learning some life lesson (humility, confession, love, trust, openness) battles his way through to success, health, and happiness. His weapons are will power, strength, hope, perseverance, and a little help from his friends.

It is the narrative form in the story of A Beautiful Mind’s John Nash. And it is the narrative form when the story is told about a victim of cancer.

The difference is that when we read the story and see the pictures of someone’s struggle with cancer, we know he or she has undergone one or many courses of radiation or chemotherapy, that he or she is still undergoing treatment.

The focus of the story may be on the courage and optimism of the patient, their loving  family, a special group of supportive friends, a cancer support group, or all that the patient is able to accomplish despite their illness – but we never lose sight of the fact of medical treatment for cancer.

It is good to bring mental illness out of the shadows. It is good to tell our stories. But we need to drop the euphemisms of mental health issues, and (a new one for me) mental health “situations”, and we need to include the fact of medical treatment for serious mental illness, because we don’t assume it as we do with cancer narratives. In fact, a very popular heroic struggle narrative is “I overcame my (illness, depression) without resorting to medication.”

This heroic struggle narrative has shaped the recovery movement; it has clearly influenced members of the mental health commission.

And who would bother watching a show, or reading a story with a tagline of: “A man develops depression, goes to his doctor; the doctor treats his depression and he gets better.”

This is not to denigrate the role of courage, optimism, hope, and support required to live with a chronic illness, or recover from an acute illness. But…

Update:

Another day, April 5 to be exact, and it seems it is OCD Day with several news items and videos appearing. Much is shared in these articles and videos, distinguishing crippling OCD symptoms from mild everyday forms of compulsions and obsessions. Psychological treatment is also explained, exposure and desensitization therapy. But not once, not once in the articles and videos I watched was it explained that there are medical pharmacological treatments that work with great success for about 90% of sufferers. Not once is this mentioned.

One of these medications has been around since the 1960’s, though at the time we didn’t know how effective it was for OCD and psychological/psychoanalytic thinking about the illness dominated.

I am not sure who or what is to blame for this. But for the psychologists who were interviewed to not mention this readily available medical treatment is akin to naturopaths not mentioning antibiotics when discussing the treatment of pneumonia.

Paradoxically, Jack Nicholson starred as a novelist with OCD in “As Good as it Gets” 20 years ago. At the end of the movie Nicholson’s character decides to be a better man and go back on his medication. Critics were not happy with that ending, and it did ruin the “heroic struggle” narrative. It was, as the third act of a story, very unsatisfying. “What? To quell his OCD all he had to do was take his medication?”  Well, yes.

 

Lies, damned lies, and statistics

by David Laing Dawson

Mark Twain said that long before we had computers and a few dozen algorithms we could apply to random numbers to find ‘meaningful’ patterns.

Data mining and scientific studies that find nothing or negative results seldom get published. So it behooves all academics to find something. To find at least an association that can be inflated by the manner the data is reported. Then it will get published, and the press might even pick it up if it is startling enough.

I am writing this because an article on the front page of our local paper tells us that people who take antidepressants are at risk of premature death. This is based on a local academic’s data mining and meta-analysis. The figure quoted is 33% higher risk of premature death and 14% more likelihood of death from cardiovascular disease. They also have to explain away the fact that if you have previous cardiovascular disease the use of antidepressants does not increase risk.

First, these are associations, not cause and effect. Secondly the variables are numerous. And the first variable that comes to mind is that the people who take antidepressants probably suffered from anxiety and depression, undoubtedly felt unwell, and did ask their physicians for help. The people who never took antidepressants did not. The only way these figures can be clarified would be to take 10,000 people who attend doctors complaining of anxiety, OCD, and depression and give antidepressants to 5000, and nothing to the other 5000, (randomly selected) and follow over 20 or 30 or 50 years.

Then we have the startling 33%. Well, if 3 people out of 1000 die in one group and 4 in the second group, that is a 33% increase, looking at it one way, but really a 0.1% difference looking at it in a real life way. These kinds of statistics are often misused in the press. When the actual risk (sorry, not actually RISK, just different finding) of contracting something increases from 1 in a million in one study to 2 in a million in another study that can be reported as a 100% increase.

I am sure antidepressants are both underused and overused. Underused in the rush of clinical practice when severe depression is not recognized or not reported, underused when the person is already self-medicating with marijuana, alcohol or opioids, underused when the dosages used are too small for severe depression – and overused as the go-to-drug for angst and unhappiness.

I am also sure any drug should be avoided if it can be. That goes for anti-hypertensives, statins, antibiotics, and aspirin.

So I did a little data mining of my own. It turns out that the people of Australia, Iceland, and Sweden rank in longevity 2, 3, and 4 in the world. Canada and New Zealand follow closely. Japan holds the number one spot but antidepressant data (for interesting cultural reasons) can’t be found so I have excluded Japan. On average the people in spots numbers 2,3, and 4 live between 82.4 and 82.8 years. Let’s average that to 82.6 years of life expectancy. Iceland, Australia, and Sweden also rank as the highest antidepressant users, ranking one, two, and four. (Denmark is number three)

Among the lowest antidepressant users (where data for life expectancy and antidepressant use can be accurately determined) are Estonia, Turkey and Slovakia.The life expectancy for the people of those countries averages 76. So by simple association we find that the longest lived people in the world consume the greatest number of antidepressant pills per person.

Applying my own meta analysis to this data I can arrive at the conclusion that high average consumption of antidepressants prolongs (oops, is associated with an increase in) life expectancy by 6.6 years, or almost 9%. The headline this could generate would be: Prozac increases life expectancy by 9%

But, academics have an ethical duty to explain the limitations of associations found in population studies and meta-analysis, and the true meaning of various statistical analyses in real life terms.

Reporters should have an ethical duty to avoid golly gee whiz headlines in health matters. (probably in a few other matters as well)

And medical historians should point out the dramatic change in the number of home and hospital beds utilized by moribund patients suffering from severe depression pre 1960 and today.

A curious side note: On the same Google page for Health news there is a report of a British teen dying from “eating her own hair”. They go on to discuss Rapunzel syndrome, and trichophagia. But such a compulsive behaviour is just that. A compulsion. A serious symptom of OCD. And easily treated today with one of those antidepressants maligned in the other article, along with some counseling of course.