A searchable, downloadable PDF of the original article appears below. George Nichols is a medical doctor who works with depressed people.

Suicide. I lost my son Bill this way. He was a fine young man. He fought bravely, but silently, and alone.

Misperceptions

People didn’t used to talk much about suicide, at least not in public. Even today when someone takes his own life we hear people say – that he made the wrong decision, or that he chose a permanent solution to a temporary problem. There is shame on the person, he shouldn’t have done it, it wasn’t worth dying for, he wasn’t strong enough, or he didn’t have enough religion, or enough faith. And there is shame on the family, the family has failed too.

Barriers

These old attitudes and opinions about suicide reflect a strong sense that we are each responsible for our own lives and our own behaviour, for our own success or failure. Certain things, however, are outside our control. For example, we cannot accept responsibility or blame for earthquakes or sickness, including mental illness. And these old misperceptions about suicide are causing harm by keeping us from the action needed to prevent such tragedies.

The Truth

We seem to be completely unaware that nearly all suicides, 95 percent of them, suffer from a treatable mental illness.1 Mental illness is common and affects one out of every four or five of us during our lifetime. Yet public understanding of mental illness is poor. According to surveys last year, many of us still think that mental illness is chosen and can be willed away, that it is a result of emotional weakness, and that it is a result of bad parenting.2 Misperceptions like these must be replaced by better information. For example, suicide is much more than a “wrong choice.” This is not a normal choice by a normal brain. This is a poor sick brain which cannot function normally. It is not under normal self-control. It cannot handle life’s daily flow. The sick person may suffer great anguish at his or her own lack of understanding or the apparent hopelessness of their situation that they turn to death to relieve the awful emotional distress, not knowing or believing that there is a cure.

New Views Need Public Help

Preventing suicide is not the complicated social problem we had thought. Prevention depends mainly on recognizing and treating the underlying mental illness. And for this, public help and understanding are essential. We are not being asked to identify mental illnesses such as schizophrenia and personality disorders, but to help in recognizing “depressive illness” – the one which causes most suicides.

There is More to Depression than Social Stress

Social stresses such as failure, loss, and isolation often appear to bring on depressive illness, but depression itself produces social misery. And sometimes it pops up when people are not having any problems. Depression is not primarily a social or a counseling matter. It is an illness which seems to be caused by a mixture of factors. Genes and body chemistry make some persons and some families exceptionally prone to depression. And, for reasons which are not clear, depressive illness is present in many alcoholics and drug abusers; these people often have a rather dismal future, but their outlook improves considerably when we can recognize the associated depressive illness and treat it.

Depression is a Dangerous Illness

Depression is not the same as “the blues” which we all have from time to time, and it’s not just being unhappy. Depression is a highly curable medical illness which ends fatally for about 10 to 15 percent of the people who have it and are not treated. It is one of the most common (about as common as high blood pressure) and most destructive illnesses today. It is also one of the least recognized. While high blood pressure may kill someone in twenty years, depression can kill immediately. Recognizing and treating it correctly not only saves lives3, but prevents much needless suffering in those who are depressed, and in their families and friends who also suffer.

Some depressions are mild, others are severe. Some depressions last for months, others last for years, and some last a lifetime. Some come and go or have ups and downs (manic depressive illness), and at times depression is confused with schizophrenia and other mental illness.

There are still no reliable laboratory tests for depressive illness. We recognize it by its symptoms and signs – and by asking questions. A person with depressive illness usually shows several of these signs together, lasting two weeks or longer. Here they are, in plain language – the same basic signs which the psychiatrists use3:

  1. A very “down” mood (you may feel gloomy yourself just talking with a person who is depressed. Their mood may show in themes and revealing remarks. And sometimes you must look behind the smile, the behaviour, the alcohol, and the drugs)
  2. Loss of interest in everything
  3. Feelings of hopelessness, loss, guilt
  4. Low energy
  5. Difficulty thinking or remembering
  6. Change in appetite, weight, or sleep
  7. Thoughts of death and suicide.

People who are depressed, especially youths, seldom talk directly about their painful feelings. They may deny them or feel ashamed of them. They can’t come to you; you must see their problem and go to them. So whenever your suspicions are aroused that someone is depressed, then you must ask a few questions to bring out these basic signs. These questions are very important, but ask them softly, gently, one-on-one, and in a caring way. The doctor must do the same in making his or her own diagnosis.

“John, you sound kind of down. How are you?”
“Are you worried about something?”
“What are you doing that you enjoy these days?”
“Do you have trouble getting started doing things?”
“Have trouble thinking, concentrating, deciding?”
“Any trouble sleeping? Has your weight changed?”
“Are you disappointed in yourself? Do you blame yourself?”
“Have you thought of suicide?”

Go Ahead and Ask

You may not feel qualified to ask these questions, but you can do no harm, the stakes are high, and you may be the only one this person will ever see who has guessed what’s wrong and who knows what to do. Have you seen anyone who was depressed this week? Chances are you have.

Suicide has increased among youths, but it continues to be most common among older adults. The underlying depressive illness seems to be the same at all ages, even when it occurs in very young children. Just as we all look different on the outside (face, clothes, height), we also have differences on the inside, so that the same depressive illness may show itself differently in different people, and instead of a quiet sadness, we sometimes see depression as:

A heavy personal problem
Medical symptoms persisting without apparent cause (stomach ache, headache, etc.)
Unusual anxiety, nervousness, irritability
Trouble with alcohol, drugs, behaviour.

Is This a Problem or a Depression?

One of the most common ways for depression to show itself is – as a heavy personal problem, and you may think, “If I had those troubles, I might feel that way too.” Or you may think the person just has a bad attitude about life’s problems. But whenever you find someone complaining, perhaps too much, about either a medical symptom or a difficult personal problem, stop and think, “Is this a problem? Or is this a depression?” Then ask those questions. Problems need counseling, but depression needs medical care.

Sometimes you can tell more about a person’s mood by noticing the things he watches, hears, reads, or draws. Themes of gloom, sadness, and death are very serious signs. We must also pay attention to those revealing little remarks which we sometimes hear and ignore, such as “I just don’t care anymore.” Check it out. Ask those questions.

Many people look to their religious faith for help when they feel depressed not realizing that these feelings may be due to a curable sickness. Prayer is important in all things, but there is no longer a need for prayer to be more important for someone with a depressive illness than for someone with pneumonia, or diabetes, or Alzheimer’s disease. As one minister told me, he has “learned that people feel tremendous shame about being depressed, when actually they should feel no more remorse about depression than they should about breaking a leg.”4

Action and Behaviour Problems

Youths are action-oriented, and the signs which warn of suicide here often show up as a change in behaviour – high risk activities, multiple accidents, truancy, stealing, lying, violence, poor judgement, and impulsiveness. And there is added concern when there has been the loss of a boyfriend or girlfriend, conflict with peers, family stress, or suicide in the community.

What to do

If you suspect depression, or if you are concerned that there is a chance of suicide, don’t decide to watch and wait. Don’t let that person’s brain get used to sick thinking. And don’t let outdated stigma against psychiatric care kill your child or friend. Step right in and take him or her to a doctor, or a psychiatrist, who can verify your amateur diagnosis (other diseases and conditions can imitate depression) and who can prescribe the antidepressant medicines which are so often needed. Effective medicine for treating depression created a revolution in psychiatry thirty years ago. The original medicine, Imipramine, or Tofranil, is still useful. It works very well, is relatively safe, is not habit forming, and is no more of a “crutch” than penicillin.

First the rescue. Psychotherapy is important but it will be more effective later.5

A Trace of Hope

Remember: grief needs sympathy, problems need counseling, and depression needs medical care. In my medical practice, along with our patients with high blood pressure and other illnesses, we always seem to have half-a-dozen folks recovering from depressive illness. If anything can awaken a trace of hope in a person filled with despair, it is to hear you say – that we are quite familiar with his or her condition, and despite the black mood of today, the outlook for recovery is usually very good, because we have a good treatment – and a new understanding – of this ancient disease.

For additional information on suicide and mental illness, please send a stamped self-addressed envelope to George Nichols, M.D., 424 East Longview Drive, Appleton, WI. USA 54911.

Endnotes

  1. Roy, A.: “Suicide”, in: Kaplan H.I., Sadock B.J., eds. Comprehensive Textbook of Psychiatry. Philadelphia: Williams & Wilkins Pub. Co. 1989: 1414.
  2. Modified from a public bulletin by the National Institute of Mental Health, Rockville, Maryland, 1989.
  3. Wender, P.H. Depressive Illness: Recognition & Treatment, 1988.
  4. Jones, W.H. Personal Communication, 1986.
  5. Fink, P.J. Diagnosis & Treatment of Depression & Suicidal Children & Adolescents, 1990.