International Journal of Psychiatry in Clinical Practice 1997 Volume 1 Pages 131 - 134
(C) 1997 Martin Dunitz Ltd
131
Recognition of depression and prevention of suicide: the role of general practitioners and general physicians
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of California Irvine on 10/30/14 For personal use only.
ZOLTAN RIHMER National Institute for Psychiatry and Neurology, Budapest, Hungary
Correspondence Address Zoltan Rihmer MD PhD, National Institute for Psychiatry and Neurology, 1021 Budapest, Huvosvolgyi ut 116, Levelcim 1281 Bp 127 Pfl, Hungary Tel: +36 I 155 4411 Fax: +36 I 200 2459 Received 15 November 1996; accepted for publication 20 December 1996
Suicide is a major health problem throughout the world. After briefly describing the risk factors for suicide, the author focuses on depression, which is the major cause of suicide. Depression is a common illness, treatable not only in psychiatric settings, but also in primary care and general medicine. Consequently, physicians other than psychiatrists (primarily general practitioners) have an important role in suicide prevention. (Int J Psych Clin Pract 1997; 1: 131- 134) Keywords depression general medicine general practitioners
INTRODUCTION
I
t has been known from time immemorial that
psychiatric illness, principally the melancholic state (nowadays called depression), and suicide are strongly related to each other. In the last two decades the relationship between suicide and depressive disorders has been well established. Well-operationalized and standard diagnostic procedures have consistently shown depressive disorders (mostly untreated) to have been present in 50-70% of suicide victims from different parts of the world (Table 1). Because schizophrenia and substance (alcohol and/or drug) abuse or dependence are both found in 10%of Victims’-5, the vast majority (over 90%) of suicide victims kill themselves during a period of active psychiatric illness. Suicide, which is the most serious complication of untreated affective disorder, is among the most tragic events in human life, causing serious psychological distress
Table 1 Rate of. depressive disorders* . among consecuthe suicide victims
suicide suicide prevention
among the surviving relatives, as well as imposing a great economic problem for the whole society. Suicide is a major cause of years of life lost, and its prevention is receiving more and more attention. Since the majority of suicide victims contact different levels of health care services some weeks, months or years before their death'^^'^, health care professionals, both psychiatrists and others, have an important role in suicide prevention.
DEPRESSION, THE MOST IMPORTANT RISK FACTOR FOR SUICIDE Suicide is a complex phenomenon, with many causes and associated with a number of ‘risk factors’ However, these different risk factors have varylng prognostic utility. The hierarchical classification of suicide risk factors’ is presented in Table 2. Although suicide is more frequent in Spring, in
Source
Country
No. of victims
Barraclough et a1 1974l Arat6 et a1 19M2 Rich et a1 1988*’ Henriksson et a1 19933 Cheng 1995’
UK Hungary USA Finland Taiwan
100
70
200 204 229 116
63 47 59 65
% depression
*Major and minor depression, dysthymia, bipolar (manic-depressive) illness, depressed phase
132
Z Rihmer
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of California Irvine on 10/30/14 For personal use only.
Table 2 Hierarch~al classfication of suicide nsk factors7
Primaty risk factors: psychiatric illness (depression, schizophrenia, substance abuse or dependence) previous suicide attemptb) communication of suicide intent Secondary risk factors: early parental loss isolation unemploymenthajor financial problems severe negative life events Tertiary risk factors: male gender adolescence (males), old age (females) vulnerable intervals (spring, premenstrual period)
men, in older women and during the pre-menstrual period, the predictive power of these tertiary risk factors in the general population is limited. Secondary risk factors, such as early parental loss, isolation and major financial problems are associated with higher risk, since a significant proportion Primary risk of suicide victims show one or more of factors such as major psychiatric illness (depression, schizophrenia and substance abuse), particularly if there have been previous suicide attempts, are the strongest predictors of suicide'. Although a relatively small minority of these victims directly express the wish of taking their own lives, many patients do so indirectly, i.e. say they do not want to live or would not mind dying'0*''. Personality disorder in itself is extremely rare as a principal diagnosis in suicide victims while as a comorbid diagnosis it is quite common in depressed suicide victims5.12. Depression, the major cause of suicide, is not a rare phenomenon. Epidemiological studies conducted since 1980 showed that the point prevalance of depressive disorders (including either severe or milder forms) is around 6% while the lifetime prevalence rate is more than 33% in the general pop~lation'~. In addition, several studies have demonstrated an increase in the cumulative lifetime risk of major depression in successively younger birth cohorts during this ~ e n t u r y ' ~ . Depression rarely occurs as a single episode, and in the majority of the cases it is a recurrent illness, indicating the need not only for acute but also for long-term prophylactic therapy4*14. Depression is much more than 'feeling blue', and, contrary to general belief, it is not a personal weakness. Rather, it is a medical illness with various (sometimes rich, sometimes poor) clinical presentations. It has a well-defined genetic and biological background and shows a clear treatment response4.14.Although untreated (or inadequately treated) depression can be highly dangerous, this disorder is in fact the most treatable illness in psychiatry and one of the most treatable in medicine.
The most widely accepted diagnostic criteria for major depression (DSM-IV35) are presented in Table 3. The core symptoms consist of depressed mood, loss of interest or loss of pleasure in usual activities. In addition, patients have other symptoms (disturbed sleep, appetite changes, concentration difficulties, decreased energy, pessimistic orientation, altered libido, decreased self-esteem, hopelessness, feelings of guilt and thoughts of death or suicide ideas). Anxiety is often present, and rarely psychotic symptoms (depressive, i.e. mood-congruent delusions) also appear. Depressive illness can also occur in relatively mild forms. The DSM-IV diagnostic criteria for mild, mostly chronic depressions, called dysthymic disordef5, are presented in Table 4. Somatic complaints, particularly pains and paraesthesias without any obvious 'medical' illness are frequent components of the clinical presentation of depression and these symptoms can 'mask classical depressive symptoms. The psychiatric (i.e. the affective) nature of these so-called masked depressions often remains unrecognized and the patients are treated only symptomaTable 3 Short summary of DSM-lV35 definition of a major depressive episode
Table 4 Short summary of the DSM-IP5 definition of dysthymic disorder (chronic, mild depression)
Five (or more) of the following symptoms have been present during the last 2-week period and represent a change from previous functioning. At least one of the symptoms is either (1) or (2). Depressed mood Diminished interest or pleasure in all, or almost all activities Decrease or increase in appetite or weight Insomnia or hypersomnia Psychomotor agitator or retardation Fatigue or loss of energy Feelings of worthlessness or guilt Reduced concentration or indecisiveness Recurrent thoughts of death or suicide or suicide attempt.
Depressed mood for most of the day, for more days than not, either subjectively or objectively, for at least 2 years, and presence of two (or more) of the following: (1) Poor appetite or overeating (2) Insomnia or hypersomnia (3) Low energy or fatigue (4 Low self-esteem (5) Poor concentration or difficulty making decisions (6) Feelings of hopelessness.
Recognition of depression and prevention of suicide
Table 5 Clinical charactenstics which hclp the diagnosis of
depression i n
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of California Irvine on 10/30/14 For personal use only.
medically 111 pahents
Family history of depression and/or mania Family history of suicide Previous depressive episodes (and good response to antidepressants in the Past) Previous suicide attempts Seasonal fluctuation of the illness Diurnal variation of the symptoms
tically. Although ‘masked depression’ is not a distinct diagnostic category and does not have a special rubric in the DSM system, all types of depressive illness (major depression, dysthymic disorder etc) can go unrecognized in medical
PREVALENCE OF DEPRESSION IN GENERAL MEDICAL CARE Although depression is a psychiatric illness, only a small minority of patients (probably the most severe cases) are treated by p~ychiatrists’~. Depression is one of the most common disorders in primary care, with a reported point prevalence of between 6% and 26% of consecutive primary health care attenders’8-20. Unfortunately, approximately half of such cases remain unrecognized or misdiagnosed’*-20. Particularly, depressions with a predominantly somatic symptom presentation and with significant physical comorbidity remain unrecognizedL6-”. A significant proportion of people who are high utilisers of health care have (mainly unrecognized) depression”. Fortunately, depression, when identified, can be successfully treated even in primary c a ~ e ’ ~ - ~ ~ . Other professionals such as general physicians, cardiologists, neurologists and gerontologists also frequently see depressed patients. The point prevalence of depression (mainly major depression) in cardiovascular disease, stroke, Parkinson’s disease, diabetes mellitus and dementia has been reported as being between 20%and 50%,a figure well in excess of the point prevalence rate for the general p o p ~ l a t i o n ~Concomitant ~. depression increases the morbidity and mortality from concurrent medical illness and patients with simultaneous medical disorder and depression are less compliant with treatment and take longer to recover than non-depressed medical patientsz5. The diagnosis of depression is sometimes difficult in medical patients, since many symptoms (for example, anorexia, fatigue and weight loss) are seen in both depression and medical illness. However, there are several clinical characteristics, frequently seen in healthy depressives, which are cues to the diagnosis of depression in medically ill patients. They are listed in Table 5. In spite of the great progress in the diagnosis and treatment of depression during the last two decades, it remains extremely under-referred, under-diagnosed, un-
133
treated and under-treated, this being particularly true for depressed suicide victim^'.'^.'^^^^-^^. Since the majority of depressed patients respond well to an adequate course of antidepressant medication4.14,it is evident that the early recognition and adequate treatment of depression is one of the most important factors in suicide prevention.
THE ROLE OF GENERAL PHYSICIANS IN SUICIDE PREVENTION Although the elimination of an acute danger of suicide by all possible means should be a task for many agencies, it is primarily in the domain of health care that people with high suicide risk should be identified and managed successfully. Patients with acute suicidal intention related to severe mental disorder often need urgent psychiatric hospitalization and pharmacological treatment with supportive psychotherapy. The new psychotropic drugs, including the selective serotonin re-uptake inhibitor antidepressants (SSRIs) provide a safe and effective pharmacotherapy ,since it has been repeatedly and con-sistently demonstrated that disturbed central serotonin function plays a fundamental role in suicidal behaviour, both in depressed and nondepressed p e r s o n ~ ~ , ’ ~ . Follow-up studies in selected clinical populations have shown that adequate treatment of affective disorder reduces the short-term risk of suicide7. However, successful antidepressant acute treatment can only prevent the suicide connected with a given depressive episode, whereas prophylactic therapy can produce long-term results in patients with recurrent mood disorder. Several studies have reported that long-term prophylactic lithium therapy significantly reduces the suicide (and somatic) morbidity and mortality in recurrent depressive and manic-depressive
patient^^.^. To diagnose and treat depression (except the most severe, acutely suicidal or stuporous patients) in general medicine is no more complicated than identifymg and managing patients with hypertension or diabetes mellitus. Studies show that training of non-psychiatrist professionals (mainly general practitioners) in the diagnosis and treatment of depression increases their vigilance and knowledge about this illness, including the recognition and management of suicidal patients. The best scientific argument for the significant role of general practitioners in suicide prevention comes from the Swedish Gotland Study. Rutz et al” demonstrated that after a short but intensive postgraduate training programme for general practitioners on the island of Gotland on the diagnosis and treatment of depression, the suicide rate and the rate of hospital admissions for depression dropped significantly during the following years. The percentage of depressive suicides among all suicides decreased significantly after the training, indicating that the significant decrease in suicide rates after the education resulted from a
134
Z Rihmer
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of California Irvine on 10/30/14 For personal use only.
robust decrease in the suicides of depressed patients31s3’. This is in agreement with a recent Hungarian study. Investigating the regional distribution of the suicide rate, rate of diagnosed depression and prevalence of working physicians in Hungary, it was found that the more physicians per 100 000 inhabitants, the better the recognition of depression and the lower the suicide rate in the given region33. Recent Swedish epidemiological data based on nearly half a million depressed people also show that the risk for suicide among untreated depressive patients is almost twice as high as among treated depressives, in spite of the fact
that the inclusion of inadequately treated and noncompliant patients in the treated group tends to obscure differences in suicide risk between drug-treated and untreated depressive~~~. We are, of course, unable to prevent all suicides. Nevertheless, our present theoretical knowledge and the available treatment strategies are hopefully sufficient to prevent many suicides. However, since health care professionals can help only those patients who contact them, public education about the symptoms, dangers and treatable nature of depression is clearly very important.
REFERENCES 1. Barraclough B, Bunch J, Nelson B, Sainsbury P (1974) A hundred cases of suicide. Br J Psychiatry 125: 353 - 73. 2. Arato M, Demeter E, Rihmer Z, Somogyi E (1988) Retrospective psychiatric assessment in 100 suicides in Budapest. Acta Psychiat Scand 77: 454- 56. 3. Henriksson MM, Aro H, Mattunen MJ, et a1 (1993) Mental disorders and comorbidity in suicide. Am J Psychiatry 150: 935 -40. 4. Goodwin FK, Jamison KR (1990) Manic-depressive illness. New York Oxford University Press. 5. Cheng AT (1995) Mental illness and suicide. Arch Gen Psychiatry 52: 594-603. 6. Isometsa E, Henriksson MM, Aro HM, et a1 (1994) Suicide in major depression. Am J Psychiatry 151: 530-36. 7. Rihmer Z (1996) Strategies of suicide prevention: Focus on health care. J Affect Disord 39: 83 - 91. 8. Appleby L (1992) Suicide in psychiatric patients: Risk and prevention. Br J Psychiatry 161: 749 - 58. 9. Heikkinen M, Aro H, Lonnqvist J (1993) Life events and social support in suicide. Suicide Life Threat Behav 23: 34358. 10. Rihmer Z, Barsi J, Arat6 M, Demeter E (1990) Suicide in subtypes of primary major depression. J Affect Disord 18: 221 -25. 11. Isometsa E, Heikkinen ME, Henriksson MM et a1 (1995) The last appointment before suicide: Is suicide intent communicated? Am J Psychiatry 152: 919-22. 12. Isometsa ET, Henriksson MM, Heikkinen ME et a1 (1996) Suicide among subjects with personality disorder. Am J Psychiatry 153: 667- 73. 13. Wittchen H-U, Knauper B, Kessler RC (1994) Lifetime risk of depression. BrJ Psychiatry 165 (Suppl. 26): 16-22. 14. Kasper S, Schindler S, Neumeister A (1996) Risk of suicide in depression and its implication for psychopharmacological treatment. Int Clin Psychopharmacol 11: 71 - 79. 15. Rihmer Z, Szadoczky E, Arat6 M (1983) Dexamethasone suppression test in masked depression. J Affect Disord 5: 293 - 296. 16. Zung WWK, King RE (1983) Identification and treatment of masked depression in a general medical practice. J Clin Psychiatry 44: 365 - 68. 17. Ustun TB, Gater R (1994) Integrating mental health into primary care. Curr Opinion Psychiatry 7: 173- 80. 18. Freeling P, Tylee A (1992) Depression missed or mismanaged in primary care. In: Long-term treatment of depression (ed S Montgomery, F Rouillon), 15-31. Chichester: Wiley. 19. Spitzer RL, Williams JBW, Kroenke K et a1 (1994) Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study.JAMA 272: 1749-56. 20. Roberts A, Priest RG (1995) Depression in the community. Primary Care Psychiatry 1: 5- 13.
21. Tylee AT, Freeling F, Keny S (1993) Why do general practitioners recognize major depression in one woman patient yet miss it in another? Br J Gen Practice 43: 327 - 30. 22. von Korff M, Ormel J, Katon W, Lin EHB (1992) Disability and depression among high utilizers of health care. Arch Gen Psychiatry 49: 91 - 100. 23. Rosenberg C, Dambso N, Fuglum E et a1 (1994) Citalopram and imipramine in the treatment of depressive patients in general practice. A Nordic multicentre clinical study. Int Clin Psychopharmacol 9 (Suppl. 1): 41 -48. 24. Baldwin DS, Bullock T, Montgomery DB, Montgomery SA (1991) 5-HTreuptake inhibitors, tricyclic antidepressants and suicidal behaviour. Int J Clin Psychopharmacol 6: 49-55. 25. Cunningham LA (1994) Depression in the medically ill: Choosing an antidepressant. j Clin Psychiatry 55 (suppl. 9): 90 - 97. 26. Isacsson G, Bergman U, Rich CL (1994) Antidepressants, depression and suicide: An analysis of the San Diego study. J Affect Disord 32: 277-86. 27. Wells KB, Katon W, Rogers B, Camp P (1994) Use of minor tranquilizers and antidepressant medications by depressed outpatients: Results from the medical outcomes study. Am J psychiatry 151: 696- 700. 28. Marzuk PM, Tardiff K, Leon AC et a1 (1995) Use of prescription psychotropic drugs among suicide victims in New York City. AmJ Psychiatry 152: 1520-22. 29. Rich CL, Ricketts JE, Fowler RC, Young D (1988) Some differences between men and women who commit suicide. Am J Psychiatry 145: 718- 22. 30. Rutz W, von Knomng 1,Palinder J (1992) Long-term effects of an educational program for general practitioners by the Swedish Committee for the Prevention and Treatment of Depression. Acta Psychiat Scand 85: 83- 88. 31. Rihmer Z, Rutz W, Pihlgren H (1995) Depression and suicide on Gotland. An intensive study of all suicides before and after a depression-training programme for general practitioners. J Affect Disord 35: 147-52. 32. Rutz W, WAlinder J, Von Knomng 1,Rihmer Z, Pihlgren H (1997) Prevention of depression and suicide by education and medication: impact on male suicidality. An update from the Gotland Study. Int J Pysch Clin Pract 1: 39-46. 33. Rihmer Z, Rutz W, Barsi J (1993) Suicide rate, prevalence of diagnosed depression and prevalence of working physicians in Hungary. Acta Psychiat Scand 88: 391 -94. 34. Isacsson G, Bergman U, Rich CL (1996) Epidemiological data suggest antidepressants reduce suicide risk among depressives. J Affect Disord 41: 1-8. 35. American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Washington DC: APA.
(C) 1997 Martin Dunitz Ltd
131
Recognition of depression and prevention of suicide: the role of general practitioners and general physicians
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of California Irvine on 10/30/14 For personal use only.
ZOLTAN RIHMER National Institute for Psychiatry and Neurology, Budapest, Hungary
Correspondence Address Zoltan Rihmer MD PhD, National Institute for Psychiatry and Neurology, 1021 Budapest, Huvosvolgyi ut 116, Levelcim 1281 Bp 127 Pfl, Hungary Tel: +36 I 155 4411 Fax: +36 I 200 2459 Received 15 November 1996; accepted for publication 20 December 1996
Suicide is a major health problem throughout the world. After briefly describing the risk factors for suicide, the author focuses on depression, which is the major cause of suicide. Depression is a common illness, treatable not only in psychiatric settings, but also in primary care and general medicine. Consequently, physicians other than psychiatrists (primarily general practitioners) have an important role in suicide prevention. (Int J Psych Clin Pract 1997; 1: 131- 134) Keywords depression general medicine general practitioners
INTRODUCTION
I
t has been known from time immemorial that
psychiatric illness, principally the melancholic state (nowadays called depression), and suicide are strongly related to each other. In the last two decades the relationship between suicide and depressive disorders has been well established. Well-operationalized and standard diagnostic procedures have consistently shown depressive disorders (mostly untreated) to have been present in 50-70% of suicide victims from different parts of the world (Table 1). Because schizophrenia and substance (alcohol and/or drug) abuse or dependence are both found in 10%of Victims’-5, the vast majority (over 90%) of suicide victims kill themselves during a period of active psychiatric illness. Suicide, which is the most serious complication of untreated affective disorder, is among the most tragic events in human life, causing serious psychological distress
Table 1 Rate of. depressive disorders* . among consecuthe suicide victims
suicide suicide prevention
among the surviving relatives, as well as imposing a great economic problem for the whole society. Suicide is a major cause of years of life lost, and its prevention is receiving more and more attention. Since the majority of suicide victims contact different levels of health care services some weeks, months or years before their death'^^'^, health care professionals, both psychiatrists and others, have an important role in suicide prevention.
DEPRESSION, THE MOST IMPORTANT RISK FACTOR FOR SUICIDE Suicide is a complex phenomenon, with many causes and associated with a number of ‘risk factors’ However, these different risk factors have varylng prognostic utility. The hierarchical classification of suicide risk factors’ is presented in Table 2. Although suicide is more frequent in Spring, in
Source
Country
No. of victims
Barraclough et a1 1974l Arat6 et a1 19M2 Rich et a1 1988*’ Henriksson et a1 19933 Cheng 1995’
UK Hungary USA Finland Taiwan
100
70
200 204 229 116
63 47 59 65
% depression
*Major and minor depression, dysthymia, bipolar (manic-depressive) illness, depressed phase
132
Z Rihmer
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of California Irvine on 10/30/14 For personal use only.
Table 2 Hierarch~al classfication of suicide nsk factors7
Primaty risk factors: psychiatric illness (depression, schizophrenia, substance abuse or dependence) previous suicide attemptb) communication of suicide intent Secondary risk factors: early parental loss isolation unemploymenthajor financial problems severe negative life events Tertiary risk factors: male gender adolescence (males), old age (females) vulnerable intervals (spring, premenstrual period)
men, in older women and during the pre-menstrual period, the predictive power of these tertiary risk factors in the general population is limited. Secondary risk factors, such as early parental loss, isolation and major financial problems are associated with higher risk, since a significant proportion Primary risk of suicide victims show one or more of factors such as major psychiatric illness (depression, schizophrenia and substance abuse), particularly if there have been previous suicide attempts, are the strongest predictors of suicide'. Although a relatively small minority of these victims directly express the wish of taking their own lives, many patients do so indirectly, i.e. say they do not want to live or would not mind dying'0*''. Personality disorder in itself is extremely rare as a principal diagnosis in suicide victims while as a comorbid diagnosis it is quite common in depressed suicide victims5.12. Depression, the major cause of suicide, is not a rare phenomenon. Epidemiological studies conducted since 1980 showed that the point prevalance of depressive disorders (including either severe or milder forms) is around 6% while the lifetime prevalence rate is more than 33% in the general pop~lation'~. In addition, several studies have demonstrated an increase in the cumulative lifetime risk of major depression in successively younger birth cohorts during this ~ e n t u r y ' ~ . Depression rarely occurs as a single episode, and in the majority of the cases it is a recurrent illness, indicating the need not only for acute but also for long-term prophylactic therapy4*14. Depression is much more than 'feeling blue', and, contrary to general belief, it is not a personal weakness. Rather, it is a medical illness with various (sometimes rich, sometimes poor) clinical presentations. It has a well-defined genetic and biological background and shows a clear treatment response4.14.Although untreated (or inadequately treated) depression can be highly dangerous, this disorder is in fact the most treatable illness in psychiatry and one of the most treatable in medicine.
The most widely accepted diagnostic criteria for major depression (DSM-IV35) are presented in Table 3. The core symptoms consist of depressed mood, loss of interest or loss of pleasure in usual activities. In addition, patients have other symptoms (disturbed sleep, appetite changes, concentration difficulties, decreased energy, pessimistic orientation, altered libido, decreased self-esteem, hopelessness, feelings of guilt and thoughts of death or suicide ideas). Anxiety is often present, and rarely psychotic symptoms (depressive, i.e. mood-congruent delusions) also appear. Depressive illness can also occur in relatively mild forms. The DSM-IV diagnostic criteria for mild, mostly chronic depressions, called dysthymic disordef5, are presented in Table 4. Somatic complaints, particularly pains and paraesthesias without any obvious 'medical' illness are frequent components of the clinical presentation of depression and these symptoms can 'mask classical depressive symptoms. The psychiatric (i.e. the affective) nature of these so-called masked depressions often remains unrecognized and the patients are treated only symptomaTable 3 Short summary of DSM-lV35 definition of a major depressive episode
Table 4 Short summary of the DSM-IP5 definition of dysthymic disorder (chronic, mild depression)
Five (or more) of the following symptoms have been present during the last 2-week period and represent a change from previous functioning. At least one of the symptoms is either (1) or (2). Depressed mood Diminished interest or pleasure in all, or almost all activities Decrease or increase in appetite or weight Insomnia or hypersomnia Psychomotor agitator or retardation Fatigue or loss of energy Feelings of worthlessness or guilt Reduced concentration or indecisiveness Recurrent thoughts of death or suicide or suicide attempt.
Depressed mood for most of the day, for more days than not, either subjectively or objectively, for at least 2 years, and presence of two (or more) of the following: (1) Poor appetite or overeating (2) Insomnia or hypersomnia (3) Low energy or fatigue (4 Low self-esteem (5) Poor concentration or difficulty making decisions (6) Feelings of hopelessness.
Recognition of depression and prevention of suicide
Table 5 Clinical charactenstics which hclp the diagnosis of
depression i n
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of California Irvine on 10/30/14 For personal use only.
medically 111 pahents
Family history of depression and/or mania Family history of suicide Previous depressive episodes (and good response to antidepressants in the Past) Previous suicide attempts Seasonal fluctuation of the illness Diurnal variation of the symptoms
tically. Although ‘masked depression’ is not a distinct diagnostic category and does not have a special rubric in the DSM system, all types of depressive illness (major depression, dysthymic disorder etc) can go unrecognized in medical
PREVALENCE OF DEPRESSION IN GENERAL MEDICAL CARE Although depression is a psychiatric illness, only a small minority of patients (probably the most severe cases) are treated by p~ychiatrists’~. Depression is one of the most common disorders in primary care, with a reported point prevalence of between 6% and 26% of consecutive primary health care attenders’8-20. Unfortunately, approximately half of such cases remain unrecognized or misdiagnosed’*-20. Particularly, depressions with a predominantly somatic symptom presentation and with significant physical comorbidity remain unrecognizedL6-”. A significant proportion of people who are high utilisers of health care have (mainly unrecognized) depression”. Fortunately, depression, when identified, can be successfully treated even in primary c a ~ e ’ ~ - ~ ~ . Other professionals such as general physicians, cardiologists, neurologists and gerontologists also frequently see depressed patients. The point prevalence of depression (mainly major depression) in cardiovascular disease, stroke, Parkinson’s disease, diabetes mellitus and dementia has been reported as being between 20%and 50%,a figure well in excess of the point prevalence rate for the general p o p ~ l a t i o n ~Concomitant ~. depression increases the morbidity and mortality from concurrent medical illness and patients with simultaneous medical disorder and depression are less compliant with treatment and take longer to recover than non-depressed medical patientsz5. The diagnosis of depression is sometimes difficult in medical patients, since many symptoms (for example, anorexia, fatigue and weight loss) are seen in both depression and medical illness. However, there are several clinical characteristics, frequently seen in healthy depressives, which are cues to the diagnosis of depression in medically ill patients. They are listed in Table 5. In spite of the great progress in the diagnosis and treatment of depression during the last two decades, it remains extremely under-referred, under-diagnosed, un-
133
treated and under-treated, this being particularly true for depressed suicide victim^'.'^.'^^^^-^^. Since the majority of depressed patients respond well to an adequate course of antidepressant medication4.14,it is evident that the early recognition and adequate treatment of depression is one of the most important factors in suicide prevention.
THE ROLE OF GENERAL PHYSICIANS IN SUICIDE PREVENTION Although the elimination of an acute danger of suicide by all possible means should be a task for many agencies, it is primarily in the domain of health care that people with high suicide risk should be identified and managed successfully. Patients with acute suicidal intention related to severe mental disorder often need urgent psychiatric hospitalization and pharmacological treatment with supportive psychotherapy. The new psychotropic drugs, including the selective serotonin re-uptake inhibitor antidepressants (SSRIs) provide a safe and effective pharmacotherapy ,since it has been repeatedly and con-sistently demonstrated that disturbed central serotonin function plays a fundamental role in suicidal behaviour, both in depressed and nondepressed p e r s o n ~ ~ , ’ ~ . Follow-up studies in selected clinical populations have shown that adequate treatment of affective disorder reduces the short-term risk of suicide7. However, successful antidepressant acute treatment can only prevent the suicide connected with a given depressive episode, whereas prophylactic therapy can produce long-term results in patients with recurrent mood disorder. Several studies have reported that long-term prophylactic lithium therapy significantly reduces the suicide (and somatic) morbidity and mortality in recurrent depressive and manic-depressive
patient^^.^. To diagnose and treat depression (except the most severe, acutely suicidal or stuporous patients) in general medicine is no more complicated than identifymg and managing patients with hypertension or diabetes mellitus. Studies show that training of non-psychiatrist professionals (mainly general practitioners) in the diagnosis and treatment of depression increases their vigilance and knowledge about this illness, including the recognition and management of suicidal patients. The best scientific argument for the significant role of general practitioners in suicide prevention comes from the Swedish Gotland Study. Rutz et al” demonstrated that after a short but intensive postgraduate training programme for general practitioners on the island of Gotland on the diagnosis and treatment of depression, the suicide rate and the rate of hospital admissions for depression dropped significantly during the following years. The percentage of depressive suicides among all suicides decreased significantly after the training, indicating that the significant decrease in suicide rates after the education resulted from a
134
Z Rihmer
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of California Irvine on 10/30/14 For personal use only.
robust decrease in the suicides of depressed patients31s3’. This is in agreement with a recent Hungarian study. Investigating the regional distribution of the suicide rate, rate of diagnosed depression and prevalence of working physicians in Hungary, it was found that the more physicians per 100 000 inhabitants, the better the recognition of depression and the lower the suicide rate in the given region33. Recent Swedish epidemiological data based on nearly half a million depressed people also show that the risk for suicide among untreated depressive patients is almost twice as high as among treated depressives, in spite of the fact
that the inclusion of inadequately treated and noncompliant patients in the treated group tends to obscure differences in suicide risk between drug-treated and untreated depressive~~~. We are, of course, unable to prevent all suicides. Nevertheless, our present theoretical knowledge and the available treatment strategies are hopefully sufficient to prevent many suicides. However, since health care professionals can help only those patients who contact them, public education about the symptoms, dangers and treatable nature of depression is clearly very important.
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