Mr. Thomas was a colleague, neighbor and close family friend. I had seen him earlier in the morning out for a Sunday morning run. We stopped and exchanged small talk about what a beautiful day it was going to be. Just hours later his wife ran out of their home with tears pouring down her face screaming that he was dead. I was shocked. On the outside he appeared healthy. He was successful, with a beautiful young family. He was only 36 years old, with what appeared to be everything going for him. No one knew that he had been struggling with depression until it was too late.
Stories like this are all too common. Families and friends feel blindsided and abandoned, left wondering if they could have done more. Doctors who lose patients to suicide search for missed clues and overlooked symptoms. Everyone assumes the tragedy could have -- should have -- been prevented.
In many cases, they are right. The most common cause of suicide is depression, a disease that can easily be screened for and effectively treated. The proper mix of therapy and medication leads to fewer symptoms, improved quality of life and most importantly can prevent suicide. Evidence also shows that effective depression treatment leads to improved control of other chronic diseases. This is critical since patients with chronic illnesses like diabetes and heart disease are two to three times more likely to suffer from depression.
Depression is pervasive and often triggered by social stressors. A troubled relationship, difficulty in the workplace, and financial problems can precipitate a depressive episode. Lacking the energy to even get out of bed, or the ability to focus on ordinary tasks, depression can leave one feeling they would be better off dead.
This year 25 million Americans will suffer at least one episode of depression, but only half will receive treatment. The consequence of this sad truth is that 15 percent of those will eventually take their own life.
The gap between suffering and treatment persists for several reasons. On the one hand, patients with depression see their symptoms as a weakness, leading to embarrassment due to cultural beliefs and fear of being stigmatized. On the other hand, doctors may not identify depression when the patient has another physical illness. Reports of vague aches and pains mask the emotional suffering. And even when the diagnosis is correct, studies have shown that treatment is often short-term and inadequate.
So how can the health care system improve the recognition and treatment of depression? Put more bluntly, how do we prevent suicides? There is certainly no lack of opportunity. Across all ages, nearly half of all suicide victims had contact with a primary care provider during the prior month, and 75 percent had contact in the previous year.
Organized interventions, including consistent depression screening strategies in the primary care setting, can help identify those suffering from depression. Once recognized, multi-disciplinary health care teams working collaboratively can assure accurate diagnosis, effective treatment and careful follow-up.
Ultimately, a trusting relationship between doctors and patients is a two-way street. In order for patients to feel secure enough to share their innermost feelings and fears, doctors and nurses need to open the conversation, provide a safe and caring ear and non-judgmentally ask about emotions and suicide. Patients need to be educated about their disease and encouraged to be their own advocate, and doctors need to empower their patients to take control of their health and well-being. After all, the patient is the most important person on their healthcare team.
Effective screening tools can be easily administered, even in the busiest practices. The Patient Health Questionaire-9 is a simple nine-item screener that can help identify those who should be evaluated further for depression. Straightforward screeners (P4 Screener and the Columbia Suicide Severity Rating Scale) can also be used to identify patients at high risk for suicide so that lifesaving interventions can be made before it is too late. At Bellevue Hospital's Ambulatory Care Center where I work, every patient receiving primary care is systematically screened, improving depression recognition and treatment for thousands of NYC patients.
It was Mrs. Moore's second visit to Bellevue's walk-in clinic this month. A 38-year-old mother of three with poorly-controlled diabetes, Mrs. Moore today complained of headache. The nurse had asked her to complete a routine depression screener. As she answered the questions she stared at the floor. "It's just so hard," she said, "My husband lost his job and we are struggling to make ends meet."
"Have you had thoughts of suicide?" The nurse asked.
Mrs. Moore looked up with tears in her eyes... "Yes" she answered.
Mrs. Moore's suicidal thoughts could have easily been missed, but thanks to a simple screen her depression was recognized and treated. She gained control of her diabetes and her headaches improved. Instead of her life ending prematurely, she realized it was worth living. No one was left wondering what they could have done, or what clues they missed. Three adoring children still have their mother, and a husband his wife.
Depression is a disease, not a weakness, and suicide is its tragic consequence. By taking a few simple steps, primary care providers can better identify depression and ensure that patients receive needed treatment. If you are feeling depressed, know that someone is there to help.
Have a story about depression that you'd like to share? Email firstname.lastname@example.org, or give us a call at (860) 348-3376, and you can record your story in your own words. Please be sure to include your name and phone number.
Need help? In the U.S., call 1-800-273-8255 for the National Suicide Prevention Lifeline.