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Depression Can Be Treated, but It Takes Competence

Posted by Administrator on Dec 12 2014
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THE OPINION PAGES NYT
To Know Suicide - By KAY REDFIELD JAMISON AUG. 15, 2014

When the American artist Ralph Barton killed himself in 1931
he left behind a suicide note explaining why, in the midst of a seemingly good
and full life, he had chosen to die.

“Everyone who has known me and who hears of this,” he wrote, “will have a
different hypothesis to offer to explain why I did it.”

Most of the explanations, about problems in his life, would be completely
wrong, he predicted. “I have had few real difficulties,” he said, and “more than
my share of affection and appreciation.” Yet his work had become torture, and he
had become, he felt, a cause of unhappiness to others. “I have run from wife to
wife, from house to house, and from country to country, in a ridiculous effort to
escape from myself,” he wrote. The reason he gave for his suicide was a lifelong
“melancholia” worsening into “definite symptoms of manic-depressive insanity.”

Barton was correct about the reactions of others. It is often easier to account
for a suicide by external causes like marital or work problems, physical illness,
financial stress or trouble with the law than it is to attribute it to mental illness.
Certainly, stress is important and often interacts dangerously with
depression. But the most important risk factor for suicide is mental illness,
especially depression or bipolar disorder (also known as manic-depressive
illness). When depression is accompanied by alcohol or drug abuse, which it
commonly is, the risk of suicide increases perilously.

Suicidal depression involves a kind of pain and hopelessness that is
impossible to describe — and I have tried. I teach in psychiatry and have written
about my bipolar illness, but words struggle to do justice to it. How can you say
what it feels like to go from being someone who loves life to wishing only to die?
Suicidal depression is a state of cold, agitated horror and relentless despair.
The things that you most love in life leach away. Everything is an effort, all day
and throughout the night. There is no hope, no point, no nothing.

The burden you know yourself to be to others is intolerable. So, too, is the
agitation from the mania that may simmer within a depression. There is no way
out and an endless road ahead. When someone is in this state, suicide can seem a
bad choice but the only one.

It has been a long time since I have known suicidal depression. I am one of
millions who have been treated for depression and gotten well; I was lucky
enough to have a psychiatrist well versed in using lithium and knowledgeable
about my illness, and who was also an excellent psychotherapist.

This is not, unfortunately, everyone’s experience. Many different
professionals treat depression, including family practitioners, internists and
gynecologists, as well as psychiatrists, psychologists, nurses and social workers.
This results in wildly different levels of competence. Many who treat depression
are not well trained in the distinction among types of depression. There is no
common standard for education about diagnosis.

Distinguishing between bipolar depression and major depressive disorder,
for example, can be difficult, and mistakes are common. Misdiagnosis can be
lethal. Medications that work well for some forms of depression induce agitation
in others. We expect well-informed treatment for cancer or heart disease; it
matters no less for depression.

We know, for instance, that lithium greatly decreases the risk of suicide in
patients with mood disorders like bipolar illness, yet it is too often a drug of last
resort. We know, too, that medication combined with psychotherapy is generally
more effective for moderate to severe depression than either treatment alone. Yet
many clinicians continue to pitch their tents exclusively in either the
psychopharmacology or the psychotherapy camp. And we know that many
people who have suicidal depression will respond well to electroconvulsive
therapy (ECT), yet prejudice against the treatment, rather than science, holds
sway in many hospitals and clinical practices.

Severely depressed patients, and their family members when possible,
should be involved in discussions about suicide. Depression usually dulls the
ability to think and remember, so patients should be given written information
about their illness and treatment, and about symptoms of particular concern for
suicide risk — like agitation, sleeplessness and impulsiveness. Once a suicidally
depressed patient has recovered, it is valuable for the doctor, patient and family
members to discuss what was helpful in the treatment and what should be done
if the person becomes suicidal again.

People who are depressed are not always easy to be with, or to communicate
with - depression, irritability and hopelessness can be contagious - so making
plans when a patient is well is best. An advance directive that specifies wishes for
future treatment and legal arrangements can be helpful. I have one, which
specifies, for instance, that I consent to ECT if my doctor and my husband, who
is also a physician, think that is the best course of treatment.

Because I teach and write about depression and bipolar illness, I am often
asked what is the most important factor in treating bipolar disorder. My answer
is competence. Empathy is important, but competence is essential.
I was fortunate that my psychiatrist had both. It was a long trip back to life
after nearly dying from a suicide attempt, but he was with me, indeed ahead of
me, every slow step of the way.

Kay Redfield Jamison, a professor of psychiatry at the Johns Hopkins School of Medicine,
is the author of “An Unquiet Mind: A Memoir of Moods and Madness” and
“Night Falls Fast: Understanding Suicide.” A version of this op-ed appears in print on
August 16, 2014, on page A19 of the New York edition with the headline:
To Know Suicide. © 2014 The New York Times Company 

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