Suicide and depression

With the recent suicide by Robin Williams there has been a lot stated in the press about depression and suicide. Many have concluded that he was depressed when he suicided and this was one of the main causes. It is understandable why people do this. Upon hearing of his death by suicide people get upset and perhaps even feel some confusion. Many will then ask the question – why?

The answer of depression gives them some solace in this way. It is convenient, simple and satisfies the need to have an ‘answer’. However it also propagates mis-information that is not helpful in the long run. The relationship between suicide and depression is a complex one. The following two quotes come from my book:

“7. Depression as an indicator of suicidal thoughts and actions. A great deal has been written about suicide and depression and one sees all sorts of statistics quoted. For instance George (2008) states, “A retrospective study of 132 young people who completed suicide in Western Australia found that nearly three quarters had shown definite signs of depression in the weeks prior to their death”(p.25) Or, “Depression increases the risk of suicide by 15 to 20 times, and about 4% of people with depression die by suicide.”(p1373), Hawton, and van Heeringen, (2009). Based on this research this means that ninety six percent of people with depression do not die by suicide. On this point the research presents varying figures. Clark and Fawcett (1992) estimate that fifteen percent of those with a diagnosis of major depression will complete a suicide. The statistics tend to waver around the ten percent mark meaning the vast majority of those with depression will not complete a suicide attempt. There are many depressed people who are not suicidal at all. Of course this does not mean that one forgets about making an assessment of suicide risk with the person reporting depression but one needs to be realistic about its occurrence which is not often stated in the literature.”

“More contemporary research by Akechi, Okamura, Kugaya, Nakano, et al (2000) reports that in patients with major depression fifty three percent had suicidal ideation. Wada, Murao, Hikasa, Ota, et al. (1998) also report a similar finding of around fifty percent of those with major depression having suicidal urges as well. This allows the conclusion that about fifty percent of those with some form of depression do not report any recurrent suicidal thoughts. Thus it seems safe to say that fifty percent of depressed people are not at risk of suicide as they are not even thinking about suicide let alone planning anything.”

Of note in these quotes we find that those people who are severely depressed (major depression) 50% are at no risk of suicide as they are not even thinking about it. If depression causes suicide how can this be, when the most severely depressed in our community, half of them don’t even think about it. If depression causes suicide how can it be that only 10% will eventually die by suicide. That means that 90% of the depressed wont die by suicide. One can hardly conclude that suicide causes depression.

One is also left with the eternal problem of prediction. You can have two depressed people standing side by side and one is quite suicidal and one is not suicidal at all and never will be. How do those who propose depression causes suicide, explain that.

Similar is the sociological explanation of the cause of suicide. These people say that suicide is a result of poverty, unemployment and homelessness. Again you can have two people standing side by side who have very poor socio economic conditions. One is suicidal and one is not. How can that be if these things cause suicide?

The problem with the media coverage of depression and suicide with Robin Williams is it will create unnecessary concern for many. If one has a brother, wife or friend with depression this could lead one to worry about their possible suicide when 50% of suicidal people never even think of taking that solution to their difficulties. It is simply mis-information on an important public health issue.

However there is actually a clear answer and that is the Don’t exist injunction. This explains why some depressed people are suicidal and others are not. If one has a such an injunction we know this person has decided that suicide is a possible solution to their problems later in life. If they become depressed or if they become homeless they can use suicide as a solution. Whilst there are other reasons for suicide it is quite possible that Robin Williams did have a Don’t exist injunction sitting in his psyche until the right environment conditions arose such that he acted on that injunction.

This is what we need to be screening for and indeed this is what I did when I worked in prison identifying suicidal and self harming inmates. If one identifies people with this injunction, as I did with many in the prison system, one knows this person is quite capable of suicide at a later time. When the conditions are met such as an episode of depression of chronic unemployment the person can then act on that injunction. If identified, one is then in a much better position to avoid the potential suicide attempt.

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