Sometimes, Depression Is A Terminal Illness

Despite being chronically depressed for most of her life, Phoebe didn't seek help until a particularly scary episode hit when she was 39. Nearly two decades later, Phoebe* had another severe, acute case, this time accompanied by suicidal thoughts. One day, on her commute to her administrative job in New York City, she saw a sign on the subway that asked, simply: "Are you feeling depressed?" She realized she needed help again. Phoebe sought out the advertised Columbia University study and was able to find a combination of therapy and medication that worked for her. In Phoebe's case — as in many people's — depression is a long-term illness.

But, today, on World Mental Health Day, Phoebe is definitely not alone. According to the Centers for Disease Control and Prevention, 1 in 10 adults in the U.S. experience depression, and women are about twice as likely to develop depression as men. Additionally, about 350 million people are dealing with depression around the world, according to the World Health Organization. Although its manifestation varies by individual, there are symptoms that many sufferers share, including persistent feelings of sadness, worthlessness, or hopelessness. These can often occur after a triggering event or life change of some sort, but they don't have to — depression can hit without warning or cause.

It's impossible to ignore the link between depression and suicide. Depression is the most common illness in those who commit suicide, and suicide is the 10th leading cause of death in the U.S., with an average of 105 suicides per day. For those between the ages of 10 and 24, suicide is the third leading cause of death.

These stats, in addition to front-page reminders like Robin Williams's recent suicide, have led some to rethink our concept of depression, labeling it a "terminal illness." While this isn't the case for everyone suffering from depression (current treatments work well in many cases, and not everyone who is depressed commits or considers suicide), it does ring unfortunately true for too many. With every depression-related suicide, celebrity or otherwise, we are forced to recognize that there are some people who — due to social isolation, stigma, substance abuse, or other factors — are beyond our current medical reach.

Thinking about chronic depression in this way — as a long-term disease with a potentially fatal outcome — means we need to also rethink our first-line treatments. The possibility of having to try more than one antidepressant medication (which may or may not work, can take between two and six weeks to take effect, and which comes with a long list of side effects), may be a process that's too long and involved for a severely depressed patient to endure. Instead, our focus for these patients is beginning to shift toward fast- and long-acting treatments that can be administered easily in a crisis situation. Research in this area has recently centered on drugs like ketamine, MDMA, and even Botox to facilitate this process. Other researchers are exploring options like transcranial magnetic stimulation or deep brain stimulation, which may prove useful, especially for patients who don't respond to medication. But, these are still at an experimental level, and finding the right combination of exercise, mindfulness training, and other lifestyle changes can be lifelong quest.

Those who suffer from chronic major depression (or dysthymia, its less-severe version) are at an even greater risk for committing suicide. With chronic depression, says David Hellerstein, MD, patients have been depressed for at least two years. But, in his studies at Columbia University (including the one that Phoebe participated in), Dr. Hellerstein says patients are more likely to have gone much longer — 10 to 20 years — without really understanding their condition.

When the symptoms of depression — including suicidal ideation — are a part of a person's regular, day-to-day life, it can be difficult for them to recognize their feelings as abnormal. "It's like a stomachache for someone suffering from chronic indigestion," says Alexander Neumeister, MD, whose research at NYU focuses on the biological basis of mood disorders. And, he adds, most people experiencing these symptoms aren't going to talk openly about them due to the stigma associated with mental illness and suicidal thoughts.

Depression does often co-occur with other serious issues that are, on their own, risk factors for suicide. For instance, Dr. Hellerstein says those with chronic depression are more likely to self-medicate through misusing prescription medications or other forms of substance abuse. Depression is also common in those suffering from other chronic or terminal illnesses, such as cancer, AIDS, or other advanced diseases.

"The biggest difficulty is often getting the person to realize they even have a condition if that's their baseline," says Dr. Hellerstein. But, even after it's been diagnosed, chronic depression is, by definition, difficult to treat. Often, he says, patients will need to try different combinations of medication, therapy, and other lifestyle changes before finding a method that's effective. And, if a depressive state is the patient's baseline, getting through an acute episode of severe depression will not cure them — it will likely just bring them back to their baseline. Dr. Neumeister says that talking about suicidal thoughts or making a pact with a therapist — such as a promise to attend next week's session — can dramatically reduce the likelihood that a patient will go through with a suicide attempt. But, even then, that person has to get to the point of going to therapy and being comfortable enough to really open up and discuss their issues and feelings.

As difficult as it can be for patients to confess their suicidal thoughts, Dr. Neumeister says it can be just as difficult for doctors to ask about them. "Physicians in general have no problems asking depressed patients if they can sleep," he says, "but when it comes to talking about suicide, there’s suddenly a huge barrier, as if you’ve asked an embarrassing question." He stresses that suicidal ideation needs to be treated like any other symptom of any other disease — and like any other symptom of depression. Meaning, both doctor and patient need to be able to have those difficult conversations.

This is especially necessary when there are still those who won't acknowledge that depression is an illness, much less one that can lead to death. "It's not a character flaw," Dr. Neumeister reminds us. "We can tell you it's real." And, it's only when we break down that stigma that we can begin to truly help those who need it the most.