BALTIMORE — 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.
Continue reading the main story Write A Comment 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.
This article first appeared on The New York Times on 15 August 2014.