From Our 2014 Archives
When Depression Becomes Deadly
By Kathleen Doheny
Reviewed by Arefa Cassoobhoy, MD, MPH
Aug. 12, 2014 -- The apparent suicide of Oscar-winning actor and comedian Robin Williams on Monday rocked the entertainment world.
Williams' publicist said in a statement he'd been "battling severe depression," according to media reports.
Millions of U.S. adults struggle with depression. Often, medication and psychotherapy help their moods and outlook.
For some, though, hopelessness reigns, even with treatment. About 39,000 suicides happen each year in America, many driven by depression, anxiety, or psychosis.
What makes depression deadly for some? And are there concrete warning signs to help loved ones intervene?
WebMD asked two psychiatrists to weigh in. Neither doctor was involved in Williams' treatment.
For some, depression is a lifelong struggle. What makes depression so widespread and hard to treat?
"It is a lifetime issue for some, and we don't know why," says Lon Schneider, MD. He's a professor of psychiatry, neurology, and gerontology at the Keck School of Medicine of the University of Southern California. "The phrase 'battling depression' is quite true."
The disease is complicated, he says, and it can take many forms and courses. Someone with chronic depression, for example, "is in a major to minor depressed state most of the time," he says. Someone who has "recurrent episodes" might recover from a bout of depression, be in a relatively stable mood, then get depressed again. Many people have recurrent depression, he says.
"Depression is a very difficult illness to treat because it has genetic underpinnings with environmental stressors," says Scott Krakower, DO. He's the assistant unit chief of psychiatry at The Zucker Hillside Hospital North Shore-LIJ Medical Group. "The genetics are not entirely understood."
Those with fame, power and success aren't immune. "You could be having a really great life, a successful life, and be really depressed," Krakower says.
What other things might affect depression?
"Physical illness, especially chronic [long-term] illness, can worsen depression," Schneider says. In 2009, Robin Williams got heart surgery, although it's not known whether this affected his struggles with depression.
Alcohol or other drugs can also affect depression, Schneider says. But, he adds, "I think one has to be fairly careful about a person who has alcohol or drug dependence in the past, and then [saying], 'Oh, that must have been it, alcohol must have contributed, cocaine must have contributed.'"
Williams had been open about his rehab efforts to combat alcohol and drug use. He reportedly made at least two trips to rehab centers, most recently earlier this summer.
"Much depression is part of bipolar illness," Schneider says. Bipolar disorder is marked by wide shifts in mood, energy, and activity levels. People diagnosed with it tend to have many more depressive episodes than manic ones, Schneider says. It wasn't known if Williams had bipolar disorder.
People often don't take medicine correctly, Krakower says. His patients tell him they don't want the side effects of the medication. "People don't want to be labeled as being mentally ill," he says. When they take the medication, some feel that way, he says.
Even if they take the medication, once they start feeling better, he says, "they think they don't need their medicines." So, they stop taking them, and are worse off when depression hits again, he says.
The risk of suicide may rise when people first start antidepressant medications, according to the FDA. Some patients who stop taking their antidepressants may have suicidal thoughts, even when weaned off, Schneider says.
Why does depression turn deadly for some?
The pain of mental illness, often not understood by those not affected, can be unbearable, Schneider says. Those affected can have feelings of hopelessness and emptiness that many others can't empathize with, he says.
"Severe major depression can be just profound," he says. Some commit suicide not so much to end their lives as to get rid of the pain. Even with treatment, the feelings can persist, doctors know. ''Some people develop depression that is treatment-resistant," Krakower says.
For those whose depression is part of bipolar disorder, what may make them so prone to suicide attempts is the ''rapid switch from being happy to really, really sad," Krakower says.
Is there any way for loved ones to spot depression about to turn deadly?
Even for doctors, ''it's hard to predict who is going to make a suicide attempt," Schneider says. But there are sometimes warning signs and behaviors that may point to a potential suicide attempt.
One of the most urgent signs, which calls for immediate action, is talking about death or suicide.
Other warning signs, according to Schneider, Krakower, and the American Foundation for Suicide Prevention, may include:
Identifying someone at risk of a suicide attempt is only half the battle, Schneider says. "It's hard to say exactly when they would make an attempt."
Not all suicide attempts are thought out or planned, Krakower says. "Suicide attempts can happen out of impulse," he says. "Something goes wrong and people just hurt themselves."
What's the best advice for family and friends if a loved one is depressed and seems in danger of a suicide attempt?
Insist the person get mental health help, Krakower says. "I think a lot of times when people make these statements [about suicide], people don't know what to take at face value. They become numb. They don't know what to do for them."
Steps to take may include:
Schneider reports consulting work with pharmaceutical companies that manufacture antidepressant and antipsychotic medications.
SOURCES: Scott Krakower, DO, assistant unit chief, psychiatry, Zucker Hillside Hospital, North Shore-LIJ Medical Group; assistant professor, psychiatry, Hofstra North shore-LIJ School of Medicine, Glen Oaks, N.Y. Lon S. Schneider, MD, professor, psychiatry, neurology, and gerontology, Keck School of Medicine of USC, Los Angeles. National Institute of Mental Health: "Major Depression Among Adults," "Bipolar Disorder." CDC: "Suicide and Self-Inflicted Injury."