I was reading about a suicide of a college student recently and when I read his friends description of his behavior it was clear that he had a major depression. I wondered if his friends did not recognize his depression or simply did not know what to do.

Some of the advice for helping a depressed friend goes something like:

• Listen
• Suggest professional help, facilitate an appointment and offer to go with the person.
• Have the person call a suicide hotline  or helpline

Although this is good advice, often with severely depressed persons these interventions are not enough.

If you believe someone is severely depressed what to do and they do not respond to the above ideas what do you do?

1. I suggest calling the police who will make a mental health arrest (if they feel it is warrented) and take the person for psychiatic evaluation. (although this may seem drastic and your friend may be initially be angry with you, this may save his life)
2. Consider an “intevention” using the model of AA. That is when  important people in the person’s life go together to see the friend and clearly and firmly express  their worries about the person who is depressed.  It is  critical to offer hope by clearly stating depression gets better with treatment (this is true) and sharing personal experiences and recovery if you are able. The person usually has a hard time believing depression will ever go away so it is critical to let them know otherwise. Have a plan (referral, visit to Emergency room) ready.

What is Depression?

People use the word depression loosely to mean a number of different moods. We use it when we are down about something going on in our lives, when we are grieving or just sad. I prefer to use the term “clinical depression” to distinguish these moods from the more serious type of depression that may need medication to relieve. Clinical depression is more than the “blues” or sadness. It is not something a person can “just get over” or talk themselves out of. Clinical depression is at least partially based on brain biochemical imbalance (we are still in early stages of understanding this) and often runs in families. Stress and psychological factors also play an important role, although we do not fully understand the causes and factors that result in clinical depression

Common symptoms of depression include:

• Sad or irritable mood
• Loss of interest / energy
• Poor or excessive sleep and appetite
• Difficulty with concentration and memory
• Physical complaints

Medication is often necessary in serious depression and MAY be helpful with less severe types.

Helping a loved one who is depressed can be very difficult. Sometimes caregivers feel helpless and unsure of what to say or do. Fear can cause helpers to be overbearing, hovering and treat the depressed person like a child. This is not particularly helpful for either the depressed person or the helper.

Here are some principles to keep in mind when someone you love is depressed.

1.  Listen, listen, and listen.
2.  Be non-judgmental but give honest responses
3.  Avoid platitudes or cliches.
4.  Do not treat the person as an invalid.
5.  Try to be yourself. This is very important, as persons who are depressed can be very sensitive to changes.
6.  If you can’t be yourself because you are worried tell them so. Ask questions as needed.
7.  Do not be afraid to bring up feelings, events or questions about suicide if this is a concern.
8.  Engage in physical activities with the person, even simple walks can be very helpful. Be outside as much as possible.
9. Call the person at different times of the day.
10.  Find out what the worst time for the person is and try to be available then.
11.  Talk about other things beside feelings.
12.  Keep conversations & activities short if the person appears tired.
13.  Ask about feelings.
14.  Do not be a martyr, take care of yourself.
15.  Talk about your own feelings with honesty but do not say things like “I know how you feel, I went through the same thing.”
16.  Statements of suicide intent should be taken seriously. Encourage the person to call a suicide hot line or their therapist. Ask them what their therapist suggested they do if these thoughts come up. If unsure of what to do, do not hesitate to call the police to have the person taken to an emergency room for suicide assessment.
17.  If suicide threats are a common occurrence, talk to the person’s therapist (with permission) about how to deal with this situation.
18.  Encourage treatment. Offer transportation and company to appointments; combine with a social event such as a movie or lunch.

Take a look at my book “Behavioral First Aid:Managing Emotions During Emergencies”
It is a practical crisis intervention Guide: Learn to calm emotions, prevent violence, and reduce panic in an emergency. Written for those who work with people in distress: EMS, Counselors, Customer service personnel, Nurses, Social Workers, Teachers, and more. Clear practical examples and advice, no psychobabble!

Sunshine

I have been hearing alot about vitamin D lately.

 My doctor said I should have a blood test for Vit D levels to make sure I am not deficient.  Later that same week a physician friend of mine said her doctor put her on Vit D after a blood test showed a deficiency.   She told me she had multiple joint and muscle pains that went away with addition of the supplement.

Although currently there is a lot of hype and misinformation about Vit D we are still learning about how it effects the body, how to get it,  and if supplements work.

All the worry about skin cancer and avoidance of the sun may have put us at risk for ViT D deficiency thought diseases. 

Low levels of Vit D have been linked to the following (and more) diseases.

• depression
• muscle and joint pain
• osteoporosis
•  prostate cancer
•  breast cancer
• diabetes
•   obesity

The amount of sun exposure needed to get the proper dose of vitamin D depends on a person’s skin type, where they live, and time of year, and time of day the exposure occurs.  It appears that if you live north of Atlanta in USA it is impossible to get enough Vit D from the sun in the winter. However, in the summer a light-skinned person at the beach should be able to get all the vitamin D they need in about five minutes.

Although it is possible to get vitamin D through foods or supplements it is not easy. The daily dose according to FDA the recommended daily allowance is  about  4-600 international units (iu) a day. Some experts however believe that 1000 IU is more like it.

Here are the amounts of Vit D found in food.

8 oz fortified milk or fortified orange juice = 100 international units (IU) 

Salmon. 3 ounces=425 IU of vitamin D

Herring. 3 ounces=765 IU of vitamin D

Sardines  Canned, 3 ounces=255 IU of vitamin D

(your grandmother was right about fish oil!!)

Multivitamin supplements commonly provide 200-400 IU of vitamin D daily.

Cod Liver Oil is the best ! 1 tablespoon=1360 IU of vitamin D 

My suggestion is keep up with the new information and ask your doctor about getting tested.

 I was thinking about this and wondering why this was so much worse then in the past. What I thought might be a contributing factor is the new military policy of extending duty time at will. This is very hard on soldiers or anyone for that matter. As we all know, you can live through almost anything when there is an end in site. However, when the end time is unsure, or can get extended or put off at any time for unknown reasons, those affected feel out of control, helpless and hopeless.

 Helplessness, hopelessness (having no belief that things will get better) are major factors in depression and potential suicide. Hope for the future and change for the better is what keeps us holding on through bad times! I believe these factors may also influence suicide bombers who have no expectation for anything better on this earth, thus make their decision to die in hopes of something better on the other side.  

 So the question becomes, how do we keep up hope in a world that makes this difficult?

 Here are some of my ideas about activities and thoughts that may help ward off hopelessness. Please send your ideas to help expand the list.

•  Avoid hopeless situations, books, movies, people etc.
•  Try to surround yourself with upbeat (but realistic) hopeful people and thing.
• Expose yourself to positive TV shows, movies etc. Go see a good comedy or read a hopeful book.
• Avoid newspapers and news for a while. It’s ok not to watch the news daily.
• Stop thinking so much! We tend to try to solve problems in our heads even those with no solutions.
  Rumination is the experience of going over and over situations or thought in our head. This is a useless exercise and does not help anything. Try some meditation or other thought stopping techniques. 
• Eat some comfort foods, putter in the kitchen make a healthy heartwarming soup.
• Spend time with friends who are uplifting, don’t spend a lot of money arrange a weekly potluck, card or game night.
•  Avoid people who are depressing or negative, some people seem to make themselves feel better by bring others down.
•  Do not allow yourself to constantly talk of hopeless things.
•  Expose yourself to the sun, or sunlamps if necessary.
•  Take 3000 mg of fish oil a day.
• Work on some small, sure to be successful, fun projects to donate or give away.
• Sit by a fire.
• Visit a museum.
• Spend time with children, if you don’t have any offer free babysitting to someone who needs it. 
• Help someone else. 
• Do volunteer work. 
• Do not do, read or watch scary things. 
• Take short walks often. 
• Avoid TV 
• Read a fabulous (not deep or sad) book.
•  Read magazines or short stories. 
• Visit a church.
• Go to library.
• Shop at a thrift store.
•  Experience nature. 
• Listen to calm uplifting music; try some relaxation tapes. (Check out my site for a sampler of relaxation techniques) 
• Work with an eye on what needs to be done today, let the future take care of itself. 
• Keep goals short term. 
• Keep self-expectations reasonable.
•  Keep expectations of others reasonable. 
• Sing, hum, dance, skip, ride a bike (do exercise that does not feel like exercise). 
• Get a Massage, if you can afford it trade back rubs with a friend (not at the same time). 
• Stop thinking so much. 
• Do not start new intimate relationships at this time. 
• Cultivate old faithful friends.
• Avoid overly sweet, silly, Pollyanna-ish, insincere people, places and things. 
• Its ok to be avoidant sometimes. 
• Take care of pennies dollars will take care of themselves.
• Remember constant worry does not help and makes you feel worse. 
• Put up pictures of nature, loved ones animals.
• Be social but cultivate solitude also.
• Place some upbeat sayings and posters where you can easily see them. 

Send me your upbeat sayings and I will post mine later.

Anne Writes

I am worried about my brother, he is depressed and refuses to consider going for counseling or medical care.  What Can I do to help him?

Answer from Dr. Duffy:

It is very difficult to help someone who refuses help. First I suggest you encourage him to tell you what his objections are to getting help. Perhaps talking to you will help him clarify and overcome his fears or objections. If you have not already done so you may wish to give him information on depression as a real medical illness, not a weakness of character.  The Mayo Clinic website is a reliable, good source of such information. Perhaps it would be better to encourage a friend of his to discuss the situation with your brother and tell him what he is seeing. Often family members are not the best ones to convince another member.

If he still refuses or won’t talk about it, I suggest trying a little guilt. For instance, the effect of his depression on those he loves who love him. If he won’t get help for his own sake perhaps he would do it for those he loves.

If he still refusing dispite your efforts you need to set limits. This means not always  being available to help him or to listen to him.  Sometimes a type of tough love is called for in situations like this. You need to take care of yourself, and let him know that although you love him, this is what you must do for your own sake.

If you think he is suicidal you may need to call the police to have him forced to have a psychiatric evaluation. I know this will be difficult to do and he may be angry. However this may save his life.

My last suggestion is to give him information on fish oil. Some studies show this to be just as effective in treating depression as antidepressants. Many people are less resistant to taking  3-4000 mg of fish oil a day

 Dear Dr Duffy,

Where do I begin? First, a little background: I am a 23 year-old female. I have been married for 4 years to a man that is 20 years older than I. We have had two children age 3 and a newborn. We plan to have more children. They are a wonderful family.

For several years I have felt frustrated and disappointed with life, although I realize that I am extremely fortunate and very blessed. There is an emptiness inside that seems to echo louder with time and yet I cannot put a finger on what is eating away at me.

 Earlier attempts at communicating with my husband regarding these issues have left me feeling weak, unimportant and angry. He doesn’t seem to hear me in anything that I say, so anymore I don’t say anything other than superficial conversing. While I am constantly surrounded by my immediate family I feel extremely alone.

 I have never been a morning person, however, I sleep in as long as my children will allow me and I dread the new day for the tireless effort that will be required. I love the evenings because the day is finally over and sleep offers one slight reprieve of the emptiness. Even simple tasks seem dreadfully difficult.

 I work at home but I avoid my duties and responsibilities as long as possible. The house is often in disarray and I can’t get my work done. It seems that most things that I start I cannot finish.

 One of the only things that gets me through the day is the thought of alcohol at the end of the day, after the boys are in bed. I can easily drink 20-30 ounces of wine in an evening and be able to function quite well.

My biggest regret is that I am breastfeeding, and while I try to time things in the evening so that he doesn’t nurse until the early morning hours, occasionally he wakes up before then and needs to feed. Each morning I resolve to stop drinking but the strong desire to slip into oblivion at the end of the day is too much to resist, and so the cycle continues.

 I used to create fantasy stories that I would live out in detail in order to escape the reality of this life. In a way I used it to cope with reality, and have always enjoyed the stories. However, since I have married and have children I have little to no time to engage in my fantasy worlds.

 When I do things I enjoy my husband gets angry because I am neglecting my other duties and shoots down the small enjoyment I had, so I am back to simply mulling through life and feeling miserable.

 I don’t feel that I can trust my husband with my inner feelings. I feel myself withdrawing from him. I avoid physical intimacy and have a strong desire (sometimes an uncontrollable urge) to pull back from his advances. Why do I avoid him; what is wrong with me?

•  How can I engage in life with joy and enthusiasm?
•  How can I rekindle my relationship with my husband?
•  How can I stop drinking and find something else to take its place?

 I do not want to live like this… and I pray that the Lord will help me through. If you have any suggestions, I would be very grateful.

 -Alone and desperate

Answer From Dr. Duffy 

Dear Alone,

 There are a number of things about your letter that I would like to respond to.

 First I believe you may be depressed. This could be postpartum depression or may have been present before as some of your comments suggest. Here are some things you said that make me concerned about depression.

• “Emptiness inside”
• “I used to create fantasy stories that I would live out in detail in order to escape the reality of this life”
• “The house is often in disarray and I can’t get my work done.”
• “It seems that most things that I start I cannot finish”
• “…sleep in as long as my children will allow me”
• “I dread the new day for the tireless effort that will be required”
• “I love the evenings because the day is finally over and sleep offers one slight reprieve of the emptiness.”
• “Even simple tasks seem dreadfully difficult.”

 Of course I cannot make this diagnosis over the internet, I encourage you to be evaluated by a mental health professional. You may need an antidepressant but it will not help much if you continue with the alcohol.

  Second: Your relationship with your husband. Although you start off saying what a wonderful family you have, you quickly talk about how unsatisfying your marriage is. It is certainly not the situation where you should have more children.

 My suggestion is that you tell your husband that you are very unhappy and the situation must be taken seriously or it most likely will get worse. Be honest about your feelings and worries. Couple therapy may be necessary. If he refuses to go you need to find a professional to talk to for yourself. This will help you to figure out what to do next and help you to answer your final questions.

 Third: Your alcohol intake. It sounds like you have a serious problem because you cannot stop despite multiple attempts and worries about breastfeeding. Many experts feel 2 drinks will not hurt the infant but anything over that may. (you are way over this limit!)

 The other issue is alcohol makes depression worse!  It is hard to know what comes first the alcohol or the depression. My suggestion would be to get some help to stop drinking first. This can be done through many programs and AA. You must do this and it sounds as if you cannot do it alone.

 Please get some help, for your own sake and for the sake of your children, and your marriage. I am truly concerned about you, and send you my best.

 Recently a teenage boy who jumped out of a dorm window while drunk left a local college campus and community deeply shaken. He will probably be paralyzed for the rest of his life.  After hearing about this I read a distressing study about teenage self-destructive behavior. The Child and Adolescent Self harm Study From Europe (Brunel University September 4, 2008) reveals more disturbing data about teenagers and cutting.

1.    One out of four cases is not reported and 25% had not told anyone else. How many do we not know about?

2.    Alcohol is a factor in one out of five cases, drugs in one out of eight cases.

3.    Six in ten self-harmers talk of suicide.

4.    Thoughts of self-harm are said to occur in 6 out of every 10 teenage girls and 1 in 10 boys.

5.    59% of these teenagers said they wanted to die.

How To Help

 Recognize those at risk

1.    Those with family history of suicide or self injury or risky behaviors

2.    Those who have been sexually, physically or emotionally abused.

3.   Those who are self critical, with low self esteem, depression anxiety, substance abuse problems and  eating disorders.

 4.    Teenagers who are impulsive with few problem-solving skills are at higher risk.  

 Prevention Involves Teachers, Families, Friends And Other Social Supports

1.  Teach coping skills in school and at home
2.  Encourage healthy social networks.
3.  Educate teenagers and adults about the problem.
4.  Promote programs to help teenagers develop healthy friendships and decrease secrecy.
5. Do not expect more from teenagers then they can do. Remember they are not always sufficiently mature enough to make high level decisions that require recognition of long term consequences.

 References:

Mayo Clinic Website: Self-injury

 Science Daily: September 7, 2008

Did you know that nearly 5,000 teenagers commit suicide each year and that suicide is the third leading cause of death among those aged 15-24 ?

There has been a number of teenagers suicides in the news lately that have been connected to bullying. Many of use are worried and frustrated about the rising problems in schools with bullying and teasing. The connection between bullying and teen depression and  suicide is becoming clearer.  It has been shown that teen suicide is often related to depression that can be worsened by rejection,  isolation,  being bullied, and not fitting in. 

I found what I think is a great video about a program to reduce bullying, teasing and foster acceptance in schools. It is a program worth looking at if your childs school is not addressing this issue in a serious ongoing, manner.  

Take a look!

Of course we can’t expect the schools to do it all. Here are some things that parents can do.

• Keep your children out of your marriage problems.  Certainly you need to talk to your teenager about what is going on because they are well aware of it already. Sometimes their imagination is worse then the reality so be honest with them .  Do not subject them to your fights and arguments or ask them to take sides. Try to remember that no matter how angry you are at your spouse, you both want whats best for your children.
• Acceptance of your teenager (not necessarily his/her behavior) is critical. Yes I love you and always will BUT I do not love that behavior and won’t allow it.
• Reassure him/ her that you love him no matter what.  Remind him that no matter how bad things seem you want to help and problems can be solved.
•  Listen to what they say, you don’t have to agree just acknowledge you heard and try to explain (briefly) why you disagree. No long debates.
• Even if you say it a hundred times, it helps to say ” I love you and will not let you do anything I believe will end up hurting you.”
• Ask him/ her to talk about her feelings. Listen carefully. Model this by talking about your own feelings ( I am frightened for you when I see you doing risky things)  (see my blog on listening)
• Do not make light of  problems ( relationships, thinking no one likes them etc.)  Avoid terms like “puppy love”, break up of relationships can be Very traumatic for kids and often is a precipitant to suicide.
• Do not give glib answers or get angry.
• If you are worried about your child, don’t be afraid to say the word “suicide.” Using the word will not “give him/her ideas” but will provide relief by saying its ok to talk about this.
  
• Remove guns from your home.
• Seek professional help. Finding a good therapist is difficult. Ask around, school counselors may be a good source of referrals but usually can not handle this problem on their own.
• Get help yourself to deal with this. Do not be ashamed of this problem, it is not uncommon enough.

There is a long complicated article in the NY Times today about suicide and impulsivity that is worth a read (if you can manage it.)

“Suicide autopsy” studies can give us lots of information, but no one really knows what goes through the head of a person just before he or she dies from suicide, it may be regret as suggested by one person interviewed by the author.

There are a few comments I would like to make about the article and suicide in general that are based on my own years of experience, and thoughts. If you can’t get through the article hopefully they will still make some sense to you.

In terms of the debate about impulsivity vs planned suicide; I believe that there is always an impulsive piece of suicide. People may have a long complicated plan in their head “just in case”, but it takes a trigger to finally push them over the edge. I wonder if sometimes this can be just the opportunity as well as it be the “last straw” type event. It is not an either/or choice.

One study indicated that victims of what look like highly impulsive methods of suicide (bridge, gun) often “display few of the classic warning signs associated with suicidal behavior” ” …jumpers have a lower history of prior suicide attempts, diagnosed mental illness…” It seems to me that these persons may have not been treated or recognized as being depressed which may put them at high risk.

Also the person who is most determined to kill them self may be less likely to let others know, due to not wanting intervention. Use of an almost guaranteed to succeed method, does not seem to me to be a sure sign of impulsivity.  Some people have been planning for a while and have chosen the method they believe least likely to fail, thus the use of a gun or a bridge.

I will never forget a man I saw years ago, who had given away all his possessions. He denied suicide, did not look in the least depressed, and had no psychiatric history. I would never have thought him to be suicidal.  If it hadn’t been for a family member who was very worried about his “generosity” with lack of explanation and forced an evaluation, I have no doubt this man would have killed himself. (He later admitted his intention).

Suicide is another one of those things we will never have all the answers for. There are many different motives and types of suicide: some with depression, some with psychotic thinking where voices are telling them to kill themselves, some with existential pain, some with physical pain, some with end of life issues. Some are carefully planned while others are impulsive. It is my belief that most have components of both.

Are we trying to categorize and understand something that may not fit into a neat clean framework? Our frantic efforts to figure things out are often attempts to control something we fear.

We certainly can help to prevent suicide, and we should keep learning, but we also need to acknowledge that there are some things we may never understand completely, and may never be able to control. Life and death are not so neatly black and white.

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