1979

Let’s talk about suicide.

Depression can affect anyone. After musicians Chris Cornell and Chester Bennington died, I had their songs on constant repeat for days on end. I was born in 1979 and basically grew up with their music, along with that of the Smashing Pumpkins. As the Smashing Pumpkins is one of the few bands still alive and well, I’m celebrating with several references to their music in this post. Recently, chef Anthony Bourdain & designer Kate Spade killed themselves and my social media feed was filled with messages honoring their memories.

However, I also noticed many comments expressing confusion over why celebrities with everything end their lives. When a close friend of mine committed suicide almost ten years ago, the online criticism from strangers were merciless, condemning him for feeling sad enough to kill himself despite small children dying of cancer. I wonder if these trolls realise that people who commit suicide aren’t just having a bad day. They may not have a perspective that allows them to compare their apparent lives of abundance to sick kids’. Because they are themselves sick from an illness known as depression.

When is sadness actually depression?

Healthy people may experience transient sadness following loss or setbacks. When the sadness is prolonged, profound and pervasive, it may suggest a depressive disorder. Early symptoms of depressive disorder are low mood, loss of energy, poor sleep, poor appetite and loss of interest in activities. While people with mild depressive disorder can still continue vocational function, those with moderate to severe disorder cannot. They may have marked lethargy, poor concentration, inability to work and increased suicidal tendency.

In the Singapore National Mental Health Survey done 2 decades ago, the prevalence of depressive disorder in the adult population was estimated to be at 8%. Precipitating problems included family or relationship conflicts and work stress. Since early detection and treatment can lead to quick recovery and prevent suicidal behaviour, we must do better in detecting depression which can happen to anyone, including young people who seem to have it all. For elderly people, increasing frailty due to physical illnesses, loss of independent living and loneliness are risk factors. https://onlinelibrary.wiley.com/doi/abs/10.1046/j.1479-8301.2003.00013.x

Try, Try, Try

What can I do as an emergency physician?

In the emergency department, many patients who might have depression come seeking for help but for other conditions, like a chronic headache or chest pain, or a plethora of symptoms that don’t add up to any specific identifiable physical cause. Mostly I think doctors are relieved for the patient’s sake that his symptoms are not due to a life or limb-threatening condition, but then we fail to address to underlying issue which may be psychological. Truthfully, most of us don’t remember too many details from our psychiatric training in medical school, including how to pick up clinical depression and the tools used by qualified psychiatrists are too complex. Yet we must try.

How do I diagnose depression?

Dr Doug Rund, an emergency physician, developed a bedside depression screening tool, “In SAD CAGES“, which stands for:

Loss of Interest in activities, Sleep disturbance, Appetite change, Depressed mood, Difficulty in Concentrating, Activity level change, Excessive Guilt, Loss of Energy, Suicidal thoughts, plans or attempt.

To screen positive for depression, the patient must have at least 5 out of the above 9 criteria on a daily basis for at least 2 weeks, including either loss of interest in activities or depressed mood. Several studies, including one done by Dr David Hoyer, show that the prevalence rates of depression in ED patients range from 20-30%.

How do I treat depression?

So the next challenge to emergency physicians is, what do we do with patients whom we have diagnosed with possible depression? Dr Hoyer believes in starting treatment with antidepressants from the ED. However many emergency physicians would prefer to refer such patients to a psychiatrist for initiation of treatment as some antidepressants have side effects. I think we can still try to help our patients, maybe with non-pharmacological methods while awaiting follow-up or even admission, to expedite team-based treatment especially if the patient has active suicidal ideation.