Each year, thousands of American adults commit suicide—39,518 in 2011, the most recent year for which data are available. But it took one suicide, that of actor/comedian Robin Williams, to focus attention on the problem for at least a day.
Williams was a beloved figure, and the epitome of the character who is always "on" and keeps people laughing. But it was no secret that he suffered from depression, a struggle that he had spoken openly about. So is the old saying, "Laughing on the outside, crying on the inside," more than just a cliché?
"There are people who are depressed who are not able to cover it up, and depression very much shows in their speech and behavior," says Erik Nelson, MD, an adjunct associate professor in the University of Cincinnati (UC) College of Medicine Department of Psychiatry and Behavioral Neuroscience and UC Health psychiatrist. "But then there are people who have depression who may appear normal and may even be able to laugh or use humor and appear to everyone else to be fine.
"This can make it harder for loved ones and people who are in communication with the depressed person to see that the person is quite depressed and may even have suicidal thoughts."
Nelson adds: "It's also possible that a person who is very funny or jovial or full of life can have periodic depression where the depression is not there all the time. So there may be times when they seem the opposite of depressed in terms of being full of life and energy."
Cheryl McCullumsmith, MD, PhD, an associate professor in the Department of Psychiatry and Behavioral Neuroscience and UC Health psychiatrist, says suicide should be viewed as an illness, similar to heart disease, asthma or diabetes.
"Just as there are many ways to have heart disease—hypertension, smoking, high cholesterol, genetics—there are many ways to become suicidal—depression, drug abuse, alcoholism, bipolar disorder, schizophrenia, social distress," McCullumsmith says. "The good news is that, as an illness, we can screen for and treat people with suicidal thoughts.
"The bad news is that we as mental health professionals and researchers still have no objective way to 'test' for suicidal thinking. The stage we are at in suicide assessment would be like diagnosing a heart attack by asking someone to describe their pain for you—no EKG, no blood tests, no X-rays."
McCullumsmith says groups—including research teams at UC and Cincinnati Children's Hospital Medical Center—are working on more objective methods to aid clinicians in assessing suicide risk, such as analysis of facial movements and voice.
"Additionally," she says, "we are finally beginning to have some treatments that may rapidly and specifically decrease suicidal thoughts, such as low-dose ketamine, among others. However, these treatments and their side effects are still in investigatory phases."
According to the American Foundation of Suicide Prevention, warning signs of suicide include:
• Talking about wanting to die.
• Hoarding medicine or buying a gun.
• Losing interest in things and becoming withdrawn from family and friends.
McCullumsmith notes that substance use is a significant contributing factor to suicide.