Feeling sad or depressed is a natural reaction to tragic situations, but for many people – as many as 16 million in the United States alone – depression is more than just a feeling; it is a persistent, chronic state of mind that bleeds into everything else in life. Having this form of major depression raises red flags for other mental health concerns; the progression from depression to addiction and the risk of suicide has been charted many times, but treatment and help are possible at every step.
What Is behind Depression?
In order to understand the relationship between depression, addiction, and the risk of suicide, it is necessary to examine what depression it, what causes it, and why it is such a serious medical problem. Major (or clinical) depression is not just a case of unhappiness; as the American Psychiatric Association puts it, this kind of depression is as intractable as a physical injury.1 A person in a depressive state cannot simply be cheered up or shaken off; it robs the sufferer of a desire to do anything, changing and poisoning their worldview and state of mind. A writer at Vicemagazine says that “depression steals your soul.” It also takes your time, your energy, your thoughts, and even what you think about yourself. What it leaves behind are unshakable and seemingly irrational feelings of isolation and despair.
Major depression has no solitary cause. When it develops, it is usually the result of a number of genetic, social, and psychological factors occurring in some combination. A professor of psychology at Drexel University in Philadelphia told US News & World Report that when people who have some arrangement of these factors in their life endure a stressful event, their unique makeup “makes them susceptible to depression.”
There could also be biological factors that determine whether a person has a chance of becoming severely depressed as the result of a stressful event. Mayo Clinic explains that chemical messengers in the brain, called neurotransmitters, are responsible for how people feel; if there is a change in the function of these neurotransmitters, particularly how they engage with the brain’s circuits responsible for regulating mood, then there is a high likelihood that a person with this kind of neurotransmitter imbalance might experience clinically depressive periods compared to a person who has no such imbalance. What causes there to be the imbalance in the first place could depend on genetics (inheriting the chance of altered brain chemistry from a parent or grandparent), lifestyle (such as substance abuse) or environment (if the person is exposed to constant amounts of stress or trauma).2
A deficiency in the serotonin neurotransmitter also causes problems with memory and learning, leading people who have depression to be trapped in negative, looping thought patterns. Not only does this hinder concentration and learning new information, it also forces individuals into the same negative thought patterns that feed the depression.
Genetics and Hormones
The degree to which genetics plays a part in determining whether a person can develop major depression is hotly debated. The consensus is that depression does run in families, and people who have first-degree relatives (parents and siblings) with depression are more likely to have depression themselves. Twin studies have found that if one identical twin has clinical depression, the other twin has a 70 percent chance of going through at least one depressive period.3
Hormones might also play a role in depression. Women undergo drastic changes to their hormone composition and balance during pregnancy and childbirth, which can lead to postpartum depression; men can experience hormonal imbalances as part of aging and certain medical conditions associated with aging, such as thyroid problems and diabetes.
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Signs and Symptoms of Depression
Whatever the causes of someone’s major depressive disorder, the signs of the condition being in effect run the gamut from the innocuous to the undeniable. In a list created by the Anxiety and Depression Association of America, the most common symptoms are the persistently negative ones: despair, hopelessness, guilt, and worthlessness, even when there is no apparent reason to feel guilty or pessimistic. For a sufferer in the midst of a depressive episode, which can last for weeks or months, depending on various factors, the certainty of the negative feelings is overpowering and resistant to any attempt at changing them.4
People experiencing depression might also lose interest (and energy) in activities and hobbies they once enjoyed. They are unable to work up the enthusiasm to play sports, go out with friends, or even to have sex with a partner. Sufferers feel a constant sense of fatigue, sometimes having to make a concerted effort to simply get out of bed in the morning. The fatigue and the depression itself contribute to difficulty concentrating, remembering things, or making decisions; bills might go unpaid and deadlines might be missed because the person is so tired, and also because the depression blacks out any important things to get done.
Naturally, sleep patterns are affected. Despite the fatigue, sleep might be hard to come by; when sleep does come, it is often light, short, and easily disturbed. People going through a depressive period lose their appetite, and thus lose weight; they may try to compensate for this by overeating (or eating unhealthy foods), thus experiencing an increase in their weight. Either extreme contributes to unhappiness with body image and feeds into the depression.
A serious sign of major depressive disorder is when the person has recurrent thoughts of death and mortality, which include thoughts or ideas about suicide. This may or may not include actual suicide attempts, but according to Psychology Today, depression is “without question the most common reason people commit suicide.”5 One of the defining characteristics of depression is a constant sense of suffering and the belief that such suffering makes the person unworthy of life. A writer at The Salt Collective confesses that her depression makes her question if she deserves to simply “take up space.”6 Depression fools its victims into thinking that the world would be better without them, and their friends and family will be relieved of the burden of their existence. Psychology Today says that such thoughts are as much a sign of depression as physical pain is a sign of an injury.
As a result of this, many people suffering from depression think about death, their death, and committing suicide. In the throes of a depressive state, suicide seems almost natural. Everyday Health says that “suicidal depression is like having to sneeze,” a strong impulse that becomes irresistible the more it is held off.7 However, “depression alone rarely causes suicide,” according to Scientific American. Even though most of the people who take their own lives suffer from depression, under 4 percent of those who have depression commit suicide. The clear conclusion, writes Scientific American, is that there is more behind a suicide than depression. The magazine identifies three contributing factors:
- Past attempts at suicide
- The severity of mood and behavioral disorders
- Substance abuse
The introduction of mind-altering substances (alcohol or benzodiazepines) can make depression that much worse. As a depressant, alcohol buries the brain’s reward centers even deeper than what the depression itself naturally does, making it harder to restore the initial equilibrium. As many as 60 percent of the people who take their own lives were drinking before they died.8
Depression, Substance Abuse, and Suicide
Researchers writing in the Current Opinions in Psychiatry journal note that 33 percent of people with major depression engage in some form of substance abuse. The euphoria and artificial feelings of happiness, escape, and relief that come with drug and/or alcohol consumption are a kind of self-medication, providing a temporary boost to mood that alleviates the weight of the self-loathing and hopelessness that characterizes depression.9 In 2001 and 2002, a large-scale national study of 43,093 adults found that among those who were addicted to alcohol, there was evidence that more than 20 percent could also be diagnosed with concurrent clinical depression. This group was 3.7 times more likely to have major depressive disorder than those who were not dependent on alcohol.10
The relationship between depression and addiction is not always a straightforward one. Psych Central compares it to the chicken-or-the-egg question, with one therapist saying that the answer to whether substance abuse caused the depression or whether the depression triggered the substance abuse is “always a resounding “maybe”.” This ambiguity can complicate treatment methodology because therapists will have to determine which came first: the depression or the substance abuse. Depending on the severity of the patient’s co-occurring conditions and the length of time that the conditions have been in effect, this may not be an easy determination to make, and it is important to treat the conditions in the right order and with the right approach.
Generally speaking, a patient who had depression before the substance abuse will need treatment for a longer period of time (usually in the form of Cognitive Behavioral Therapy) than a patient who was addicted to drugs and/or alcohol first and then developed major depressive disorder. A patient whose depression was caused by substance abuse will normally not need the same rigor of treatment as a patient whose depression developed before the substance abuse took hold.11
Alcohol, Depression, and Suicide
As stated, alcohol depresses the central nervous system. It initially works as a stimulant, which fools many people into abusing alcohol to boost their mood (more so in the case of someone in a depressive period); however, the effect this has is the complete opposite of the desired outcome. When the brief stimulation ends, the person is left feeling lethargic, drowsy, and even more depressed than before (and, for many people, this serves as a source of compulsion to keep drinking). Additionally, alcohol lowers inhibitions and impairs judgement, and in some drinkers, this has the effect of inducing risky behavior. This could mean anything from picking a fight, to driving drunk, to engaging in unprotected sexual activities; for people with major depression, this could mean attempting suicide. The American Association of Suicidology observes that around half the people who try to commit suicide have some form of depression (major depression, bipolar disorder, postpartum depression, seasonal depression, etc.), and people who have depression are 25 percent more likely than people without depression to act on their suicidal thoughts. In too many cases, alcohol (or some other form of mind-altering substance) is the catalyst that makes the difference.12
This leaves people who have substance use disorder and major depressive disorder at a higher risk for committing suicide, says Psychology Today. Suicide is the 10th leading cause of death in the United States, and mood disorders like depression are the primary risk factors for suicide, but fatalities caused by alcohol and drug abuse come in at a close second. People with addiction issues are 60 percent more likely than the general population to take their own lives; clinical depression edges that percentage even higher.13
Powerful drugs do not just increase the chance that a depressed person will commit suicide, but also provide the means to carry out the act. Around 33 percent of the people who commit suicide “typically [use] opiates such as oxycodone or heroin,” according to Psychology Today. Prescription drugs are linked to most of the fatal overdoses that take place in America, but whether the resultant deaths were intentional (i.e., a knowing suicide attempt) or the person had no legitimate intention of bringing about their death is hard to determine.14
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Withdrawal and Psychological Effects
One of the most challenging things about drug abuse and depression is that as much as the consumption of drugs can feed into the depressive state of mind, attempting to stop the drug use does much the same. This is because the way that mind-altering substances target specific neurotransmitters (the chemical messengers in the brain) that control mood, and feelings of pleasure, reward, and expectation. The substances enforce their presence for so long, and so deeply, that the brain cannot adequately function without them. When a person tries to go off the drugs or alcohol, the brain cannot produce enough neurotransmitters to resume normal processing. The result of this is that the person experiences withdrawal symptoms – painful and distressing effects of trying to adjust to the new reality of the drugs not dictating terms.
Withdrawal has physical components (e.g., flulike symptoms, muscle cramping, etc.), but there is also a psychological component to withdrawal – one that ties in very strongly to mood disorders like depression. Depending on the nature of the drugs not in the patient’s system anymore, as well as the length of the abuse, the patient can go through periods of depression and anxiety, alternately feeling hopeless and lost, and nervous and agitated. A key characteristic of withdrawal, and one of the most dangerous of its symptoms, is a desperate craving for the drug consumption to resume. This is borne from the belief that the withdrawal symptoms are so uncomfortable and unbearable that the only way to achieve any kind of comfort and relief is by going back to the habit.15
This is, of course, not true, but to a person whose body and mind have become devastated by addiction, perception is deeply skewed in favor of continuing the addiction. The real threat is that withdrawal takes a significant toll on physical and psychological fortitude, leaving a patient in a weakened and vulnerable state. Resuming drug intake during this stage will further deepen the dependence and addiction on the drug, far beyond the levels before withdrawal was attempted. This will also exacerbate any suicidal instincts, meaning that the likelihood of a depressed person on a new wave of substance abuse following through with their suicidal ideation is much higher than it previously was.
Researching the Connections
The link between substance abuse and suicide accounts for some of the most widespread scientific literature on subject, says Psychiatry Today.16 Depression and substance abuse disorders are among the mental health conditions that are most strongly linked to suicide attempts (either fatal or nonfatal).17
Much of the research that exists on the connection between suicidal behaviors and addiction is focused on identifying the people with addiction disorders who have the highest possibility for committing suicide. This line of reasoning examines the risk factors for suicide in the general population since those factors can also apply to people who have the right balance of substance use disorders and mental health imbalances to make suicide a greater risk. For example, the Journal of Studies on Alcohol and Drugs found that older males with substance use disorders have a higher chance of both nonfatal suicide attempts and death by suicide than younger people.18 Additionally, past suicide attempts have proven to be “a strong risk factor for subsequent suicidal behaviors in those with substance use disorders,” according to Alcoholism: Clinical and Experimental Research.19 Being in a clinically depressed state of mind is such a factor for suicidal behaviors that multiple researchers have said that it “predicts a greater likelihood of suicide in those with alcohol or drug use disorders.”20
As scientists have dug deeper, they have uncovered trends that suggest that people who abuse particular substances may be more likely to experience suicidal thoughts and behaviors, than people who abuse other substances. For instance, research published in the Addiction journal has found that people who take opioids, cocaine, and sedatives (like benzodiazepines) have a “noticeably” higher risk of committing suicide than people who consume other drugs.21 For people who are addicted to alcohol, episodes of increased drinking were connected with an increased chance of both suicide attempts and suicide mortality.
Depression, Addiction, and Suicide in Montana
A real-world example of the tragic intersection between depression, addiction, and the specter of suicide comes from a traditionally robust demographic that social scientists and public health experts say is now an endangered one: white, middleclass Americans, aged 45-54. There is a cultural “sea of despair” among white, working-class people in the United States, says the Washington Post, and The Guardian writes that the death rate for this group has spiked between 1999 and 2016, but in one state in particular, local officials are struggling to answer why their home state has twice the national average suicide rate and why this number is rising.22, 23
The convergence between this demographic and substance abuse, depression, and suicide seems to be unique to Americans. No other developed country, and no other racial group within the United States, has experienced such notable death rates. Fatalities as a result of drug or alcohol consumption have risen so much that lung cancer has dropped to second place for this age group; intentional suicide achieved by means other than drug intake takes a close third place.
The intersection of this public health factors may be found in Butte, Montana. The fifth largest city in the state, it also has the highest rate of suicide across the United States: 7.3 percent and rising. The city’s health director told The Guardian that there is yet no consensus on why her city’s middle-aged adults are killing themselves with drugs and alcohol, but potential reasons include economic losses, unhappiness with life, isolation, and the national rise in the availability of addictive and lethal drugs.
Two Princeton economics (whose work was cited by both the Guardian and the Washington Post) identified rising economic inequality in the wake of the end of the predominantly white, working-class generation that celebrated its heyday in the 1970s but were rendered obsolete by the cultural and social upheavals of the following decades. Mechanization and outsourcing of jobs led to the decline of the farming and mining industries, leaving many people from this group unemployed and unemployable in the new economy while still nursing a plethora of injuries incurred from their labor-intensive work. Many feared that, unlike their parents and their grandparents, they had nothing to look forward to in the twilight of their years.
After the jobs went, these people found validation in conservative religion and politics but also in unhealthy lifestyle choices – specifically, increased alcohol consumption and compulsive eating habits.24
The prescription drug boom of the late 1990s and early 2000s added opioid-based medication into the mix, and aggressive marketing tactics targeted this demographic of mostly elderly, chronically injured, uneducated, unemployable, and untrainable Americans, who found escape from feelings of cultural and social abandonment in the pills they took for their aches and pains. The first person profiled by The Guardian confessed to being in such persistent pain that he contemplated suicide to end his life; at 56 years of age, his baby boomer expectations dashed against the rocks of failing health, a shuttered mining industry, and “enormous stress,” he has medical debts and a poor retirement to look forward to while his daughter needs help of her own.
Many of the people in his position are so scared of having to pay out-of-pocket expenses for their medical treatment that they think twice about going to a doctor for their ailments. Their pain increases, their sleep eludes them, and they fall deeper into the psychological rut that is only alleviated by drinking, illegally obtained (and abused) prescription medication, and, for some, ultimately suicide.
Karl Rosston, Montana’s suicide prevention coordinator, says that socioeconomic causes are to blame as to why the residents of his state are losing hope, using drugs, and ending their lives. Over 150,000 Montanans don’t have access to healthcare (23 percent of the state’s population), even though they have to pay for the insurance; most insurance policies require the holders to pay the first few thousand dollars every year before the coverage itself goes into effect. Additionally, many people from this demographic are reluctant to admit to the kind of fundamental unhappiness that is a sign of major depressive disorder. Living below the poverty line with no prospect of an economic or cultural revival on the horizon has led to many people in the 45-50 age group not seeing any hope in retirement. Instead, they see decades of financial and physical struggle ahead of them, and the physical struggle might be the catalyst for thoughts of suicide. When one pulp mill closed its doors in 2009, four workers took their own lives.
30% OF THE PEOPLE WHO COMMIT SUICIDE STRUGGLED WITH CHRONIC PAIN
The two Princeton economics pointed to chronic pain as “a big driver of suicide among middle-aged people,” and Karl Rosston agrees. Whenever he reviews a death certificate for a 55-year-old white male who committed suicide, there is usually a note from the coroner about untreated chronic back pain. Across the country, 30 percent of the people who commit suicide struggled with chronic pain; the number is considerably higher in a state like Montana.
The Guardian noted that the national surge of prescription opioid abuse is connected to more people reporting pain even if they are unable to afford the insurance coverage to get prescriptions. Nonetheless, they remain popular; in Montana, doctors prescribe 82 prescriptions for every 100 people.
Asking for Help
With alcohol and drugs in easy reach, depression is not far away. A 2014 assessment published by the county found that more than 33 percent of the residents displayed symptoms of chronic depression.25The sense of despair prevents many of the people in Montana, and numerous other economically and socially depressed regions of the country, from asking for help. Karl Rosston, the state’s suicide prevention coordinator, explained to The Guardian that despite the high rates of substance abuse, most of the people who take prescription medication “have never even spoken to a psychiatrist.” Part of the problem is that the age of that particular demographic sees depression as a form of weakness, and asking for mental health help comes at the cost of swallowing what little pride they have left.26
But something that connects them to everyone suffering from major depressive disorder is that no matter who they are, their depression makes them think that they are a burden. Rosston says that when he reviews suicide cases, the people who died confessed that they felt they were no longer serving any purpose with their lives, and they were tired of dealing with their pain, their bills, their debt, and the uncertainty of their future. Pushed to the limit of what they felt they could endure, they had no interest in asking for anyone’s help.
- “What is Depression?” (January 2017). American Psychiatric Association. Accessed May 1, 2017.
- “Depression (Major Depressive Disorder).” (July 2016). Mayo Clinic. Accessed May 1, 2017.
- “Overview of the Genetics of Major Depressive Disorder.” (December 2011). Current Psychiatry Reports. Accessed May 1, 2017.
- “Depression.” (n.d.) Anxiety and Depression Association of America. Accessed May 1, 2017.
- “The Six Reasons People Attempt Suicide.” (April 2010). Psychology Today. Accessed May 1, 2017.
- “Questions I Can’t Stop Asking Myself Because Depression is a Soul Sucking Monster.” (n.d.) The Salt Collective. Accessed May 1, 2017.
- “What Suicidal Depression Feels Like.” (September 2014). Everyday Health. Accessed May 1, 2017.
- “Robin Williams: Depression Alone Rarely Causes Suicide.” (August 2014). Scientific American. Accessed May 1, 2017.
- “Major Depression and Comorbid Substance Use Disorders.” (January 2008). Current Opinions in Psychiatry. Accessed May 1, 2017.
- “Introduction to the National Epidemiologic Survey on Alcohol and Related Conditions.” (n.d.) National Institute of Alcohol Abuse and Alcoholism. Accessed May 1, 2017.
- “Depression and Substance Abuse: The Chicken or the Egg?” (2016). Psych Central. Accessed May 2, 2017.
- “Depression and Suicide Risk.” (2014). American Association of Suicidology. Accessed May 1, 2017.
- “Suicide: One of Addiction’s Hidden Risks.” (February 2014). Psychology Today. Accessed May 2, 2017.
- “Prescription Drugs Linked to Most Fatal Overdoses.” (February 2013). Medical News Today. Accessed May 2, 2017.
- “Craving: When the Brain Remembers Drug Use.” (February 2010). Psychology Today. Accessed May 2, 2017.
- “The Link Between Substance Abuse, Violence, and Suicide.” (January 2011). Psychiatric Times. Accessed May 3, 2017.
- “Prevalence of and Risk Factors for Lifetime Suicide Attempts in the National Comorbidity Survey.” (July 1999). Archives of General Psychiatry. Accessed May 2, 2017.
- “Risk Factors for Suicide and Medically Serious Suicide Attempts Among Alcoholics: Analyses of Canterbury Suicide Project Data.” (July 2003). Journal of Studies on Alcohol and Drugs. Accessed May 2, 2017.
- “Predictors of a Suicide Attempt One Year after Entry into Substance Use Disorder Treatment.” (April 2007). Alcoholism: Clinical and Experimental Research. Accessed May 2, 2017.
- “The Association Between Violence and Lifetime Suicidal Thoughts and Behaviors in Individuals Treated for Substance Use Disorders.” (February 2010). Addictive Behaviors. Accessed May 2, 2017.
- “Suicidal Behaviour and Associated Risk Factors Among Opioid-dependent Individuals: A Case-control Study.” (December 2007). Addiction. Accessed May 2, 2017.
- “New Research Identifies A ‘Sea of Despair’ Among White, Working-class Americans.” (March 2017). Washington Post. Accessed May 2, 2017.
- “Financial Despair, Addiction and the Rise of Suicide in White America.” (February 2016). The Guardian. Accessed May 3, 2017.
- “Rural America Fatter than Urban America.” (September 2012). ABC News. Accessed May 2, 2017.
- “2014 PRC Community Health Needs Assessment Report.” (2014) Butte-Silver Bow Public Health Department. Accessed May 3, 2017.
- “Asking for Help Is Hard.” (January 2016). Psych Central. Accessed May 3, 2017.