The sudden death of actor Robin Williams has put mental illness and Parkinson’s disease in the spotlight. Kim Penberthy, PhD, works with patients who have severe depression and talks about the stigmas, myths and what you can do to help.
Are there any common myths about depression and suicide you want to address?
I think that the biggest myth may be that depression and suicide are indicators of immorality and weakness in a person. Depression is an illness. People who suffer from mental illness may be drawn to suicide because they feel that they have no other option to deal with the pain and suffering of severe chronic depression.
Does depression always have a physical cause, such as a chemical imbalance?
Depression and bipolar do seem to run in families, and there does seem to be a genetic component to many mental illnesses. But even when you find a genetic component, it still only accounts for a very small percentage of the likelihood of developing the disorder.
We are all also impacted by environmental factors, which include your development history or the way you were raised, the culture in which you live, and your current environment. In my field, we assume it’s a combination of biological, psychological and social factors.
Not being Robin Williams’ doctor, it’s hard to say what happened. I will say he is part of a demographic that is increasingly attempting and completing suicide — white middle-aged men. It used to be the highest rates of suicide occurred in the elderly and teenagers, but that has changed recently and we don’t really know why. There might be something unique about the stress of being a white middle-aged male in our society at this time that is driving that rate to increase.
Men are more likely to commit suicide than women. The data indicate that for every women who kills herself, 3.6 men commit suicide. Men also use more lethal means, like hanging themselves or shooting themselves.
Robin Williams made us laugh, so it’s easy to assume he was a happy person. But people often make jokes to avoid discussing serious topics. Is there a link between this and depression?
Yes, some people use humor to avoid discussing, but it’s hard to make generalized statements about depressed people using humor to cope with or avoid dealing with their depression. For example, many of the severely depressed individuals that I treat are so lethargic and sad that they have no energy or interest in making jokes. They may be barely able get out of bed and get dressed, so they certainly don’t have the energy to make a joke.
I think it really depends on the severity of the depression that we’re talking about. But I think we also have to realize that actors are acting a lot of their lives. He was a very talented actor, and I don’t think any of us have a full understanding of his private life.
What are some of the treatments for depression and bipolar disorder?
There is a difference diagnostically between chronic and episodic depressive disorders. It sounds like from what I read that Robin Williams may have had a chronic illness, and these kind of persistent disorders respond best to treatments designed specifically for them.
Cognitive Behavioral Therapy (CBT) and antidepressant medications and/or mood stabilizers are typically the most common and most effective treatment for depression and bipolar disorders and can be very effective in alleviating symptoms in these disorders. We have found, however that chronic or persistent depression may require an augmented treatment approach.
Something called Cognitive Behavioral Analysis System of Psychotherapy or CBASP is the only proven effective psychotherapy treatment for chronic or persistent depression when combined with effective antidepressant medications. A challenge is that many of these very sophisticated treatments that take a lot of training to learn are not available to many people, and we need to change that.
Patients often need to be on medication and therapy, and some research does show that both are more effective combined than alone.
What can you do to help a friend or family member? How should you react if the person blows it off with a joke or seems to snap out of it?
Sometimes it really helps to let the person know they have people in their life who care about them, but often with persistently depressed individuals, they may not believe this or acknowledge it. If a loved one is suffering from depression or bipolar disorder and has not been seen for treatment, I would recommend talking with them in a supportive and loving way about getting treatment. I recommend you ask them, if they really feel like they don’t want to get treatment for themselves, could they do it for the people they love.
If someone is actively suicidal, you need to call 911.
Why is there a stigma around mental illness?
I really don’t know. That’s a really good question. I used to think it was because mental illness is not always physically visible in the person who has it — it is more evident in our moods and thoughts — and it seems somehow different than other diseases and illnesses such as diabetes or cancer. Because of this, there may be a sense that we can control it and because of this we may think if a person is sad and cannot snap out of it they are weak or not trying. We equate it with our own emotions: ”I remember when I was sad that my cat died, and I got over it, so why can’t you get over this?”
If anything good comes out of it this tragic event, it may be an increased awareness that this could happen to anyone. Anyone can be depressed or bipolar, just like anyone can have diabetes or cancer. It’s got nothing to do with your morality or character. I hope additional conversations continue about implementation of early detection, assessment and effective treatments for depression, bipolar illness, and other mental disorders.
What are some of the warning signs of suicide?
The warning signs can be variable or non-existent. Obviously, people suffering from depression and bipolar disorder are at higher risk, and people who endorse wanting to kill themselves are at very high risk. Some people will let you know that they are feeling overwhelmed and thinking of killing themselves while others may go about discussing it in non-direct ways like saying, “I can’t go on like this.” Often, people may make plans for their death by suicide, such as giving items away or planning for their pets to be cared for. So when you see someone preparing to not be there, when they’re not going on vacation or going on a trip, that can be a warning sign.
Additionally, anyone using drugs or alcohol, may be at increased risk for suicide due to the disinhibiting qualities of such substances.
Often increased hopelessness is associated with increased risk of suicidality. It is thought that this may happen because the depressed individual does not see any possibility of change. The pain is too bad, the pain is too intense, and they don’t have any hope of change – they can see no other way out
When pain from the depression is intense and hope is low or nonexistent, that’s when depressed individuals may be at highest risk for suicide.
What about someone who has just experienced a tragedy like the death of a child? Is that person more likely to become suicidal?
My understanding is that this may not be a common factor in increasing the likelihood of suicide. Suicide is usually associated with a severe mental illness, something like bipolar disorder or depression, but certainly may be exacerbated by situations in the person’s environment.
How can you help a friend or family member who has lost someone to suicide?
Listening and being there for that person are going to be the most important things you can do. If you think they’re suffering so much that they need treatment, you may wish to gently suggest such. It may be an overwhelming, confusing time for a person who has lost a loved one to suicide and often the people who remain are experiencing a wide range of emotions. They may be angry, confused, they may be frustrated — deeply hurt and sad. That’s OK, don’t take it personally, just be there for them.
If you or a loved one is having symptoms of depression, start by talking to your primary care doctor. Don’t have a PCP? Find one and make an appointment online.
If you think someone may be suicidal, contact the National Suicide Prevention Lifeline at 1.800.273.TALK (8255).
Thank you for this timely and throughtful response.