Depression

Julian was 25 years old and had been depressed for the past four years. He was not seeking any help or treatment. He was also unemployed, had financial problems, and was struggling to publish some of his writings. Julian was also on probation for theft charges. His parents became concerned when his girlfriend broke up with him, and he started isolating himself. When his father had not heard from him for a few days, he asked the police to do a welfare check. When the police went to his home, Julian was not at his apartment, and his car was not in the garage. Four hours later, his father called the landlord and asked him to check on Julian. Julian was found in his garage seated in his car which was still running. He was unresponsive and by the time medical help arrived, it was too late. Julian left notes and pages of his unpublished writings listing, among other things, the reasons he should live and the reasons he should kill himself. These reasons (which we have arranged side by side) included the following:

In the new Diagnostic Statistical Manual of Mental Disorder-Fifth Edition (DSM-V, 2013), depressive disorders are separated from bipolar and related disorders. It lists four main depressive disorders: major depressive disorder (clinical depression), persistent depressive disorder (formerly dysthymia disorder), disruptive mood dysregulation (diagnosed in children and adolescents), and premenstrual dysphoric disorder. Julian was experiencing clinical depression. While feeling sad, “blue,” despondent or dejected are normal reactions to major life events, such as the loss of someone or major health problems, or can be a side effect of medical treatment, clinical depression is much more severe. Someone who is experiencing clinical depression will usually experience a mood disruption that affects his or her thoughts, feelings, behaviors, and overall well-being. During this state, the person might feel persistent sadness, anxiety, hopelessness or pessimism, helplessness, worthlessness, guilt or irritability. He or she finds it difficult to enjoy or engage in previously pleasurable activities. Other symptoms include an increase or decrease in sleeping or eating, feeling tired or restless, difficulty concentrating or making decisions, moving or talking more slowly, forgetting things, and the person may even attempt, think or plan suicide. The person can also have physical symptoms such as aches or pains, headaches, or cramps (DSM-V, 2013).

Clinical depression affects different people in different ways. Some people experience only a few symptoms while other may experience many symptoms. The severity, frequency, timing, and duration of symptoms depend on the person. Clinical depression can be caused by a combination of genetic, biological, environmental, and psychological factors. Clinical depression often begins in early adulthood (Depression, 2015). When depression occurs in middle adulthood or among older adults, often it can be connected with other serious medical illnesses, such as cancer, diabetes, heart problems, or chronic pain (de C. Williams, 1998). Some other risk factors include other co-occurring psychiatric disorders, a family history of depression, or medication usage. Clinical depression can be precipitated by stress due to a major change or trauma such as the death of a family member, divorce, or loss of a job (Depression, 2015).

Depression is a serious illness that individuals may not want to admit to themselves, or that family and friends may not understand. It is always important to seek professional help (Depression, 2015). Individuals with clinical depression are at a 25 times greater risk for suicide than the overall population (American Association of Suicidology (AAS), 2014). The AAS reports that in individuals with untreated depression, the lifetime risk of suicide ranges from 2.2% to 15%. Fifty percent of the people who commit suicide suffer from clinical depression (AAS). Comorbidity of depression and anxiety may create an even greater risk of suicide than depression alone (Bronisch & Wittchen, 1994).

Although in the general population, women and girls are twice as likely as men to suffer from depression (Jamison, 1999). In our sample of people who committed suicide, those who were identified as depressed were mostly men (81%) and Caucasian (94%) with an average age of 46 (in a range of 11–91 years old). Most killed themselves at home (78%), most frequently on Mondays (19%). Many of them experienced physical illnesses (40%), drug abuse (32%), or interpersonal (37%), legal (14%), or financial problems (19%). Almost one-fourth (23%) had previously attempted suicide, threatened to hurt themselves (33%) or expressed suicidal ideation (29%). In 35 cases (7%), individuals completed suicide in front of others and 5 were murder-suicides (1%). The most common methods of suicide were firearms (49%), followed by asphyxia (27%).

Eighty people in this group (16%) left notes and most (65%) left only one note. It is likely that individuals who are experiencing depression have been contemplating the act over a long period of time, as opposed to acting impulsively, as seen in other psychiatric disorders (Anestis, Soberay, Gutierrez, Hernández, & Joiner, 2014). Most addressed their notes to a specific person such as children (32%), parents (31%), family (30%), and partners (28%). Harry, discussed in Chapter 4, Escape as a Motivation for Suicide, wrote an entire note to his dog, Seneca. In it he said:

Harry agonized over his decision to leave his dog, and he prayed about it at church. The note never mentions his death, only his leaving. His depression, mentioned in a separate letter to a friend, was hidden underneath layers of love and gratitude to his dog.

Most individuals, like Harry, provided a justification for death (56%) and expressed their love for others (70%). Sometimes, the victims mentioned God (32%) and gave a justification to God about why they were taking their lives. Additionally, individuals talked about their interpersonal problems (40%). The underlying tone of individuals who discussed their interpersonal problems was often characterized by tension, negative affect, and hostility. Evidence of tunnel vision or constricted thought processes (23%), and/or dichotomous thinking (11%) also appeared in the notes. Sometimes the constricted thoughts resulted in individuals discussing their inability to see or generate other options, feeling out of control, or expecting that their future outcome would also be out of their control.

Kim was a 46-year-old woman who had a history of depression, chronic back pain and arthritis, and was known to abuse prescription drugs. She was diagnosed with major depressive disorder and had attempted suicide a number of times. She took an overdose of her prescription pills and left a note for her two daughters saying, “This was the only way; I’ve made a big mess out of too many lives. Just let me go. I love you.”

People in this group identified a precipitant (21%) and directed apologies to specific individuals (33%) or general apologies (28%). They asked forgiveness for themselves (26%) and sometimes gave advice (22%). They were more likely to absolve others from blame (18%) than to blame others (11%). One middle-aged white man left a note to a friend he had just been talking to on the phone, “This development is no one’s fault and no one is responsible for it but myself, just as there is no single catalytic trigger event, but extensive accumulation of failures, disappointments and dead-end (no pun intended).”

Some note writers suffering from depression specifically discussed their need to escape (28%). Janis was a 30-year-old woman who said, “I am sorry to bring pain to everyone My life has no meaning anymore all I do is drag everyone around me down. I am such a disappointment. I dug myself a hole so deep I cant get out this is my only way to have piece of mind.” Some referred to their psychological pain (25%) or physical pain (18%) or just talked about unspecified pain (17%). While many people who consider suicide seek to escape something, those who were clinically depressed expressed the weight they felt going through life.

Those who suffered from depression were less impulsive than those with other mental illnesses (Anestis et al. 2014), which meant they could plan for the aftermath of their deaths and instruct others. A few left instructions regarding how to dispose of their bodies (26%) or their property (25%), and how to manage their affairs (22%). Others asked that survivors take care of friends or family (21%). For example, Gina left a note to her friends and family with the following instructions:

A few of them also left quotations, giving advice, referring to favorite songs, and sharing poems in their notes (6%). One person wrote, “The most important thing in life is relationship—do anything you can to protect & preserve them. Don’t judge the ‘gentle spirit’ as being weak—for therein lies humanities greatest strength. Please take care of the earth, its animal, and each other.” Gina paraphrased the song, “Vincent,” writing, “This world was never meant for one as beautiful as me.” Many of these quoted songs or poems were sad, referenced suicide in some way, or focused on themes of things coming to an end. On one man’s list were “Sittin’ on the Dock of the Bay,” by Otis Redding and “Hear My Train A Comin’” by Jimi Hendrix, next to crossed out songs that he had written. The connection to lyrics, music, and lost dreams was present in several notes.

Some note writers mentioned explicit sentiments in their notes. Specifically, they talked about feeling loved (15%), like a failure (15%), tired (13%), sad (12%), that life was not worth living (11%), hopeless (8%), lonely (8%), and ambivalent (8%). Some of these feelings are relatively consistent with the presentation of clinical depression. When individuals expressed these feelings, the overall sentiment was that there was no way out and no hope left.

In her novel The Bean Trees (1989), Barbara Kingsolver wrote, “There is no point treating a depressed person as though she were just feeling sad, saying, ‘There now, hang on, you’ll get over it.’ Sadness is more or less like a head cold—with patience, it passes. Depression is like cancer” (p. 232). Cancer is a serious illness, but it is not always fatal, and neither is depression. For the individuals in our study who were clinically depressed, it became impossible for them to find hope. Some had come to the end of their rope because they had been through several bouts of depression, and it was the repeated nature of it that ground them down. It is common for relapses in depression to occur, even with the use of antidepressants. Evidence exists that cognitive therapy may reduce relapse rates (Paykel et al., 1999; Teasdale et al., 2000). For those suffering from depression, consistent treatment, coupled with maintaining social support and having a reason for living, is the key to maintaining wellness.

Bipolar Disorder

Len was a 50-year-old salesman who had been diagnosed with bipolar disorder in his early thirties. He had mood swings that included both mania and depression and a history of prior suicide attempts. Len had been inconsistently taking his medications, preferring to self-medicate with alcohol. He was separated from his wife and was living alone. Recently he had lost his job, which had led to financial problems. Because of this, Len felt that he was not a good provider for his wife and his daughter. All of this led to a state of agitation, and Len was unable to sleep for several days. One night while he was awake, he decided to end his life. The day he killed himself, Len was on the phone and was speaking to his daughter. He asked her if she would help with his memorial service and when she said yes, she heard a shot followed by her father gasping on the phone. Len had shot himself in the chest. He wrote this letter before he took his life.

I AM FULLY MEDICATED, SO MY BIOLOGICAL ISSUES ARE NOT TO BLAME FOR THIS. HOWEVER, BEING MEDICATED DOES NOT ALTER THE FOLLOWING, INESCAPABLE FACTS:

Bipolar disorder (BD) was once known as manic depression. BD is a mental disorder described by mood changes that fluctuate from periods of intense high mood states (mania) to extreme low mood states (depression). Those with BD often die prematurely. At one time, the higher premature death rate among people with bipolar disorder was attributed to a higher rate of suicide and accidents. More recently, researchers discovered that suicide and accidents only partly account for the higher premature death rate (National Institute of Mental Health, 2016). Emerging evidence shows that the majority of early deaths among people with bipolar disorder come from medical conditions (Roshanaei-Moghaddam & Katon, 2009). Nevertheless, suicide rates are 20 times higher than in the general population (Tondo, Isacsson, & Baldessarini, 2003).

Symptom patterns differ for every individual diagnosed with bipolar disorder (Ostacher, Frye, & Suppes, 2016). In a manic episode individuals may be erratic and irritable with extreme changes in energy, activity, sleep, and behavior. As we can see from Len’s list, he experienced these symptoms. His job as a salesman may have benefited from periods of mania if they were not out of control, since mania may include talking fast and an elevated mood, lending an air of excitement to conversation. Yet the person experiencing mania may also jump from one idea to another, have racing thoughts, be easily distracted or overly restless, be unable to sleep and have unrealistic beliefs related to one’s abilities. They may also behave impulsively and engage in pleasurable but high-risk behaviors, such as unsafe sex.

In the depressive episode, they may experience feelings of being sad or tired and a lack of interest in activities they once liked. They may have problems with concentrating, remembering and making decisions, and become restless or irritable and experience changes in eating, sleeping or other habits. They often have increased thoughts of death and suicide. Individuals may have a mixed episode, in which they experience both mania and depression within a week’s time (Ostacher et al., 2016). Among the 45 cases of people with BD in our study, 18 cases specified that the person had episodes of both mania and depression. A hypomania episode is similar to a mixed episode, but it has less extreme mood swings and is shorter in duration (Ostacher et al., 2016). Individuals diagnosed with BD often experience a multitude of problems due to their mental illness.

Sandra was a 45-year-old woman who was diagnosed with bipolar disorder. She refused to take medications and self-medicated with alcohol. Sandra had been divorced from her husband for over five years, and attempted suicide multiple times in that period. Sandra isolated herself and avoided people and problems. She was facing foreclosure due to her financial problems and was worried about the ramifications of an incident where she assaulted a state trooper. Sandra also suffered from multiple medical issues such as diabetes, hypertension, and obesity. Additionally, Sandra recently experienced multiple losses. Her sister, who was also diagnosed with BD, committed suicide and her father died unexpectedly. Then, her niece died of a drug overdose. In addition, Sandra’s son was being deployed to Iraq where he was to be stationed for the next two years. Sandra decided to hang herself, and left a note to her boyfriend. “Baby, I’m sorry I just can’t survive the mess I’ve created. Please forgive me. I love you. This is nobody’s fault but my own. You & my family have done everything to support me. I love you. Please tell my family I love them. Love, Sandra.”

Sandra’s illness and the many problems that stemmed from it meant that her life was full of stress in addition to the other symptoms of BD. In our sample, 45 individuals (7%) were diagnosed with BD. It is likely, based on the documented risk of suicide for persons with BD, which is 20 to 30 times greater than in the general population, that there were more who suffered from it (Pompili et al., 2013).

Three individuals with diagnosed BD left a note. The demographics of this particular sample are similar to our overall SMI sample consisting mostly of Caucasian (93%) and male (62%) victims. However, this category has a higher percentage of women than other categories. The average age of people in this group was 39.

In unipolar disorders, like depression, women out number men two to one (Kawa et al., 2005). Gender, once thought to be irrelevant to BD discussions because of its equal distribution, has been shown to matter. Women’s first experience of BD seems to occur as depression, while men first experience mania. When women have mania they are more likely to be hospitalized. Women also have more rapid cycling and experience more mixed mania (Kawa et al., 2005). Men with BD may be more likely than women to have substance abuse issues. The abuse of substances is itself a mental disorder and when combined with BD, it is sometimes called a “dual diagnosis.” In our sample 33% of patients with BD also had substance abuse problems. Sandra, who was self-medicating with alcohol, struggled with maintaining treatment for her BD. Dual diagnoses are notoriously hard to treat, as discussed in Chapter 6, The Complexity of Suicide Motivation.

Sometimes substance abuse can trigger symptoms of BD. Twenty percent of those with BD in our study consumed substances before or while they completed the suicidal act. Not surprisingly, as opposed to the overall sample and the SMI sample, the most common method of committing suicide in BD cases was overdose on some toxic substance (40%). Most people with BD have easy access to prescription medications, including antidepressants, mood stabilizers, antipsychotics, antianxiety medications and, too often, opioids.

Nearly half of the people diagnosed as bipolar were trying to escape psychological problems and had attempted suicide in the past. A little more than a fourth had expressed suicidal ideation and a fifth made threats of suicide in the past. Sandra’s and Len’s problems are representative of people diagnosed with BD. Less than a quarter of the people in our sample diagnosed with BD had interpersonal problems, and fewer still had legal or financial problems. In three of the cases of individuals with bipolar disorder, they took their lives in front of others. Many individuals who are diagnosed with BD act impulsively, so it is not surprising to find a smaller number of notes.

Schizophrenia

Arthur was 42 years old and had a longstanding history of schizophrenia, paranoid type. He was known to create problems in the apartment building where he resided. Oftentimes, he was caught pulling the fire alarm and kicking neighbor’s doors. He was known to the police officers in the neighborhood. For the most part, he said his behaviors were commands made by the voices that he kept hearing. Eventually, Arthur could not take the voices and took his life by jumping from a tenth-floor apartment window.

Fred was 50 years old and lived in a group home. One day he was found wandering and reported that he was hearing voices which were telling him to jump off a bridge. He was taken to the hospital and admitted to the psychiatric unit. When the staff went to call him for dinner, Fred was found unresponsive in the bathroom. He had wrapped the bedsheet around his neck and tied it to the handicap railing. Fred had a long standing history of schizophrenia and had attempted suicide every time he was hearing voices and was not taking medications.

Saul was diagnosed with paranoid schizophrenia when he was 20 years old and had been living with it for another 20 years. He resided with his brother and had been especially unhappy for the past week. Saul thought that people at work, and his neighbors, had been saying he was the devil. He was employed as a maintenance worker but had not been to work that week. On the day he completed his suicide, Saul waited for his 10-year-old son to leave for school. A few hours later, Saul’s neighbor dropped by after he was unable to reach him by phone. Saul was found unresponsive in the living room. He had overdosed on his prescription medications.

While Arthur, Fred, and Saul’s stories differ, they were all diagnosed with schizophrenia, which increased their risk for suicide. Schizophrenia is one of the most chronic, disabling psychological conditions. It has a broad range of symptoms including hallucinations (auditory, visual, or other type), unusual or strange ideas, disorganized speech, and difficulty distinguishing between what is real and what is imaginary. In order for an individual to be diagnosed with schizophrenia, he or she must exhibit two or more of the symptoms (DSM-V, 2013). Twenty to forty percent of individuals diagnosed with schizophrenia have attempted suicide (Harkavy-Friedman, 2007), while 4% to 10% complete the act of suicide (Martin-Fumadó & Hurtado-Ruíz, 2012). Not all symptoms of schizophrenia increase the risk of suicide. Hallucinations, for instance, are associated with a reduced risk of suicide, but a history of depression, prior suicide attempts, drug misuse, fear of mental disintegration, poor adherence to treatment and recent losses all increased the risk for suicide among people with schizophrenia (Hawton, Sutton, Haw, Sinclair, & Deeks, 2005).

In our sample 14 individuals were diagnosed with schizophrenia. While research suggests that substance abuse is usually linked to suicide risk in people diagnosed with schizophrenia, only 23% of our sample had a longstanding history of substance use/abuse problems (Hawton et al., 2005). Furthermore, no one in the sample had consumed any substances at the time of their deaths. Three individuals experienced interpersonal difficulties, two individuals had attempted taking their lives in the past, one person expressed suicidal threats, and one person attempted to kill himself in front of others. Also, none had legal problems, although some had a history of abuse. The means by which individuals completed the suicide were also similar to the overall SMI sample. However, the individuals in our sample completed the act during summer (43%), and mostly on Thursday (36%), as opposed to the overall SMI sample. Christodoulou, et al. (2012) found autumn and winter were more common seasons for the suicides of those diagnosed with schizophrenia, but noted that some studies have shown a rise in suicide associated with psychiatric illness in the summer and a rise in economically motivated suicides in the winter.

Schizophrenia is an illness with distressing symptoms for the sufferer and often for others. It usually, though not always, manifests for the first time in late adolescence to early adulthood, and there seems to be little if any difference in age of onset between the sexes (Eranti, MacCabe, Bundy, & Murray, 2013). Its onset is sometimes so sudden that family members and friends react with disbelief, and may even deny the person needs psychiatric help. Schizophrenia is a psychotic disorder, and when it takes over a person it wreaks havoc on their senses, their emotions, their reason and their ability to act (Jamison, 1999). Both sufferers and observers can find its symptoms terrifying.

Kerry was 60 years old and living with her sister. She was diagnosed with schizophrenia in her forties and was in the Supplemental Security Income disability program (SSI). Three months prior to her death, she had to move in with her sister for support, because of her medical problems, including diabetes and a heart disease. On a recent birthday none of her children called her or visited her. During her last appointment with her psychiatrist he told her that her symptoms from schizophrenia were not going to improve and she just had to learn to “deal with it.” Kerry’s sister knew that she was unhappy about having to move in with her, and about finding out that she was not going to improve. Yet she had never heard her sister make any suicidal statements or threats. However, when Kerry’s sister returned home after running errands one day, she found Kerry unresponsive in her chair. She had overdosed on her prescription pills.

Kerry was at risk for suicide, because she was deeply depressed about her prognosis. It is not uncommon for people diagnosed with schizophrenia to find it hard to cope with their symptoms. For others, the suicide act can be a response to delusions. Delusions in the individuals diagnosed with schizophrenia are false beliefs based on psychotic thinking about external reality. Hallucinations, in contrast, are false or distorted sensory experiences that appear to be real. While hallucinations can be more frightening, both hallucinations and delusions are dangerous to the individual. Delusions, however, create a greater risk of suicide in people diagnosed with schizophrenia (Hawton et al., 2005; Kelleher et al., 2013).

The only note left in this sample was from Ben, a 26-year-old who was diagnosed with delusional disorder. Though Ben had been under psychiatric care for a long time, he did not adhere to his treatment plan. He was suspicious of his family and friends and believed that a few of his family members were conspiring against him. In fact, he believed that he was under surveillance seven days a week. At times, he believed his parents were part of a plan and were drugging him, so he refused to take his medications. He became more and more secretive and suspicious. Even though Ben never discussed any suicidal thoughts, nor attempted or made suicidal threats, he killed himself. Ben left a note for his father in large handwriting, the few words stark against the white paper, “I LOVE YOU ALL I LOVE YOU ALL I LOVE YOU ALL IM SORRY… I DON’T KNOW WHAT I DID, BUT I DIDNT DESERVE ALL THIS. IT WAS REAL.” When his father found the note, it was too late, Ben was found hanging in the bedroom closet with a dog leash wrapped around his neck. The note written by Ben was short (i.e., less than 25 words), expressed love for others, and provided a general apology. It was not surprising that the majority of individuals in this category did not leave notes. Research has found that people diagnosed with schizophrenia commit suicide with greater violence and lethality and are more likely to commit suicide without warning (Fenton, 2000).

Chad was a 46-year-old man with a history of depression and schizophrenia. Chad had been suffering from schizophrenia since he was a teenager. Chad had attempted several times to kill himself. Once, he walked out onto a bridge with the intent of taking his life, but he was talked out of it by the police. Chad’s parents had a restraining order issued against him, because he was abusive towards them. The last his parents knew he was living in New York and was homeless. Chad returned to Ohio and committed suicide by walking into a river. A nearby fisherman heard a sudden splash and saw Chad going under water just off the shoreline. When they retrieved the body, police found empty bottles of his prescribed medications in his pocket.

In Chad’s case, it was unclear whether he suffered from schizophrenia and later developed symptoms of depression, or whether they existed concomitantly. He may have been diagnosed first with depression and then developed symptoms of schizophrenia. In any case, depression is common among individuals who are diagnosed with schizophrenia, and it is likely to increase the risk of suicide (Hawton et al., 2005). In our sample, nine cases had schizophrenia co-occurring with depression. Similar to the overall sample of individuals who were only diagnosed with schizophrenia, the individuals in this group did not leave any notes. We cannot know their thoughts and feelings, but the case files reveal a history of painful struggle.

Multiple Diagnoses

Tammy was 65 years old and had a history of schizophrenia, bipolar disorder, hypertension, hyperlipidemia, hypothyroidism, and breast cancer. She was a retired nurse who lived by herself and received disability benefits. Tammy did not adhere to her treatment plan and her brother and daughter checked on her regularly in an attempt to make sure that Tammy was taking her prescription medications. The night before she killed herself her brother spoke with her and felt something was wrong. He said it seemed as though she was having a conversation with someone while he was talking to her on the phone. The next day after she did not return his calls, he went to check on her. He found Tammy on the bathroom floor with numerous prescription bottles and with two suicide notes. In one note, Tammy wrote, “I worry that the demons are trying to possess me, Arlene. I can’t keep battling this, Arlene I am sorry to leave such a mess.”

Tammy was coping with the challenges caused by multiple diagnoses, and all of them were difficult and complicated. Comorbidity was not only a risk factor in suicide attempts, but it heightened the risk of lethality (Kessler, Borges, & Walters, 1999). In our sample, the people who had multiple diagnoses included individuals with dual diagnoses or diagnosed with comorbid disorders. Comorbidity refers to individuals who are diagnosed with two or more mental health disorders. Approximately 79% of individuals who are diagnosed with a lifetime psychiatric disorder are dealing with complications arising from multiple diagnoses (Farmer, Kosty, Seeley, Olino, & Lewinsohn, 2013). Sixty individuals in our sample were identified as having comorbid diagnoses. Sixteen of these individuals left notes.

The number of men (53%) and women (47%) completing suicide were almost equal in this sample, and two-thirds had attempted suicide in the past. Almost one-fourth had expressed suicidal ideation or threatened to hurt themselves. Two-thirds were also dealing with physical illness and problems in interpersonal relationships. Less than a quarter had a history of drug use and only a few had legal and financial problems. The most common means of completing suicide was overdose (37%), followed by guns (33%). Twenty-two percent consumed alcohol or some type of substance at the time of their deaths. Nearly half of these individuals committed suicide to escape from psychological problems.

Eighty-one percent of the note writers in this group provided justifications for their suicides in their notes. Their notes were full of apologies, general and personal, as they shared their interpersonal problems. They overwhelmingly spoke of their love for others, and nearly half talked about God. Some of them gave advice. More than half of them talked about escaping, especially psychological pain (31%), and indicated that suicide was the only solution to their problems (38%). They asked for forgiveness (38%), and absolved others from blame (25%).

Jeannette placed the letter to her landlord in the mailbox. She told him to bring his keys, and not to bring his son.

In her notes, Jeannette talked about her struggles with depression and anxiety. In this excerpt, she provided a justification for her actions. Like many in our sample with depression, she also mentioned God, asked forgiveness from others, and expressed how suicide was the only solution. At the foot of her bed were a half-full bottle of vodka and empty bottles of the antidepressant amitriptyline, an antianxiety pill called alprazolam, and methocarbamol, a muscle relaxant often used for back pain. Comorbidity is itself a risk factor for suicide, but patients also often have numerous drugs that can have bad interactions with one another. In this case two of the drugs caused severe drowsiness, and none was supposed to be consumed with alcohol.

Those note writers with comorbidity were also likely to plan their suicides and not be impulsive. Half left instructions in their notes, mostly discussing managing affairs (38%) and the distribution of their personal property (31%). Additionally, 50% included specific requests in their instructions. Many notes paid attention to financial details. Jeannette reminded her landlord that her lease provided for a 30-day grace period before her things had to be removed. One man gave precise instructions for his ex-wife and daughter to be taken care of and wrapped up his own financial affairs:

Xavier then ingested more than a liter of vodka and some medication, in addition to poisoning himself with ethanol.

The most frequent co-occurring conditions with depression were anxiety (37%), unspecified mental illness (18%), schizophrenia (15%), and dementia (7%). We found one person diagnosed with depression and attention deficit disorder (ADD), one individual diagnosed with depression, bipolar disorder, and attention deficit and hyperactivity disorder (ADHD); and one individual diagnosed with depression, anxiety, and unspecified mental illness. While these cases were not high in frequency, it is quite common to have individuals be at risk of complications arising with two or more diagnoses.

Dementia

Depression and anxiety can be co-occurring conditions in the aged (Beekman et al., 2000). Between 2010 and 2030, all of the “baby boom” generation will age past 65. The old age dependency ratio will grow from 22% to 35% in that period (Vincent & Velkoff, 2010). Older adults with depression often experience cognitive difficulties. Depression is also common during dementia, with reported prevalence rates of up to 86%, and may even be the first sign of a dementing illness (Wright & Persad, 2007). A study of the elderly (55–85 years old) in the Netherlands found that comorbidity of depression and anxiety was highly prevalent: 47.5% of those with major depressive disorder also met criteria for anxiety disorders, whereas 26.1% of those with anxiety disorders also met criteria for major depressive disorder (Beekman et al., 2000).

Solomon was 60 years old and had suffered from depression for a long time. In addition, he had conflictual relationships with many family members. When he was diagnosed as being in the early stages of Alzheimer’s disease, he became afraid and felt life would not be worth living. His father had attempted suicide after being diagnosed with Alzheimer’s disease. One day, after leaving his son’s residence, Solomon went to his farmhouse, which had been vacant for months. Later that morning, a passerby reported the farmhouse was on fire. After the flames subsided, Solomon’s body was found in his bedroom and his dog, who was always with him, was found in the bathroom. Solomon had shot his dog and then shot himself with a handgun.

Alzheimer’s disease is the most common type of progressive dementia in older adults. Other types of dementia include vascular dementia, Parkinson’s disease, Huntington’s disease, Pick’s disease, Creutzfeldt-Jakob disease, AIDS dementia, alcoholic dementia (Korsakoff’s), dementia due to head trauma, and mixed dementia. Although each of these forms of dementia is distinguishable, with its own symptoms and pathology, all forms of dementia affect one’s memory, thinking, and social abilities, which interferes with the ability to complete daily activities (Alzheimer’s Association, 2013).

The connection between increased risk of suicide in those who are diagnosed with depression and dementia is not well-documented. Some studies found a low incidence, especially when compared with the higher risk of suicide in those with comorbidity of depression and substance abuse (Waern et al., 2002). There is evidence that Alzheimer’s disease does increase a “wish to die” and suicidal ideation (Draper, MacCuspie-Moore, & Brodaty, 1998). A study of veterans by the Department of Veterans Affairs found the majority (75%) of suicides among that population occurred in those with a new dementia diagnosis, and the individuals in the study who died by suicide were significantly more likely to have been diagnosed with depression.

Anxiety Disorders

Cameron’s life was no longer the same after he returned from serving his country. He could not find a job and did not have steady relationships. He had a long history of depression, anxiety, Crohn’s disease, diabetes, and impotence. One day, Cameron went to the local Veteran’s Affairs (VA) Hospital to seek other treatment options for his Crohn’s disease. After the appointment, Cameron went to an inexpensive motel near the hospital and checked in. When he failed to check out of the room, the manager went to his room. He found Cameron on the bed unresponsive. When the police arrived, Cameron was already dead. He had left a suicide note addressed to his sister and with it was an empty bottle of his prescription pills. In his note, Cameron wrote,

It’s not unusual for someone with an anxiety disorder to also suffer from depression or vice versa. Anxiety is a typical reaction when one is faced with uncertainty. Anxiety is not always a disorder. It often helps an individual to find a way to retreat from a situation or to get ready to face difficult life events. For a person affected with an anxiety disorder, the worry or fears are not temporary and usually worsen over time. All anxiety disorders involve persistent, excessive fear or worry that interferes with daily activities. Comorbid depression and anxiety are highly prevalent conditions, and there may even be genetic and neurobiologic similarities between them. Patients with panic disorder, generalized anxiety disorder, social phobia, and other anxiety disorders are also frequently clinically depressed. Nearly 85% of patients with depression also experience anxiety; comorbid depression occurs in up to 90% of patients with anxiety disorders (Gorman, 1996).

Among the 21 cases of people diagnosed with an anxiety disorder in our sample, the anxiety disorders that were often mentioned were generalized anxiety, panic, posttraumatic stress disorder (PTSD), and agoraphobia. In some of the cases, the relationship between the anxiety and depression was unknown to us. Eleven individuals, over half of the sample, left notes. Sometimes, comorbidity is one of the chief reasons that anxiety disorders go unrecognized and untreated (Gorman, 1996). The overlap of symptoms associated with depressive and anxiety disorders makes diagnosis, research, and treatment particularly difficult. Early recognition of the multiple conditions is key to successful treatment of patients with mixed depressive and anxiety disorders in order to develop comprehensive treatment.

Miscellaneous Other Diagnoses

In our study we occasionally found cases that were not easily compared to others, because there were so few with a particular diagnosis. For example, attention deficit hyperactivity disorder (ADHD) is a condition frequently diagnosed in children and adolescents. Researchers have found a relative risk ratio of 2.91 compared to United States national suicide rates in general, but if ADHD is combined with depression or a conduct disorder, the risk goes up (Impey & Heun, 2012), especially for young men (James, Lai, & Dahl, 2004).

In our study two boys, one with ADHD and one with an unspecified mental illness who had been prescribed Adderall, hanged themselves. Jamal was 11 years old and had a history of ADHD. Over the weekend, when his parents were doing different household chores, his father came to the carport to do some work in the garage. When he opened the door he found Jamal hanging from a rafter. Jamal never expressed suicidal ideation, nor had he ever attempted suicide. However, Jamal was impulsive and had had a recent conversation about death with his mother, but it did not suggest that he had any suicidal intent. Timmy was one of five children removed from his home by Children’s Services, and he was placed in a group home. Although he was only 12 years old, Timmy was known to have behavioral problems and had been prescribed Adderall. Timmy threatened suicide when he was disciplined, but he never attempted to hurt himself. On the day he took his life, Timmy was sent to his room for breaking a minor rule. When a resident went to find him for dinner, he opened the closet and found he had hanged himself. In Jamal’s case, it is impossible to determine whether his ADHD was a factor in his suicide. In Timmy’s case, his removal from his home and his family could have played a role in his suicide, but as he was on medication typically assigned for attention disorders and other problems, we don’t know what else might have contributed.

A third young boy had Asperger’s syndrome. One day at his private high school, Nathan was confronted by a member of his school’s administration who noticed that his shirt was not tucked in. He was asked to go to the guidance counselor for violation of the school dress code. Although his mother attempted to explain to him about the school dress code, Nathan was devastated and could not be consoled. Nathan grabbed the dog leash and ran out towards the back side of the house. His mother just thought he needed some time to himself. She later found that Nathan used the dog leash to hang himself from a tree.

Like many parents, Nathan’s mother did not expect him to have such a drastic response. Asperger’s syndrome is a complex disorder. Not only does it impair social interactions, but it is a source for nonverbal communication problems. Little research exists to affirm that Asperger’s is a risk factor in suicide (Fitzgerald, 2007). It is important to consider and evaluate the extent of a child’s inability to cope with his current situation, his level of impulsivity, and his constricted thoughts, all of which may have factored into Nathan’s decision.

Among the 46 cases in this category of miscellaneous other diagnosis, the majority were identified as having a mental illness, but in 40 cases the diagnoses were unspecified. A total of seven people, or 15%, left suicide notes. The vast majority of note writers expressed love for others and discussed the psychological pain they felt, and all of them gave justifications for completing suicide. Similarly, in this category more than half the note writers discussed their fear of failure, asked for forgiveness for themselves, and left instructions, mostly for managing property, and nearly half gave advice.