Howard Markel, MD, PhD


May 27, 2005

Despite the widespread use of Prozac and its progeny of powerful serotonin-reuptake inhibitors, depression remains a potentially fatal disease. According to the National Institute of Mental Health, suicide was the 11th leading cause of death in the United States in 2000, claiming almost 30,000 American lives or 1.2% of all deaths. Roughly 500,000 people require emergency room treatment for attempted suicide each year, and estimates suggest there may be 8 to 25 attempts at suicide for every suicide death.[1,2,3]

More than 90% of those who kill themselves suffer from depression or another mental health or substance abuse disorder that brings on its symptoms. This is incredibly important because recent research indicates that changes in neurotransmitters, such as serotonin, can increase one's risk for suicide.[4]

Pediatricians or other clinicians working with children and adolescents can no longer consider this merely a problem of adults. Suicide has increased dramatically among young people. In 2000, it was the third leading cause of death among 15- to 24-year-olds, or 10.4 per every 100,000 persons in this group. It was the third leading cause of death among 10- to 14-year-olds, or 1.5 deaths per 100,000 children. Incidentally, unintentional injuries and homicide were the first and second leading causes of death for these age groups. Suicide rates for 15- to 19-year-olds was 8.2 deaths per 100,000 teenagers and was 5 times more common in young men than in young women. Among people 20 to 24 years of age, the rate was 12.8 deaths per 100,000 and was 7 times more common among men.[1,2,5]

I was reminded of these facts last week, as I read a student's medical school application in which he described his experiences with clinical depression and how his recovery had inspired him to become a physician. He wanted to help improve the diagnosis and treatment of this serious malady. His confession was striking.

Twenty-four years ago when I was applying to medical school, no applicant would have admitted any type of mental health problem because it would have been instantly interpreted as evidence that the applicant was not "strong enough" to practice medicine. Sadly, many still subscribe to this erroneous belief.

What struck me hardest about this application, however, was a tragic coincidence. Two hours earlier I had learned that a colleague had committed suicide after a long struggle with depression. She was an accomplished physician, a loving mother, and wife. She was 51 years old. Stunned, I rushed to her funeral that afternoon.

I thought I knew Dr. T. well. She began medical school in her late thirties after a successful career as a speech pathologist. At 42, she was an intern on my hospital service while I, her attending physician, was a callow 34. She always performed her job with distinction and was lit from within by a desire to become a pediatrician. Perhaps her wisdom and kindness were inspired by the fact that she was the child of Holocaust survivors, but I think it was something far more intrinsic to her character.

Her area of clinical expertise was counseling parents about adoption issues. Unable to conceive, Dr. T. was not about to let biology get in the way of becoming a parent. She and her husband adopted and raised 2 wonderful boys. But she also understood the desperate need in our community for pediatricians to understand and explain the myriad medical, emotional, and behavioral issues surrounding adoption, and soon built up a successful practice.

It was only recently that I learned about her downward spiral. Over the past year, Dr. T. consulted doctors, psychiatrists, and support groups; was prescribed antidepression drugs at higher and higher dosages; and engaged in futile attempts at self-medication with alcohol and tranquilizers. Nothing seemed to work.

Sadly, her insidious but powerful disease won. While at a weekend retreat for women with mental health problems, she left the group and took her life.

Doctors have conducted postmortem examinations since, at least, the Renaissance. Using clinical evidence and scientific data, we try to figure out why someone's life ended and, more importantly, what we could have done to help avoid that outcome. The great physician Sir William Osler called this practice the "doctor's final court of appeals." Sitting at Dr. T's funeral, I wondered what else might have been done -- if anything -- to prevent this tragedy.

As if reading my mind, a psychiatrist colleague next to me lamented, "when it comes to depression, we really don't know all that much, but its anonymity often has disastrous consequences for those suffering from it and everyone who cares for them." If a psychiatrist admits this dangerous blind spot, what does it say for the thousands of pediatricians, family practitioners, internists, surgeons, and other primary care clinicians who see depressed patients on a daily basis but fail to recognize, let alone adequately treat, them?

When I got back to my office, I reexamined the young man's essay about his battle with depression. I realized that a few hours earlier I, too, had some reservations about his fitness to become a physician. Had he written about recovering from cancer or a chronic physical disease, I know I would have not responded in the same way. And so I decided to send him a note congratulating him for his honesty and predicting a bright career in medicine for him. "All of us need to know a lot more about depression," I wrote, "and I hope you come to my medical school."