Abstract
This essay describes the symptoms and diagnostic criteria for major depressive disorder, with an emphasis on the symptoms of thoughts of death and suicidal ideation. It further reviews methods of treatment, and then finishes with a review of ways therapists can forge and strengthen therapeutic relationships with suicidal patients.
Introduction
To exist or not, as a human being, is up to us. Albert Camus (1979) contends suicide is the only genuinely profound philosophical question to answer. True, every individual has the choice to exit life, however the cost of that exit can be significant for those left behind. Not even counting the invaluable cost of loss of life, suicide attempts alone accounted for nearly $27B in health care costs in 2019 in the United States (Hughes, et al., 2023). Even despite the massive expense from the fallout of suicide attempts, the emotional toll and impacts heaped on loved ones and friends who remain behind in the wake of a successful or unsuccessful suicide will take countless hours of therapy and grieving and perhaps even significant pharmacological expense to remediate. From a psychological, to an emotional, to an economic perspective, any way to advance the understanding of the patient’s motivation for suicide and greater insight into how to prevent suicides would be a worthy endeavor not only for the individual, but also for the common good. To that end, this essay will explain the most common disorder which leads to suicide.
This essay will describe major depressive disorder, including all the criteria that must be met in order to diagnose an individual with major depressive disorder (Maddux & Winstead, 2016 and American Psychiatric Association, 2022). Along with those criteria, it will also outline the symptoms and warning signs of those seeking to end their life (National Institute of Mental Health, 2022). It will then review three major avenues of treatment for major depressive disorder, which include electroconvulsive, psychopharmacological and psychotherapeutic forms (Maddux & Winstead, 2016). Lastly, the essay will delve into the topic of clinicians establishing the clinician-patient therapeutic alliance to assist patients in opening up about the challenges they face with suicidal ideation (Foster, et al., 2021).
Description, Symptoms, Diagnostic Criteria
While the impacts of major depressive disorder (MDD) can be persistent and influence human productivity, symptoms can worsen and lead to the untimely death of the sufferer. Maddux and Winstead (2016) note that MDD will perhaps be the number one cause of premature death and human disability globally in the next one hundred years. In the United States alone, the suicide rate has increased over a third between 1999 and 2018 and with the recent COVID-19 pandemic, that trend has continued to rise (Moutier, 2021). Therefore, spotting MDD symptoms effectively and early is key to suicide prevention.
The symptoms of MDD described in the DSM-5-TR (American Psychiatric Association, 2022) begin with understanding what a major depressive episode is. Symptoms include nine key markers: 1) a depressed mood, which may include feelings of helplessness and hopelessness, 2) the loss of interests or pleasure in activities the person normally enjoys, 3) losing 5% or more of their weight in 30 days while not intending to diet, 4) poor sleeping habits stemming from insomnia or perhaps sleeping all day, 5) constant agitation in movement or a significant lack of movement, 6) general lack of energy, 7) self-loathing, exceptional feelings of guilt or worthlessness, 8) significant challenges in concentration, deliberation, thinking or even decision-making, and most importantly, 9) repetitive thoughts of dying, death or suicide. As for this ninth symptom, the patient does not need to demonstrate it every day for a two-week period; once is sufficient to qualify. The patient must exhibit five or more of the nine listed symptoms (two of which must be a depressed mood and loss of interests) for a period of at least 14 days, and these must cause a substantial impact on their social life, job or other important aspects of their life, and the attribution of these symptoms must not stem from some other condition such as drug use, or another disorder such as schizophrenia (American Psychiatric Association, 2022, p. 183, 185). Lastly, in order for MDD to qualify as the diagnosis, the patient must demonstrate having one or more major depressive episodes, without any type of mania or hypomania.
One other important aspect of the diagnosis is related to whether there is an identifiable cause of the patient experiencing the symptoms. Some people may have recently dealt with an impactful and emotional event in their life such as the loss of a baby, a bankruptcy or loss of job, living through an act of God such as having a home and all possessions burned down in a wildfire or even having contracted a serious medical illness such as terminal cancer (American Psychiatric Association, 2022, p. 183). While many people may exhibit major depressive episode symptoms stemming from one of these drastic life events, it does not mean the person qualifies for the diagnosis of MDD.
As noted in the ninth symptom of MDD, if a patient has repetitive thoughts of death or suicide just once in a two-week period, along with the other symptoms, then they may have MDD. It is also important to note external markers which may predict if a patient is suicidal. Maddux and Winstead (2016, p. 193) observe that a majority of suicidal people convey their intent to kill themselves. More specifically, the National Institute of Mental Health (2022) provides a list of warning signs which loved ones and other people around the patient can spot. The patient may verbally express ideas of suicide, feelings of guilt or sense of being a burden on other people. They may express feelings such as helplessness, hopelessness, being trapped, having no purpose, or being sad, anxious, angry or expressing unendurable pain be it physical or emotional. Lastly, the patient may communicate in non-verbal ways such as searching online for ways to die, pushing close ones away or retreating from normal social interactions, acting with recklessness (e.g. risky skiing, driving, cliff jumping), consuming more drugs or alcohol, and sleeping and eating less. Related to the warning sign of recklessness, Maddux and Winstead (2016) note that suicides may be underreported because the act of suicide may appear to be accidental. For example, 15% of automobile accidents with a fatality may actually have been suicide related.
Treatment Options
There are three major avenues of treatment for MDD: electroconvulsive, psychopharmacological and psychotherapeutic therapy. The essay will briefly describe mechanisms which address the first two methods and then more deeply address the third method through a discussion on cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT).
Electroconvulsive therapy (ECT) was discovered as a form of therapy in the 1930s (Maddux & Winstead, 2016, p. 205). The method for application is to deliver between 70 and 130 volts of electrical shock to the patient’s brain. The patient may endure nine or ten rounds of ECT over the course of several weeks. While ECT has proven to be somewhat effective, experts still do not know exactly why it works in some cases. One theory is that electrical shocks downregulate 5-HT (serotonin) receptors. Despite proving somewhat effective, patients’ memory functions degrade, and they have a more difficult time learning and recalling knowledge. Related to ECT is transcranial magnetic stimulation (TMS). TMS does not produce memory dysfunction and can be more precisely tuned. The only side effects reported are benign headaches and minor discomfort.
Pharmacological forms of therapy for major depressive disorder address dysfunction in serotonin regulation (Maddux & Winstead, 2016). Studies have shown that when individuals’ serotonin levels are depleted or if reuptake has been altered, then it begins to have a negative impact on mood, which may act as a catalyst for a depressive episode. Three medications have been used for quite some time to treat depression: monoamine oxidase inhibitors, tricyclic and tetracyclic antidepressants. More recent developments in antidepressant medications include selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). All five medications work in some form or fashion to regulate serotonin levels. As for which one should be used with a patient, it is often a matter of finding the right medication and dosage with the least harmful side effects. One emerging medication to address depression is ketamine. Rather than targeting the regulation of serotonin, ketamine seems to aid in the regrowth of important synapses in the brain, improving brain neuroplasticity (Yale Medicine, 2021). Researchers are discovering that ketamine treatment coupled with CBT provides rapid and long-lasting positive change. Not only do ketamine and CBT together prove efficacious, but Maddux and Winstead (2016, p. 198) note that CBT coupled with other appropriate medication is more effective than either CBT or medication alone.
CBT and ACT are two well-known psychotherapeutic frameworks which help the patient to fundamentally change their underlying thinking to address negative perceptions of themselves and environment (Maddux & Winstead, 2016, p. 197-199). CBT encompasses multiple ways to help the patient alter the underlying thinking framework for how the patient processes events, as well as to couple their thinking to action. For example, people who suffer from MDD would be asked to recognize and write down their negative thoughts, along with the causes and effects which lead them to think this way. They would then be asked to assess and question those thoughts to ascertain if they truly match reality and rationality. Through this process, the patient begins to reconstruct their thinking narrative in a more positive and productive manner.
CBT is especially helpful in challenging and questioning hopelessness thinking in suicidal patients. In fact, studies have shown (Bryan, 2019) that versions of CBT for suicide prevention (CBT-SP) are so effective, that these specific forms of CBT have been recommended as standard care procedures for all suicidal patients. CBT-SP typically includes three successive phases. In the first phase, clinicians assess the risk of the patient and then collaboratively work with the patient to form a crisis and treatment plan. In the second phase, the therapist and patient work on revealing the dysfunctional thinking patterns and negative internal dialogues which lead to feelings and emotions related to helplessness, hopelessness, being trapped, and having no purpose. In the last phase, therapists and patients tie everything together by creating a plan to minimize relapse. Bryan (2019, p. 249) further observes the effectiveness of CBT-SP by stating that patients of CBT-SP were one-half to two-thirds less likely to attempt suicide when compared to treatment as usual.
ACT can be viewed as an extension and evolution of CBT (Maddux & Winstead, 2016, p. 198-199). While ACT is similar to CBT, it differs from its aim. ACT does not focus on minimizing the negative symptoms of depression, but to empower the patient with greater flexibility in their thinking. ACT helps the patient understand their core values and then proceed in a consistent manner with those values. ACT prompts the patient to pause and reflect on what they deeply value in life, and then to engage with their emotions and thoughts, rather than questioning them. By engaging with their thoughts and emotions through a comparison with their core values, the patient is able to discern gaps between who they are and who they wish to be, and then take specific and meaningful action. For example, ACT has proven to be quite successful with veterans dealing with suicide (Walser, et al., 2015, p. 30). It has shown that when a patient experiences suicidal ideation, the therapist would work with the patient to explore the patient’s core values, either through dialogue or a values assessment test. As the patient is confronted with ideas of death, they can accept those thoughts and pivot toward ways to pursue and fulfill meaning in their life by focusing on something they value.
Article Summarization: Strengthening the Therapist-patient Alliance
In the context of suicidal ideation, it has been observed that most suicidal individuals do not explicitly disclose through self-reporting. Foster, et al. (2021) note that only 24% reveal their suicidal plans through disclosure. The driving causes of hesitating to divulge their thoughts of ending their life are fears of judgement, hospitalization, and losing independence. Therefore, if therapists, clinicians and others who are in a position to help the patient can establish trust and openness in communication, they may be able to garner the patient’s confidence and assist them in getting the needed medication and therapeutic treatment. Foster, et al. (2021) argue that three specific aspects on which clinicians can focus to improve the therapist-patient alliance are: 1) awareness and management of countertransference of negative emotions, 2) deploying communication techniques which are empathic and 3) leveraging the patient’s subjective experience as feedback.
Countertransference occurs when the therapist experiences conscious or unconscious projections or judgements of the patient, which in some cases may interfere with the therapeutic process (American Psychological Association, 2018). Foster, et al. (2021, p. 258) note that therapists can exude negative emotions to an individual intent on ending their life. Quickly assessing countertransference is crucial to strengthening the therapist-patient alliance. The Therapist Response Questionnaire-Suicide Form is an innovative tool to rapidly assess countertransference and enables the therapist to secure supervisory coaching and support to manage countertransference.
Empathy is how one person relates to another, including focusing on commonalities as well as differences, which enables shared insight between individuals (Foster, et al., 2021, p. 259). Clinicians and therapists must have a life-long commitment to developing and mastering empathy in their practice, especially when working with suicidal patients. Besides continuing education and hands-on training seminars to learn and practice empathy, there are also tools which assist therapists to hone their empathy skills. The Empathic Communication Coding System (ECCS) assists in identifying opportunities for the therapist to practice a range of empathic responses. The ECCS aids in identifying the patient’s statements as emotion, progress or challenge and then suggests a range of potential ways a therapist could use empathy. For example, a widow may mention how she constantly thinks of her deceased husband, to which a therapist could respond with, “Are you thinking about death?” or with the more empathic response of, “It seems that these thoughts you are having are difficult. Has suicide crossed your mind?” Therapists who master the art of empathy will improve the chances of the patient opening up and being more receptive to treatment rather than suicide.
Lastly, when therapists form a solid alliance with the patient, they can leverage that trust to gain insight from the patient feedback. Gathering feedback from a patient who has attempted suicide or had thoughts of suicide can prove rich in understanding the paths leading to death as well as paths leading to recovery (Foster, et al., 2021, p. 259). Collecting this feedback and sharing it broadly enables the wider community to benefit from this untapped resource. Tools such as the Consultation and Relational Empathy assessment and Working Alliance Inventory collect data from the patient’s perspective. These feedback mechanisms reinforce patient autonomy as well as shed light on the subjective experience of the patient.
In sum, there are innovative ways and tools to facilitate greater collaboration between the therapist and suicidal patient. First, the therapist must be aware of and manage countertransference of negative emotions. Second, they must constantly improve their communication techniques by focusing on improving empathy. Lastly, they can tap into the patient’s subjective experience to use as feedback in the therapeutic process.
Conclusion
In conclusion, with the increasing trend of suicides globally, and the severe impacts they have on society, this essay endeavored to illuminate the reader on the topic of major depressive disorder, with an emphasis on the symptom of suicidal ideation and the diagnostic criteria indicating a risk for suicide. The essay then examined three methods of treatment in the forms of electroconvulsive therapy, pharmacological and psychotherapeutic avenues. It specifically addressed CBT, CBT-SP and ACT in the context of suicidal patients. Finally, the essay discussed the importance of the clinician-patient therapeutic alliance, along with a set of tools to enable the fortification of that collaborative effort.
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders, text revision (5th ed.). American Psychiatric Association.
American Psychological Association. (2018). APA Dictionary of Psychology. Dictionary.apa.org. https://dictionary.apa.org/countertransference
Bryan, C. J. (2019). Cognitive behavioral therapy for suicide prevention (CBT‐SP): Implications for meeting standard of care expectations with suicidal patients. Behavioral Sciences & the Law, 37(3), 247–258. https://doi.org/10.1002/bsl.2411
Camus, A. (1979). The Myth of Sisyphus, and Other Essays. (J. O’Brien, Trans.). Penguin Books Ltd. (Original work published 1955)
Foster, A., Alderman, M., Safin, D., Aponte, X., McCoy, K., Caughey, M., & Galynker, I. (2021). Teaching Suicide Risk Assessment: Spotlight on the Therapeutic Relationship. Academic Psychiatry, 45(3), 257-261. https://doi.org/10.1007/s40596-021-01421-2
Hughes, P. M., Phillips, D. C., McGrath, R. E., & Thomas, K. C. (2023). Examining Psychologist Prescriptive Authority as a Cost-Effective Strategy for Reducing Suicide Rates. Professional Psychology, Research and Practice, 54(4), 284–294. https://doi.org/10.1037/pro0000519
Maddux, J. E., & Winstead, B. A. (2016). Psychopathology : Foundations For A Contemporary Understanding (4th ed.). Routledge/Taylor & Francis Group.
Moutier, C. Y. (2021). Innovative and Timely Approaches to Suicide Prevention in Medical Education. Academic Psychiatry, 45(3), 252–256. https://doi.org/10.1007/s40596-021-01459-2
National Institute of Mental Health. (2022). Warning Signs of Suicide. Www.nimh.nih.gov. https://www.nimh.nih.gov/health/publications/warning-signs-of-suicide
Walser, R. D., Garvert, D. W., Karlin, B. E., Trockel, M., Ryu, D. M., & Taylor, C. B. (2015). Effectiveness of Acceptance and Commitment Therapy in treating depression and suicidal ideation in Veterans. Behaviour Research and Therapy, 74, 25–31. https://doi.org/10.1016/j.brat.2015.08.012
Yale Medicine. (2021, July 30). Ketamine & Depression: How it Works - Yale Medicine Explains. Www.youtube.com. https://www.youtube.com/watch?v=nW21-AYY_fs
No comments:
Post a Comment