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MAJOR DEPRESSIVE DISORDER AND SUICIDE

Mrs. Chaitali Madan Mulchandani

Major depressive disorder (MDD) is often referred to as the common cold of mental
health, with more than 264 million people of all ages suffering from it (World Health
Organization [WHO], 2019). It is generally characterized by sadness and loss of interest, which
lasts for at least two weeks and is accompanied by cognitive and physical distortions.
According to DSM–5 (2013), a major depressive disorder is characterized by prolonged
helplessness, which is usually accompanied by low self-esteem, feelings of worthlessness, and
changes in sleeping and eating patterns. Also, a person suffering from MDD lacks the energy and
ability to appreciate previously favorable activities (anhedonia). Bowl-by (1980) argued that
MDD is maladaptive sadness or mourning, which is resulted from distorted cognitions about the
self.
Quite often, depression is associated with suicide. However, the Diagnostic and
Statistical Manual of Mental Disorders 5th edition (DSM–5; 2013) categorizes suicide as a
separate mental disorder rather than a symptom of MDD or Borderline Personality Disorder.
At its worst, depression can lead to suicidal behavior (Arsenault-Lapierre, Kim &
Turecki, 2004; Large, 2016). According to Kessler, Berglund, Borges, Nock & Wang (2005),
suicidal behavior involves suicidal ideations, suicidal plans, suicidal attempts, and completed
suicide (the act of killing oneself). Every year "around 800,000 people die from suicide" and "it
is the second leading cause of death in 15-29-year-olds" (WHO as cited in Hicks, 2018, p. 24).
Although suicide and depression have similar symptoms, it had been argued that numerous
disorders such as schizophrenia, substance use disorders, particularly with alcohol (Inskip, Harris
& Barraclough, 1998; Conner & Duberstein, 2004), personality and anxiety disorders (Nepon,
Belik, Bolton & Sareen, 2010), might lead to suicide (Mann, 2003) and about 10% of those who
display suicidal behavior have no psychiatric illness at all (Oquendo, Baca-García, Mann &
Giner, 2008). At the same time, only 5% of patients who are diagnosed with any mood disorder
kill themselves (Bostwick and Pankratz, 2000) and 15% of patients diagnosed with MDD will
ultimately die from suicide (Gonda, Fountoulakis, Kaprinis, Rihmer, 2007).
According to a recent study by Van Ballegooijen et al. (2019), lack of optimism and
hopelessness are the main indicators of depression in patients with suicidal ideation compared to
non-suicidal depressed patients. The patients with non-suicidal depression display dissatisfaction
and liveliness (Van Ballegooijen, et.al. 2019).
Complex and combined interaction between biological, social, environmental, cultural,
and psychological factors are generally considered the cause of any mental health disorder. This
theory was first proposed by Engel (1977) and was named the bio-psycho-social model of
causation. It is the most recognized concept among mental health specialists and researchers for
understanding the cause of disorders such as MDD.

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Numerous interrelated causes exist for any mood disorder, including major depressive
disorder. Various biological factors might lead to the occurrence of MDD. One of them is a
genetic contribution, which might be difficult and complex to determine. Traditionally, family
and twin studies are the main sources of estimating this contribution, with some of them showing
that mood disorders might be heritable (McGuffin et al., 2003).
Depression is commonly considered to be a neurochemical disorder, in which the
decrease or increase of dopamine, norepinephrine, and serotonin is associated with specific
symptoms of depression (Nutt, 2008), and is often treated with antidepressant medications.
Belmaker & Agam (2008) reviewed current studies into biological causes of MDD and found
that patients with MDD have a deficiency in serotonin and norepinephrine, increased level of
CRH (corticotrophin-releasing hormone), and decreased size of the hippocampus.
According to Belmaker & Agam (2008), depressed and non-depressed people show
significant differences in neurophysiological factors such as mean differences in hypothalamic–
pituitary–adrenal axis function, hippocampal size, or brain-derived neurotrophic factor. These
differences could thus be related to MDD or could be a result of myriad healthy neurobiological,
psychological, and behavioral responses to adversity.
Also, biologically women are more susceptible to have MDD in comparison to men (Eid,
Gobinath & Galea, 2019; Albert, 2015). Albert (2015, p. 219) suggests "the fact that increased
prevalence of depression correlates with hormonal changes in women, particularly during
puberty, before menstruation, following pregnancy, and at perimenopause, suggests that female
hormonal fluctuations may be a trigger for depression". Besides, autoimmune diseases and
severe infections can lead to developing mood disorders according to Danish Nationwide Study
(2013).
Cognitive psychologists (Beck, 1967; Ellis, 1957), on the other hand, believe thought
processes to be a major cause of depression. According to Beck (1967, 1976), negative thought
patterns about the world, the future, and the self are the main cause of depression.
However, several studies insisted that the environment, stress, and negative life events
can cause depression (Brown & Harris, 1978; Mitchell, Cronkite & Moos, 1983). In the modern
world depression and (attempted) suicide are often identified as a cultural trend, which
emphasizes the negative impact of technology on adolescents and young adults (Twenge, 2019).
Suicidal ideations can be caused by genetic contribution or by psychological factors such
as stressful events (O'Connor, 2011). Like the environmental causes of MDD, most suicides are
triggered by external factors, such as stress and negative events in life (Lewinsohn, Rohde &
Seeley,1994; Oquendo et al., 2014). Successfully dealing with these events depends on the
personality traits, which consist of learned characteristics and genetic individual differences.
Researchers also suggest that suicidal adults display certain types of temperament, impulsivity,
and aggressiveness (Moeller, Barratt, Dougherty, Schmitz & Swann, 2001). Such temperaments
might be explained by some genes that regulate neurotransmitters in the brain.
Mann (2013) found that suicidal behavior could be caused by genes that "govern the
function of the serotonergic system and although different polymorphisms in the genes that
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CASIRJ Volume 12 Issue 3 [Year - 2021] ISSN 2319 – 9202

encode tryptophan hydroxylase, the serotonin transporter, the different serotonin receptors, and
monoamine oxidase have been found, their relationship to suicidal behavior remains unclear".
Autoradiographic examination of individuals, who exhibit suicidal behavior, clearly indicate to
abnormalities in the ventromedial prefrontal cortex. Such abnormalities are strongly
corresponding "with the neurochemical deficits that have been reported in the population"
(Mann, 2003). Substance abuse as a cause of suicide is also supported by Wrede-Jantti's report
for the Nordic Centre for Welfare and Social Issues (2017). Moreover, according to Professor
Rory O'Connor (2011), people who commit suicide have higher physical pain tolerance or
sensitivity and less fear about death.
Numerous studies show that females are twice as likely to be affected by depression in
comparison to males (Albert, 2015) and experience more severe forms of depression (Kornstein,
et.al. 2000; Eid, Gobinath & Galea, 2019). Moreover, female adolescents are twice as likely to
experience depression in contrast to male adolescents due to pubertal development (Hankin &
Abramson, 2001). Therefore, the majority of suicidal attempts are made by females, however,
more males die from suicide, partially due to the choice of method of suicide (Vijayakumar,
2015), the only exclusion is China (Cheng & Lee, 2000). The high death rate in men from
suicide can explain the low rate of primary care consultation among men. Typically, women tend
to seek help for mental illness more than men, who are considered weak if seeking the same
help. Furthermore, gender differences are higher in individuals from disadvantaged areas
compare to those who came from a privileged background (Wang, Hunt, Nazareth, Freemantle &
Petersen, 2013).
Negative or maladaptive thinking patterns can contribute to depression. Another major
trigger for depression could be losing a loved one or any other form of disappointment. Past
conflicts that are not completely resolved also make a person vulnerable to depression.
Moreover, the presence of social support and the avenues for fulfillment also play an important
role. It is also vital to understand that depression may occur with suicidal ideations or without it.
It is, therefore, pertinent to use suitable measures for the assessment of depression as well as
suicide to make a proper diagnosis and design the appropriate treatment plan.
Assessing depression is generally a complex procedure, which includes observations,
semi-structured interviews, self-reported and clinician-administered questionnaires. There are
several widely used self-reported questionnaires, such as The Beck Depression Inventory-II
(BDI-II) (Beck, Steer & Brown, 1996) and The Self-Rating Depression Scale (SDS) (Zung,
1965); and clinician rating questionnaires, such as The Hamilton Rating Scale for Depression
(HRSD) (Hamilton, 1960) and the Montgomery Asberg Depression Rating Scale (MADRS)
(Montgomery & Asberg, 1979).
The difference between these is not only in the form of administration but also in the
symptoms that are being assessed. According to DSM-5 (2013), to diagnose depression a mental
health professional should use the symptom checklist regarding the patients' emotions, energy
level, sleeping patterns, eating habits, unexplained physical pain, and difficulty concentrating.

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CASIRJ Volume 12 Issue 3 [Year - 2021] ISSN 2319 – 9202

Assessing suicidal behavior can be similar to assessing depression, however not all
suicidal intentions are obvious, sometimes even concealed (Freedenthal, 2007). A widely used
scale to assess suicidal behavior is Beck's Suicide Intent Scale (SIS) (Beck, Schuyler, Herman as
cited in Beck, Resnik & Lettieri, 1974) with more than 400 studies citing this scale (Freedenthal,
2007). Another scale is The Colombian Protocol, known as Columbia Suicide Severity Rating
Scale (C-SSRS) (Posner et al., 2011). The main goal of these assessments is to identify a risk of
imminent harm, as typically suicidal behavior is sudden and fast developing and requires
immediate attention (Weber, Michail, Thompson & Fiedorowicz, 2017).
There are several treatments for depression, depending on the severity of the disorder.
Normally, a non-drug approach, such as self-care or psychotherapeutic approach, is widely
utilized for a milder version of MDD. Cognitive-behavioral therapy (CBT), interpersonal
psychotherapy (IPT), and short-term psychodynamic supportive psychotherapy (SPSP) are
considered the most efficacious psychotherapies nowadays (Park et al., 2014). A study by
Morres et al. (2019) also supports a non-drug approach by suggesting that regular exercise can
minimize symptoms of mild depression. However, for more severe forms of depression
biological treatments (Kennedy & Bagby, 1996) or biological with a combination of
psychological treatments are highly effective (Cuijpers et al., 2014). Biological treatments
include antidepressant medications; cranial therapies such as electroconvulsive therapy (ECT)
and transcranial magnetic stimulation (TMS); and chronotherapies such as wake therapy
(D'Mello, 2008) and total sleep deprivation (TSD) (Giedke & Schwärzler, 2002). After re-
analyzing the FDA database, Hengartnera and Plöderlb (2019) found that patients with MDD are
at higher risk of suicide due to prescribed antidepressants. The patients should be closely
monitored when start taking antidepressants.
There is no treatment available for suicide since it is an act of self-killing. However,
suicidal ideations and suicidal attempts can be prevented and treated. Selective-serotonin
reuptake inhibitors (SSRIs) is commonly prescribed antidepressant drug, however, it can
increase risk of suicide, especially in the first month of taking (Teicher, Glod & Cole, 1990).
Another psychotic drug clozapine is the only medication, which is approved by Food and drug
administration (FDA) for reducing suicide risk (Reid, Mason & Hogan, 1998). Apart from
medicated treatment, suicidal patients can be treated with psychotherapies. CBT, which is
commonly used for depressed patients, and dialectical behavioral therapy (DBT) have shown
positive results in preventing suicidal behavior (Brown, 2005; Probst et al., 2018).
When talking about depression and suicide, it is important to understand that both have
biological, psychological, and social components. A study by Seney et al. (2018) "reveals
divergent corticolimbic molecular changes in men and women with MDD". Results of their
study suggest that treatments to suppress immune function may be more appropriate for men
with MDD, while treatments that boost immune function may be more appropriate for women
with MDD (Seney et al., 2018). Therefore, future treatments in MDD could be gender-based,
which could be more effective than the present treatments.

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