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Dear
Dr. Bill,
I am really terribly upset over the recent suicide
of one of my best friends. He was a doctor on the staff
of an area hospital. A couple of weeks ago he jumped
out of a window of his private office in New York. I
knew he had a problem with his drinking and he could
get moody at times. What I don't understand is that
during the last few days before he jumped he seemed
happy, friendly and even more communicative than usual.
He was under a colleague's care who put him on some
antidepressant medicine. We all wonder, did we miss
some clue which would have helped us to stop him?
Sad
Friend - Teaneck
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Dear
Sad Friend,
Unfortunately, there are thousands of horror stories
like yours. I would guess your friend had legitimate
signs of clinical depression, thus the anti-depressant
meds were prescribed by his doctor. The problem is,
in the case of alcoholics anyway, the depression must
be understood as secondary to the disorder. Not diagnosing
the patient's disease of alcohol addiction and dosing
him with antidepressant drugs without also addressing
the patient's primary illness can be a fatal mistake,
as the death of your friend illustrates. As I reported
in my column last October, even today, medical students
are rarely being taught more than simple screening techniques,
some information about detoxification, and very little
about treatment follow-up or brief interventions. This
is irresponsible. Until adequate addiction courses become
part of the core curriculum of all medical schools,
tragedies such as the one you have described, will continue
unabated.
There
is considerable data supporting the strong relationship
between alcoholism and depression. There is virtually
no disagreement on the fact that alcoholics become depressed
with symptoms patterns which mimic those of primary
depressives. One of the significant differences between
the syndrome in alcoholics and non- alcoholics is the
periodicity factor. A non-alcoholic individual who is
clinically depressed will often maintain these symptoms
for days, weeks, even months. The alcoholic slips in
and out of depression with an often startling rapidity.
The alcoholic presents a living roster of affective
disorder symptoms which are constantly shifting. Thus,
behaviorally, the alcoholic's symptoms often mimic that
of a bipolar depression with the patient far too often
mistakenly diagnosed simply as a manic-depressive.
It
is this switching of symptoms which often makes the
alcoholic such a prime candidate for suicide. It is
estimated that 10,000 known alcoholics kill themselves
in every 12 month period. Alcoholics constitute 25%
of all successful suicide attempts and more than 60%
of all failed attempts. These are conservative figures,
I am sure, as most alcoholics, like your friend, are
never diagnosed as having the illness.
The
alcoholic's constant symptom switching should have some
real practical import to some of the readers of this
column.....A nonalcoholic individual who is diagnosed
for depression is usually watched closely by those who
love or care for him or her. The possibility of suicide
is always present and recognized. But the alcoholic,
who keeps switching symptoms, is never considered to
be truly in danger because he or she will always come
out of the depression into something else.
As
a result of years of experience treating addictive patients
and in the context of the above information, I would
suggest two clinical axioms for my readers and, especially,
my medical colleagues to consider:
(1) depressed individuals should be considered alcoholic
until proven otherwise;
(2) all alcoholics should be considered suicidal unless
proven otherwise.
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