Depression and Suicide

by Dr. Tedla w. Giorgis

In my office, the phone never stops ringing. So, I didn’t find it at all unusual that the light indicating that there were messages on my voicemail was already blinking at 8:00 a.m. I pressed the play button and sat down to listen. I had at least five frantic messages. Before I had a chance to listen to my messages, there was a call. I picked up the receiver, and on the other end was a family friend who sounded both excited to find me and pissed off that I hadn’t returned his call right away. I said to him, "Listen, it is only 8:00 o’clock." He replied anxiously, "I did not sleep a wink last night, I need your help." He told me that he had spent the night at an emergency room assisting and comforting family friends who were trying, unsuccessfully, to have their brother examined because he was socially withdrawn, uncommunicative, and at times extremely irritable. This friend wanted to bring the family and the patient to my office immediately.

When they arrived, I approached the waiting area to find a group of five people huddled together looking anxious and frightened. They were holding various parts of the patient’s body as if the patient would bolt out the door if they let go. We introduced ourselves and I escorted them into my office, bringing in extra chairs to accommodate all of us. When I inquired what had happened, the sister immediately began to cry, saying "if something happened to him, my mom would die, he is her favorite." His brother went on to say, "If he can only get a little better, we can send home to Ethiopia." After everyone except the patient had had a chance to vent their frustration, fears, and solutions, I looked toward the patient and asked, "How are you doing? After a long silence, which was consistently interrupted by the others who cajoled him by saying "tenager inji, atifra," he said "min Tiqim alew," with a dejected look and a barely audible voice. Before I had a chance to probe further, the brother let out a loud sigh of frustration and said, "you see, Doctor, what we had to face for the past three months, he does not work, eat, talk … he stares at the wall the entire day."

One by one, frustrated and indignant, his family tried to impress upon me that there should be nothing wrong with the patient, because "minim yegodele neger yelm." They said that they took him to the emergency room after they found him wandering in the middle of the night outside the apartment oblivious to oncoming traffic. After six hours in the emergency room, the doctors prescribed a medication and told the family to take him to a mental health center the next morning. Throughout this entire dialogue, the patient did not show any sign of emotion, but sat staring at the floor as if he was in a trance. Mentioning his name, I said "Can you please look at me when I talk to you?" When there was no response, I got close to him, and tapping his shoulder I said " ayzoh, yalehibet huneta yigebaNal." He barely noticed my face and said, "No one does." After a pause, I said, "It must have been difficult for you to explain what you have been going through to your family." This time, he looked at my face a little bit longer and said "awo kebad neger new." Again, after a measured pause, I said, "One really doesn’t understand what you are going through unless they experience it themselves." This time, the patient looked up, took a thorough look at me and then at his family, and nodded his head up and down in the affirmative. Seizing the moment and opportunity that the empathy and understanding had provided, I said to him "I am not sure how I can help, but when I see you, I see someone that is really down, unhappy, and hurting and really not interested in life." Before he had a chance to comment on my observation, I asked, "How long have you been feeling this way?" With a look of amazement, as if I had read his mind, he said "negeru quoyitwal." Again, after a carefully measured pause, and after inquiring exactly how long these feelings persisted, I said, "It must have been quite a struggle to cope with all the demands of everyday life." This time, with better composure and with a long exhale he replied, "I know, memot yishalal."

By this time, half an hour had gone by, and the sister asked impatiently, "Doctor, why don’t you simply ask him min endegodelebet, sira alew, genzeb alew, gwadeNoch alut, min yibalal yihE, Tigab ayibal?"

"It must have been difficult for you and the family to help out without understanding what is going on," I replied. After all of the family members had chorused their approval of my comment, I said, "As much as you have had a problem understanding him, it also appears that he may have felt that even if he had told you what he was going through, you still would not understand." Unlike the whispered voice before, the patient looked right at the family members, and with a glaring look, he said "ahun gebachuh."

I felt as though I had spoken in the voices of both the patient and the family in order to communicate and explain their feelings of frustration and exasperation toward each other. Now that we had identified the feelings and misunderstandings between the patient and the family members, both appeared willing to listen and share their concerns. After probing the patient and the family with many open-ended questions, it was revealed that the patient started to withdraw from family and friends over six months ago for no apparent reason. The patient explained that he had started to lose interest in many things that formerly gave him pleasure: his girlfriend, visiting friends and families, playing soccer, etc. Moreover, the patient’s tardiness from sleeping late and irritability with colleagues and customers cost him his job three months ago. Since then, he had a continued problem with sleeping and inability to concentrate. With a big sigh he said, "dekemegn, I just can’t see going on like this." My subsequent questions revealed that he had an active thought of suicide and actually worked out the details on how he was going to act upon it. Once I determined that he was a "danger to himself" I convinced both the patient and his family that he should be immediately hospitalized for observation and medication. Although there was a great reluctance by both the patient and the others, he was hospitalized after a good deal of discussion.

After having hospitalized the patient, I continued to complete some of the paperwork for the medical chart that goes with such intervention. Approximately two hours later, there’s a knock on my door. Surprisingly, it was one of the patient’s cousin who had accompanied him and who had sat in and listened attentively to all the questions and answers. I asked, "Is everything OK?" He replied that he came back because he started to feel scared when he realized that some of the questions I asked struck a chord with his life. I asked him to sit and we began to talk. To make a long story short, he confided to me that he had had several suicidal thoughts in the past year and actually attempted to kill himself approximately a month ago. He said he swallowed a bunch of pills and he fell asleep thinking that he wouldn’t wake up. In his words, "I am still here, in the world and unhappy." He said that listening in when I interviewed his cousin resonated with everything he was going through, and said "I had to come back and talk to you." For me, hearing such a request from the very person who was in my office trying to save his cousin’s life was a pleasant surprise. After a thorough assessment we both agreed that he should also be hospitalized for observation and medication. Because he did not want his relatives to find out, I managed to find another hospital in another part of town that would admit him.

Depressive illnesses are among the most prevalent of the psychological problems in Ethiopian communities, affecting Ethiopians of all ages, socioeconomic classes, and educational levels. Depression continues to be like the "common cold" for many immigrant/refugee communities, including our own. Fortunately, depressive disorders respond well to treatment. Over 80 % of all serious depressions can be treated successfully. Unfortunately, however, relatively few Ethiopians who experience symptoms of depression seek professional help.

Too many Ethiopians suffer needlessly because of a taboo associated with seeking help for psychological problems. Many do not recognize that their aches and pains, and their exhaustion and irritability, may be symptoms of an underlying depression. Many do not seek help because they attribute their symptoms to personal weakness. For many, recognition of their depression comes either at a friend's insistence, or when the pain becomes unbearable.

According to the U.S. National Institute of Mental Health, major depressive disorder — often referred to as depression — is a common illness that can affect anyone. About 1 in 20 Americans (over 11 million people) get depressed every year. However, fewer than half of those suffering from depression seek treatment for it. One out of five adults will experience depression at some point in life. Twice as many women as men experience depression. A World Bank report estimates that in the developing world, depression ranks fifth in illnesses among women and seventh among men. There are no reliable statistics regarding the prevalence of depression among Ethiopians; however, a survey of patients visiting primary health care clinics in sub-Saharan Africa indicates that depression is the principal or secondary reason for seeking care in as many as one-fifth to one-third of cases. My twenty two years of experience, as well as the findings of my research suggests that there is a high prevalence of depression in Ethiopian communities in the United States.

Depressive illnesses should not be confused with the transient or passing feelings of unhappiness that everyone, including immigrants and refugees, experience. Depression is also different from the periods of sadness associated with unhappy events and failures, or the emotional letdowns that commonly occur around holidays. Sadness and loneliness are normal and temporary reactions to life's stresses. Usually, time heals, the mood lifts, and people continue to function. In contrast, individuals afflicted with a depressive illness do not feel better for months, if not years in some cases. Depressive illnesses affect feelings, thoughts, and behavior.

When someone is depressed, that person has several symptoms nearly every day, all day, that last at least two (2) weeks. Below, put a check mark next to any symptoms you have had for two (2) weeks or more.

_____Loss of interest in things you used to enjoy, including sex.*

_____Feeling sad, blue, or extremely down *

_____Feeling slowed down or restless and unable to sit still.

_____Feeling worthless or guilty.

_____Changes in appetite or weight loss or gain.

_____Thoughts of death or suicide; suicide attempts.

_____Problems concentrating, thinking, remembering, or making decisions.

_____Trouble sleeping or sleeping too much.

_____Loss of energy or feeling tired all the time.

Other symptoms include:

_____Headaches.

_____Other aches and pains.

_____Digestive problems.

_____Sexual problems.

_____Feeling pessimistic or hopeless.

_____Being anxious or worried.

If you have had five (5) or more of these symptoms, including at least one of the first two symptoms marked with an asterisk (*) for at least two (2) weeks, you should consider being evaluated by a mental health professional.

On the other hand, individuals who suffer from another form of depression, called bipolar depression (also called manic-depressive disorder) experience alternating bouts of depression and mania (an excited state). When depressed, these persons experience the symptoms associated with major depression. These terrible "lows" (depression) and inappropriate "highs" (mania, see listing of manic symptoms below) can last from several days to months. In between the highs and lows, they feel completely normal.

Just as eye or hair color is inherited, bipolar disorder is, in most cases, inherited. It can also be caused by other general medical problems, such as a head injury or neurological or other medical conditions.

You can use the following list to learn the symptoms of mania and to check off symptoms you might have.

_____Feeling unusually "high," euphoric, or irritable*

_____Needing less sleep

_____Talking a lot or feeling that you can't stop talking

_____Being easily distracted

_____Having lots of ideas go through your head very quickly at one time

_____Doing things that feel good but have bad effects (spending too much money, inappropriate sexual activity, foolish business investments).

_____Having feelings of greatness

_____Making lots of plans for activities (at work, school, or socially) or feeling that you have to keep moving.

If you have had four (4) of these symptoms at one time for at least one (1) week, including the first symptom marked with an asterisk (*), you may have had a manic episode. You should consider an evaluation by a professional. There are effective treatments for this form of depression.

Not everyone who is depressed or manic experiences every symptom. Some people experience a few symptoms, some many. Also, severity of symptoms may vary from person to person.

In a culture where any form of mental illness is associated with "madness," it is not surprising that Ethiopians avoid seeking professional help. Many of us have difficulty recognizing when we experience psychological depression. Our tendency is to attribute depressive symptoms to physical reasons rather than to psychological causes. Often, we seek help only when the bad feelings become intolerable. Consequently, our desperation reaches crisis proportions. While some of us only contemplate the idea of suicide, others act on it and succeed. There are no reliable statistics available to show the prevalence of depression and suicide in the various Ethiopian communities around the world. However, one need only ask any member of the Ethiopian community about his or her perceptions of the prevalence of depression and suicide incidents to get an earful of anecdotes regarding the subject.

The ultimate goal of this article is to help those who are suffering from depression. In some cases, they may be able to save the lives of other Ethiopians who are contemplating suicide because of their depressive illness; in most cases, they may prevent unnecessary suffering from depression. Achieving an understanding of how we feel and how we cope with our roles as immigrants and refugees is especially important.

There is a definite relationship between depression and suicide, with more than 1.4 million people around the world committing suicide in 1990. Men are more likely (ratio 4:1) to commit suicide than women. According to the Center for Disease Control (CDC) "more people die from suicide than from homicide in the United States, and everyday approximately 86 Americans commit suicide, and 1,500 people attempt to commit suicide." A more recent statistics also reveals that suicide took the lives of 30,575 Americans in 1998 (11.3 per 100,000 population).

Most people who take their own lives do so during a depressive episode. Furthermore, most people who commit suicide are not in treatment at the time of their death. This is one of the reasons I stress the importance of seeking treatment for depression. Often, with treatment, suicidal thoughts can significantly diminish.

There are no specific statistics to indicate the exact prevalence of suicide among Ethiopians. One study indicated that there was a 14% prevelance among 519 randomly selected adolecents in Addis Abeba. And according to Dr. Atalay Alem of Amanuel Hospital there is only one study on completed suicide in Ethiopia in which cultural attitudes have been addressed. A study by Dr. Abdulreshid, regarding the trends in suicide, parasuicide and accidental poisoning in children in Addis Ababa, reported on the variation of rates in various age groups.

Nevertheless, various professionals who work closely with Ethiopian communities have observed that, in the past ten years, there has been a growing suicide rate among Ethiopians. The number of emails that I received from those that read my article on Seleda regarding depression (Volume II, Issue I) from across the US, Canada, Europe, and Ethiopia have also pointed out their concerns regarding the high incidence of suicide in their communities.

I am also personally privy to many incidents where a number of Ethiopians have either attempted suicide, and or succeeded. The harsh methods they use to kill themselves, such as jumping off bridges, poisoning (drinking Clorox), or hanging, do not provide an opportunity for rescue. The nature of the methods they use to kill themselves, common in Ethiopia, makes it very difficult to intervene quickly enough to prevent death.

Remember, not all Ethiopians who are depressed attempt suicide. However, it is clear that suicide is the most serious complication of depressive illnesses. Feelings of worthlessness and guilt, combined with a special kind of pain associated with leaving one's homeland, may overwhelm the individual. This can lead to feelings that (s)he is unable to go on, or is unfit to live. Sometimes these thoughts of ending life haunt an individual for months or even years, leading to suicide attempts.

Who can forget about the incident that took palce at Harvard University. Sinedu Tadesse was a twenty-year-old junior from Ethiopia. For two years she had roomed with Trang Phuong Ho, a refugee from Vietnam. Both were juniors and pre-med biology majors. One tragic day, Trang's body was found by Sinedu's bed where she had been stabbed forty-five times. And Senedu, was found hanging by a rope from a shower-curtain rod. After her tragic death, I had an opportunity to review Sinedu’s extensive and detailed diary, which made it evident that she was clinically depressed and crying out for help.

Many Ethiopians use the expression "I would rather die than . . . or memot yishalegnal " casually. Such casual expressions becomes problematic when heard by a mental health professional who is not familiar with Ethiopian cultures and expressions. In the past, some Ethiopians have been involuntarily committed to inpatient settings (hospitalized) because of such statements. Even though it may be difficult to know whether or not a verbal threat is serious, in such cases it is better to err on the side of caution. Again, not all those suffering from depressive illnesses attempt suicide, nor are all those who attempt suicide suffering from a depressive illness. However, it is estimated that 15 percent of depressed persons may eventually commit suicide and, among suicide victims, more than 50 per cent suffer from a depressive illness. A person hospitalized for depression at some time in his or her life is about 30 times more likely to commit suicide than is the nondepressed person, with the greatest risk during or immediately following hospitalization. A family history of suicide is an additional risk factor.

Tragically, as many as 17 percent of untreated depressed persons will eventually succeed. A majority of those whose depression is profound enough to cause suicidal impulses do attempt suicide. Therefore, depression must be thought of as a potentially fatal illness. Friends and relatives may be deceived by the casual way that profoundly depressed people speak of suicide. Any comment such as, "I would be better off if I were dead," or "I wish I could just jump out of a window," signals an immediate danger; the depressed person must be taken to a professional who can monitor his or her condition. A concrete statement such as, "I'm going to jump in front of the next car that comes," may signal a medical emergency, and requires an immediate intervention such as taking the person to a hospital emergency room.

Depressed persons who are suicidal often give little warning of and need little time to plan for an attempt to kill themselves. They are also willing to attempt more painful and immediate means, such as jumping from a bridge or hanging themselves.

Following are myths and realities regarding suicide.

Myth: Individuals who talk about killing themselves rarely do.

Fact: Of every ten people who have killed themselves, eight gave definite warnings of their intentions.

Myth: Suicide acts are impulsive, occurring without warning.

Fact: Most suicides are planned, with lots of clues for the careful observer.

Myth: Suicidal individuals have made a clear decision to die.

Fact: Most suicidal individuals are ambivalent. In other words, they are not completely

sure whether they should act on suicidal thoughts.

Myth: Once an individual is suicidal, (s)he is always suicidal.

Fact: Usually, individuals who wish to kill themselves are suicidal only for a limited period.

Myth: The risk of suicide is over when improvement occurs in mood swings.

Fact: Most suicides occur when the individual is still depressed but improving.

Myth: Suicide is more likely among the rich and famous.

Fact: There are no differences due to economic status.

Myth: Suicidal individuals are sick, psychotic, etc.

Fact: Suicidal people are often extremely unhappy, but do not have to be severely mentally ill.

It was a year later that I was walking into an Ethiopian restaurant when I saw the cousin that I had hospitalized. He was standing by the door of a restaurant with a couple of people talking. Our eyes met, and I felt both surprised and curious. As is my usual policy, I do not go out of my way to say hello to my patients in public. Because I am afraid that they might be uncomfortable or others who are with me may suspect that they might be a patient. This time, just when I was about to enter the door of the restaurant, he extended his hands and said, "selam Dr. Tedla." Actually, since a year had elapsed, I did not remember his name, and I simply said, "selam," but I clearly remembered who he was and what brought him to my office. And I asked, "How is everything going?" He smiled at me and replied, "Fine." With all my curiosity, I couldn’t help but continue to probe, and inquired after his family. Again with a big smile, he said "hulum dehna new, menor Tiru, bizu yasayal." I smiled and said , "awo, Tiru new, bizu yasayal." That evening, after such a pleasant encounter and a wonderful meal of "kitfo," I said to myself, "Yes, it is great to be alive."

[Dr. Tedla is author of "Understanding and Surviving Depression, Alcohol & Drugs: A Personal Guide for Ethiopians." For information about his book and about depression, please send email to Giorgistw@aol.com. He may also be reached via mail: P.O. Box 73145, Washington, D.C. 20056-3145. And by phone: (202) 671-1212.]