The ultimate tragedy of mood disorders is suicide. Suicide is a double disaster. Not only does it prematurely end a life, it wreaks havoc on the lives of those left behind. Devastated survivors can be traumatized by feelings of grief, guilt, anger, resentment, and confusion. "There was no time to say good-bye," and "Perhaps I could have done more," are examples of comments that are made by shell-shocked friends and relatives. Moreover, the stigma surrounding suicide makes it very difficult for family members to talk about what has happened.

      By far the major cause of suicide is untreated depression. According to the National Institute of Mental Health, 15 percent of those afflicted with a major depressive disorder and who are not treated (or who fail to respond to treatment) will end their lives by suicide. (This is 35 times the normal suicide rate.) People with serious illnesses such as cancer and heart disease do not kill themselves in large numbers; depressed people do.

      Many theories exist that attempt to explain the motivation for suicide. Freud postulated a death instinct. Others have suggested that humans are endowed with "a drive to destruction." But to anyone who has experienced the suicidal pain of depression, the explanation is so simple, so self-evident, that it requires neither psychiatric nor psychological jargon. Death is chosen because suffering is so acute, so agonizing, so intolerable, that there comes a time-depending on the individual's tolerance for pain and the available support-that ceasing to suffer becomes the most important thing. This "aggregate pain model" of suicide is supported by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the official diagnostic resource of the mental health profession. In it's section on major depression, the manual says:

The most serious consequence of a major depressive disorder is attempted or completed suicide. Motivations for suicide may include a desire to give up in the face of perceived insurmountable obstacles or an intense wish to end an excruciatingly painful emotional state that is perceived by the person to be without end.

      Suicide has been defined as a "permanent solution to a temporary problem." For the person caught in the black hole of depression, however, there is nothing temporary about the hell he or she is experiencing. The resulting sense of hopelessness is the major trigger for suicidal thoughts, feelings and attempts. This hopelessness includes:

• no hope for the future.
• no hope that things will ever change.
• no hope that I will ever be well or stable.
• no hope that I will be able to meet my goals in life
  (or even have goals).
• no hope that the pain will ever stop.
• no hope that I can do anything to change it.

      When the psyche is assailed by this level of despair, suicide feels like the only way out. If you are feeling suicidal, here are some thoughts that can help you to counter the suicidal urge:

1. Remember that you are under the influence of a "drug" called depression which is distorting your view of reality. As a result, your feelings of hopelessness do not accurately reflect your true potential for recovery.
   
   
2. Depression, like everything else in the physical world, is cyclic. In most cases, it comes and goes; it has a beginning and an end. A useful affirmation to repeat is, "Nothing stays the same forever. This, too, shall pass."
   
   
3. An overwhelming majority of people who have suffered from suicidal feelings have fully recovered. The odds that you will get better are in your favor.
   
   
4. If you have family and/or friends in your life, realize that they will be devastated by losing you. Their suffering will only add to the existing suffering in the world.
   
   
5. Use the techniques described in the depression survival plan in this book to increase your coping resources and to keep yourself safe.
   
   
6. Remember that feelings and actions are two different things. Just because you feel like killing yourself, it doesn't mean you have to act on it this minute. This is one time when procrastinating is a good idea.
   
   
7. Do not remain alone when you are feeling suicidal. If you are feeling overwhelmed, ask for help. Set up a suicide support system with people who can spot your mood swings even before you do, and will take action to keep you safe. Make a pact that you will contact them when you are feeling suicidal. If you don't have friends who can do this, try to locate a depression support group at a hospital or clinic.
   
   
8. Use your local crisis hotline as a resource. Their job is to support you through your struggle, one day at a time. If you don't have a local hotline, call (888) SUICIDE-(888) 784-2433.
   
   
9. Regulate anything in your environment that may be used to harm you. Flush old medications down the toilet, keeping only small quantities of those you take regularly. Dispose of all firearms you have, or give them to a support person for safekeeping.

Finally, remember, people do get through this, even when they feel as bad as you do right now. Here is a passage from Kathy Cronkite's At the Edge of Darkness that was very helpful in restoring my hope.

Part of the anxiety and dread of depression is that "storm in the brain" that blocks out all possibility of sunlight. In the depths of despair that by definition murders faith, courage may have to suffice. Keep slogging. Even if you don't believe it at the moment, remind yourself of the existence of good. Reassure yourself: "Once I enjoyed 'X,' I will again." The disease may have turned off the spigot of love, but it will come back.

      Many Americans have mistaken ideas about the suicidal feelings that result from major depression. Depressed people who say they are suicidal are often not taken seriously by their friends and family. (For example, a day before a 14-year-old boy went on a shooting spree in a Georgia school, he told his friend that he wanted to kill himself. "You're crazy," came the reply.) What follows are some do's and don'ts on what to say to a suicidal individual.

      DO ask people with suicidal symptoms if they are considering killing themselves. Contrary to popular opinion, it will not reinforce the idea. "In fact, it can prevent suicide," says Dr. Joseph Richman, professor of psychiatry at the Albert Einstein College of Medicine in New York. Since the suicidal person feels isolated and alienated, the fact that someone is concerned can have a healing effect.

      DON'T act shocked or disapproving if the answer to the question "Are you suicidal?" is "Yes." Don't say that suicide is dumb or that the person should "snap out of it." Suicidal feelings are part of being clinically depressed, just as a high white blood cell count is a symptom of an infection.

      DON'T lecture a suicidal individual about the morality or immorality of suicide, or about responsibility to the family. A person in a state of despair needs support, not an argument.

      DO remove from easy reach any guns or razors, scissors, drugs or other means of self-harm.

      DO assure the person that although it may not feel like it, suicidal feelings are temporary.

      DO ask the person if he or she has a specific plan. If the answer is yes, ask him to describe it in detail. If the description seems convincing, urge the person to call a mental-health professional right away. If he or she is not seeing a therapist or psychiatrist, offer a ride to the emergency room for evaluation, or call the local crisis line-or (888) SUICIDE-(888) 784-2433.

      DO make a "no-suicide" contract. This means that the person agrees (in words or in writing) that if he feels on the verge of hurting himself, he will not do anything until he first calls you or another support person. You in turn promise that you will be available to help in any way you can. Ideally, it is best if the suicidal person has prepared a list of people (three or more is ideal) that he or she can contact in the midst of a crisis.

      DON'T promise to keep the suicidal feelings a secret. Such a decision can block much-needed support and put the person at greater risk. If a person needs help from a medical professional or a crisis-intervention center, make sure that he or she gets it, even if you have to go along.

      DO pay particular attention to the period after a depressive episode, when the person is beginning to feel better and has more energy. Ironically, this may be a time when he or she is more vulnerable to suicide.

      DO assure the person that depression is a treatable illness and that help is available. If the individual is too depressed to find support, do what you can to help him or her find support systems-e.g., psychotherapy, medical treatment, and support groups that are described in this book.

      DO call a suicide hotline or crisis hotline if you have any questions about how to deal with a person you think may be suicidal. Help is available for you, the caregiver.

      Finally, there exist a number of telephone hot lines and Internet sites that can provide immediate support and relief for anyone who is struggling with feelings of suicide.

1. American Suicide Survival Line (888) SUICIDE-(888) 784-2433. This nationwide suicide telephone hotline provides free 24-hour crisis counseling for people who are suicidal or who are suffering the pain of depression.
   
   
2. The Samaritans Suicide Hotline (212) 673-3000 or e-mail: jo@samaritans.org. They will respond to your e-mail within 24 hours.
   
   
3. Covenant House Nineline (800) 999-9999
   http://www.covenanthouse.org This hotline provides crisis intervention, support and referrals for youth and adults in crisis, including those who are feeling depressed and suicidal.
   
   
4. Internet site: http://www.metanoia.org/suicide/ This is an excellent Web site which I visited when I was suicidal. I credit it with being one of the factors that prevented me from taking my life.
   
   
5. Internet site: http://www.save.org/index.html This is the Web site for SA\VE (Suicide Awareness Voices of Education), whose mission is to educate others about suicide and to speak for suicide survivors. I also frequented this Internet site when I was suicidal and found it to be extremely helpful.