Depression and suicide too often plague our society. This is especially true when it comes to members of the legal community. The purpose of this article is to define depression, discuss the connection between depression and suicide, specifically with adolescents, and examine the intricacies legal professionals need to understand when representing clients who are diagnosed as depressed and/or suicidal.
What Is Depression and How Dark Can It Become?
Depression is a long, dark, and deceptive road to unpredictable mortality. Feeling extreme pain from trauma can trigger a depressive state, oftentimes leading to a numb, worthless feeling of oneself. Without proper attention, depression can result in serious consequences.
Depression can oftentimes become a saturated term used to describe bouts of sadness. It is a mainstream term used by the public but with much confusion and lack of understanding. Mental health professionals, however, refer to the Diagnostic and Statistical Manual (DSM) when defining depression. DSM-5, the latest edition, is published by the American Psychiatric Association’s leading authorities of professionals in the field who research and practice the understanding and treatment of mental disorders. It is the standard reference for clinical practice in the mental health field, and includes a classification of mental disorders associated with criteria designed to facilitate more reliable diagnoses of these disorders. According to DSM-5, under the vast umbrella of depression, the following conditions are related to depressive disorders:
- disruptive mood dysregulation disorder,
- major depressive disorder (including major depressive episode),
- persistent depressive disorder (dysthymia),
- premenstrual dysphoric disorder,
- substance/medication-induced depressive disorder,
- depressive disorder due to another medical condition,
- other specified depressive disorder, and
- unspecified depressive disorder.
The common feature of these disorders is the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function. According to a study conducted by Myles-Worsley, Weaver, and Blailes (2007), “the most common depressive symptoms were anger/irritability, fatigue/sleep disturbances and depressed mood” (p. 188). What differs among them are issues of duration, timing, or presumed etiology (DSMS, p. XII & 155). Depression impacts how one feels, thinks, and behaves and can lead to a variety of emotional, social, behavioral and physical problems.
It is the responsibility of a mental health professional to assess, identify, and recognize which depression type the client is suffering from. Then, together through a therapeutic alliance, decide on the appropriate and most effective treatment plan. Misdiagnosis means wrong treatment and an undesirable outcome(s). Wrong outcomes can impact the client, patient, and those that care for their loved ones in many negative or even life-threatening ways. It can provide you (the legal professional) with the wrong diagnosis in helping make a decision related to legal matters. Understanding your client’s mental health is imperative to representing them appropriately. Therefore, it is tantamount that the mental health professional discuss all options of treatment, including in-patient, out-patient, sessions, and medication so that the individual client or patient understands the severity of his or her depression—and the legal professional obtains accurate psychological reporting. Establishing an understanding between the client, the mental health professional, and attorney is key to obtaining the desired legal outcome.
It is not recommended that an individual self-diagnose himself or herself, nor a non-mental health professional diagnose a patient. Mental health professionals have completed thorough training to properly diagnose clients. Researchers agree that scales and assessments to diagnose clients must be conducted by those who are licensed to do so. This builds validity to the mental health profession as well as adds credibility to you and all legal matters when building a case.
Once an individual is accurately diagnosed with depression, it is a fight of ownership. If properly treated, the client can live a normal, healthy life. If left untreated, it can lead to life-threatening behaviors (American Association of Suicidology, 2014). According to the Centers for Disease Control (CDC) (2014), extensive research conducted longitudinally spanning the years from 2009 to 2012, the following statistics emerged:
- 7.6% of Americans aged 12 and over had depression,
- depression was more prevalent among females and persons aged 40–59,
- persons living below the poverty level were nearly 2½ times more likely to have depression than those at or above the poverty level, and
- almost 43% of persons with severe depressive symptoms reported serious difficulties in work, home, and social activities (CDC, 2014, https://www.cdc.gov/nchs/data/databriefs/db172.htm).
These statistics confirm the prevalence of depression and how an individual suffers in personal, work, physical, and social environments due to the depressive symptoms. It is recognized as a disease and should not be treated lightly. Although the statistics point to a higher propensity of population that might encounter depression, no individual is safe from trauma or crises. Legal professionals must recognize the impact of depression on their clients’ daily activity’s performance—including but not limited to social, cognitive, and emotional states and how all of those areas impact their legal matters.
Hence, attorneys reviewing the psychiatric records of their clients need to make sure they have been accurately diagnosed and properly treated. Misdiagnosis is common, especially if a full psychological evaluation did not take place. One should ask, “Was my client accurately diagnosed and treated?” As an example, one of the authors of this paper, based on personal clinical experiences, would like to share the result of an improper treatment plan of a young patient that reported in a personal letter:
As a 15-year-old female, I was unaware of the previous medical issues that my Mother experienced before I was born. To me, she did everything any other Mother did. Little did I know that she was a cancer survivor and the cancer had had returned with a vengeance. One evening, after discussing the next day’s agenda, she fell back onto the bed, convulsing, and died immediately. Due to the rapid spread of cancer, she experienced a blood clot from her heart to her brain. Shocked and in disbelief, I screamed out to my Father, who tried to resuscitate her, to no avail. The ambulance arrived and took us to the hospital. After almost two hours since our last conversation, she was pronounced dead.
As an only child, I was lost and numb. I could not think past the next minute. I was scared for my own life. I knew that life continued but at the same time didn’t know how to live it. I was in pain but couldn’t feel. I was hurt but couldn’t cry. I took unnecessary risks because I felt unworthy to be alive. I felt no hope. I sought help but never found the right resource. Unbeknownst to me, I was building walls to protect myself for when it was time, almost 25 years later, to work through the grief.
Finally, at the age of 40, the grief overtook my life. I had reached my tipping point. Over the years I had gone to counseling, but nothing helped. Yes, I was diagnosed with depression, but the treatment plan did not help me. I was told to read a book, but it didn’t change my cognitive distortions. On a few occasions, I became the counselor to the counselor. Nothing seemed to work until I learned about the reputation of your services and the out-patient part-time treatment facility in a group setting using Gestalt therapy and Combined Therapeutic Treatment. The psychotherapy incorporated activities and role play, something that I was able to see, hear, and visualize. This created concrete and measurable results. It included talk, brainstorming, finding solutions, confronting issues on hand, building, resolving, as well as listening skills. Hearing others describe the same symptoms validated my own for the first time in years. After a month of bonding with the shared dialogue and breaking down the walls of depression, as I was taught to do, I was finally able to “feel” again. I now had strategies to use when I was at home that worked, that helped me get out of bed and face the world. I truly believe in counseling and utilizing strategies for those suffering from depression because it will work if the individual is properly treated. Finally I am not thinking of ways to kill myself; and I want to thank you for helping me be free of depressions and suicidal thoughts.
Depression and Suicide
It is also important to know that depression is most commonly associated with suicide, present in at least 50 percent of all suicides (American Association of Suicidology, 2014). “Although most people who are depressed do not kill themselves, untreated depression can increase the risk of possible suicide. It is not uncommon for depressed individuals to have thoughts about suicide whether or not they intend to act on these thoughts. Severely depressed people often do not have the energy to harm themselves, but it is when their depression lifts and they gain increased energy that they may be more likely to attempt suicide.”
For example, suicide is the second-leading cause of death for children and youths aged 10–24. In fact, more teenagers die each year from suicide than from cancer, heart disease, AIDS, birth defects, pneumonia, and influenza combined (Thibault, 2015). Suicide is the third-leading cause of death for children ages 5 to 14 in the United States, according to the Centers for Disease Control and Prevention. Such deaths do occur an average of about 33 per year in the United States in children ages 5 to 11, research suggests. Unfortunately, depression or suicidal thoughts in teens can go unnoticed, and professionals may not realize that even when children don’t act on suicidal impulses, their thoughts often signal grave difficulties. Hence, it is safe to assume and realize that children with depression are more likely to think about or attempt suicide (Weir, December 2016). Outlined on a web-based support group for suicide, some astounding statics are bulleted below:
- Up to 15% of those who are clinically depressed die by suicide.
- In 1997, suicide was the eighth-leading cause of death in the United States. 10.6 out of every 100,000 persons died by suicide. The total number of suicides was approximately 30,535.
- In 1996 there were an estimated 500,000 suicide attempts.
- There are an estimated 8 to 25 attempted suicides to 1 completion; the ratio is higher in women and youth and lower in men and the elderly.
- More than four times as many men than women die by suicide. However, women report attempting suicide about twice as often as men.
- Suicide by firearms is the most common method for both men and women, accounting for 58% of all suicides in 1997.
- 72% percent of all suicides and 79% of all firearm suicides are committed by white men. The highest suicide rate was for white men over 85 years of age—65 per 100,000 persons.
- Over the last several decades, the suicide rate in young people has increased dramatically. In 1997, suicide was the third-leading cause of death in 15- to 24-year-olds—11.5 of every 100,000 persons—following unintentional injuries and homicide.
- The suicide rate among children 10 to 14 years old was 303 deaths among 19,040,000 children in this age group.
- For adolescents aged 15 to 19, there were 1,802 deaths among 19,068,000 adolescents. The gender ratio in this age group was 5:1 (males:females).
- Among young people 20 to 24 years of age, there were 2,384 deaths among 17,512,000 people in this age group. The gender ratio in this age group was 7:1 (males:females).
- The majority of suicide attempts are expressions of extreme distress that needs to be addressed, and not just a harmless bid for attention. A suicidal person should not be left alone and needs immediate mental health treatment (http://allaboutdepression.com/).
In addition to the above statistics, recent surveys indicate that as many as one in five teens suffers from clinical depression (Depression in Teens, 2016). “Suicide is the third-leading cause of death among adolescents and teenagers. According to the National Institute for Mental Health (NIMH), about 8 out of every 100,000 teenagers committed suicide in 2000. For every teen suicide death, experts estimate there are 10 other teen suicide attempts” (Depression in Teens, 2016).
These are alarming statistics, reiterating the necessity to educate, properly diagnose, and treat individuals who suffer from depression. For the legal professionals, it is a signal for making sure that your client is appropriately diagnosed and treated, and that his/her psychological profile reflects current and past issues impacting the behaviors, emotional and psychological, as well as mental state.
Adolescents, Depression, and Suicide
When dealing with legal cases that may involve children or adolescents, depression in general can be difficult to diagnose, especially when other psychiatric disorders increase the risk of suicide in children and adolescents ages 6 to 18—such as ADHD, autism, oppositional defianct disorder, and intellectual disability (Weir, 2016). Teens and adolescents, during the stages of puberty, often tend to act moody or exhibit extreme highs and lows in feelings and attitudes. Unfortunately, adolescent depression is increasing at an alarming rate. While health professionals understand that adolescents find it hard, and may not be able, to understand or express their feelings clearly, children are not aware of the symptoms of depression, and are not likely to seek professional help or tell their parents or teachers about it. Add to that the fear of speaking to a forensic mental health expert. Hence, an experienced forensic expert will be able to better deal with a situation while still assuring the forensic evaluation is on course—legally, ethically, and clinically.
What legal professionals need to realize is that depression is usually confused with teenage adjustment and discounted as teenage mood. Working with an experienced mental health expert will be the only professional way to find out what is really going on. Therefore, these symptoms must not be dismissed.
The legal professional should realize that parents, teachers, and teens need to be educated on the symptoms of depression or any drastic changes in mood and temperament. Then, the goal is to hire a mental health professional that understands depression in teenagers, and is able to comprehensively diagnose disorders for that age group. As an attorney, the most important recommendation is to refer the client for a comprehensive psychological evaluation before they seek treatment (psychopharmacology, psychotherapy, or both). Additionally, always ask your client (young or old) if s/he is depressed, and if so, seek psychological attention for your client immediately. Do not wait.
Depression can be the paving stones of suicide. It must be recognized and assessed correctly. Suicidal thoughts or related behaviors should always be taken seriously and a referral to a mental health professional or emergency room must be an immediate action of response. According to Mental Health America (2016): “Each year, almost 5,000 young people, ages 15 to 24, kill themselves. The rate of suicide for this age group has nearly tripled since 1960” (http://www.mentalhealthamerica.net/suicide). Suicide is a potential outcome stemming from depression. Depression can rob you of your will to live, overwhelm you with painful emotions, and make death seem the only escape from the pain. The result of suicide is extremely painful for the survivors: parents, spouses, grandparents, close relatives, and friends. It is also underestimated by some legal professionals, courts, and the like.
Yet, most of those who committed suicide could have been helped. It is important to know the signs of suicidal tendencies in teens. These include:
- suicide threats, direct and indirect
- obsession with death
- poems, essays, and drawings that refer to death
- giving away belongings
- dramatic change in personality or appearance
- irrational, bizarre behavior
- overwhelming sense of guilt, shame, or rejection
- changed eating or sleeping patterns (http://www.mentalhealthamerica.net, 2016)
If you are working with a client who exhibits the above symptoms, seek a mental health professional immediately.
Once depression is identified and diagnosed by a licensed psychologist or psychiatrist, treatment must take place. Treatment is two-fold:
1. Psychopharmacology: medicating the patient using single or multiple medications along with psychotherapy to treat symptoms of depression is most importantly especially in moderate to severe depression.
2. Psychotherapy is recommended for mild, moderate, and severe depression utilizing combined therapeutic techniques including cognitive behavior therapy, instructional therapy, and cognitive rehabilitation therapy twice a week for no less than six months.
Mental Health Advice
It is important for legal professionals to conduct a self-check on how your workload, personal issues, family issues, and the like are affecting you personally. Self-care includes reflecting on your own behaviors and stress levels so that one can function properly in your professional assigned role. If you begin to feel overwhelmed, burned out, unable to get up in the morning, subject to bursts of anger or explosive behavior or bouts of sadness—or any of the other criteria set forth in the DSM-5—you, the attorney, must also seek psychological help. This can include a visit to a mental health professional to discuss your case and how it is affecting you or impacting your personal and professional life and daily activities. Talk therapy (counseling), psychotherapy, or other forms of theoretical foundations will be applied to assist in your mental well-being. This is not an option for when you have the time or inclination, but a necessity in order to be in the best mental health shape possible when working with clients—and undergoing tremendous stress.
There is a direct correlation between depression and suicide. Depression is a serious medical illness that must not be taken lightly. If someone is experiencing depressive symptoms as outlined in the DSM-5, then action must be taken. Know the signs of depression and ask questions. Depression or suicidal thoughts must not go unnoticed. Children’s suicide is a terrible tragedy that could possibly be prevented with the right mental health care.
As a legal professional, realize that your professional work and daily activities will have a stressful impact in your life. This will contribute to your overall mental health, and therefore, it is important to understand what depression is so that when you experience such symptoms, you can seek help. Know when your clients are affecting you personally. Complete a self-awareness checklist to reflect on your mental health so that you can be healthy for each client and case you represent.
American Association of Suicidology (2014). Depression and suicide risk. Retrieved from http://www.suicidology.org/portals/14/docs/resources/factsheets/2011/depressionsuicide2014.pdf.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM–5). 5th ed. Arlington, VA. 2013.
Centers for Disease Control and Prevention (2014). Depression in the U.S. household population, 2009–2012. Retrieved from https://www.cdc.gov/nchs/data/databriefs/db172.htm.
Weir, K. (2016). Research on Suicide Overlooks Young Children and Psychologists Are Working to Change. Monitor on Psychology. Pp. 28–31.
Depression in Teens. (2016) Retrieved on December 23, 2016 from http://www.mentalhealthamerica.net/conditions/depression-teens.
Depression and Suicide. (2016) Retrieved on December 23, 2016 from http://www.caps.ucsc.ed/resources/depression.html#chapter1.
Krans, B. (2016) Adolescent Depression. Retrieved on December 23, 2016, from http://www.healthline.com/health/adolescent-depression#overview1.
Monroe, S. & Reed, M. (2009). Life Stress and Major Depression. Current Directions in Psychological Science. (18)2, Pp. 68–72.
Myles-Worsley, M., Weaver, S., and Blailes, F. (2007). Comorbid depressive symptoms in the developmental course of adolescent-onset psychosis. Early Intervention in Psychiatry 2007; 1: 183–190.
Smith, M., & Segal, J. (2016) Parent’s Guide to Teen Depression. Retrieved on December 23, 2016, from http://www.helpguide.org/articles/depression/teen-depression-signs-help.htm.
Teen Depression. (2016) Retrieved on December 23, 2016, from https://www.webmd.com/depression/guide/teen-depression.
Seligman, L., & Reichenberg, L. (2014). Theories of counseling and psychotherapy: systems, strategies, and skills (4th ed.). Upper Saddle River, NJ: Pearson.