Robin Williams' death is, first and foremost, a horrible tragedy for his family and friends. For the public at large, it's a dark reminder that depression and suicide are shockingly common, both in America and in the world, and radically under-diagnosed and under-treated. Here are 12 things you need to know to understand the gravity of the threat depression poses.
1) Almost one in fifteen American adults suffers from depression
According to the National Institute of Mental Health (NIMH), 6.9 percent of Americans aged 18 or older (about 16 million people) had at least one major depressive episode in the past year.
Such an episode is defined as "a period of two weeks or longer during which there is either depressed mood or loss of interest or pleasure, and at least four other symptoms that reflect a change in functioning, such as problems with sleep, eating, energy, concentration, and self-image."
Depression is more common among women and young people. Note that these findings are based on a survey, and the social stigma surrounding depression may make it look less prevalent than it really is:
It is important to remember that major depressive disorder is not the only prevalent mood disorder. 2.6 percent of Americans suffer from bipolar disorder and 1.5 percent suffer from dysthymic disorder, or "chronic low-level depression." In total, 9.5 percent of Americans suffer from a mood disorder of any kind.
The US is roughly in the middle of the pack globally in terms of depression rates, according to a recent study in PLoS Medicine. Countries in green are in the middle, while those in blue or purple have less depression than average and those with redder coloring have more:
2) Most people with depression don't get the care they need
According to NIMH, 50.9 percent of adults with mood disorders receive treatment of some kind. But only 19.6 percent of those people received what NIMH defines as minimally adequate treatment.
What it means for treatment to be minimally adequate varies from disorder to disorder; for major depression, it is defined as receiving an antidepressant or mood stabilizer prescription for at least 30 days and going to at least four psychiatric appointments, or, in lieu of drug treatment, at least eight therapy sessions of least a half hour each. People with bipolar disorder are slightly less likely to receive treatment.
3) Mood disorders are common with children too
14 percent of 13 to 18 year olds have a mood disorder. They are more common the older teens get, and significantly more common among young women:
While major depression can manifest at early ages, bipolar disorder most commonly emerges among young adults.
4) Depression is treatable
It really, truly is.
Many, many studies have found that cognitive-behavioral therapy (CBT) is effective with mood disorders, particular major depression. CBT focuses on identifying negative thought patterns — exaggerating negatives, ignoring positives, etc. — and working to replace them.
Psychodynamic therapy, which is closer to traditional Freudian psychoanalysis and devotes more time to exploring the unconscious, also has some evidence supporting it, though some scholars dispute its effectiveness.
The evidence surrounding antidepressant drugs is more mixed, with some arguing that they, and in particular selective serotonin reuptake inhibitors (SSRIs), the most common kind of antidepressant, perform no better than a placebo. Other researchers have conducted reviews with more promising findings, and there are some studies suggesting that severely depressed people are likelier to respond well to medication.
Overall, the National Alliance for Mental Illness's (NAMI) medical director, Kenneth Duckworth, estimates that about 70-80 percent of patients with major depression respond to treatment. But everyone's depression reacts to treatment differently, and if initial treatment fails, it's possible that a different set of medications or therapeutic techniques would perform better. There's also some evidence that aerobic exercise can be an effective treatment for depression.
In extreme cases of severe depression where multiple treatment approaches have failed, techniques like vagus nerve stimulation — wherein a small device is implanted into your chest and sends electrical pulses to the vagus nerve in your neck — or electroconvulsive therapy can help. Very preliminary trials have suggested that deep brain stimulation could work in some treatment-resistant patients as well.
5) Most depressed people aren't suicidal
Suicidal tendencies and depression tend to get conflated in public discussion, but it's worth remembering that the majority of depressed people do not attempt or even consider attempting suicide.
A 2008 survey found that 3.7 percent of adults 18 or older had thought about suicide, 1 percent had made plans to commit suicide, and 0.5 percent had attempted suicide. Those figures are far, far too high, but they suggest that most people suffering from depressive disorders are not suicidal:
Also worth noting is the fact that even most suicidal people do not end up committing suicide. There are 25 suicide attempts each year for each suicide, and 90 percent of people who attempt suicide and survive die from a cause other than suicide.
6) But most suicides are connected to depression
According to the American Academy of Suicidology, about two thirds of people who commit suicide are depressed at the time of their death, and the risk of suicide is about 20 times greater among people with major depression; it's also significantly higher among people with bipolar. About 7 percent of men and 1 percent of women who have ever been diagnosed with depression die by suicide.
However, the Association notes that while the lifetime risk of suicide for patients whose depression goes untreated is nearly 20 percent, the risk for treated patients is a mere 0.141 percent. Some of that is likely due to selection bias; less suicidal people might be more willing to seek out treatment. But some of it could be due to the effectiveness of treatment.
Social factors can also influence suicide rates. One influential recent study found that a ten percent increase in unemployment (say, from 6 percent to 6.6 percent) increases the rates of suicides for adult men by 1.47 percent. Divorced and separated men are about 2.4 times more likely to commit suicide than married men; no similar increase was found for divorced and separated women.
7) Suicide is most common between age 45 and 64
People aged 24 or younger are actually the least likely age group to commit suicide. While historically, people over 85 have had the highest suicide rate, the rate among people aged 45 to 64 has overtaken it in recent years, as this chart from the American Foundation for Suicide Prevention shows:
8) Suicide rates are much higher among white and American Indian people
While depression rates are much higher for American Indians and Alaska natives and significantly lower among Asian Americans, they don't differ much between white people, African Americans, and Latino/as. Suicide rates, however, do differ significantly, and are nearly three times higher among white people:
9) Most suicides are committed with guns
While the share is falling, in 2010 50.5 percent of suicides were committed using a firearm:
Much of this seems to result from the fact that suicide attempts with guns are likelier to result in death. The CDC found that in 2001, 85 percent of suicide attempts involving guns resulted in death, significantly above other methods. A study looking at hospital admissions for suicides and suicide attempts in Illinois found that 96 percent of firearm cases resulted in death, while only 6.7 percent of cases involving cuts and 6.5 percent of cases involving poisoning did.
There is significant evidence that reducing access to guns, and their pervasiveness, can reduce suicide rates.
10) While men commit suicide more often, women are likelier to attempt it
Between 2008 and 2009, according to the CDC, 3.5 percent of adult males and 3.9 percent of adult females had suicidal thoughts. 1 percent of both men and women made suicide plans, while 0.4 percent of adult men and 0.5 percent of adult women attempted suicide.
Other researchers find an even greater discrepancy between male and female suicide attempts, with the American Association of Suicidology reporting 3 female attempts for each male attempt. And there's a well-established gender gap in depression rates, with significantly more women suffering from it.
This is somewhat surprising in light of the fact that suicide is almost four times more common among men than women in the US:
This disparity between suicidal thoughts and behavior and actual suicide rates is known as the "gender paradox" of suicide. At least some of it can be accounted for by the fact that men are more likely to use guns to commit suicide than women, suggesting that part of the differential in suicide rates could be due to women choosing less lethal methods to attempt suicide than men do.
11) Suicides are much more common among LGBT people — especially trans
A recent study from the Williams Institute at UCLA and the American Foundation for Suicide Prevention found that 46 percent of trans men and 42 percent of trans women have attempted suicide at some point in their lives — far greater than the 4.5 percent of the general population who have. The risk of an attempt was greater among trans people of color, of lower incomes, with less education, with a disability, or living with HIV.
Rates of suicide attempts are also elevated among gay, lesbian, bisexual, and queer youth. One meta-analysis in 2011 found that compared to straight youth, LGB youth were 3.18 times more likely to make suicide attempts, 4.17 times more likely to make attempts requiring medical attention, 2.2 times more likely to make suicide plans, and 1.96 times more likely to have suicidal ideation.
12) Suicides are often impulsive, and can be prevented at the last minute
About 90 percent of people who attempt suicide and survive do not die by suicide. One survey found that 87 percent of people who attempt suicide and survive had deliberated for less than a day, 71 percent for less than an hour, and 24 percent for less than five minutes.
In a particularly vivid example of this, Ken Baldwin, who survived a jump off the Golden Gate Bridge, once told the New Yorker's Tad Friend that as he was falling, he "instantly realized that everything in my life that I’d thought was unfixable was totally fixable — except for having just jumped."