Here, perhaps, is the great advantage possessed by the general practitioner over his hospital colleagues. He knows the patient and his family and is much better equipped to appreciate such subtleties. The onset is more likely to be abrupt, with an evident relationship to some situation that is stressful for that particular patient.
The early history of the patient provides evidence of the vulnerability of his personality. In childhood, shyness, timidity and phobias may have been prominent and the stresses of daily everyday life may have proved impossible to absorb due to undue anxiety or depression. The illness is generally much more variable and responsive to environmental factors than endogenous depression. The patient can brighten up if daily life seem hopeful, but is readily tilted into gloom if circumstances become adverse. Good days and bad days are a feature of the history of depression.
The quality of the depression experienced by the neurotic patient is often more akin to normal sadness or grief than to the emotional experience of the endogenously depressed patient. It tends to be aggravated by the variation of the day and to be at its worst in the evenings. Though generally mild to moderate in degree, the depression may, in occasional patients, be severe. The mood of the patient tends to reflect self-pity rather than self-blame or guilt. Initial insomnia is the common form of sleep disturbance. Anxiety is often prominent and is associated with poor concentration and fatigue. Suicidal ideas and both attempted and successful suicide are common and certainly, the belief that the depression is 'only' neurotic should not engender any false optimism.
Throughout the world the rate of depression related suicides, or problems directly related as a result of depression is on the increase as our daily lives become more and more fast paced. A relationship between a large number of social factors and suicide has been made evident as the result of epidemiological studies. Social class, the nature of employment, geography, race and the degree of social disorganisation exert subtle influences on the individual decision to kill oneself; but through the determinants of suicide are always multiple and complex, in the majority of patients mental illness is of the utmost importance. Although depression is not the only psychiatric disorder associated with suicide, it is unquestionably the most important.
Important epidemiological differences between those who commit and those who attempt suicide have been demonstrated. Nevertheless, the similarities are more important than the differences. Both those attempting and those succeeding in suicide the same psychiatric disorders play their interacting parts. A patient showing signs of severe depression may have already entertained the idea of suicide. There need be no fear that one will put ideas into the patient's head - the ideas are there already. Naturally, there is no need to be blunt about it. The question should be put gently and sympathetically. Some such query as, "Do you sometimes feel life is not worth living?" is a useful beginning and it is seldom necessary to be more pointed.
The recognition of the protean presentations of depression is the most important way we can help to prevent suicide; and it is well to recognize that certain groups of individuals such as the elderly, those living on their own and those recently bereaved are especially at risk.