Fink! Still at Large: A Recent Suicide Raises Questions about the Heritability of Depression and Suicidal Behavior. What Should We Be Looking for While Working with Depressed Patients?

Article excerpt

The suicide of Nicholas Hughes, the son of the famed poets Sylvia Plath and Ted Hughes, not only has led to much conjecture and age-old questions about heritability of depression. It also raises questions about suicide, suicide clusters, and the mimicking of suicidal behavior in families.

Nicholas Hughes was a well-known citizen of Fairbanks, Alaska, an acknowledged scholar in his own field of biology, and he clearly eschewed discussions about his mother, according to The New York Times ("A New Chapter of Grief in Plath-Hughes Legacy," April 12, 2009).

We are frequently confronted by a suicide in which the victim is described as being in good shape with, ostensibly, "everything to live for." What goes on in the mind of someone whose career is going well, who is in a good intimate relationship, and who has a supportive social circle--and who nonetheless chooses to end his or her life? It is very mysterious.

Yet it appears that despite appearances, such people are extremely vulnerable to minor stressors--a word, a small event, an attack on their self-esteem--and much more so than is the average person.

According to the piece in The Times, Nicholas Hughes had battled depression for years, "as his mother had, and on a recent trip to New Zealand he had even talked of suicide."

The average person rarely, if ever, expresses this kind of vulnerability--the feeling of having been hurt, attacked, undermined, or betrayed. But people with depression frequently have these feelings. And these feelings and concomitant mood swings can lead to suicide.

What did his mother's suicide and the suicide deaths of several other important people in his life contribute to his ending his own life? Although most Americans are familiar with suicide as a possible method for exit, it is not something most people think about very often or even consider as an option.

However, people with suicide in their lives are more likely to think about it and might even consider suicide normal behavior. One of the criteria in measuring lethality when someone expresses a suicidal wish is whether a significant family member--particularly first-degree relatives--has committed suicide.

According to the American Psychiatric Association's Practice Guidelines for the Assessment of Patients With Suicidal Behaviors, other factors associated with an increased risk for suicide include recent lack of social support (including living alone); sexual and physical abuse; hopelessness; thought constriction (tunnel vision; male gender; white race; and widowed, divorced, or single marital status, particularly for men.

There is growing literature demonstrating that depression and suicide have a genetic basis. For example, a few years ago, researchers in Germany found that two genes might be involved in the vulnerability for suicidality: intronic polymorphisms of the tryptophan hydroxylase 1 (TPH 1) gene, and the insertion/deletion polymorphism of the serotonin transporter gene (5-HTTLPR) (Mol. Psychiatry 2006;11:336-51).

As researchers continue to look for diagnostic specific genes, we see suggestions of such heritability in family histories as we examine and evaluate patients.

We often find that a parent or grandparent has suffered from depression, and the patient will say, "I've been depressed all my life," with little recognition of stressors that have pushed them further and further into a depressive state. Such patients often have thought about suicide and/or made attempts. We always worry about patients who have thought about it or tried it. The patient might succeed in ending his or her life. What should we do?

The story of Mr. Hughes sounds atypical. From the outside, it looked as if he was having a good day. He told his companion that he was going out for a walk, but he actually carried out his suicide instead. His friends knew him as a man of "immense energy and curiosity" who pursued his scientific career and received a lot of professional recognition and positive feedback. …