LITERATURE HAS taught us that grief, misery, and melancholy can force us into near-death states of mind. Think for example of Hamlet, Sylvia Plath's The Bell Jar, and William Styron's recent memoir of his experience with major depression, Darkness Visible. But except for those who die by suicide, these mental or spiritual deaths in literature have not led to early physical deaths.
However, in the 1930s Malzberg1 and later others reported observations of increased mortality rates among hospitalized mentally ill patients. Formal mortality studies among depressed patients began in the 1960s, and now a group of over 60 studies suggests that depression may increase the risk of death in some populations, such as those with heart disease.2 Suicide explains only a small proportion of the increase in mortality among the depressed, almost exclusively among the severely depressed psychiatric population. But the important questions remain unanswered. We do not know, for example, what severity and duration of depression increases the risk of early death, nor do we know the mechanisms by which depression might precipitate early death.
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