DP: According to the American Foundation for Suicide Prevention, suicide is the 10th leading cause of death in the U.S. In 2017, there were an estimated 1,400,000 suicide attempts. In 2018, 48,344 Americans died by suicide. While middle-age white men are in the highest risk group, the suicide rates of people between the ages of 15 and 24 increased from 10% in 2000 to 14.46% in 2017. What are some factors that explain a rise in suicidal concerns in teens and young adults?
Dr. Rowland: The advent of smart phones and the growing ubiquity of social media has likely played a role. These factors tend to increase young people’s social stress and the frequency and impact of bullying. Technology also decreases kids’ sense of having their own space and time to relax. Whether real or perceived, the expectations on adolescents in terms of what they need to do to be successful has escalated. Competition for college spots has increased along with the general message that “everyone has to go to college,” which is not true. Finally, more people live more structured lives these days. This is certainly true of children and adolescents. They have less free play time due to their days being filled with tutoring and athletics and college prep courses. Some young people who feel they are not at the top of their class or school fear they will fail in life. This gets amplified by social media, where we only post the fantastic things that happen in our lives. People get a skewed perception of where they compare to their peers. Everyone having their own small screen in front of them, compared to the whole family watching the same show together, can also increase young people’s exposure to morbid topics without others being aware.
DP: When you are treating a young person for depression, what are some important things you look for or encourage parents to look for?
Dr. Rowland: When you are treating a young person or an adult for depression, there may be suicidal thinking there, too. However, before their depression is well treated, they may lack the energy or motivation to take action on those thoughts. So, during the early phase of treatment, you have to be cautious because, for the time window when the person’s mood improves, the risk of acting on underlying suicidal thoughts may increase. You have to ask important questions, even though most of us are uncomfortable talking with someone about these suicidal feelings. If the person’s mood is getting worse rather than better, that should be brought to the caregiver’s attention. If the person’s risk factors for acting on suicidal thoughts increases, you have to consider how to make sure their environment is safe by removing opportunities to act on impulsive thoughts. For example, remove weapons such as handguns from the home. Provide closer parental supervision during times when young people’s stress levels might typically increase, such as at bedtime or before school in the morning.
DP: Any other suggestions you would offer parents?
Dr. Rowland: Again, most people have a discomfort with talking about, and really listening to, suicidal thoughts that their children may be having. Parents understandably want to jump in and solve the problem. The work is about supporting they child while he or she does their own work to get back to a healthier state of functioning. If the young person reaches a point where they aren’t safe, then you have to consider hospitalizing them to provide round-the-clock care for their safety. Short of that, though, a young person may say, “I wish I were dead,” without really meaning it. This may be likely to happen in the midst of a heated argument with parents. Once the young person calms down they realized they don’t wish that. There, you want to help that young person develop better ways to give voice to their pain and frustration without expressing it that way. To assess risk level, I ask questions to better understand the context. Do you really mean that? You can be in a lot of pain and be really frustrated; it’s okay to express that. What do your statements about those feelings really mean? I also look for other factors that can increase a young person’s risk of suicide. These include things such as active substance abuse, a history of suicide attempts by that person or other family members, and things such as pills or handguns that are readily available. If the person is having such thoughts on a regular basis and they also have a plan, these situations require immediate care.
I also think it’s important for parents, teachers, and other professionals to realize that depression doesn’t always show up as tearfulness and sadness. Sometimes its primary symptoms are a lot of irritation and anger. These symptoms usually emerge as a change in behavior, although those changes may occur gradually over time. They are usually accompanied by other symptoms such as a loss of interest in former pursuits or spending less time with friends. Again, talk with the young person if you can: What has changed? What are those feelings about? If adolescents can’t or won’t talk with their parents, try to help them find someone else they can talk to about these things. These patterns may be bigger than, “Oh, they’re just a teenager. They’ll outgrow this.”
DP: Finally, let’s talk about prescription medications to treat depression in young people. I know a lot of parents are concerned about the black box warning on these medications. What would you like to say about this?
Dr. Rowland: I think that warning has harmed more people than it’s helped. It originally came out in the mid-2000’s. Two years later, they expanded it from children and adolescents to people up to age 25. The warning emerged as a result of a study based on clinical trials of SSRI’s, mostly, in children and adolescents. About 4% of young people in the treatment group expressed suicidal thoughts; about 2% of the control group participants did, too. These are artificially low numbers because the trials excluded young people who had reported suicidal ideation before entering into the trials. Prior to the black box warning, the vast majority of prescriptions for antidepressant medications were written by primary care physicians, not psychiatrists. Due to their concerns about liability with the black box warning, the number of prescriptions dropped steeply. Studies that have looked at suicidal ideation in people of all ages after starting on an antidepressant medication have found an overall decrease in suicidal ideation over time.
We need to remember two things about all of this. First, back in the late 1980’s when SSRI’s came on the market and were gradually prescribed more frequently in children and adolescents, the rates of suicide went down. Second, after the black box warnings were issued and the number of prescriptions for antidepressants declined sharply, the rates of suicide have gone up. There are other factors beyond a decrease in the number of prescriptions being written that have contributed to this trend, but I believe this is an important one. For many children, their main access point for treatment was the pediatrician or family practitioner, but these physicians, understandably, no longer felt comfortable prescribing these medications and there was no corresponding increase in use of psychotherapy as the prescribing rate went down. Many young people simply went untreated.
Good psychotherapy plays a critical role in the effective treatment of depression and anxiety. Virtually every study finds that the combination of medication and therapy has the best outcomes. Therapy helps people learn skills for recognizing and responding more effectively to stresses and thought patterns that contribute to suicidality.