Teen Suicide – PediaCast 315
This week, Dr Mike takes a comprehensive look at Teen Suicide. We discuss the scope of the problem, risk factors, warning signs, prevention strategies, treatment options, long-term outlook for suicidal teens and ongoing research projects aimed at identifying at-risk youth and getting them plugged-in to the help they need. Dr David Axelson, Dr Jeff Bridge and Dr Dan Cohen are our guests. Join us!
Epidemiology of Youth Suicide and Suicidal Behavior (NIH)
Keep Calm and Parent On (Suicide Prevention)
STAT-ED: Suicidal Teens Accessing Treatment After an Emergency Department Visit
Kristin Brooks Hope Center
The Jason Foundation
National Suicide Prevention Lifeline: 1-800-273-TALK (8255)
National Hopeline Network: 1-800-442-HOPE (4673) or 1-800-SUICIDE (1-800-784-2433)
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello everyone, and welcome once again to PediaCast. It's a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. It is Episode 315 for April 15th, 2015. We've a lot of fifteens there. We're calling this one "Teen Suicide".
I want to welcome everyone to the program.
The title says it all. And we're going to talk about a very difficult topic, but it's also an important topic. It's not one to sweep under the rug. After all, suicide is one of the leading causes of death in adolescents, and it's a cause of death that can be prevented, especially if warning signs are recognized and taken seriously and if intervention is pursued.
So there's lots to talk about. I don't want to spend too much time with introductions this week. We have lots of important information coming your way.
Some of the items — just how big is the problem? Why do teenage suicides sometimes occur in clusters? You'll have suicide in a school, and then you'll hear about several more that follows on the heels of that. Why does that happen? What are the risk factors and warning signs? What's a parent to do if you're worried that your child is at risk? What steps do you take if your child is suicidal or has attempted suicide?
Where do you turn for help? What kinds of treatment are available, including counseling and medications? How successful is the treatment? What dangers may treatment bring, especially in the case of anti-depressants and other medication?
What's the long term outlook for suicidal teens? What steps can parents take now to lessen the risk?
And then, we'll explore some of the latest research projects aimed at identifying suicidal teens and getting them plugged in to the help that they need before more serious problem takes place.
So we have another nuts and bolts edition of our program on a pretty serious topic. It's one you'll definitely want to share with family and friends, and on social media, so we can reach as many parents as possible with the message. Because when it comes down to it, lots of families are dealing with suicide concerns even if you don't know about it on the outside. We're pretty good at putting up our walls and not letting anyone know until tragedy strikes. We want to prevent those tragedies and one way to do that is by breaking down the walls and talking about it.
So please be sure to share today's program with as many people as you can, even if you don't think you know anyone who needs to hear it. Chances are there are plenty of people in your sphere of influence who would benefit from today's show.
In our usual fashion, I have some great studio guest line-up to help me talk about teen suicide. Dr. David Axelson is a child and adolescent psychiatrist and medical director of Behavioral Health at Nationwide Children's. Dr. Jeff Bridge is an epidemiologist and principal investigator with the Center for Innovation and Pediatric Practice, and Dr. Dan Cohen is an attending physician in Emergency Medicine in Nationwide Children's, who is not only involved in suicide research, but also takes care of many suicidal teens when they first show up in the emergency department.
I'll make proper introductions in a few minutes, but first I want to remind you about our 700 Children's blog where we call upon the collective pediatric expertise of our entire institution and present a fantastic collection of articles for moms and dads, written in the way you can understand and hopefully find useful. It's at 700Childrens.org.
Some recent topics: how to talk to your children about death; are laxatives safe for children? Injury prevention in young athletes, toddler nutrition — how much is enough — and the ABC's of BMI. So lots of great material on the blog. Again, you can find these articles and more at 700Childrens.org.
Also, I want to remind you, you can get in touch with the program if you have a topic idea, or you have a question for me, it's easy to get in touch. Just head over to PediaCast.org and click on the Contact link. You can also call our voice line at 347-404-KIDS. That's 347-404-K-I-D-S or 5437 if you need the digits. Just leave a message there, and we'll try to get your voice on the show. You can ask your question or suggest your topic that way.
Also, I want to remind you, the information presented in every episode of this program is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.
All right, let's take a quick break and I will be back. We'll introduce our guests and we'll talk about teen suicide right after this.
Dr. Mike Patrick: All right, we are back. Dr. David Axelson is a child and adolescent psychiatrist at Nationwide Children's Hospital. He serves as a medical director of the hospital's Behavioral Health Program and is a professor of Psychiatry at the Ohio State University, College of Medicine.
Dr. Axelson attended medical school at Duke University and completed his training in Psychiatry at the Western Psychiatric Institute and Clinic at the University Of Pittsburgh Medical Center, which is consistently ranked as the one of the nation's best hospitals for psychiatry.
This is Dr. Axelson's first appearance on PediaCast, although we've already convinced him to participate in an upcoming CME version of the program.
So let's give a warm PediaCast welcome to Dr. David Axelson. Thanks for stopping by.
Dr. David Axelson: Thanks Dr. Mike.
Dr. Mike Patrick: We really appreciate it.
Dr. Jeff Bridge is an epidemiologist and principal investigator in the Center for Innovation and Pediatric Practice at Nationwide Children's and an Associate Professor of Pediatrics at the Ohio State University, College of Medicine. His research focuses on the epidemiology of suicidal behavior in young people, neuro-cognitive vulnerability to suicidal behavior, and improving the quality of care for children and adolescents who have attempted suicide.
The National Institute of Mental Health, the center's for disease control and prevention and the American Foundation for Suicide Prevention have all provided funding for his research in these areas.
It's also Dr. Bridge's first time on PediaCast, so a warm welcome to you as well. Thanks for stopping by.
Dr. Jeff Bridge: Thanks, Dr. Mike. Great to be here.
Dr. Mike Patrick: And finally, to round out our conversation today, Dr. Dan Cohen returns to the studio. He's quickly becoming our go-to guy for all things emergency medicine, including teen suicide.
Dr. Cohen is an attending physician with the Section of Emergency Medicine in Nationwide Children's and an associate professor of Pediatrics at the Ohio State University, College of Medicine.
A quintessential jack-of-all-trades, Dr. Cohen excels at caring for patients, teaching medical students and residents and contributing to the many on-going research projects in the Emergency Department.
It's always a pleasure having him in the studio, and today is no exception. Thanks for joining us again.
Dr. Dan Cohen: Thank you for having us.
Dr. Mike Patrick: So let's get right into it. Dr. Bridge, tell us a little bit about the scope of this problem. Just how common is teen suicide?
Dr. Jeff Bridge: Sure. So suicide is the second leading cause of death in the United States among young people age ten to nineteen years. Suicide claims more lives in this country than by nine other leading causes of death combined. And the rates are increasing. So in 2013, which is the year the latest data that are available, the suicide rate among teens was 5.1 per 100,000, which is higher than it's been in the last 15 years.
Dr. Mike Patrick: Wow. Is this pretty much across the board when we talk about all teenagers ? Or, do you see differences in terms of males versus females and different races, ethnicity? Or is it pretty much equal?
Dr. Jeff Bridge: No, we see differences. Males are much more likely than females to complete suicide. Females, on the other hand, are more likely to attempt suicide. We think that some of the gender difference in this gender paradox in suicide is related to the lethality of the attempt. Males tend to make more lethal attempts. They tend to have more impulsive aggression which is a reactive form of aggression, and they often have psychiatric co-morbidities. So you'll see males with depression and alcohol and drug use, and that greatly elevates your risk for suicide.
Dr. Mike Patrick: When you talk about just thinking about suicide or what we call suicidal ideation or thoughts of suicide, is that pretty much equal between men and women? Or is there a difference there as well?
Dr. Jeff Bridge: No, there is a difference there as well. Females have much higher rates of thinking about, planning and attempting suicide compared to males.
Dr. Mike Patrick: But the males are more likely to actually carry it out once they do get to that point?
Dr. Jeff Bridge: Correct.
Dr. Mike Patrick: And then do you see a difference among different ethnic groups or races or is that pretty equal?
Dr. Jeff Bridge: No, we see differences there as well. So Hispanic females have the highest suicide attempt rates, but if you look at ethnicity as far as completed suicide, there's no difference in terms of ethnicity for rates of suicide.
If we look at race, American Indian and Alaska Natives have by far the highest suicide rates in this country in young people and across other age groups.
Dr. Mike Patrick: And do you think that has something to do with the social economic situation that they find themselves in, or do we think it's beyond that? Or, no way to know?
Dr. Jeff Bridge: Well, that certainly contributes, too.
Dr. Mike Patrick: Do you see some differences there as well?
Dr. Jeff Bridge: The research isn't as great if you look within the American Indian/Alaska Native population, but that certainly contributes. There are higher rates of alcoholism. It's inter-generational, and the young people are dealing with a lot of stressors.
Dr. Mike Patrick: But having a lot of money does not make you immune from this problem or high socio-economic, as we saw with Robin Williams just last year?
Dr. Jeff Bridge: Certainly not.
Dr. Mike Patrick: What are some of the known risk factors for adolescent suicide?
Dr. Jeff Bridge: Well, you hinted out a few. So there are demographic risk factors. We touched on gender. Age is a risk factor as well. Suicide rates increase throughout adolescents and into early adulthood. You also touched on race and ethnicity.
If we look clinically, depression, drug and alcohol use, disruptive disorders, and again, that combination of disorders greatly increases risk. History of exposure to abuse or trauma, bullying — these are all risk factors. Probably one of the most important risk factor for suicide is prior suicide attempt. That increases your risk for suicide thirty- to sixty-fold.
Dr. Mike Patrick: Yeah, and I want to go back to the bullying that you mentioned. It seems that there's a lot in the news about that, in particular, online bullying, which is something that none of us had to worry about when we were growing up.
Talk a little bit about how that plays a part in this.
Dr. Jeff Bridge: Oh yeah, bullying is very important. There've been a couple of well done studies over the last few years looking at the impact of bullying on suicide attempts. It's something that when you control for other factors like depression — like a family history of suicidal behavior — bullying emerges as significant robust predictor of suicidal behavior.
Dr. Mike Patrick: And that's one of those things too if you're really — you don't want to cross that line into invasion of privacy, but you still want to have a good handle on what's going on in your kid's life, whether they're being bullied or whether they're doing the bullying. So parents too, with regard to bullying and how that's kind of become such a big issue, it's not just a kid problem; it's a parent problem, too.
Dr. Jeff Bridge: Correct. It's a school problem as well. Schools are taking this very seriously. You see, school programs are being rolled out across school districts all throughout America. So, we need to see more of that.
Dr. Mike Patrick: One of the questions I had — I think we already answered this, but I just want to make it pretty clear that thinking about suicide does not always lead to a defined plan in suicide attempt — in fact, just sort of having that thought pass through your mind is pretty common, isn't it?
Dr. Jeff Bridge: It is common. If you look at Youth Risk Survey Behavior Data — this is national surveys of high school students in the US that's been conducted for about 25 years — about 17% in the latest survey reported some thought of suicide in the last year.
Dr. Mike Patrick: So pretty common.
Dr. Jeff Bridge: Pretty common.
Dr. Mike Patrick: What methods do teenagers most commonly use to plan and attempt suicide? And that does differ from adults, let's say?
Dr. Jeff Bridge: It's deliberate self-poisoning, for sure. Up to 80 to 85% of all suicide-related hospital admissions are going to be for deliberate self-poisoning. That's common in adults as well. But again, if you're talking about suicide, then the most common suicide methods would be suffocation, hanging or suffocation, firearms, and then poisoning.
Dr. Mike Patrick: One of the questions I had kind of brought up during the introduction of the program, why is it that teen suicide sometimes occur in clusters? You know, we see or hear the new stories. In fact, we just had a school in our local area not too long ago where this occurred. But all parents out there who are listening to this know what I'm talking about. Why does that happen?
Dr. Jeff Bridge: Well, so first just to define what a cluster is — a cluster is an excessive number of suicides that occur in closed temporal or geographic proximity. They're more common in young people than adults.
Maddie Gould, researcher at Columbia University did a study and found that young people are probably two to three times more likely to be influenced by the suicide of another person, and so there's a term called "suicide contagion". It is what it sounds — that suicide can be contagious. Young people tend to be more vulnerable to that influence, to media reports about suicide, to hearing about and knowing the death of someone, be at a local school or within a community.
Dr. Mike Patrick: So that really makes it important when the first case occurs, it's really important for the school to have a support or program for parents to be in tune and understand that this just happened and really be there to talk with their kids about it and get a pulse on what's going on.
Dr. Jeff Bridge: Absolutely. An adequate response is paramount to containing, you know, the situation.
Dr. Mike Patrick: Yeah. Now, when I say the parents should have a pulse on that, that means that, well, when they ought to understand what's going on, but then there's some warning signs that parents should be looking for that could indicate a teenager may be thinking about suicide. Dr. Axelson, talk to us a little bit about what those warning signs are that a parent should be paying attention to.
Dr. David Axelson: So, oftentimes these are symptoms that overlap with symptoms of depression. So, thinking about change in eating habits or sleeping habits, withdrawal from friends, family and their regular usual activities that they like to do. It can turn into sort of more irritability, violent actions, rebellious behavior or running away. Certainly, onset of drug or alcohol use is of concern. An unusual neglect of their personal appearance, they used to take care of the way they look and then, suddenly not caring about that. Concern about loss of interest in pleasurable activities, being persistently bored.
It can affect the declining quality of school work or difficulty concentrating could be a consideration.
Sometimes youth with thoughts about suicide have a lot more frequent physical complaints like stomach aches, headaches, fatigue that you go to the doctor and you don't have a physical explanation for it.
Sometimes there can be warning signs that a teenager who was planning to commit suicide might complain about feeling very rotten inside or being a very bad person. It could give verbal hints such as, "I won't be a problem for you much longer," or "Nothing matters. It's no use," or "I won't be seeing you again."
Dr. Mike Patrick: Yeah.
Dr. David Axelson: Those would be warning signs to consider. Also, doing things like putting their affairs in order like giving away favorite possessions, throwing away important belongings, leaving a note or sort of a will.
Something that can be also of concern, if somebody has been depressed for a while, then suddenly very cheerful. That could be a warning sign that they may have thought about suicide or planning suicide.
Dr. Mike Patrick: Like they've coming to terms with it at that point.
What about cutting? A lot of parents see that they're child is doing some self-harm behavior. Is that a different entity altogether, or is that a precursor to suicide?
Dr. David Axelson: That's a difficult question, and it's sort of kind of goes both ways. Certainly, most sort of cutting or what we call non-suicidal self-injurious behavior is not an actual suicide attempt or related to the child actually wanting to commit suicide. However, it is associated with increased future risk of suicide attempt.
Dr. Mike Patrick: And I'm sure that from the parent's point of view, it's very concerning that my child's hurting himself. Could they take that further?
Dr. David Axelson: Yes, and so I think when you see those kinds of signs or concerns, the most important thing is to talk to your child about those concerns.
Dr. Mike Patrick: How do you go back doing that? So, you do you see any number of these warning signs. I think that there's this notion out there that if I talk about suicide, I might put that idea in their head. That's not necessarily the case. Is it?
Dr. David Axelson: Absolutely not the case. It really is important I think to be direct and ask your teenager if you have concerns whether they're feeling depressed, whether they have any thoughts about killing themselves or committing suicide. Talking about it will not put the thought in their child's head. Actually, in many cases, they might be relieved or feel supported that you're actually sort of in tune with their concern. So, I think actually talking about it might show that you care.
Dr. Mike Patrick: So, let's say you do bring that topic up, and your child says, "Yeah, I have thought about this." Or let's say they have actually attempted suicide, what do parents do next? What's the next step? Where do you go for help?
Dr. David Axelson: So as you've mentioned with Dr. Bridge, transient suicidal thoughts are very common. I think that if those are arising and you have concerns, and there's no eminent risk — meaning they're not planning to do something right this minute or it's not persistent that's causing them a lot of distress — the first thing to do is either talk to your family doctor, or arrange for a assessment with a qualified mental health professional.
However, if there's been actual attempt, that's a very different story. If they meant an attempt to kill themselves, I think that they may need an urgent evaluation. If there's injury or the child has ingested a substance or pills, it's very important to get a medical evaluation to make sure they're stable. For instance, even sort of over-the-counter medications such as Tylenol might not show any physical symptoms if you've taken it, but actually, they're very, very dangerous and can have a delayed reaction.
So if there's been ingestion, any serious injury, that should go right to the emergency room.
I also think that if their medical status is stable, they still need to be evaluated immediately by a qualified mental health professional to help decide whether a higher level of care is needed, to help safely intervene, to prevent a subsequent attempt.
It doesn't mean that every child that's had a suicide attempt needs to have a psychiatric hospitalization, but they do need an evaluation to come up with a safety plan to decide what's the best way, the next best steps.
Dr. Mike Patrick: Yeah. So if it's just a fleeting thought, and you really, as a parent… I want to be pretty specific about this so parents have an idea in their minds, like "What do we do?" If it's a fleeting thought, maybe you can call your doctor, whoever's on call for your doctor's office, and just talk to them. Maybe they could give you an idea on other questions to ask or give you idea whether you really need to go to the emergency department or not. But if, really, you think that this is serious, then this is not something that you don't want to…
Dr. David Axelson: You want to wait around. And, I think asking your child, if it's a fleeting thought, to say, "If this gets worse or if you start thinking about actually doing something, please let me know immediately and then, we can seek an immediate evaluation."
Dr. Mike Patrick: Now, here in the Columbus area in Central Ohio, we have plenty of resources that folks can tap in to. But what if you're a hundred miles from the largest city in a small town, what kind of resources could a person in that situation look for?
Dr. David Axelson: There's a couple of different possibilities. Many counties do have sort of an emergency crisis line or a county mental health crisis phone number or center that you can go to. Certainly, hospital emergency room can be a possibility. There are also different suicide hotlines that can direct you to resources, but if there's been an attempt and there's any concern about medical stability, the best thing to do is call 911 and access medical care as soon as possible.
Dr. Mike Patrick: Absolutely. Do you recommend like the National Suicide Lines that are out there? I know that there's one, the National Suicide Prevention Lifeline and the National Hopeline Network. I mean, there are different ones out there. Do you recommend that people use those? Or is that just if there's not a local resource, then that's something that you would use?
Dr. David Axelson: Yeah. I think that those resources can be helpful. Particularly, it's better to reach out to something rather than nothing. If there are local resources, because sometimes it really needs a face-to-face evaluation to really get an understanding about what's going on, I think that's a better option if it all possible. But, certainly, those helplines certainly can provide some helps if it's better to access that than nothing. I guess that would be the way I would suggest it.
Dr. Mike Patrick: And, really, your regular doctors should know what resources are available in your area because they've dealt with this before. So that would be an excellent resource as a first point of contact.
Dr. David Axelson: Certainly.
Dr. Mike Patrick: So let's say a person does make their way into the emergency department because they have had some suicidal thoughts. Dr. Cohen, describe the emergency department approach to teenagers who were thinking about suicide.
Dr. Dan Cohen: So I would first put on my parent hat and think about it, how that feels for a parent showing up in the emergency department. I'd say, in general, most parents really don't want to be there unless they have to. I think that is even more the case for mental health challenges as well.
The other thing, just to add, first glance I would say is that the definition of teen, I know this is teen suicide, the definition of teen maybe a little younger than we usually think of, and you've probably covered this in other PediaCasts as well. Unfortunately, we see even younger kids and that provides other challenges as well with suicidal thoughts or even suicide completed.
I think it is particularly challenging both for the providers as well as for the parents. So, I think parents are at a moment of crisis, and this is a great opportunity for us to really intervene as a team. With the three of us here talking with you, Dr. Mike, I think that's really an example of how important the process is for the families that they go through.
When I think about our evaluation in the emergency department, I kind of break it down into a few buckets and they all relate to safety. So the first step to us as emergency medicine folks, we triage, and our first triage is the medical safety. Clearly, we can see kids with really serious injuries related to a suicide attempt, whether they're in toxicants they take or physical injuries such as near hanging. So we really need to stabilize that medical parts. Medical safety comes first.
Psychological safety, that's the face-to-face time with real in-depth talking to the family, and we do get tremendous help from our mental health providers.
I think, also, we need to think about in terms of social safety. So, some of the problems may have a larger context, and it may not just be that individual. There can be pretty complicated situations.
Dr. Mike Patrick: So, if there's abuse going on behind the scenes, or there's the bullying issue. You got to tease all that out.
Dr. Dan Cohen: Correct. Many times mental health challenges don't really happen in isolation. It's not just one individual, but it's in the context of a social situation. There are often times other forms of abuse that might be happening in the back ground. And, clearly, those sometimes cause other emergency department or urgent care visits, are associated with those kinds of challenges, including depression.
Finally after medical safety, individual psychological safety, social safety, I think that there's also issues for staff safety or facility safety that we need to think about in terms of protecting the kids while they're with us, until we really ascertain what needs to happen next.
Dr. Mike Patrick: Absolutely. How do you go about deciding — obviously, as a physician it's nice to have a lot of resources at our disposal and mental health professionals to help us with this — but sort of in general, how do you decide if this is something that a person can go home with some education versus you need help now, which may include being admitted to the hospital and seeing Psychiatry the next day? How do you decide that?
Dr. Dan Cohen: I think that is sort of a million-dollar question, to getting at to who really is safe and not. Obviously, if there is a medical concern, if they're not medically cleared, if we need to check another acetaminophen level, if there's any medical concern, then we would hospitalize for that with consultation alongside.
I think it really is contextual. It depends on past suicidal attempts, and there's a cadre of questions that I think are really relevant to trying to get to that risk assessment. Really, a lot depends on the families, in their resources and their ability to follow through. And we really, really are very concerned about, yes, this is a great moment of crisis, and we could use this as a moment to coalesce as a team, including the families, but they really need to be engaged in that process.
Dr. Mike Patrick: To some degree, this is where the art of medicine kind of comes into play a little bit. You could have a computer, go through, and tick, "Okay, they do have this. They don't have that. They get admitted, or they go home." But, really, there's way more that has to be synthesized together, and there's that human element, and so I think the art of medicine is a good example over that, where that comes in.
Dr. Dan Cohen: Yes, it's trying to predict the future and that can be pretty hard.
Dr. Mike Patrick: We've talked about this concept of a safety plan. What exactly is — and anyone can chime in try them in here — what is a safety plan? What does that mean?
Dr. Dan Cohen: Well, I'll just start off as lead of header, and then, we'll get greater contact to follow. I think of it in terms of like, take for example home safety for toddlers. We know, we talk about that a lot as pediatricians. Well, it is a lot harder to make your home safe for a teenager who really wants to hurt themselves. They have greater access. They're not always at home necessarily. They're more cognitively faster than a three-year-old to do that which they want to do.
So I think the idea of making your home safe-er is the objective. Complete safety is not necessarily achievable.
Dr. Jeff Bridge: In another aspect of the safety plan is that you're giving the patient and the family a tool box for when they become suicidal. When they're thinking about making an attempt or a plan, you're giving them some guidelines that they're developing. That's their own tool box to help prevent an attempt from occurring.
Dr. David Axelson: Yeah. I would agree. Unfortunately, as Dr. Cohen said, we can't accurately predict future suicide risk. It's definitely an art and there is enough data. It's not something that we can do perfectly.
Looking at situations, though, oftentimes suicide attempts in teenagers can be triggered by either certain situations or certain cues. So being able to remove some of those can potentially reduce the overall risks. So, for instance, locking up medications, especially if that can be sort of a cue risk factor for that individual child. Removing guns from the home, for instance, I think can be very important aspect, but understanding that you cannot make it a 100% safe.
We're just reducing the risk, and also providing a tool box and coping skills for when those thoughts happen, the kids and families have a way of sort of managing it, and then, also, ways of understanding when it's important to comeback and seek emergency evaluation again.
Dr. Mike Patrick: And you talk about keeping them away from the items with which they may hurt themselves, but there may also be environmental situations that they're in or people-relationships that may be they ought to avoid in this acute phase. So there's that the whole social aspect of the safety plan as well.
Dr. Jeff Bridge: I was just going to pick up on Dr. Axelson's point about the social cues. So, you give, as part of their tool box, they understand certain social cues that may set them off, that may get them thinking more about suicide and you help them to de-escalate that situation. And if they can't, then you give them tools to talk to people so that they can keep themselves safe.
Dr. Mike Patrick: So let's say, you do have someone that comes in. You've done the medical evaluation, the social and mental health evaluation, social evaluation, and you come up with the idea that we can do a safety plan. They're going to go home, but they're going to follow up in a few days with a counselor, whether that be a psychologist, a psychiatrist. I think, too, just in terms of the different roles of professionals that are out there — I know, I'm sorry I didn't ask, this wasn't one of my questions, but I think it's one that's in parent's mind — how do you know who to go see?
Dr. David Axelson: Well, that's a good point because really, there are many folks that can provide good quality mental health services. And that's why we do use the term 'qualified mental health professional', and there's actually a spectrum of different disciplines that can do this.
We are looking for somebody though that is licensed. I think it's a key issue, but there are licensed social workers, clinical counselors, marriage and family therapist, psychologist, and psychiatrist and psychiatric nurses, nurses and nurse practitioners — all can provide over all in treating kids with health problems and with suicide at suicidal ideation.
Dr. Mike Patrick: And I just want the kind of hang on to that with the license and with background and training and experience because there may be — I don't want to get myself into trouble here, but at the same time this is really what happens out in the real world — there are folks that may be with your faith let's say or there may be someone at church or the synagogue or where ever you go, who has an interest in helping people with these kind of problems. There may be some folks who are great at that and others who aren't so great at that. There may be family members who think, "Well, I've dealt with this before." Or maybe an uncle or aunt had a kid who went through this so they feel like they know. And they might, but they might not.
So, when you're talking about your kid's future and their life and their social and mental well-being, I think you want someone at least involved who we know does have the tools that they need. Does that make sense?
Dr. Dan Cohen: It makes complete sense. I know it's very hard because there is no easy way to determine from the web or from a phonebook who is the right person. I think that's where you start. You can certainly use primary care physician as sort of a resource, I think.
In our emergency room, we try to link up with services that we know have experience working with teens with mood problems and suicidal thoughts, and I think that's important that they are licensed in their discipline.
It doesn't mean that lay people don't have a role as far as support, certainly can be helpful. It's also sometimes good to ask some of those folks if they've had experienced with other professionals to get recommendations, but I think having somebody that has experience working with teens with these problems is important in the said specialized training in that area.
Dr. Mike Patrick: What kind of counseling then? So let's say they do get plugged in with someone who's licensed? I would suspect that you don't jump right into medications. What kind of counseling is helpful for these kids?
Dr. David Axelson: Well, I wish that there is more research in this area to sort of say, "We know this type of counseling is going to work." Looking at counseling that helps the actual sort of potential core problem is I think at issue, because as Dr. Bridge mentioned, most kids who have had suicide ideation or suicide attempts have some mental health diagnosis or substance, a drug and alcohol dependence diagnosis.
Certainly, there's some therapies that have been shown to be helpful for treating teen depression. Cognitive behavioral therapy is one that have been shown to be helpful. Interpersonal therapy is another. There has been some recent studies looking at adaptations of a therapy that's been used in suicidal adults called Dialectical Behavior Therapy or it's called DBT for short, which has been showing promise for suicidal teens.
But we don't have a definite "This is the kind of therapy that works." I think, really establishing a good relationship with a quality therapist is probably the most important basic ingredient. And then, most therapist that are comfortable treating these teens do have some experience in training in one of those modalities that I mentioned.
Dr. Jeff Bridge: Some good news on the intervention front is that there are studies that are underway. There is a study looking at attachment-based family therapy for suicidal teens. There's another study that's looking at a cognitive behavioral therapy approach for teens who are suicidal and also abused alcohol or drugs. Those are funded right now by National Institute of Health, and hopefully, in the next few years, we'll have some results.
Dr. Mike Patrick: I do peruse the pediatric literature as we come up with new stories and interesting things for parents. It seems that there's been a lot of focus here recently on family therapy, with regard to depression. One I saw recently, in particular, was preteens, in that age range. Do you see a difference if you have the whole family involved with therapy versus just the individual? Or, is it a kind of a case-by-case? What's your feelings on that?
Dr. David Axelson: I think case by case is important, because there are some evidence that if you don't match the therapy to where the family is going and sort of forces a particular approach, sometimes that can actually be counterproductive. But I think, especially with preteens, the family contact is incredibly important. Not that it isn't important for teenagers as well, but there is sort of a process of individuation and sort of sometimes forcing a family approach on a teenager is not the best idea. Whereas, I think in preteens, it starts to make more sense that you have to include that component.
Dr. Mike Patrick: And that's where you really want to know — what are the family dynamics, and what the stressors, relationship issues may already be there or may not be there and all that.
Dr. David Axelson: And a good therapist often times would be able to work that into the approach. So primarily working individually with the teenager, but knowing when to bring the family in, recognizing the family dynamics might be the most important contributing factor to the stress.
Dr. Mike Patrick: And when do you consider medications?
Dr. David Axelson: Really looking at medications for the underlying disorder or mental health diagnosis that may be occurring, there's not specific anti-suicide medications, but there's medications that treat the underlying conditions. So as we mentioned depression is the most common condition associated with suicidality in teens, and there are anti-depressant medications that have been shown to be effective. Particularly, fluoxetine or the trade name Prozac has been clearly shown to be helpful and is FDA approved.
However, if there are other illnesses, such as severe anxiety can be treated with anti-depressant medication. If there's a prominent ADHD or attention problems that contribute to stress, there are medications such as stimulants that can be used for that.
And then, unfortunately, sometimes very serious illnesses like bipolar disorder, psychotic symptoms like hallucinations, or delusions, or schizophrenia can be associated with suicide ideation and attempts, and there are medications, such as anti-psychotics can be helpful.
Dr. Mike Patrick: Some of the mental health professionals that we talked about have the ability to prescribe medicines and some don't. How would a parent navigate those waters?
Dr. David Axelson: So psychiatrist and psychiatric nurse practitioners, as well as pediatricians and family practice doctors, can prescribe medications. It's great when you can actually have sort of a team approach, meaning that you might have a therapist working with one of those practitioners or therapist that's very comfortable sort of referring and has a working relationship with one of those practitioners. That's oftentimes where you get the best sort of synergy about therapy has been started, but there's other problems that medications can help in working together.
That being said, there are some psychiatrist that do both therapy and medication treatment, and so you can get certain practices do both.
Dr. Mike Patrick: Sure. With regard to if the child did get started on medicines, there are a couple of specific risks that I wanted to talk about. One thing that parents hear is the anti-depressants can actually increase the risk of suicide. Talk about that.
Dr. David Axelson: This is quite a controversial topic. Since 2004, the FDA put a warning on all anti-depressant medications that they may increase the risk of suicidal thoughts and behaviors in youth. This warning was based on data analysis that many experts including myself feel had some significant flaws.
Since then, there has been data indicate that anti-depressant treatment is probably not associated with increased risk of completed suicide, and in fact, some data indicating they might actually reduce the risk long term.
So it puts us in a very difficult situation where there's a black box that may not have been the best idea, and certainly puts things in a difficult situation. I think it's important to note that any medication that affects the brain, including antidepressants, can change somebody's mood and behavior and, in certain cases, can be individual cases be associated with an increase risk of suicidal thoughts.
Another thing is depression and suicidal thoughts have a natural course that sometimes can get worse independent, whether medication treatment was introduced or not.
So, I think the key take-home issues, it's very important that if suicidal thoughts intensify, whether you're taking medication treatment or not during the course of treatment, that prescriber or your mental health professionals contacted as soon as possible.
Dr. Mike Patrick: The way I understood it in the past, and maybe I'm wrong about this, is that risk, they felt was in particular like the first six weeks or so that you are on it.
Dr. David Axelson: Well, the data that they had was mostly based on acute or sort of a short-term trials of antidepressants and not to get too much in the weeds, but it was spontaneously reported suicidal thoughts or behavior were more common on kids taking an anti-depressants compared to a sugar pill.
However, in those same studies, one, it's important to note that there were no completed suicides even though there were thousands of kids that participated in that study. Also, when we use structured scientific assessments of suicidal thoughts and behaviors there was no difference when asked whether you're on medication or not. And that's where I think the data analysis might be a little bit flawed.
Dr. Mike Patrick: Very interesting. The other one that I wanted to bring up is the antipsychotic medications — things with brand names like Risperdal, Seroquel, Abilify — those can be associated with something called metabolic syndrome, and so it's really important that a doctor really is following up on those kids.
Dr. David Axelson: Absolutely correct. I mean those are not the first line medications for treatment of depression for instance, although they are first line for treatments of bipolar disorder and psychosis. They do have a real risk of increasing weight gain and changing cholesterol and lipid profile and slightly increase the risk of developing diabetes.
So it is important that regular lab tests are performed and prescriber is monitoring weight appropriately. They can be safe medications if they're dosed properly and monitored closely, but they're not medications that should be just given without that consideration.
Dr. Mike Patrick: I think a lot of parents look at these things as black or white. You know, either it's safe or it's not safe, and really, it's more of you got to look at risks versus benefit. Certainly, for large number of kids, the benefits are going outweigh the risks, you just need to know what the risks are and prepare for those and watch.
Are there any other medication issues other than… I mean, I think those were the two biggest ones. Are there any others that…
Dr. David Axelson: No, I mean those are really the primary medications that we're considering. I think understanding about the black box and not being intimidated by it, but also understanding that these kids, whether they're on medication or not, can have an increased sudden intensification of these thoughts is important.
Dr. Mike Patrick: What is the long-term outlook for suicidal teens? Is this something that they sort of grow out of, or is this going to be an issue for them into adulthood?
Dr. David Axelson: It's a great question, and it's not something that is sort of black and white clear. I think it's sort of mixed in some ways. Unfortunately, most teens that have suicidal thoughts or even have made suicide attempts aren't going to go on to complete suicide. However, as Dr. Bridge mentioned, a prior suicide attempt is a risk factor for completed suicide. So the teenager with a suicide attempt is at higher long-term risk.
Teens who attempted suicide as they grow into young adulthood are at higher risk for having a mental health diagnosis, higher risk for developing drug and alcohol problems, can have a more difficult social functioning.
So I think the take-home message is that it's important for us to take this seriously. Make sure that the teenagers that have these difficulties are getting into treatment if they're having difficulties getting back into treatment as a young adult, because sometimes a depression in particular is a recurrent illness. You can get better and then get worse again, and recognizing those warning signs as you get older to get back into treatment is important.
Dr. Mike Patrick: Are there things that parents can do to sort of head this off with the past even before there are warning signs? Is there a way to prevent this from becoming an issue in the first place?
Dr. David Axelson: Well, there's not a lot of strong research in this area. There are some evidence that there's certain prevention programs might reduce the risks of suicide attempts, which then we assume would reduce the rate of completed suicide. Some of these programs are provided in schools. There's a curriculum called Science of Suicide that have been shown to have some benefit.
There's also a study in Europe looking at this, and they genuinely focus on educating teens about depression, risk factors for suicide and really encouraging teens to talk to an adult if they have suicidal thoughts or if a peer communicates to them that they have suicidal thoughts. So not keeping this a secret among teens; getting it to a responsible adult who can help such the situation.
Some interesting evidence of a classroom program that we designed for elementary school to help instil good behavior and pro-social behavior that when used in first and second grader showed in later life a reduced risk of both substance use and suicide attempts.
I think getting at the social environment can be really important. As Dr. Bridge mentioned, bullying is certainly a risk factor. There's some good anti-bullying program that are out there. We haven't shown a direct correlation yet, but I think certainly it's a very reasonable.
So, really having a good communication with your child or teen, asking them what's wrong, having them feel comfortable talking to you. Regular contact, I think, is really the best way to think about preventing.
Dr. Mike Patrick: What's the role or sleep in all of this? I mean, I would think that sleep is important. It's one of those things, too, where if you were depressed, maybe you don't sleep so well. Or are you depressed because you're not sleeping well? I mean, it's kind of like the chicken and the egg sort of thing.
Dr. David Axelson: Well, disrupted sleep is a risk factor for increased risk for suicide attempts. So getting good sleep is important and I think it's independent above probably just depressive symptoms. So I think having a good regular sleep-wake cycle, using what we call good sleep hygiene is important. It's very challenging for teens, but limiting screen use before bedtime, not being texting in the middle of the night, keeping a regular bed time are all sort of key components of a good sleep hygiene.
Dr. Mike Patrick: And I think it's also would be important for parents to model good mental health hygiene for themselves. So as a mom or dad, if you feel like you're depressed or you have suicidal thoughts or having anxiety issues, seek help. If your kids see you seeking that help and getting the help that you need, maybe they would be more willing to be open about their feelings and what they're going through.
Dr. David Axelson: I think that's a great point. I mean, having family discussion, certainly depression and mood disorders and suicidal thoughts and behavior actually run in families. There's a genetic component to it. And you can't really help your child unless you're functioning at your best. So if you're struggling the same difficulties, getting help yourself is an absolute key component to helping your child.
Dr. Mike Patrick: So we have a couple of studies going on through the emergency department here at Nationwide Children's. Not just here, but it's a multi-center kind of studies.
One is called the STAT-ED Study. Dr. Cohen, could you give us an overview, what is STAT-ED? Stands for Suicidal Teens Accessing Treatment after an Emergency Department Visit. Break that down for us. What's going on there?
Dr. Dan Cohen: Sure, thanks for the opportunity talk about it. I would also reference ClinicalTrials.gov. It's great website. It's pretty easy to access for parents and for researchers to know what's out there, what people are studying locally or around the country. This is a great resource from the government, ClinicalTrials.gov.
Dr. Mike Patrick: I'll put a link to that in the Show Notes, so folks can find it pretty easily at PediaCast.org for this episode, 315.
Dr. Dan Cohen: That's great. Thank you. So STAT-ED is a two-center study. Dr. Bridge, my comrade in this effort is the PI, and it's been really a fascinating experience working on the study.
It is screening children in the emergency department, not with mental health challenges. So these are otherwise for injuries or other things with a four-question screen. It is called the ASQ, and filled by Dr. Bridge and his colleagues, asking four very simple questions about suicide risk, and then putting either these kids into Enhanced Usual Care, enhanced follow-up, or a motivational interviewing arm to the study.
The objective is to, as the study idea, to see if these suicidal teens will access care and follow-up. Because we know this is a great opportunity for patients to then engage in the process and maintain that level of communication. So the objective of this study is to see if they can become engaged in it.
But what's been fascinating to me is these are kids just showing up for their usual emergency department illness and injury, and we found that — the study's not quite done yet, we're getting close — a very significant number at least. The two sites are Columbus and Cincinnati, our collaborator there. In Columbus, we're seeing close to 10% of kids just as Dr. Bridge mentioned, routinely. And these are kids that we already kind of pre-screened for not having mental health issues.
Really pretty amazing, and it does feel like that's we're seeing — that mental health challenges are growing, that's for sure, in my daily work, and sometimes, that's part of the reason that they're seeking care.
Dr. Mike Patrick: So these kids that come in, let's say they have a sprained ankle, or they come in because they have a sore throat or an ear ache. So they come in, they see someone from the research team. And they're put in to either a control group or the study group. What is the study group look like? Either one of you.
Dr. Jeff Bridge: Sure. So the study group is based on a motivational interviewing approach. So what we're trying to do so to get families to recognize some potential barriers to seeking treatment. Be it logistical, family, stigma, we talk to them about that. Then, we gauge their motivation to engage in treatment. And we do this with the patient, with the child and with the family.
We have social workers who were trained in this model, and we really try to work with the families to recognize the importance of getting that mental health assessment when they leave the emergency department.
Dr. Mike Patrick: So I guess I skipped on an important step there. They come in for whatever reason, and the research team comes in, and they're given a questionnaire. Based on the questionnaire, if it looks like they're at risk for the possibility of depression or suicide, then they're either put in the control group, which sort of just give them some resources to take home, versus the study group which is really more of a n interview and trying to get the family to see how important this is, and then to see if there's a difference between those two groups in terms of follow-up. Is that…
Dr. Jeff Bridge: So couple of points.
Dr. Mike Patrick: Yeah, sure.
Dr. Jeff Bridge: They're randomized; that's important. So they're not just self-selecting into one group or another. So they're randomized. It's a stronger design. The usual care is really enhanced usual care, so it's not just getting resources. It is meeting with a social worker, but it's what would happen to a typical patient who might have been expressed some suicidal thought or suicide risk.
Then, we're following them up at two and six months. We're hoping to recruit a 160 and, as Dr. Cohen said, we're almost there. So we will probably begin analysis in the next few months to see if this intervention is indeed more effective in treating patients and families.
Dr. Dan Cohen: I didn't mean to jump into it. One of the interesting part , and we think about this a lot in terms of research design, it's either missed eligibles or people who choose not to enroll in the study. It has been really, really interesting at the grassroots level about parents who either deny the survey, they correct their children's answers. They say they're too busy, whatever their reason is for not wanting to engage in the study.
Or they say, "Well, your thoughts implanting." We covered this a little bit earlier, "Because you ask these questions, you made our kid feel suicidal." That's really how they feel. Whatever that is, it's just been very interesting about the kids who do not engage in the study. I think there's something to be learned from that.
Dr. Mike Patrick: It kind of goes back in the introduction, when I talked about building up those walls around us, and that we really need to break those walls down and talk about this.
Dr. Dan Cohen: It's one of the challenges of doing research in the emergency department in general, but definitely from mental health issues. People who showed up, and they agreed because they have good integrity, they want to help out. But they didn't really come for a more prolonged visit for a sprained ankle. And it's pretty much a big shock to them, but it's out there, and it's a great opportunity for us to try to help folks out.
Dr. Mike Patrick: So the question before the researchers is, really, will this enhance intervention, provide better plugin into mental health system versus just what we do now?
Dr. Jeff Bridge: Yes, that's it.
Dr. Mike Patrick: Great. And when do we expect to have some numbers from that? Would love to have you come back once it's published, right?
Dr. Jeff Bridge: We'll be happy to do that. So we are wrapping up recruitment right now. Like we said, the goal is to recruit a 160 across the two sites. We plan to be finished with recruitment probably by June of this year, possibly July. And then, at that point, we'll begin data analysis in the early fall, and we hope to have a manuscript in preparation before the end of the year.
Dr. Mike Patrick: Great. Then, there's a second one, so the first one is STAT-ED. This one is ED STARS. Tell us, Dr. Cohen, about ED STARS.
This one's a little more preliminary, correct?
Dr. Dan Cohen: Yes. So were actually headed up to Michigan for training, shortly. And this is part of the PECARN, the Pediatric Emergency Care Applied Research Network, plus there's an add-on of another site that engages Native Americans as well, because Dr. Bridge mentioned that to be a high-risk group. This is in collaboration with PIs including Jackie Grupp-Phelan, a shoutout to her from Cincinnati who's a co-PI on this study.
The objective of ED-STARS is to try to get at that risk assessment for an individual child, for an individual teenager, using a personalized, computerized adaptive screen. So this is going to involve kids all over the country — 6000 kids — a couple of population within that to test it, and then re-test it, to try to come out with a screen that we think could really re-stratify into low, moderate and high severity.
One of the comparators for it, one of the first steps of the study is the ASQ screen test as well. Maybe Dr. Bridge can help take me away.
Dr. Mike Patrick: So that's the screening test being used in the other study to try to identify at-risk kids.
Dr. Jeff Bridge: Yes, and one of the limitations of that screening measure is that when we developed it, our gold standard (what we tested it against) was not a future suicide attempt. That would have been the ideal situation, which is what the gold standard is in ED-STARS.
So we had a separate measure of suicide ideation risk and the gold standard was whether or not they were positive in terms of being a clinically significant suicide risk on that measure. So this really is a step. This is an improvement over that method, but what we're going to do is, in this study we're going to recruit — there really are two studies — Study 1 is we'll recruit about 6,700 youth throughout all these centers. They're going to come in, and they're going to be asked about a 100 questions pertaining to depression, bullying, impulsivity, impulsive aggression, abuse, etc.
From that list of questions, about 2,000 will be followed up. They're are going to be risk-stratified — I think that's the right term, risk- stratified — into high, medium or low risk. They're going to be followed up at three and six months, and the goal was to develop an algorithm, to develop a computerized adaptive screening measure, so that it's dynamic. So that patient may come in and based on an initial risk profile of being male and older adolescent, a particular question might appear for that patient unlike the ASQ, which is a fixed four-item screener. This would be dynamic and it would be based initially on demographic characteristic, but then on each prior response.
And the idea is that this dynamic response may yield a better predictive ability to predict who is most at risk for making an attempt at six months.
Dr. Mike Patrick: So you start out with all the questions, and then you looked down the road and find out who made suicide attempts, and then go back to their questionnaire, and start to see if there's statistical significance in the way that people answer these questions. Then, compare to their future behavior, so that then, you can design a tool that can be specific for that person's situation.
Dr. Jeff Bridge: Correct.
Dr. Mike Patrick: Wow. That's fantastic. And what kind of timeline do you think we're looking at with that one?
Dr. Jeff Bridge: So as Dr. Cohen mentioned, we're heading up to Michigan. Project is supposed to start in the next few months. It's a three-year project, so we probably won't have any products from this for at least three years, unfortunately.
Dr. Mike Patrick: Yeah, well, hopefully, PediaCast will still be around then. Hey, we made it nine years, so maybe we'll still be around, and we'll get you back on and talk about the results when you have them.
Dr. Jeff Bridge: That would be great. We'll celebrate the 12th anniversary.
Dr. Mike Patrick: Great.
Dr. Mike Patrick: All right, well, I really appreciate all three of you stopping by. I do have some links in the Show Notes for folks, a lot of resources, if you head over to PediaCast.org. Click on the Show Notes for this episode. It's 315.
One of them is an interesting article that Dr. Bridge is one of the authors. It's the Epidemiology of Youth Suicide and Suicidal Behavior at the National Institute of Health, and just a really good summary of some of the things that we've been talking about today. So, I encourage folks, if you want more information, to look at that.
Also, Dr. Cohen had sent me an editorial that was written in Palo Alto Online. Did I say that right? And it's called "Keep Calm and Parent On" and talks a little bit about suicide prevention. I thought it was just a fantastic article, so I want to share that with folks as well, and there'll be a link to that in the Show Notes.
And then the STAT-ED, Suicidal Teens Accessing Treatment After an Emergency Department Visit at ClinicalTrials.gov. We'll have a link to that.
And then, we will have some of the links to a suicide prevention hotlines, in case you can't find any local resources. If you have an emergency, of course, call 911, but then you'll have some other resources available to you. But again, if your concerned about your kid, first look for local resources, local mental health emergency folks or your regular doctor and local emergency department. But if no one else is available, we'll have some phone numbers for you in the Show Notes there, too.
All right, it's been an interesting heavy topic, but I think an important one. Hopefully, folks will share this episode so we can reach a lot of parents with it.
And thanks, all of you, for stopping by, really appreciate it.
Dr. Jeff Bridge: Thank you.
Dr. Dan Cohen: Thanks, Dr. Mike.
Dr. David Axelson: Thanks, Dr. Mike.
Dr. Mike Patrick: All right, let's take a quick break and I will be back to wrap up the show right after this.
Dr. Mike Patrick: All right, we have just enough time to say goodbye. I want to thank all of you taking time out of your day and making PediaCast a part of it. Really do appreciate that.
Also, thanks to Dr. David Axelson, child and adolescent psychiatrist, and medical director of Behavioral Health Services at Nationwide Children's Hospital, Dr. Jeff Bridge, principal investigator with the Hospital's Center for Innovation and Pediatric Practice, and Dr. Dan Cohen, jack-of-all-trades and attending physician in Emergency Medicine at Nationwide Children's.
Don't forget if you're in the Central Ohio area, Nationwide Children's offers urgent care services at seven convenient locations, including our downtown Main campus, Dublin, Hilliard, Marysville, Westerville, East Broad, and Canal Winchester. You can find exact locations, hours, and approximate wait times on our website. Just head to NationwideChildrens.org/urgentcare. You can also find that information in our mobile app. It's called MyChildren's and available for iPhone and Android.
Of course, you should always check with your regular doctor before going to any urgent care, just to make sure it's the right thing to do, given your child's problem and situation. And if your child has a serious or life-threatening issue, head to your local nearest emergency department or call 911.
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That's a wrap for this one. Until next time, this is Dr. Mike, saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.
Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.