Adolescent Depression and Suicide

December 18, 2022

Michael Bloch, MD, MS - Associate Professor at the Child Study Center and Department of Psychiatry at Yale University

Youngsun Cho, MD/Ph.D. - Assistant Professor at the Child Study Center and Department of Psychiatry at Yale University

Meeting the Complexities of Adolescent Mental Health -- November 5th, 2022

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ID: 9316
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00:00Next we're going to be talking about
00:03adolescent depression and suicide,
00:04and I think I've already,
00:08I already introduced myself before,
00:11but I'm delighted to do this
00:15presentation with Youngsun Cho,
00:17who's a wonderful child,
00:19child psychiatrist and expert in depression.
00:22She's also modest enough to put her
00:25name after mine, even though she
00:27put together like the whole talk.
00:28So she should probably be listed first
00:30on this and she should get the credit.
00:33But anyway, we're really lucky
00:36to have her talking today.
00:38And I think this is a really
00:40important topic and you can
00:41advance to the next slide.
00:45We have a bunch of
00:49disclosures I certainly get
00:51funds from various pharmaceutical
00:54companies looking at experimental
00:56treatments for depression, Tourettes,
00:59other conditions including OCD.
01:03Also, we get funding from the
01:05National Institute of Health.
01:06I don't think it's particularly
01:08germane to this presentation,
01:10but just wanted to make you aware of that.
01:14Next slide.
01:15So adolescent depression is a significant
01:19public health problem and it,
01:22and I think for a lot of you are probably
01:25where it's at a borderline crisis at
01:27this point. That nearly one in five
01:30people will experience a major depressive
01:33disorder during their adolescent years,
01:35and it's probably closer to one
01:38in four since COVID started.
01:40Suicide is the 2nd leading cause of death
01:44in adolescents in the United States.
01:47Not only is depression
01:50associated, teen depression associated
01:51with significant mortality,
01:53it's also associated with
01:55significant morbidity.
01:56There's an increased, teens who are
01:59depressed have increased social problems,
02:01they have problems in terms of
02:03their functioning in school,
02:04and it's associated with a variety
02:07of other things that affect behavior.
02:12So
02:13in terms of increased risk of substance use,
02:16pregnancy and so it's and then
02:20the other thing is that people,
02:23people who experience depression
02:26as teenagers
02:28are very likely to have another episode later on,
02:31and then there also probably has
02:33the worst prognosis in terms of
02:35their adulthood depression.
02:37OK.
02:40In terms of the actual suicide effects,
02:43these are from the CDC
02:44I didn't make them up, among high
02:47schoolers in the United States
02:5017% have considered suicide, attempting
02:53suicide in the last year,
02:5614% have had a suicide plan,
02:598% have actually attempted suicide,
03:01and 3% have made a suicide attempt
03:05that required medical attention.
03:08And then we, there are, we lose
03:12approximately 5500 adolescents
03:14per year who die by suicide and
03:17just thinking about the number
03:22my, my, my kids are slated to go to
03:24Hamden High School that has about 1100
03:27students and that's and it's a pretty
03:30big building and that's five Hamden
03:32high schools worth of kids every year
03:35that die by suicide in high school.
03:38Another way to think about these numbers
03:41is just, I think about them as a parent.
03:43So these are, this is a picture
03:46of my wife Angie,
03:47my daughter Rachel and my twin boys
03:50Sam and Paul.
03:52And so there's
03:53one year that all three of them are going
03:56to be going to high school together.
03:58Just one year.
04:01And during that year, there's a two out
04:07of five chance that one of my kids will
04:13have suicidal ideation.
04:16It's about one in three chance that one
04:19of them will have had a suicide plan.
04:22There's about a one in five chance that
04:25one of them will have attempted suicide.
04:28And there's about a one in ten
04:31chance, slightly less than, that one
04:33of them will have a suicide attempt
04:35that required medical attention and
04:37and that's really scary to me as
04:40a father. And then if you look at
04:42while my three kids are at high
04:44in high school,
04:45it's more likely than not that one of
04:47them will have a major depressive episode,
04:50and it's more likely than not that they
04:52will know of a classmate who dies by suicide.
04:55And I just think that's, it's
04:57just really staggering,
04:58the numbers.
05:03So I'm going to go ahead and
05:05talk a little bit about how
05:07depression presents in teenagers.
05:08So things to keep in mind is overall
05:12teenagers and people in general who
05:14have depression typically have what we
05:16call a persistent low mood or sadness.
05:18So this is sort of a, they report feeling
05:21sad or down for most of the day,
05:23many days of the week.
05:25In teenagers, irritability can
05:26also be a persistent feature,
05:28sometimes even more than the sad mood.
05:30So that's important to keep in mind that
05:32this seems to be a developmentally
05:33specific feature. So this occurs
05:35for at least two weeks at a time,
05:38plus the sort of official criteria
05:40asks that they have at least
05:42four of the following criteria,
05:44which we kind of keep track of
05:46with an acronym called SIGE CAPS.
05:48So the four criteria,
05:494 out of the following eight
05:51criteria are sleep changes,
05:53so this could be sleeping more
05:54or sleeping less than usual,
05:56a loss of interest or motivation,
05:58so this is the teenager who maybe like to
06:00go to art classes or like to play sports,
06:02but isn't showing that interest anymore,
06:05feelings of guilt,
06:06feeling like they don't have
06:08enough energy during the day,
06:09you know,
06:10seeming like they need to take naps or even
06:12taking naps and not feeling refreshed,
06:14having cognitive difficulties,
06:16so trouble concentrating,
06:18trouble remembering things which in turn
06:20can obviously affect the school performance.
06:23Appetite changes can also be seen as well.
06:26So either an increased appetite or
06:28decreased appetite. Sometimes
06:30kids can show what we call a
06:33psychomotor agitation or slowing.
06:35So changes in how their motor movements
06:37are, either moving faster or slower.
06:40And finally a component that's a
06:41large part of today's talk as well
06:43is suicidal thoughts and behaviors
06:45can accompany depression.
06:48The key point here also I think just
06:51like Wendy had mentioned in her talk,
06:53is just to understand how different
06:55depression can be for different kids.
06:57So as I had said,
06:58you need 4 out of these eight,
07:00but it doesn't say which
07:01four you have to have.
07:02And so kids can have any number of
07:05combination of symptoms and it's important
07:07to understand what aspects of depression
07:10really impact their ability to function.
07:12So the risk factors for
07:14adolescent depression?
07:15There are a number of them.
07:16So family history.
07:17So having family members with a history
07:20of depression or other mood disorders
07:22puts teenagers at risk for having depression.
07:24Teenage depression occurs more often
07:26in female teenagers,
07:27about two to three times
07:29more often than in males.
07:30A history of early life stress or adversity.
07:34Poverty is a risk factor
07:36for teenage depression,
07:37a history of or current trauma,
07:39as well as well as peer
07:41conflicts such as bullying.
07:42Which we know is, has become a
07:44large problem in recent years.
07:46Stresses at home.
07:47Familial conflicts or stress can be a
07:50risk factor for adolescent depression,
07:52minority stress,
07:53or the stress of feeling like
07:55the stress that people who identify as
07:57minorities in society may experience
07:58is also a risk factor as well
08:01as having a disability.
08:03And just to sort of put this in context
08:05with when the pandemic is started at,
08:07the information from the
08:09CDC suggests that in 2021,
08:11since the pandemic started,
08:1455% of high schoolers have reported receiving
08:17emotional abuse from an adult in the home,
08:1911% of experienced physical
08:21abuse from an adult in the home,
08:23and 29% of had a parent or adult
08:25in the home lose a job.
08:26So these are all stressors
08:28that have been exacerbated,
08:30likely since the pandemic has
08:31started and are contributing to the
08:33increase in the rise in depression
08:35and other psychiatric illnesses.
08:38So the talks all today are
08:40focused on the adolescent years.
08:41And so it's a period that I
08:43think is really interesting to
08:44all of us who are talking here.
08:45And so I think it's important to
08:47sort of step back a little bit
08:49and think about what is special
08:50about the adolescent years.
08:51So it's a time of rapid physical,
08:53emotional, social and cognitive growth.
08:55And for everyone who works in
08:57the schools or sees teenagers,
08:58you all know this.
09:00And the developmental changes
09:01that are occurring in the brain
09:04parallel this growth that's
09:05happening that we can all observe
09:08and continues into young adulthood.
09:10The growth is, you know,
09:12purposeful and intentional,
09:13and it allows the teenagers to
09:16start to explore their identity.
09:18And ideally,
09:19this developmental stage transitions
09:21them to successfully to adulthood
09:23and that would be the sort of ideal
09:26outcome for adolescence is this
09:29successful transition to adulthood.
09:31So just to talk briefly about the
09:33brain changes during adolescence,
09:34the brain undergoes quite a bit
09:36of change during childhood,
09:37adolescence and even into
09:39the early adulthood years.
09:40And particular areas that people have
09:43really focused on are, is the cortex.
09:46So the cortex is sort of this outer
09:48layer of the brain and is really
09:50responsible for helping us think, process,
09:53executive function, do a lot of things.
09:55And what people have noticed is that it is
09:58typically normal for the cortex to thin
10:01throughout childhood,
10:02adolescence and early adulthood probably
10:04related to pruning and other processes,
10:07especially in the prefrontal and
10:08parietal cortices. And again,
10:10these are areas that help us remember,
10:12think, plan and organize.
10:16And so this, these changes sort of
10:17go all the way through childhood,
10:19through early adulthood.
10:20And the picture on here is showing
10:23the changes from five years all
10:24the way to 20 years.
10:26The warm colors in red are areas
10:28where the cortex is thicker.
10:29And as it turns cooler colors
10:31as time goes on,
10:32it means that the cortex
10:34is thinning with time.
10:36So just to kind of illustrate
10:38this with the video is this sort
10:40of dynamic changes in the brain.
10:41Again,
10:42this is sort of illustrated from
10:43five years throughout 20 years old.
10:49So, Umm, the functional sort of changes
10:52here in adolescents with depression,
10:54areas that are in the brain that
10:56are associated with receiving rewards.
10:59So this idea of feeling pleasure when
11:01there are rewards given, these areas
11:03actually show decreased neural signals
11:05in adolescents with depression when
11:07they're anticipating rewards compared
11:08to teenagers who don't have depression.
11:11Suggesting again that this idea of not
11:14being motivated, having anhedonia may
11:16be linked to sort of neural changes
11:18in the brain in these reward areas.
11:21Additionally, when people look at an
11:23area of the brain called the amygdala,
11:25which is responsible for helping
11:27us emotionally process event and
11:29seeing what's emotionally important,
11:31adolescents with depression actually
11:32have higher neural signals in this
11:35region when they look at fearful or
11:37very emotional faces compared to
11:39teenagers who don't have depression.
11:41And this sort of suggests that these
11:44emotional expressions and peers or
11:45in other people are quite salient and
11:47quite sort of important to adolescent
11:50depression,
11:50maybe even more so in teenagers
11:52who don't have depression.
11:57So, so I think one thing
12:00that's really important about
12:02adolescent depression is that we
12:03have very good treatments for it,
12:05we have good treatments,
12:06we have effective treatments for, very good
12:08is probably an overstatement,
12:10but there have been studies
12:12that have looked at treatments
12:14for adolescent depression.
12:16This is a randomized controlled
12:19study of 440 adolescents that were
12:21randomized to either medication,
12:23therapy, the combination of
12:25both or placebo for 12 weeks.
12:27And the big take home point of
12:29this is both the medications
12:32and therapy are effective
12:33and the combination is
12:34probably better than either one alone.
12:36And then,
12:39A majority of kids with depression who
12:41were given evidence based treatment get
12:44significantly better with treatment,
12:45and fairly quickly. Next slide.
12:51In terms of the guidelines,
12:53the US and the UK differ slightly
12:56in terms of treatment guidelines. For
12:59for mild depression both in the UK and
13:03the US they recommend psychotherapy
13:06alone and then for moderate and severe
13:09depression it differs a little bit.
13:11In the US it's evidence based
13:14psychotherapy and/or medication,
13:16particularly fluoxetine which is a
13:18selective serotonin reuptake inhibitor.
13:20And in the UK it's evidence based
13:24therapy plus or minus fluoxetine.
13:27So I would say personally I'm
13:29much more of a Tory in terms of the
13:31guidelines and that I think you should
13:33be whenever possible you should be
13:35offering these kids evidence based
13:37psychotherapy and the medication
13:39is an add-on that you're often
13:42choosing to use in,
13:44in terms of adding it to the
13:46therapy when it's available.
13:48The big advantage of therapy
13:50versus medication
13:51it's probably not on the efficacy part of it,
13:55but in the fact that the lessons you can
13:58learn from therapy can be more durable.
14:00When I give the kid a medication,
14:01if they stop taking the medicine,
14:03it's probably not going to work anymore,
14:05whereas the lessons from the therapy or often
14:09maintained also, therapy has less side effects.
14:13In terms of therapies for
14:15adolescent depression,
14:15we have cognitive behavioral therapy which
14:18Wendy talked about a bunch of for
14:20anxiety
14:21but in depression,
14:22it focuses more on understanding
14:24thoughts and behaviors and identifying
14:27maladaptive thought patterns and behaviors.
14:30And the other therapy that's commonly used
14:33in adolescence is interpersonal therapy,
14:36which focuses on relationships and
14:38developing effective strategies for
14:41dealing with relationship problems.
14:43Again,
14:44both are generally evidence
14:45based and time limited.
14:50In terms of medications,
14:51there are a lot of medications
14:53we have for depression,
14:55but fairly few of them actually have
14:57a strong evidence based in kids.
14:59We particularly use this selective
15:02serotonin reuptake inhibitor.
15:03So Fluoxetine and Escitalopram are the only
15:07SSRI's that are FDA approved for children.
15:10They're probably a bunch of other
15:12medications work similarly,
15:13but we certainly don't have the
15:15same evidence base in terms
15:17of trials in kids that
15:19we have in adults.
15:22Just the main class of medication we're
15:25using in kids is called selective
15:27serotonin reuptake inhibitors.
15:29They're about 6 different
15:33SSRI's and they all work by increasing
15:36serotonin at the level of the synapse
15:39and really preventing the reuptake
15:41of serotonin from the synapse.
15:46And just to say that SSRI's,
15:49these medicines, are quite
15:50effective in kids and they're not
15:53only effective for depression.
15:54So oftentimes and if anything,
15:56they probably work better and obsessive
15:59compulsive disorder or anxiety than
16:01they actually work in depression.
16:03So a lot of kids benefit and so
16:06the number needed to treat is the
16:08number of kids you need to treat
16:10with the medication for one to
16:11respond who wouldn't have responded
16:13on placebo as you can see it's
16:14the number needed to treat is
16:16as low as three.
16:17So you need to treat three kids with
16:20an SSRI for one who would not have
16:23responded on placebo and they
16:25are quite effective for anxiety,
16:27OCD and depression.
16:30And one of the big challenges in using
16:34these medicines is that even though you
16:37often see the incremental benefits of
16:40the medicine fairly early on and actually
16:44the greatest improvement compared to
16:46placebo occurs early on in treatment,
16:49they actually generally takes a while for
16:51the full benefits of the medicine to accrue.
16:53So you typically see the full
16:55benefits of the medicine after two
16:58to three months in depression.
16:59And even later in anxiety or OCD.
17:05And then on the other hand,
17:07there are a lot of side effects associated
17:10with SSRI's and antidepressants.
17:11I should say that they're fairly well
17:14tolerated medicines on the whole.
17:16That being said, they can they can have
17:19a lot of side effects and generally
17:21you see the side effects early and
17:23the full benefits much later on.
17:24So you really need to give the
17:26kids a chance to respond to the
17:28medicine and give it time.
17:30So again, it's not,
17:33it's very hard for parents or
17:35doctors for families to make decisions
17:37about these medicines after a week
17:40or two when you're generally seeing
17:45mostly the the the side effects and then
17:47you get more of the benefits later on.
17:54And then the other big thing to
17:57think about when you're prescribing
17:59the medicine in kids and using the
18:02medicines is just a black box warning
18:04on suicidal, suicidality in kids.
18:06So there have been,
18:08Umm, in the in meta analysis of these
18:12randomized control trials comparing the
18:15antidepressants and compared to placebo,
18:19there's a small but statistically
18:23significant increase in spontaneously
18:26reported suicidal ideation
18:29and actions when kids are randomized to
18:32active medicine compared to placebo.
18:35The risk difference is about 1%.
18:39So that means if you treat 100 pediatric
18:43patients with antidepressant medications,
18:46one to two of them may experience short term
18:50increases in suicidal thinking or behavior.
18:52That being said,
18:53in these trials it's important
18:55to note when they actually look
18:57at the depression scales and ask
18:59every patient about the individual
19:01suicidal ideation,
19:03there was no signal in the
19:05medications compared to placebo.
19:07So it's still controversial whether
19:09these medicines are actually really
19:12increasing suicidal ideation.
19:16And it's important to keep
19:18the risks in context.
19:19So whereas I presented the number
19:22needed to treat before that you need to,
19:24you know, you have to treat three
19:26kids with an SSRI for one to benefit
19:30who would not have benefited on
19:32placebo, the number needed to harm the
19:34number of patients you need to treat
19:36for one of them to have treatment
19:38emergent suicidal ideation compared
19:41to placebo is much higher. So that,
19:45so thats's on the order of 110 to 200
19:47in terms of the number needed to harm.
19:49So kids are, you know,
19:5210 or 11 more times more likely
19:54to benefit in depression from
19:57these medicines than to experience
19:59short-term suicidal ideation and
20:02it's probably closer to
20:0440 or 50 times is likely in
20:06OCD or anxiety disorder.
20:11So how do I discuss the black
20:13box warning with families and
20:14what would be my take home point
20:18for sort of school personnel
20:20in thinking about medications?
20:22The first one is SSRI's and
20:24antidepressants are the most effective
20:26pharmacological treatment we have
20:28for pediatric depression and a bunch
20:31of other associated conditions,
20:34OCD anxiety. That there's some signal
20:38of an increased risk of self reported
20:41suicidal ideation over the short term
20:44so the FDA put a warning
20:45on these medications.
20:46That being said, there's no evidence of
20:48any association
20:50between these medicines and
20:52attempted or completed suicide.
20:55And suicidality and suicidal ideation is
20:58really common in pediatric depression.
21:00So it's more likely when these
21:02things are reported by kids that
21:04they're coincidental and not
21:06caused by the medicine.
21:08And then again, we,
21:09the majority of kids that I see
21:12and treat for depression have
21:14some degree of suicidal ideation.
21:16It's more a matter of degree
21:18than presence or not.
21:20And then, if anything,
21:22the epidemiologic data
21:23so the data from looking at
21:26prescribing these medicines over
21:28the long term, suggests that SSRI's
21:30are effective in treating depression
21:33and may actually protect against
21:35attempted and completed suicides.
21:38And so,
21:38so then people always ask why
21:40is the warning there?
21:41So the first things I'm not sure I
21:44necessarily agree with the warning
21:45being put on the medicine in the 1st
21:47place because I think the evidence
21:49is still pretty scant for a warning.
21:51But the FDA noticed the potential
21:53increased risk associated with
21:55these medications and they want
21:57the kids to be monitored closely
21:59when they start medications.
22:00And I think I entirely agree with
22:04the the end of the warning result,
22:07which is that kids should be monitored
22:08closely when they're starting medication,
22:10because it's a point at which
22:12kids are particularly at high
22:14risk of having adverse events.
22:19So we're going to switch and
22:21just kind of transitioned into
22:23talking a little bit about
22:25adolescent suicide as well.
22:26So as people on this call are probably aware,
22:29suicide is the second and third
22:31leading cause of death in pre teens,
22:33adolescents and young adults.
22:34So this is a table from the CDC,
22:37sort of outlying causes
22:38of death for age groups.
22:40And in red at the top here are 10 to
22:4214 year olds and 15 to 24 year olds.
22:45And here's the rank order of
22:47causes of death in this group.
22:49And you can see the second leading
22:51cause of death in the 10 to 14 year
22:54olds is suicide with 581 deaths
22:56in that year and 15 to 24 year olds,
22:59it's the third leading cause of suicide,
23:02with about 6000 deaths that year.
23:05Other top causes are unintentional injuries,
23:08homicides and then malignant neoplasms,
23:10in the top three for these age groups.
23:14So kind of characterizing
23:16what a suicide attempt is,
23:18there are lots of ways
23:20in which this happen,
23:21but the thing that's in common for
23:23all of these sort of events is it's
23:25really considered any act that's
23:27linked to an intention to die,
23:29even if this intention is
23:31reported as small or minor.
23:32So even if, you know,
23:33you ask a child,
23:34did any part of you want to die
23:36when you did that particular event
23:38and they say maybe just a little,
23:40that is still considered a suicide attempt
23:43and that's something to pay attention to.
23:46So in the United States,
23:48let's go over a little bit about
23:50the adolescent suicide rate.
23:51So I think Michael went over some
23:52some of the data and we'll just
23:54sort of repeat some of this,
23:55but data from the year 2019 said that
23:5819% of high schoolers had seriously
24:01considered suicide in the prior year
24:02from when the data was collected,
24:05many more in females than in males.
24:0816% of high schoolers have made
24:10a plan in the prior year as it's,
24:13a suicide plan in the prior year,
24:14again higher in females than in males.
24:17And 9% of high schoolers are, almost
24:19one in 10 high schoolers, actually
24:21attempted suicide in the prior year.
24:24So here's a graph from the CDC that
24:26sort of looks at this and looks
24:29at the total attempted suicides
24:31during that 2018 to 2019 period,
24:33which is about 9% or one in 10.
24:36Breaking it down by male and female here,
24:39so about 7% of males,
24:4211% of females. And by race here,
24:44so 8% for those who identify as White,
24:48almost 12% for those who identify
24:50as Black and almost 9% for those
24:53who identify as Hispanic.
24:55Other groups that are not represented
24:57on this graph that also have a
25:00suicide rates that are worth noting.
25:0219% of LGBTQ plus identifying 13 to
25:0417 year olds have attempted suicide,
25:07so this is not suicidal ideation,
25:09this is attempted suicide comparing
25:11that to 9% of high schoolers in general.
25:16Other racial groups that have
25:18more limited analysis and require
25:20more research, Native American
25:21youth have a suicide rate attempt
25:24that's about three times higher
25:25than the national average,
25:27Native Hawaiian youth data from
25:292000 have about a 13% attempt rate,
25:31and the Asian American youth have
25:33an 8% suicide attempt rate and a
25:3624% rate of suicidal ideation.
25:38So these rates are quite high in
25:40aggregate across all high schoolers
25:42and teenagers and are quite
25:44alarming both in terms of
25:46the ideation and the actual attempts.
25:50The past few years have been very
25:52difficult for a lot of people,
25:54for teenagers and their families,
25:55for schools, for clinicians.
25:56And this is just some of the data that
25:59looks at the emergency room visits
26:01for suicide attempts and showing
26:03the increase since the pandemic.
26:05So the sort of take home here,
26:07I've labeled the graphs,
26:08the top one is females,
26:10the bottom one is males,
26:12and these different lines
26:13represent the different years.
26:15And so here's 2019 the dotted
26:17line at the bottom for both
26:19graphs. 2020 shows the jump
26:22both for males and females.
26:24This is probably around the
26:26start of the pandemic or so,
26:27and this increase just
26:29continues in 2021 here.
26:31So for 12 to 17 year old teenagers,
26:33the emergency room visits for
26:36suicide attempts actually increased
26:37twofold in the winter of 2021
26:39compared to the winter of 2019.
26:42Again largely driven by increases in
26:45presentations from female teenagers.
26:48So risk factors for suicide,
26:50So it is
26:51pretty impossible for us to predict
26:53who actually dies from suicide.
26:56Unfortunately we do not have great
26:58models in a being able to identify people
27:01who will actually complete a suicide
27:03but we do know some risk factors
27:06for those for suicide,
27:08and these include having prior
27:10suicide attempts puts someone
27:12at greater risk for suicide,
27:14having psychiatric illness,
27:15a recent inpatient psychiatric
27:17hospitalization, which I'll talk a
27:19little bit more about in a minute,
27:21living in middle or low income countries,
27:23so this is sort of looking at
27:25suicide as a global phenomenon,
27:26account for about 75% of suicides worldwide.
27:30So it's not just a phenomenon that
27:32happens in developed countries.
27:34A family history of suicide,
27:36again,
27:37minority stress or having stress
27:39that's related to identifying as
27:41a minority in the social sphere,
27:43having this disability,
27:45impulsive personality traits.
27:46So there's a sort of an idea of
27:49impulsivity sort of being associated
27:50with suicide and sort of not taking
27:53the time to sort of think through what
27:55the the full effects of a suicide are.
27:57So having impulsive personality traits
27:59does put someone at risk for this. The
28:02way someone may approach life events.
28:05So a tendency towards cognitive
28:06rigidity or what we would call black
28:08or white thinking or all or none type
28:11thinking is also a risk factor for suicide.
28:13And any type of interpersonal loss.
28:16So for teenagers,
28:17obviously this is very a very important one:
28:19loss of friendships,
28:20bullying,
28:20peer rejection or even the death
28:23of friends or loved ones.
28:26So a little bit more about suicide
28:28rates and how high they are following
28:30psychiatric hospitalization.
28:31I think it's important to draw
28:33attention to this because this is sort
28:35of a clear marker in which we can
28:37sort of pay attention to teenagers.
28:39So it's a clear and objective marker of
28:41when people are hospitalized and when
28:43they're released from the hospital.
28:45So in the three months in which a
28:47teenager is released from the hospital,
28:49the rate of suicide is 100 times
28:51higher than the global rate of suicide
28:54and suicidal thoughts and behaviors
28:55resulting in hospitalization occur at
28:57200 times higher than the global rate.
29:00About 24%, or about one in four of
29:04all suicides that occur are attributed
29:07to having occurred within one year
29:10of hospitalization.
29:11And attending a mental health follow
29:13up after hospitalization reduces the
29:15risk of a subsequent suicide by about 75%.
29:18So that care that's arranged after
29:20the hospitalization and following
29:22up to make sure that care has been
29:25attended to is really important
29:27for reducing suicide risk.
29:28So this monitoring suicide risk
29:30is very critical in this post
29:32hospitalization period for teenagers.
29:36And while this talk focuses on depression,
29:39it's also important to note that
29:40teenagers who have other psychiatric
29:42illnesses are also associated with
29:43an increased risk for suicide.
29:45So these include illnesses like
29:48schizophrenia, substance use disorders,
29:51ADHD, bipolar disorder,
29:54PTSD, and others.
29:55It's also important to note that
29:57suicide can also occur in the absence
29:59of any diagnosed psychiatric illness.
30:01So while we are really focusing on
30:03teenagers who have psychiatric illnesses or
30:05have been diagnosed or suspected to have
30:07psychiatric illness,
30:08it's important to note that it can also
30:12occur for teenagers who don't have
30:14any diagnosed psychiatric illnesses.
30:16So some of the warning signs for suicide
30:19include talking about not wanting to live,
30:22talking about having no reason to live,
30:24starting to isolate or being
30:26more irritable with more mood swings,
30:28talking about feeling like a burden to
30:31others, talking about feeling trapped,
30:33like there's no way to escape whatever
30:36they're going through,
30:37observing that they're increasing
30:39substance or alcohol use,
30:41observing that they're researching
30:43methods for suicide or trying to obtain
30:46a gun is another clear warning sign and
30:49finally giving away personal items.
30:51So this is sort of a tweet that I
30:53thought was kind of illustrative of
30:55someone who was going through some
30:57suicidal ideation and thoughts and behaviors.
31:00So this was posted publicly by
31:02someone named Harry Miller,
31:04who's a football player at Ohio
31:06State and a junior in college.
31:07And one of the things,
31:09some of the statements that I'll just
31:11sort of highlight here is he says
31:12that "prior to the season last year,
31:14he had told his coach of his
31:16intention to kill himself."
31:17And he sort of goes on to
31:19elaborate that at that time,
31:20one of the reasons he had been
31:22thinking was he'd "rather be dead
31:23than a coward."
31:24"I'd rather be nothing at all than having
31:26to explain everything that was wrong."
31:28And he was already being "planning
31:30on being reduced to initials on the
31:32sticker on the back of a helmet."
31:33He had "seen people seek help before,"
31:36"had seen the old age-old adage" of how
31:38his "generation was softening by the 2nd."
31:40But he says that his "skin was tough"
31:42but "not tougher than the sharp
31:44metal of his box cutter."
31:46And he said that he saw that it was
31:47"easy for people to dismiss others by
31:49talking about how they were just a
31:51dumb college kid who didn't know anything."
31:52And he talks about how he has
31:54so many strengths.
31:55He's college student, he's a football player.
31:57He has a 4.0 GPA and everything.
32:00And but yet how difficult it is still
32:03for him even with all these sort of
32:05positive things going on in his life.
32:07Any he sort of ends here by saying
32:09"a person like me,
32:10who supposedly has the entire
32:11world in front of them,
32:13can be fully prepared to
32:14give up the world entire.
32:15This is not an issue reserved for
32:17the far and away it is in our homes.
32:19It is in our conversations.
32:20It is in the people that we love."
32:22So I think this is a really eloquent
32:25and poignant sort of way of expressing
32:27sort of how he's feeling and also
32:30drawing attention to sort of how,
32:32how universal this can be and how
32:34easy it might be to miss some of
32:36the suicidal thoughts and kids
32:38and teenagers and young adults.
32:40So switching to sort of some
32:43protective factors for suicide.
32:44So some protective factors that
32:46teenagers have reported include
32:48feeling supported by family,
32:49friends and school.
32:50So this is their community -- do
32:52they feel a sense of belonging,
32:54that they feel supported by their community?
32:56Are they future oriented?
32:57What do they want to be when they get older?
32:59Are they looking forward to that
33:01activity at school or with their friends?
33:04Do they have strong relationships
33:05with their family and friends?
33:07Are they engaged in mental healthcare?
33:11Other protective factors include cultural,
33:13religious or moral objections to suicide,
33:16as well as reducing the access
33:18to lethal means.
33:19So this is really an important,
33:21again sort of action that can
33:22be taken to lock up weapons,
33:24pills and sharps in the home.
33:27So along those lines of of
33:28locking up sort of means,
33:30if we look at the suicide
33:32methods in adolescents,
33:33firearms are actually the most common
33:35method of suicide for adolescent boys.
33:37And asphyxiation,
33:38which is sort of defined
33:39as hanging or suffocation,
33:41is the most common method of
33:43suicide for adolescent girls.
33:44So if we look at the data here,
33:46this is collected I think by the CDC
33:50between 1999 and 2020, on the left
33:52here for male adolescence and the
33:55blue triangles are the deaths
33:57from firearms here the orange are
34:00the deaths from asphyxiation and the
34:03green squares are other means of death.
34:06And so highest in males,
34:07about 60, 60 to 50% from firearm
34:11deaths. In females,
34:13it's consistently asphyxiation
34:14is the method of suicide death,
34:17about 60% throughout the years,
34:19and that's consistent.
34:21So again,
34:22reducing sort of means to suicide
34:24is a really,
34:25really important step for reducing
34:27the risk for suicide.
34:29The other important point is to not
34:30be afraid to talk about suicide.
34:32There is absolutely no evidence
34:34that talking about suicide leads to
34:36greater suicide attempts or suicides,
34:38ways in which this topic can be
34:40broached or questions like do you
34:42ever think that life is not worth living?
34:45Or do you ever wish you could go
34:46to sleep and not wake up again?
34:48And do you ever think about killing yourself?
34:50These are sort of ways
34:51progressively get a little bit more
34:53explicit about whether a teenager
34:54is actually thinking about suicide.
34:59And again reducing the
35:00access to means of suicide.
35:02So this is an explicit discussion with
35:04families about locking up all the sharps,
35:07medications and weapons.
35:08And I would say don't be
35:09afraid to ask for details.
35:11Where are they being kept?
35:12Where are the keys being kept?
35:14Who knows where things are and how
35:16does the child take their medication?
35:18Does someone give it to them?
35:20The same goes for discussing supervision
35:22of the teenagers. Who is watching them?
35:24So it's really important to know
35:26whether the teenagers at home alone
35:28or going out on their own and
35:30getting that that information
35:31from families and parents.
35:36The final sort of note here is to
35:38recognize that adolescents and
35:40people in general remain under
35:42treated for mental health issues.
35:44And so again our top focus is
35:46on a number of adolescent mental
35:48health issues throughout the day.
35:50And part of our hope is, you know,
35:52to bring attention to these issues
35:54and to improve treatments, access
35:56and awareness and just to look
35:58at some of these numbers here.
36:00So this is a graph again from the CDC.
36:02So this is split into sort of three
36:06areas. So on the left
36:07here is any mental health
36:09treatment that's received.
36:10Here are the percent of kids
36:12who took medication,
36:13and here are the percent of kids
36:15who receive counseling or therapy.
36:16And they've broken it down to age groups.
36:18So the darkest purple bar is
36:21between 5 and 17 year olds.
36:23The next lightest bar is 5 to 11 year olds,
36:27and the lightest bar is 12 to 17 year olds.
36:29So in the group that we're talking
36:31about today, the 12 to 17 year olds,
36:33about 16.8% of kids
36:35have received any mental health
36:37treatment in the past year.
36:39This is data from 2019,
36:41which is a fair number.
36:43However,
36:43when you look at this across
36:45some of the other statistics
36:46that we've given in the talk,
36:48you would note that this rate is even
36:51lower for racial minority groups,
36:54and that from the same year,
36:55data showed that 19% of high schoolers
36:58seriously considered suicide.
36:59So a higher percent of high schoolers
37:01actually seriously considered suicide
37:03than the percent of this group who
37:05actually received any mental health
37:06treatment in the prior 12 months.
37:15So I think Michael's going to talk
37:17a little bit about sort of things
37:19that we're kind of doing to try
37:21to help improve our understanding
37:22of depression and suicide here.
37:25So I think that in terms of the
37:28stuff we're working on at Yale and
37:32in the clinic we're looking
37:35to develop novel treatments to
37:37help kids who don't respond to
37:39the evidence based therapies and
37:41medications we have for depression
37:44and suicidal ideation.
37:45Another big part of our research
37:47program is looking at imaging studies.
37:52MRI studies or PET studies to
37:56better understand brain mechanisms
37:58behind adolescent depression and
38:01suicide so we can hopefully develop
38:04better treatments in the long run.
38:05And I think just highlighting
38:11one of the really important things in Youngsun's
38:14presentation is that even though I,
38:17I guess in my research and clinically I'm
38:20thinking about depression in individual
38:22adolescents and how to help them get better,
38:25a lot of the things that probably can reduce
38:30completed suicide at a public health level,
38:33really part of the decreasing
38:37the deaths due to suicide
38:39is going to be developing better
38:42treatments and helping individuals,
38:43but a big part of it is about
38:47population based stuff and
38:48environmental based stuff that is,
38:50that's also probably crucially
38:52important and maybe more important
38:54than than access to individual
38:57treatments. Means reductions in terms
39:00of reducing access to to firearms,
39:03reducing access to things that increase
39:07impulsivity and impulsive decisions
39:11like access to substances and alcohol,
39:15and then also the other big thing is just
39:18enhancing protective factors to making
39:21the school environment as protective and
39:24beneficial to adolescents as possible.
39:27And societally reducing poverty and
39:31other economic and social stresses will
39:33probably be the most effective things in
39:37reducing the actual completed suicide rate.
39:40So that there's these two dual purposes one
39:43involving screening and getting individuals
39:45to effective treatment
39:46but another big part of it is decisions
39:49we make as schools and as societies
39:51and as health systems in terms of
39:54what behaviors we try to promote.
39:57Now,
39:57I will throw it to Rebecca to
40:00help moderate the questions.
40:01And I guess I would apologize for
40:03not realizing that we can unmute
40:05the participants and they can
40:07actually ask questions.
40:08Love to hear your voices rather than.
40:12Thank you everyone.
40:14Excellent.
40:16And so what I will as Dr Bloch
40:18shared I will go ahead and unmute
40:19some of the folks who have asked some
40:22really great questions in the chat if
40:24you prefer just for me to ask the, our
40:26panelists directly just feel free to
40:27to let me know and happy to do so.
40:30So we're actually going to
40:33start with Kristin.
40:34So if everyone can bear with me, just getting
40:38a little familiar with the unmuting.
40:41So Kristin you should be able
40:43to ask your question directly.
40:45Hello, how is everyone?
40:49Doing well.
40:50OK, good.
40:52So I was wondering what
40:54biopsychosocial factors you
40:56think contribute to adolescent
40:58females being more at risk for
41:01depression and suicidal ideation?
41:05Youngsun, do you want to go first?
41:08I can go first. I mean I was going
41:11to say I think some of this is,
41:13is social related as you sort of posed
41:15and these sort of expectations and
41:17stresses that come with adolescence.
41:19There probably is a hormonal component,
41:21it's probably not just
41:23social and psychosocial.
41:24But you know, I think again with
41:26the preteen and teenage years,
41:28these peer relationships just become so,
41:30so important and that's normal, right.
41:32That's developmentally normal for
41:33for teenagers and part of their
41:35sort of pathway to independence.
41:37But I think the difficulties
41:39navigating this can certainly make
41:42the risk for depression go up and I
41:44think you know females navigate the
41:46the social relationships in a bit of a
41:48different way than males typically do.
41:50So I think that that's one probably
41:53risk factor for the females.
41:55I think there probably is a hormonal and
41:57biological component to that as well,
41:59but in terms of the psychosocial
42:01component there.
42:04And another thing that I always wondered I,
42:06it's hard to control for this and study,
42:08but I wonder how much it's their sort
42:10of, our societal expectations on males
42:13and not reporting depressive symptoms
42:16in the same degree as as females and
42:19that it's at some level they're sort of
42:21still the stereotype of the stoic male
42:23who's not allowed to talk about their
42:25feelings and how much that affects
42:28the numbers because I, on the other hand,
42:31if you're looking at completed suicides it's
42:33more males than females.
42:37We definitely see more females in clinic.
42:39Yeah. Thank you both.
42:45And next I'll, Kathryn I'll have
42:48you go ahead and ask your
42:50question about the language used.
42:52Sure. Hi. Thank you.
42:54I used to teach this,
42:56so I know the answer,
42:57but I was hoping you would share
42:59with everyone your preference for
43:00using the language "die by suicide"
43:02instead of "committed suicide."
43:04I hear "committed" a lot in the field.
43:07Yeah. No, that's a that's a really great,
43:09great question and I think
43:11the language does matter.
43:12It's, it's it is important you know
43:15and I think it probably will
43:17evolve as we keep thinking about it.
43:19But certainly the things to pay
43:21attention to with the language and
43:23there are media guidelines around this
43:25because of the sensationalism that
43:28can accompany suicides and the risk
43:30for what are called "copycats" or people
43:32who get sort of inspired by suicide.
43:35So there are media guidelines for instance on
43:37how to report suicides.
43:38And so you'll see headlines
43:40that say you know,
43:41so and so is dead at whatever age instead of,
43:44you know, suicide or died or you know took
43:46their life or other language such as that.
43:48And that's purposeful.
43:49And I think it's a similar thing when
43:52we are talking with each other as well.
43:54And so I do think, you know,
43:56you raise a really,
43:57really good point about being mindful
43:59about the language in which we use.
44:03I guess just the other thing to add about this
44:05I think on this issue, die by suicide
44:08is is definitely preferable language to me,
44:12but I think you know, I think
44:16something that really bothers me
44:18about being involved in this field
44:21and treating the children and
44:23experiencing their deaths with families
44:25is that I feel like as a society,
44:28we view the death by suicide as somehow
44:31different than a death by pediatric cancer.
44:34And in terms of the lot of the public
44:37health decisions we're making as a society,
44:39this is a, you know,
44:41basically the second leading
44:42cause of death in these kids.
44:44And it, it feels to me like,
44:46even as a mental health profession we have,
44:49we often aren't placing the
44:52proper importance and sort of
44:56severity on that and I think the
44:59language partially makes a difference.
45:00The other thing I really, sort of
45:03really, I've struggled with in just
45:05sort of talking to teenagers about
45:07this and doing these talks is
45:10that a lot of times in the media sort
45:13of you know the the cause of death
45:16gets sort of hidden or not mentioned
45:18because there's a worry about sort of
45:22a suicidal contagion and I think
45:24that's a realistic worry but I also think
45:27when we're not really talking
45:29about the severity of the problem
45:31it also is hard to shine light on it
45:33and that there's sort of a constant
45:35tension there that I I'm not sure
45:38I've entirely figured out how to
45:39be comfortable with and negotiate.
45:43Yeah, that's actually a really good point.
45:44It does put the onus on the rest of
45:47the community. So parents, schools,
45:49teenagers themselves to start to have
45:52this conversation and which you know,
45:55can be a hard conversation to have for sure.
45:58But it is, it is something that
45:59is in the media that you know,
46:01teenagers are seeing and you know
46:03some of the celebrities or people
46:05that they follow maybe, you know,
46:07sort of affected by this as well.
46:12We had another
46:13question from Anonymous,
46:14so I'll ask this one of "what
46:16are the best short term in the
46:18moment interventions for suicide
46:19prevention and how should providers
46:21respond in the moment to a suicide
46:23threat that's been verbalized?"
46:28I can start, I think, you know, always
46:30probably acknowledging how hard it
46:32is for someone to probably say this.
46:34So being sort of, you know,
46:36thankful that that someone's
46:37actually sharing is it,
46:38it takes a lot for people to
46:39share this kind of information,
46:41so it sort of acknowledging that Umm.
46:44And I think so that's I think one thing
46:46that's really important and I and I
46:48do think it's important to do sort of
46:50the practical safety things you know,
46:52in this moment.
46:53"Are you safe right now?"
46:54"What are you thinking about right
46:56now?" Because it's it's really
46:58hard to guess as I have said,
47:00it's hard for us to know.
47:01There's an impulsivity factor
47:03that accompanies everything.
47:04So, you know,
47:05acknowledging how hard it is, talking about,
47:08you know, arranging for the safety in
47:10the moment is really important, Umm.
47:13And then for yourself sort of triaging
47:16how worried do you have to be
47:18and who do you notify next?
47:19Right. So you don't necessarily,
47:21depending on who you are,
47:22necessarily have to sit with
47:23this information alone.
47:24But you know,
47:25should we talk to the teenagers parent?
47:27Is there a clinician involved?
47:28Is there a someone else at the school
47:30that's involved that can be discussed
47:32with as
47:32well? And those are some of
47:34the other things I think that
47:35I would think about.
47:39And I just, so I think the big thing to
47:42just under score the need for immediate
47:44safety and to triage sort of the extent
47:47of how worried you are. I think another
47:50big thing is, and it's really hard
47:54to negotiate this again, is in terms
47:57of telling parents or referring
48:00kids to the emergency room
48:01if they're talking about suicidal ideation,
48:03it's a balance because I
48:05think in in the long run,
48:07at some level some of the time,
48:09they just need someone to talk to
48:12and if you're and if you're
48:14kind of comfortable talking about
48:17their experiences with them,
48:18often they don't need to go
48:20to the emergency room.
48:22Or something like that.
48:24And if you and that being
48:27comfortable and being able to sit
48:29with someone who's having those
48:31thoughts is important in their comfort
48:33level in coming back in the future.
48:35And so I think this is a constant
48:38tension between what to do.
48:39Obviously there are certain circumstances
48:40where you have to intervene and
48:42that's the most important thing,
48:44but it's always a double edged sword.
48:49Being mindful of time,
48:50I'm going to kind of synthesize a couple
48:52of the questions that we have left.
48:54One was from Patricia of "what are
48:56some of the novel ways that that the
48:58team has found to help?" that I imagine
49:01I know Dr. Bloch you started
49:02to hit on with some of the trials
49:03but for both of you to respond to.
49:06And then we also had a question
49:07related to that from Catherine
49:09of any specific evidence based
49:11treatment approaches that would be
49:13recommended over others for when
49:14there is the chronic suicidality.
49:19So I would say the first thing in terms
49:22of intervention is you know that one
49:25thing's helpful is really it's important
49:28to have a good therapeutic relationship
49:30and get these kids into any treatment.
49:32I think the biggest thing I see in
49:34sort of doing trials for treatment
49:36refractory depression is that the
49:39number of kids who've been in treatment
49:41for a fairly long period of time
49:43and have not really had any evidence
49:46based therapy and making sure that
49:48getting access to that's crucial and
49:51and I think that's the first part of it.
49:54I think cognitive behavioral therapy,
49:57DBT's are really good things,
50:00especially for kids with chronic
50:02suicide. We've been looking more at
50:05Ketamine and Esketamine.
50:07So these are new medications
50:10along that have an indication for
50:13treatment refractory depression in adults
50:15and also depression with the acute
50:18suicidal ideation and looking
50:19at whether they work in kids.
50:21And I think the real reason that we're
50:24interested in those interventions
50:25that at least in adults they show a
50:28larger benefit than a lot of the other
50:30second line treatments that we have
50:32available and that they work faster.
50:34So they may be particularly useful in
50:37these adolescents and patients when
50:40you look at just the practical fact
50:42of how big of a risk factor right
50:45when they start medication is,
50:47right when they get hospitalized
50:48or get released from the hospital,
50:50that's something that works better
50:52and faster would be something that
50:54would be really attractive.
50:58Rebecca, can I make one comment if I
51:00was just going to say one?
51:03First of all I just want to say
51:04this has been a really really
51:06interesting informative
51:07set of presentations. Thank you.
51:09And I just also wanted to just
51:11make a comment really quick is that
51:14I know we're focusing on adolescents,
51:17but in fact the rates have gone
51:19have been over the roof with the
51:22young, younger children for the
51:24first time in in my career.
51:27And in fact the NIMH sent out
51:30an announcement that they were
51:32interested in how can we assess?
51:35We need measures to develop,
51:38people to develop
51:39measures to assess suicide
51:41ideation in young children.
51:43And so I know the anxiety program shared
51:47with you information about our projects,
51:50but we now have a funded project to
51:53develop a suicide ideation assessment
51:57measure in children 8 to 12.
51:59You do not need to be depressed or
52:01suicidal we're just developing the measure.
52:04So I guess I wanted to share that
52:06information with you
52:07because
52:08it is happening in children 8
52:10years old and 9 years old,
52:12and this is a big public health emergency,
52:15so we're doing some work on that.
52:17So I wanted to let people know about the
52:20problem and also about our latest study on
52:23this. Thank you.