Adolescent Suicidal Behavior Evaluation and Treatment Considerations Gabriel Kaplan, M.D. Bennett Silver, M.D

Adolescent Suicidal BehaviorEvaluation and Treatment Considerations

Gabriel Kaplan, M.D. Bennett Silver, M.D.

Conference AgendaDr. Gabriel Kaplan•Epidemiology

Dr. Bennett Silver•Psychopathology

Dr. Gabriel Kaplan•Risk Assessment •Pharmacological Approach

Dr. Bennett Silver•Psychosocial Approach and Prevention Programs

Bennett Silver, MDACADEMIC CREDENTIALS

•Board Certified Adult Psychiatrist▫ American Board of Psychiatry and Neurology, INC

•Child Psychiatrist ▫ Mt. Sinai School of Medicine Trained Specialist

•Director of Residency Training▫ Bergen Regional Medical Center

•Three decades of clinical work with suicidal patients

PUBLICATIONS/PRESENTATIONS•Editor,

▫ Child and Adolescent Psychiatry Alerts national newsletter•Editor,

▫ Psychiatry Drug Alerts national newsletter•Presentations to physicians, school personnel, professional associations, parent groups, on the topic of suicide

Gabriel Kaplan, MDACADEMIC CREDENTIALS

•Board Certified Child Psychiatrist, American Board of Psychiatry and Neurology, INC•Distinguished Fellow, American Psychiatric Association •Clinical Associate Professor of Psychiatry, University of Medicine and Dentistry of New Jersey

PUBLICATIONS/RESEARCH/SYMPOSIA•Kaplan G.

▫ Co-Investigator. New York Hospital Research Grant Follow-up Suicidal Adolescents. 1986-1988•Pfeffer C., Newcorn J.H., Kaplan G., et al.

▫ Suicidal Behavior in Adolescent Psychiatric Inpatients. J American Academy of Child Adolesc Psychiatry. 1988; 27:357-361

•Pfeffer, C., Newcorn J.H., Kaplan G., et al. ▫ Subtypes of Suicidal and Assaultive Behaviors in Adolescents J Child Psychology and Psychiatry, 1989;

1:151-163•Kaplan, G., Oquendo, M., Escobar, J., and Marin, H.

▫ Assessment and Management of Depression Symposium 2006 APA •Kaplan, G., Oquendo, M., Escobar, J., and Marin, H.

▫ Assessment and Management of Suicidal Behavior across the Life Cycle Symposium 2007 APA •Greydanus D. and Kaplan G.

▫ Strategies to Improve Medication Adherence in Youths: Approaches During the Active to Maintenance Transition. Psychiatric Times pp 14-16 July, 2012

•Kaplan G. ▫ What is New in Adolescent Psychiatry? A Literature Review and Clinical Implications Adolescent

Medicine: State of Art Reviews (AM:STARs). Spring 2013 (in Press)

EpidemiologyGabriel Kaplan, MD

DefinitionsSuicidal Ideation Thoughts of harming or killing oneself.

Suicidal Communications Direct or indirect expressions of suicidal ideation or of intent to harm or kill self, expressed verbally or through writing, artwork, or other means.

Suicidal Threats A special case of suicidal communications, used with intent to change the behavior of other people.

Suicide Attempt A non-fatal, self-inflicted destructive act with the explicit or inferred intent to die.

Suicide Fatal self-inflicted destructive act with explicit or inferred intent to die.

Suicidality All suicide-related behaviors and thoughts including completing or attempting suicide, suicidal ideation or communications.

Goldsmith SK, Pellmar TC, Kleinman AM, et al. Reducing Suicide: A National Imperative. Washington, D.C.: National Academy Press; 2002.

Trends in Suicide Rates Ages 10 Years and Older, by Sex, 1991–2009

Centers for Disease Control:

www.cdc.gov/ViolencePrevention/suicide/statistics/

Rates have increased since 2004

• Influence of internet social networks

• High suicide among young U.S. troops

• Higher rates of untreated depression in the wake of recent “black box” warnings on antidepressants—a possible unintended consequence of the medication warnings, required by the FDA in 2004

Percentage of Suicides Ages 10 Years and Older, by Sex and Mechanism, 2005–2009

Centers for Disease Control: www.cdc.gov/ViolencePrevention/suicide/statistics/

Leading Causes of Death by Age

Youth Risk Behavior Surveillance System (YRBSS) • The YRBSS was developed by the Centers for

Disease Control (CDC ) in 1990 to monitor priority health risk behaviors that contribute markedly to the leading causes of death, disability, and social problems among youth and adults in the United States

• The YRBSS includes national, state, territorial, tribal government, and local school-based surveys of representative samples of 9th through 12th grade students. These surveys are conducted every two years, usually during the spring semester.

Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App




H S Students Considering, Planning, or Attempting Suicide in Past 12 Months 2009


Suicide Rates Ages 10–24 Years, by Race/Ethnicity and Sex, 2005–2009


Risk AssessmentGabriel Kaplan, MD

Common school suicidal situations

• A note is found• A student overhears another student• A student confides in a guidance counselor• A student threatens during school day• A parent confides in a teacher/counselor• A teacher discovers student’s self mutilation• A student “does not look well” and is asked• Student is absent, parents confide• Routine suicide school screening • A student who is bullied expresses suicide ideas

Risk Factors

• History of depression or other mental illness ▫ Psychiatric disorder is present in up to 80-90% of

adolescent suicide victims and attempters Most common psychiatric conditions are mood, anxiety,

conduct, and substance abuse disorders.• History of previous suicide attempts • Family history of suicide • Stressful life event or loss • Easy access to lethal methods • Exposure to the suicidal behavior of others • Incarceration • Bullying (victims and perpetrators)• Hopelessness/guilt

What to do?

• A plausible suspicion must be assessed immediately▫A usually happy go lucky 7 year old crying “I

want to die” because another student took a toy away does not need an emergent evaluation.

▫Keep in mind risk factors/age discussed here

• While rare, every suicide is “one too many”▫Thus, when in doubt, err on the side of caution

and refer a.s.a.p.

Evaluation

• Adolescent suicidal behavior is a medical emergency that must be assessed by highly qualified professionals: ▫Child Psychiatrist, ▫Psychiatrist, ▫Non-MD with training and experience in the

assessment of suicidal behavior

• If an adolescent actively threatens suicide, an assessment must be conducted asap in the Emergency Room setting

Expert evaluation

• Comprehensive psychiatric examination

• Includes medical history

• Patient, family, teacher input required

• Evaluation focused on determining potential risk and disposition

• May include rating scales

Expert will assess

• Presence of mental illness▫Large majority of patients who suicide suffer

from mental illness▫All psychiatrically ill adolescents are high risk

• Presence of aggravating circumstances▫Loss, bullying, substance abuse

• Suicide continuum stage

Suicide Continuum

Passive Death Wish

Suicidal Ideation without method

Suicidal Ideation

with method

Self-Injurious behavior

with unclear intent

Attempt Completion

Focused assessment of continuum• It is vital to assess what the adolescent is thinking• In order to determine strengths and weaknesses,

difficult questions must be asked centered on degree of desire to die

• Questions must be very specific. Trying to assess suicidality without asking about death is like trying to determine appendicitis without asking “does it hurt here?”

• There is ample evidence that asking about suicide does not “put” ideas in any adolescent’s mind

Examples of Suicide Continuum

• Passive death wish▫I wish God took me away

• Ideation without method▫I feel bad and have thought about killing

myself

• Ideation with a method▫I am thinking about shooting myself

Attempt vs. Gesture

• SUICIDE GESTURE: ▫ Self-injury in which there is unclear intent to die but instead

an intent to give the appearance of a suicide attempt in order to communicate with others (Nock & Kessler Journal of Abnormal Psychology 2006, Vol. 115, No. 3, 616 – 623)

• SUICIDE ATTEMPT: ▫ Potentially self-injurious behavior with a nonfatal outcome, for

which there is evidence (either implicit or explicit) that the person intended at some level to kill self (Goldsmith SK, Pellmar TC, Kleinman AM, et al. Reducing Suicide:

A National Imperative. Washington, D.C.: National Academy Press; 2002).

• There is evidence that these two groups differ but there is also evidence that those who engage in suicide gestures also carry a higher risk of completion.

• Those who “gesture” must be taken seriously

High Risk

•16 year old male•Abuses alcohol•Treated for bipolar disorder•History of suicidal ideas•Recent loss of mother due to medical

illness•Father is a hunter•Broke up with GF and stated he wants to

kill self

Medium Risk

•17 year old female•History of self mutilation without intent to

die•Family history of completed suicide•Doing poorly in school, ostracized by peers•Attends therapy regularly•Has good relationship with parents•During an argument with peer in school was

overheard voicing wish to die

Low Risk

•9 year old male•Parents recently separated•Stays with grandmother very often•Doing well in school and liked by peers•No family history of psychiatric problems•After watching a movie showing a suicide,

told grandmother nobody likes him and he wishes to die

Risk And Disposition

• High Risk▫ Inpatient treatment▫ If condition relapses, next time discharge to

structured setting, possibly a therapeutic day school

• Medium Risk▫ If new condition, Partial Care Program▫ If condition is chronic, structured setting advisable,

possibly a therapeutic day school• Minimal Risk

▫ Traditional Outpatient Treatment

Psychopathology of SuicideBennett Silver, MD

How it Happens

Alex was a 17 year old high school senior. He was a warm, sensitive, quiet young man; a high honor roll student and a gifted young writer. He had been accepted to an excellent college, and a promising, successful future seemed assured. Yet one late afternoon in April, upon returning home from work, his horrified mother discovered him on the floor of his bedroom. Alex had killed himself with a gunshot to the head.

How is it possible that this young man, who seemed to have everything to live for, would take his own life?

Why it Happens

In order to understand why tragedies like this

occur, we must understand the psychopathology from which it stems.

Suicide as a Symptom

• Suicide is to the psychiatrist as cancer is to the internist

• The psychiatrist may provide optimal care, yet the patient may die by suicide nonetheless

• Suicide is best viewed as a symptom of an underlying disease rather than a disease per se

• The underlying disease is usually some type of depression, or another psychiatric disorder and therefore is highly treatable

Causes of Depression• Depression has no single cause. Genetics/Biology definitely play a role (family

history)

• The environment: stressful situations, abuse, family issues, physical illness, loss, romantic breakups, conflict over sexual orientation

• Anxiety and behavior problems increase chances for depression

• Predisposing personality traits: perfectionism, inhibition, isolation, supersensitive

• Drug and alcohol dependency

• Head injuries (e.g., football, soccer, car accidents), lead to disinhibition, depression and suicide

• Sometimes no clear triggering event

A bio-psycho-social model provides the best understanding of depression

Biological Theories About Suicide• Genetic factors predispose to suicide – clusters of families with

both mood disorders & suicides and clusters with mood disorders without suicide, indicates independent inheritance of mood disorders and suicidal behavior

• Biological theories about suicide linked to studies of depression-the mental state most often underlying suicide

• Deficiency of neurotransmitters like norepinephrine/ serotonin at critical sites in brain resulting in depression

• Many studies indicate a lower level of serotonin in brains of those who suicided and in cerebrospinal fluid of depressed individuals who have attempted suicide than in depressed patients who are not suicidal

Low Brain Serotonin, Impulsivity and Suicide

• More violent suicide attempters/completers(guns, jumping) lower levels of serotonin than those using less violent means (e.g., pills)

• Studies have found decreased serotonin levels for gamblers/fire-setters/impulsive individuals, compared to control populations

• This non-specificity links lower serotonin levels with poor impulse control which increases suicidal behavior.

• Alcohol lowers serotonin at same sites in brain as seen in depressed patients. Alcohol is a disinhibiter that increases impulsivity and greatly increases risk of suicide in depressed patients.

• One third of adolescents who suicide are legally intoxicated at the time of death

Biopsychosocial Theories• Stress plays a role in development of depression, addiction and

other psychiatric disorders

• Corticotrophin releasing factor (CRF), a key brain hormone in the stress response, is implicated in the physiology of both depression & Substance use disorders (SUDs)

• Elevated CRF concentrations found in the brains of suicide victims

• Early life stress (physical/sexual abuse/neglect) and chronic stress cause sustained elevations of CRF, causing long term damage to brain pathways (neuroadaptation) which increases susceptibility to depression and substance use

• This provides the biological underpinnings of the well-established relationship between early life adversity and depression, suicide and SUDs in adolescents and adults

Suicidal Behavior • More than 90% of all completed suicides in adolescents (and

adults) are individuals with psychiatric disorders:

• Mood Disorders (most common): Major Depression, Bipolar Dis• Schizophrenia• Alcoholism• Drug Dependence• Conduct Disorders• Borderline Personality Disorder• Panic Disorder• Substance Abuse Disorders and Anxiety Disorders appear more

important as cofactors rather than primary in themselves. Co-existent high anxiety, panic, or substance use, accompanying major depressive disorder or schizophrenia markedly increase suicide risk

The Suicidal Crisis

• Often, a crisis situation, what one author called a “state of perturbation,” occurs in a vulnerable adolescent with a psychiatric disorder and that crisis converts a state of potential risk into an actual suicidal act

• The most common precipitating events are break-ups, episodes of perceived humiliation, academic or extracurricular failures, school disciplinary/legal problems, or sexual assaults

Mood Disorders and Completed Suicide

60-70% of suicide victims were suffering from a significant clinical depression at the time of their

deathsCompleted Suicide Lifetime Suicide Attempt

Bipolar Disorder 10-20% 29%

Major Depression 5-12% 16%

General Population <.0002% (16/100,000)

.02%

Any Psychiatric Disorder

4%

Some Facts About Bipolar Disorder

• Prevalence in America of approx 1% to 4%• Equally in men and women• 60% onset before age 20• 10%-15% of adolescents with recurrent major

depression go on to develop Bipolar Disorder• Residual symptoms between episodes common,

and 60% experience chronic interpersonal and school difficulties between episodes

• Strong genetic influence-one of most familial psychiatric disorders

Characterized by Recurrent Mood Episodes

•Major Depressive Episode

•Manic Episode

•Mixed Episode

•Hypomanic Episode

Manic Episode

A. Distinct period of persistently elevated, expansive, or irritable mood –causes marked impairment in functioning

B. During period of mood disturbance at least 3 of the following:

1. Inflated self-esteem or grandiosity2. Decreased need for sleep3. More talkative, pressured speech4. Flight of ideas or racing thoughts5. Distractibility6. Increased in goal-directed activity (social, school work,

sexual) or psychomotor agitation7. Excessive involvement in activities with high potential for

negative consequences (e.g., buying sprees, sexual indiscretions)

Mixed and Hypomanic Episodes

•During a Mixed Episode manic and depressive symptoms may occur simultaneously or in quick succession.

•During a Hypomanic Episode, symptoms same as during Manic Episode, but less severe - do not cause marked impairment in functioning.

Suicide Risk in Bipolar Disorder and Major Depression

Other Factors That Increase Suicidal Acts in Depressed and

Bipolar Patients

•Severity of depression•Age of onset (younger age)•Severity of ideation•Number of prior attempts•Stable levels of hopelessness•Transition points: first week of

hospitalization, incarceration, bereavement, victimization/abuse

Comorbid Substance Abuse• Prevalence of comorbid substance abuse in

bipolar I and bipolar II disorder is as high as 61% and 48% respectively

• This is greater than the prevalence of substance abuse seen with any other psychiatric conditions, including schizophrenia, panic disorder, dysthymia and unipolar depression

• Comorbid substance use increases the risk for suicide in mood disorders

Accurate Diagnosis and Early Intervention

• Bipolar Disorder is difficult to diagnose in adolescence, due to nature of adolescent moodiness, and similarities with conditions such as ADHD, Schizophrenia, and Addiction

• Bipolar Disorder has a spectrum of severity and milder forms often missed or misdiagnosed.

• Misdiagnosis leads to delayed or incorrect treatment

• Early intervention/treatment improves long – term outcome, reduces suicidal risk for teens

Major depression in adults and adolescents

At least 5 of these symptoms must be present to the extent that they interfere with daily functioning over at least 2 weeks

Adults Adolescents

Depressed mood most of the day Irritable mood; preoccupied with song

lyrics that suggest life is meaningless

Decreased interest/ enjoyment in activities Loss of interest in sports, video games, activities with friends

Significant weight loss /gain Failure to gain normal weight ; anorexia or bulimia; frequent complaint of physical illness

Insomnia or hypersomnia Excessive late night TV or computer; refusal to wake up

for school in morning in morning

Psychomotor agitation/ retardation Running away from home

Fatigue or loss of energy Persistent boredom

Low self-esteem; feelings of guilt Oppositional and/or negative behavior

Decreased ability to concentrate; indecisive Poor performance in school; frequent absences

Recurrent Suicidal ideation or behavior Recurrent suicidal ideation or behavior (writing about death ; giving away favorite objects or possessions

Signs and Symptoms of Covert Depression Often Seen in

Adolescents• The quiet, perfectionistic “good boy” who never gets

into trouble but who cannot maintain the level of perfection that he or others expect of him

• Boys with conduct disturbances who become depressed and act out impulsively

• Boys who abruptly develop conduct disturbances as their way of expressing depression

• Changes in school performance or friends

• Beginning to abuse substances

Relapse is Common in Major Depression

•After one episode 50%

•After two episodes >70%

•After three epsodes >90%

•Relapse is more common when first episode is before the age of 20 years

Symptoms and Signs of Psychiatric Illness Are Present

Prior to Suicide Although the bereaved parents of

adolescent suicide victims frequently insist that their child was totally free of any symptoms prior to the suicide, this appears rarely true on closer examination, and may reflect the parents’ denial or their inability to recognize the signs of depression

Pharmacological Approach

Gabriel Kaplan, MD

Pharmacology is just One of Many Tools within a Comprehensive Approach• Individual psychotherapy

• Group psychotherapy

• Family therapy

• School Interventions

• Medication

• Therapeutic school placement such as New Alliance Academy which can utilize all of above approaches

Medication Classes Used in Suicide• Antidepressants

• Antipsychotics

• Mood Stabilizers

• Only one medication has been proven to decrease suicide in adult schizophrenia and is FDA approved specifically for suicide▫ Clozapine (antipsychotic)

• There is ample evidence for other medications in adults ▫ Lithium (mood stabilizer)▫ Antidepressants

Antidepressants

Serotonin Enhancers -SSRI’s• Prozac (Fluoxetine)• Zoloft (Sertraline)• Lexapro (Escitalopram)• Celexa (Citalopram)• Paxil (Paroxetine)

Serotonin/Norepinephrine Enhancers- SNRI’s• Effexor (Venlafaxine)• Pristiq (Desvenlafaxine)• Cymbalta (Duloxetine)

Dopamine/Norepinephrine Enhancers• Wellbutrin (Bupropion)

Side-effects of Antidepressants

Most adolescents do not have side-effects. If they do occur they are usually mild and transient.▫ Headaches▫ Upset stomach▫ Decreased appetite▫ Flushing and sweating▫ Mild sedation▫ Jitteriness▫ Abnormal dreams▫ Rash▫ Sexual▫ BLACK BOX WARNING

Antidepressants Are Compatible With Student Performance in School

•Low incidence of side-effects

•Usually not sedating

•Once daily dosing (morning or nighttime)

•Usually compatible with other medications

How Effective Are Antidepressants ? In an important recent study funded by the

NIMH (TADS) on adolescents with moderate to severe depression :

71% of adolescents who received combination treatment (medication + therapy) improved significantly

61% of those receiving medication alone (fluoxetine) improved

Combination treatment was nearly twice as effective in relieving depression as the placebo or psychotherapy alone

March J. TADS JAMA. 2004 Aug 18;292(7):807-20.

Do Antidepressants make people suicidal?• 2003 the maker of Paxil disclosed that clinical trial data had

found an increased risk of suicidality in youth.

• FDA concluded that for every 100 treated patients, 1 to 3 patients might be expected to have an increase in suicidality.

• 2004 FDA required all antidepressants carry a black box warning

• The data did not indicate any completed suicides, thus, the identified suicidality increase referred to ideas and behaviors but not deaths.

• 2007 FDA expanded the warning to include patients up to age 24. • There are only two FDA approved agents indicated for use in

adolescent depression: fluoxetine (Prozac) and escitalopram (Lexapro).

Black Box Controversy

• Data from the CDC show that between 1992 and 2001, the rate of suicide among American youth ages 10 – 19 declined by more than 25%

• The dramatic decline in youth suicide rates correlates with the increased rates of prescribing antidepressant medication (particularly SSRI’s) to young people

• Since the black-box suicide warnings appeared on the labels of antidepressants, antidepressant use among teens plummeted. At the same time, the suicide rate among U.S. teens rose sharply – bucking a decades long trend

• There are no statistical data yet linking the black box to increased suicidality but suspicion is high amongst academicians that this may have been an unintended consequence of the warning

Data Reanalyses

• FDA studied only short term data

• Data were reanalyzed adding longitudinal information, extending the observational period beyond the short term study end point timeframes assessed by the FDA.

• For adult and geriatric patients medication actually decreased suicidal thoughts and behavior. The protective effect was mediated by decreases in depressive symptoms with treatment.

• For youths, however, although depression also responded to treatment, no significant effects of treatment on lowering suicidal thoughts and behavior were found, although reassuringly, there was no evidence of increased suicide risk in those receiving active medication.

Gibbons RD, Brown CH, Hur K, Davis J, Mann JJ. Suicidal Thoughts and Behavior With Antidepressant Treatment: Reanalysis of the Randomized Placebo-Controlled Studies of Fluoxetine and Venlafaxine. Arch Gen Psychiatry. 2012 Jun;69(6):580-7.

Mood Stabilizers

• USED FOR BIPOLAR DISORDER

• LITHIUM: ▫ Lithium Carbonate (Eskalith,Lithobid)

• ANTICONVULSANTS: ▫ Valproic Acid (Depakote) ▫ Carbamazepine (Tegretol) ▫ Lamotrigine (Lamictal)

Lithium

• Oldest mood stabilizer• Improves depression and mania• Helps prevent future episodes• Narrow dosage range (blood levels required)• Very dangerous in overdose• Side – effects: drowsiness, weakness, nausea,

fatigue, hand tremor, increased thirst, increased urination, thyroid underactivity, weight

gain

Anticonvulsants

• Improve depression and mania• Lamictal especially good for depressive episodes• Help prevent future episodes• Narrow dosage range (blood levels required)• Work better than Lithium for rapid cyclers and

mixed states• Side – effects: Nausea, headache, double

vision, sedation, liver enzyme elevation, weight gain, hormone changes in women (Depakote, e.g., absence of menstruation)

Antipsychotics

• TYPICAL▫ Haloperidol (Haldol) Less sedating, muscle rigidity, Tardive Dyskinesia▫ Chlorpromazine (Thorazine) Sedating, low blood pressure, TD

• ATYPICAL▫ Aripiprazole (Abilify) –weight neutral, less sedating▫ Risperdone (Risperdal) – Moderate weight gain, increases prolactin ▫ Quetiapine (Seroquel) – Moderate weight gain, sedating, may have

antidepressant properties▫ Olanzapine (Zyprexa) – Very effective, but significant weight gain,

metabolic effects (blood sugar, cholesterol)▫ Ziprasidone (Geodon) – Weight neutral, less sedating▫ Clozapine (Clozaril) – Most effective, weight gain, metabolic effects,

risk for severe white blood cell suppression requires regular blood tests. Used when other medications fail.

Antipsychotics

• Improve depression (as add on) and mania (combined or monotherapy)

• Control delusions & hallucinations (psychosis)• No blood levels required• Side – effects: sedation, weight gain (some),

elevated blood sugar, diabetes, restlessness, muscle spasms

• Monitor weight, blood sugar, cholesterol

Bennett Silver, M.D.

Psychosocial Approach and Prevention

Getting the Right Help Can Prevent Suicide • > 80% of adolescent suicide attempters/completers communicate

suicidal ideation prior to the attempt

• Majority of youth suicide attempters/completers have seen a doctor/mental health worker in 3 months prior to the suicidal behavior

• Few individuals with Major Depressive Disorder receive adequate treatment for depression before and after a suicide attempt

• Only 20-40% of suicidal patients continue outpatient treatment after psychiatric hospitalization-treatment dropout another suicide risk factor

• Recent Study of 102 people who killed themselves revealed more than half had visited mental health specialist during the year prior to death

• Only 5% had contact with addiction services, even though 2/3 suffered from substance abuse as well as depression - need better integration of mental health and addiction services

Psychotherapy for Suicidal Patients

• Short-term, group, behavioral, interpersonal, psychoanalytically oriented, and multiple other psychotherapy approaches have all been employed with reported success

• However, Cognitive Behavioral Therapy (CBT) by far the largest evidence base of its effectiveness

• Dialectical Behavioral Therapy (DBT) particularly effective with suicidal Borderline Personality Disorder patients

Cognitive Therapy• Cognitive theory emphasizes the psychological

significance of people’s beliefs about themselves, their personal world (including the people in their lives), and their future – the “cognitive triad”

• Maladaptive emotional distress linked to biased beliefs about this cognitive triad of self, world, and future

• E.g., clinically depressed people may believe that they are incapable and helpless, view others as judgmental, and the future as bleak and unrewarding

• Cognitive therapy modifies these maladaptive beliefs to help the person gain a more objective view of their problems and their potential solutions

Thinking Patterns Targeted by Cognitive Therapy

• Dichotomous (black-white) thinking• Cognitive rigidity and constriction• Perfectionistic standards of self/others, high self-

criticism• Over-general autobiographical memory - past

experiences cannot be used as references for effective coping strategies

• Impaired problem solving• Hopelessness/helplessness-negative expectations about

the future• “locked-in” to current perceptions, unable to imagine

alternatives • View death in a favorable light• Have difficulty generating reason for living

Critical Role of Early Intervention and Parent Education• The earlier the intervention in the course of

suicidality, the greater the potential for success

• Importance of parent education of suicidal youth – e.g., 17% of parents keep firearms even after their child’s suicide attempts (more lethal methods with repeat attempts)

• Parents are 3 times more likely to take protective actions when parent education is provided

Bullying and Suicide• Recent bullying related suicides and school shootings in

the US and in other countries have drawn attention to the connection between bullying and suicide/homicide

• Too many adults see bullying as “just part of being a kid”• Bully victims 2 to 9 times more likely to consider suicide

• 30% of students are either bullies or victims of bullying and 160,000 kids stay home daily due to fear of bullying

• Types of bullying- physical, emotional, cyber, sexting

• Being a bully also linked to an increased rate of suicide

New Jersey Anti-Bullying Bill of Rights Act

• 2011, toughest in country-extension of original anti-bullying law enacted in 2002

• Defines bullying: any harmful action towards another student or any action that creates a hostile school environment or infringes on a student’s rights at school.

• Includes cyber bullying and bullying both on and off school grounds

• All cases bullying/teasing must be reported to the State

• Written report within 2 days, families, superintendent notified, investigation within 10 days of incident

• All schools a plan to address bullying, teachers/ administrators trained to identify/respond to bullying

• All schools anti-bullying specialist/school safety team

How to Deal with a Suicidal Adolescent

• First, a person in crisis needs someone to listen and hear what they are saying

• All suicidal talk should be taken seriously

• Do not be afraid to ask directly if the person has thoughts of suicide – it will do no harm-most individuals relieved and feel given permission to talk about it

• Do not be misled by the suicidal person’s comment that he is alright and past the crisis – follow-up is crucial to insure good treatment

How to Deal with a Suicidal Adolescent - 2

• Be firm but supportive – give the impression that you know what you are doing and that you intend to do everything possible to prevent him from taking his life

• Evaluate the resources available – inner psychological resources such as intellectualization that can be strengthened & outer resources such as counselors, relatives, clergy and others who can be called in

How to Deal with a Suicidal Adolescent - 3

• Act Specifically – do something tangible, parents must be called in, arrange for him to see someone else, or if necessary, have the person brought to an emergency room for evaluation

• School staff cannot assume that a student’s family will take positive steps to respond to the situation, especially in dysfunctional families and must insure that at risk students receive the necessary services

• Don’t be afraid to ask for assistance and consultation – call upon whomever is needed. Don’t try to handle everything alone

Postvention in the School Setting• Prevention measures implemented after a traumatic event to

reduce risk to those who have been affected by the tragedy

• The suicide, violent or unexpected death of a student, teacher, even a celebrity can increase risk of suicide for vulnerable young people - “copy-cat suicides”

• Postvention includes grief counseling for students/staff, identification/support of vulnerable students, and families

• Work with the media-ensure news coverage does not dramatize/romanticize, leading to additional suicides

• Establish school- based suicide prevention programs & crisis response plans including educational activities that encourage students to recognize and find help for emotional issues

National Suicide Prevention Strategy

• Sept 10, 2012, U.S. announced $55.6 million in new grants for suicide prevention programs

• First new national strategy plan in over a decade

• Promotes new Facebook service-users can report suicidal comments they see online from friends-website sends the potential victim an email urging a call to hotline/chat online with a counselor

• New technologies-mobile apps to connect people with counseling resources

• Plan highlights the 23 million veterans (17,754 veteran suicide attempts last year- 48 per day) and efforts to identify soldiers at risk, reduce stigma and encourage them to seek help

Elements of the National Strategy• Health professionals are not adequately trained for proper assessment,

treatment and management of suicidal individuals, or know how to refer them properly for specialized assessment/treatment

• Provide targeted education for suicide identification and referral to key gatekeepers such as teachers, guidance counselors, doctors, clergy, social workers, psychologists

• Improve marketing of community-level educational

• Incorporate screening for depression, substance abuse and suicide risk as a minimum standard of care for assessment in primary care settings, schools, and colleges

• Limit access to lethal methods of self-harm -firearms, lethal doses of medicines, drugs, alcohol by underage youth, and dangerous settings such as bridges/rooftops

• For example, improvements and changes in car exhaust emissions have resulted in a decrease in deaths by carbon monoxide poisoning

Other Broad-Based Strategies

• Develop strategies to reduce stigma for consumers of mental health/substance abuse/suicide prevention services

• Increase community linkages with mental health and substance abuse services

• Improve portrayals of suicidal behavior, mental illness/ substance abuse in entertainment/news media- avoid dramatization to reduce suicide contagions

• Promote/support research on suicide/suicide prevention

Suicide Prevention Checklist for Schools

• Does school provide information to staff about the impact/prevalence of adolescent suicide?

• Does school have policies and procedures in place concerning suicide issues?

• Does it have support from superintendents/principals/teachers for suicide prevention program?

• Does school have links to the community to help with a suicidal student and are staff educated about how to contact them?

• Does your school have a crisis response plan/team that meets on a regular basis?

School-Based Youth Suicide Prevention Guide of University of South Florida

Suicide Prevention Checklist for Schools • Does school provide parents with list of community resources if

they suspect their child is considering suicide?

• Does school inform parents about risk factors and restricting access to lethal means (firearms)?

• Is school staff aware of legislation on liability for suicidal behavior in students?

• Is school aware that while students are in school, the school must act in loco parentis, or as reasonably as a concerned parent?

School-Based Youth Suicide Prevention Guide of University of South Florida

Traditional Treatment Model for Depressed, Suicidal, Vulnerable

Adolescents

Integrated School ModelNew Alliance Academy

The most effective treatment for these emotionally fragile adolescents requires a highly integrated (under one roof),

multi-pronged treatment team approach in order to prevent poor or tragic treatment outcomes

Documents

Adolescent Suicidal Behavior Evaluation and Treatment Considerations Gabriel Kaplan, M.D. Bennett Silver, M.D