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Children and Adolescents’ Depression and Suicide – Survival 101:
What We Need to Know
September 24, 2003
Nancy Rappaport, MD, Instructor at Harvard Medical School, is the Teen attending
psychiatrist with high risk students at SBHC and Director of School Consultation at
Cambridge Hospital, Cambridge, MA
This is similar to a CPR refresher course where some things are familiar about how to
identify at risk suicidal patients and about appropriate interventions.
The material that I share with you today is based on what I have found clinically useful
when I am working with high risk children, adolescents, and their families. The
presentation also is offered with a level of humility, recognizing that we don’t have all
the answers, this is a work in progress. But when our students are struggling – in crisis –
we need to be decisive in our response. They can’t wait for the longitudinal studies, the
randomized control studies to confirm and direct us and we are asked to draw from the
research and clinical treatment for best practices.
So today I am a tour guide through depression and suicide looking at clinical vignettes,
statistical information, developmental characteristics, information from psychological
autopsies that help us to appreciate the role of mental illness in suicide, identifying
depression and bipolar and treating suicidal patient.
I.
Faces of Suicidal Ideation – Individual – No typical suicidal adolescent
CV- learned to fight before ABC’s, parents’ alcoholic-administrators invested-then
disappointed- anger is the mother of depression
VM quiet girl, high-risk Internet
Acceptable option – aunt anxiety, sweating perseveration Sunday prior to school start
Early abuse, hoarded medicine, OD recognition of how devastated mother would be,
renewed focus
Boy lost father in fight – wants to get gun and even the score
Clinical vignettes are interspersed throughout the lecture to illustrate the data. The data is
used to create the sense of mosaic and to make the research pertinent to shape good
care.
It is critical to think of each child individually.
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II.
General Facts about Suicide
Fig. 1
12
10
8
6
4
2
0
10-14 years
old
15-19 years
old
1. Disturbing statistics
Fig. 1: Developmental and temporal trends in rates of adolescent suicide. Data from
Maguire and Pastore (1999).
Fig. 1.2
20
15
10
5
0
Male (15-19 yrs)
Female (15-19
yrs)
Fig. 1.2: Developmental trends since 1950 in suicide rates for 15- to 19-year old
adolescents, by gender. Data from Maguire and Pastore (1999).
322 deaths 5-14 years (.9/100,000)
4956 deaths 15-24 years (13.8/100,000)
-
Girls 3.4/100,000
Boys 15.1/100,000
For young people 15-24 years old, suicide is the third leading cause of death, behind
accidental injury and homicide. 2000 adolescents 15-19 commit suicide each year.
Persons under age of 25 accounted for 15% of all suicides in 1997.
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-
-
Within schools this statistic translates to in a district of 8,000 students, one suicide
every year.
How many of us have experienced an adolescent who we know that completed a
suicide?
How many of us initiated an evaluation of a student or patient that was suicidal this
week?
Suicide assessment is the most commonly encountered emergency situation for
mental health professionals. It probably is one of the most stressful of all clinical
endeavors (Cocktail party, terrible at small talk)
Within the next 24 hours 1439 teenagers in the US will attempt suicide (to place this
in context 3,000 kids will start smoking)
As the teenagers get older they are more at risk for suicide
Suicide is the third leading cause of death between ages of 15-24
“Age of melancholia”
“Age of self-annihilation”
Firearms are the most common method for completed suicides, followed by
ingestions leading to overdose and then hanging
65% of completed suicides use handguns. The increase in the rates of youth suicide
(and the number of deaths by suicide) over the past four decades is largely related to
the use of firearms as a method of destruction
If a gun is used to attempt suicide, a fatal outcome will result 78-90% of the time.
Boys frequently use guns, which is a more lethal method than overdose
Suicide attempts are more prevalent among adolescent girls than among adolescent
boys. Up to forty percent of teenagers who commit suicide have made a prior
attempt.
There are four hundred suicide attempts by teenage boys for every completed
suicide in males (Shaffer chapter)
Four thousand suicide attempts per every death in females (G. C door with girl
fainting with OD)
Who uses most effective method in completed suicide, boys or girls? This is a trick
question highlighting our assumption that men are more lethal in their attempts. But
death by overdose is as lethal as death by guns. Don’t be distracted with gender
statistics
2. The Center for Disease Control
The Center for Disease Control (CDC,2000) has tracked by school survey since
1991 every two years, 12,000 to 16000 students. It is fairly common for teenagers to
have suicidal ideation (to think seriously about killing themselves) as demonstrated
by students answering yes to the survey question, “ Have you seriously considered
suicide within the last year?” Although, fortunately, lethal attempts and completion
are relatively rare. Approximately 20 percent of students have had suicidal ideation,
about ten percent of students made a suicide attempt in a twelve month period, and
1-3% of teenagers will receive medical attention for an attempt (700,000), while
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.01% will complete suicide. It is key to remember that ideation is almost always
episodic. Hispanic youth report more suicidal thoughts than whites for unclear
reasons. It is difficult to assess future behavior but we have some clinical studies
and epidemiological studies that help with our decision making process.
III.
Developmental Characteristics
Why do so few youths who are between 10 -14 years old commit suicide as
compared with adolescents 15-20 years old?
It is key to think of each child developmentally as to what is appropriate for the
child’s developmental stage.
Rare suicides before twelve years old (prepubertal)
More common in males than females (3:1)
Causality not developed in children under ten years old. They don’t get degree of
lethality. (By age of ten most children understand what suicide means.)
1. Profile of children with completed suicides:
- Immature problem solving that translates into more impulsive
- Less able to tolerate frustration (with adults data shows decreased
seretonin)
- Unable to plan future actions
- Aggressive or violent outbursts(Aggressive 8-year-olds are more than
twice as likely as nonaggressive 8-year-olds to think about or attempt
suicide at age 16) (Sourander et al. 2001)
- Difficulty making decisions
- Less able to assess situations realistically then non suicidal children
- Loss of parent before age 12-perception that death is attractive
- History of parental abuse- these children can have low self-esteem from
poor relationship with parents-developmental needs not adequately met.
Difficulties with emotional regulation and poor self-soothing that can lead
to impulsivity and aggression
Early onset of suicidal behavior prepubertal predicts suicidal behavior in
adolescents. Vigilant to signs of emotional stress even though may appear
somewhat trivial initially (“I want to be with the angels”). Groholt (1998) looked
at suicides between 1990 to 1992 comparing suicides of children below 15 years
old (n=14) compared with late-adolescent suicides (15-19 years) n=115.
Conflicts with parents were present more often in those children under fifteen
years whereas older adolescents’ crisis were precipitated by disappointment in
romantic relationships. These researchers found that there were fewer warning
signs and precipitating events preceding the suicide of the children and young
adolescents compared with older adolescents. They suggested that the lower
prevalence of affective disorders among ten to fifteen year olds who completed
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suicide as well as control group might explain some of the difference in suicide
rate.
*Be Alert to potential suicide risk in children who have affective disorder.
The difficulty in determining prevention is that prepubertal suicides are such an
infrequent occurrence and comparatively unpredictable in young children and
adolescents.
Although suicide attempts in children age 12 and under are relatively rare,
suicide attempts are NOT rare in bipolar children (age 12 and under – 20%).
Usually these children are difficult to treat and there is considerable controversy
about the criteria as they are referred to, as, “rapid cyclers and often have mood
lability, mood swings, affective storms irritability and aggressiveness, periodic
agitation, explosiveness and severe temper tantrums which can also be in
response to trauma and family discord,” (Papolos 1999).
“Epidemic of bipolar” rapid shifts (FM)
It is key with young children to recognize signs of mania/hypomania
2. Symptoms of bipolar disorder: DIGFAST acronym
Distractible
Insomnia
Grandiosity
Flight of Ideas and racing thoughts
Agitation
Suicidal ideation
Talkative, pressured speech
Historical context that compelled researchers to try to understand and prevent
suicide came from the fact that in the early 1980s there was a sharp increase in
the suicide rate particularly with white male teenagers and several teenage
clusters.(Papolos)
3. Psychological autopsies
This is a technique where researchers examine the circumstances of the suicide
victim’s life reconstructed through interviews with friends and families. This
retrospective suicide research may create bias because of the devastating
outcome and that the survivors may increase their accounting of symptoms and
the limitation that the deceased can’t provide insight.
Shaffer studied large numbers of completed suicides at an average age sixteen
(170 psychological suicide autopsy) in an ethnically diverse population in 198486 interviewing multiple informants with community control subjects.
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More than 90% of subjects who committed suicide met criteria for at least
one major psychiatric diagnosis. Psychiatric disorder is the strongest risk factor
for attempted suicide. Fever reflects presence of physical illness; suicidal
behavior indicates presence of psychiatric disorder. Half of these subjects had
psychiatric disorder for at least two years. This provided compelling evidence
that there is a strong link between psychopathology and suicide.
Important implications –need for thorough diagnostic interview, never
discounting a threat especially in the context of affective or substance abuse
disorders, the importance of aggressive intervention in first-episode affective
illnesses.
The most common diagnostic groups were mood disorders (52% major
depression) disruptive disorders and substance abuse.
Two thirds of the suicides had a prior suicide attempt, mood disorder and
substance abuse.
4. Timing
Myth of Dr. Jeckyl and Hyde, teenagers turn into werewolf- reality that with
suicide over half of the depressed teenagers suffered more than two years.
In Shaffer sample more than a third of the New York suicides had an onset of
symptoms more than five years before their death.
Often comorbid (two disorders at the same time) diagnoses with suicide victims.
*With mood disorder four to five times more likely for a suicide attempt than for
a child without a mood disorder.
5. Completer profile
Evenly distributed by SES, evenly distributed by educated versus uneducated,
Western states highest, 60% fire arms,
Both with children and adults 50% of completers die on first attempt
50% of completers were never in therapy
75% of completers communicated thoughts about their suicide aloud to several
people several months before dying (This emphasizes the role of natural
screeners).
*Survivors of attempters are at greater risk of future attempts then are survivors
of completion.
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How does a suicide occur?
Active Disorder
e.g. Mood disorder
Substance Abuse
Anxiety
Stress Event
e.g. in trouble with
law/school
Loss
Humiliation
*Crisis hot line
Acute Mood
Change
e.g. Anxiety/dread
Hopelessness
Anger
Agitation
*Crisis hot line
Inhibition
Social:
Strong taboo (religiosity?)
Available support
Presence of others
Difficult to access method
Mental state:
Slowed down
SURVIVAL
IV.
Facilitation
Underlying trait:
Impulsive
Intense
(5-HT abnormality?)
Social:
Weak taboo
Available method
Being alone
Recent example
SUICIDE
Strategies for suicide prevention
A) Suicide awareness programs in schools frequently minimize the role
of mental illness and don’t help. The idea of educating students about suicidal
behavior was found to be upsetting to high-risk students who could be activated to
suicidal ideation and usually were not known to the presenter. These programs
were typically designed to encourage self- disclosure by students. Subsequently,
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Shaffer’s work at Columbia in NYC demonstrated that a Teen Screen is more
helpful to teach students to recognize in themselves the clinical characteristics of
depression and other mental illnesses and to identify substance abuse.
Schools are also excellent setting to identify children and adolescents who
are at high risk for suicide.
B) Screening. Direct case finding encouraged to assess group at greatest
risk for suicide attempt 15-17 years old. Shaffer systematically administered
screening programs with high specificity. Shaffer’s team initially screened 2,000
teenagers, 27% of the total number screen scored positively on the initial screen
(looking at depression, dysthymia, and complication of substance or alcohol use,
coupled with previous suicidal ideation and attempts.) A second stage was
implemented with a case manager and a more refined test that included a low cost
self administered computerized diagnostic interview that reduced the proportion
of students that needed to be interviewed by a clinician by 60 percent. *Most of
the adolescents who were at high risk identified by the screening were NOT
known to others and very few were in treatment. Clearly this needs to be linked to
evaluation and treatment.
(The high school where I consult had too much on the agenda despite the fact
that we have three adolescents hospitalized per month and ten percent suicidal
attempt from THC data, they were reluctant and lacked the strategic will.)
C) First step recognition of depression Symptoms – depressed mood as well as
five neurovegetative symptoms for more than two weeks to be clinically
depressed.
D) SIGECAPS
poor Sleep (hypersomnia or insomnia)
decreased Interest
Guilty feelings
low Energy
poor Concentration
change in Appetite
Psychomotor agitation or retardation
Suicidal Ideation.
With adolescents, the mood symptoms can be masked because they can look irritable,
impulsive and volatile.
With learning disorders, there can be a higher risk for depression (Robert). Symptoms of
depression (neurovegetative symptoms) are key to recognize within school setting.
Often depression in schools can present as laziness, negativity, and apathy
Frequently this can be mistaken in the classroom as normal or part of the student’s
temperament.
In children depression is less frequently seen 2% demonstrate the more severe formmajor depression with symptoms for more than two weeks, 2% of children demonstrate
dysthymia that is low level depression, chronic
7% of teenagers show depression and dysthymia.
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*Depressed younger children often present with more physical complaints such as
recurrent headaches or stomach-aches that can be mistaken for signs of an illness other
than a depressed mood.
Ratio of boys to girls with depression under twelve years old is one to one but during
adolescence, girls with depression outnumber boys by approximately two-to-one.
30-50% of children with depression has a family member with depression (genetic
vulnerability)
The average length of an episode of MDD in children and adolescents is seven to nine
months. Approximately 90% of the MDD episodes remit within two years post onset,
whereas the remaining episodes last for a longer time. MDD frequently recurs in children
and adolescents (40% chance of recurrence). Most consistently observed risk factors for
MDD recurrence are younger age at onset. (Coryell et al, 1991)
MDD typically precedes the onset of alcohol or substance abuse by about four years and
thereby allows the prevention of substance abuse in depressed adolescents.
Rate of shift to bipolar disorder is such that twenty percent of children and adolescents
will evolve into bipolar presentation. (Rao,1995)
V.
Early Detection
A. Assessment of suicidal risk in adolescents
Research about broad risk factors and assessment of attempters need to be
considered. The following is a key to draw several sources child, parent
1.
2.
3.
4.
Sex
Age recognizing that it is relatively rare incident in under twelve students.
Depression –large majority of depressed youth are not suicidal.
Availability of firearms or/other potentially lethal methods *Restricting
access to available means (SW, AFS) It is important to be explicit. Easy
access to guns six to ten times increase for completed suicide. ( This gives a
whole new meaning to live free or die).
5. Stress and protection in different family contexts. Level of discord in
family or parent psychopathology. Family structure is less important than the
relationships in the family . High levels of conflict is associated with risk for
more severe forms of suicidal behavior. Family cohesion, families that are
emotionally involved, and share common interests are less likely to be
suicidal. (CV, make my uncle hair curl and he didn’t have much hair to curl.
Sometimes the child can be blamed for the family problems. Sometimes the
perception is that the child is expendable because of inordinate shame or guilt.
The child can be enraged about perceived abandonment, hostility turned
inward (Freud calls suicide murder of the 180th degree)- treatment is to come
to terms with parent limitations, ) Often self worth and self-esteem regulation
require external support from parents. Sometimes suicide attempt can be
interpreted as a noble self sacrifice and deflection away from other conflicts.
(SW) Ask the family and the patient about how they communicate and see if
the patient can identify who she/he relies on when stressed.
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McKeown examined community based samples as distinct from samples
drawn from clinical facilities. Vulnerabilities and “stress clusters” were denial
of parent to acknowledge difficulty of adolescent, shame experienced by the
teenager and prior abuse lead to the adolescent’s difficulty asking for help.
Assess the family’s capacity to monitor and maintain sufficient watch over the
adolescent. There can be constraints with work schedule, anxiety and rage at
relentless demands. Transmission of impulsivity and aggression. Relevant
quote from Winnicott: “Why not tell him that you know that when he steals he
is not wanting the things that he steals but he is looking for something that he
has a right to; that he is making a claim on his mother and father because he
feels deprived of their love.”
6. Organized plan, intent, preparation. One in four adolescents that
completed suicides show evidence of planning. According to Shaffer the timehonored clinical inquiry about planning is a poor measure of serious intent.
Simon and Crosby (2000) determined that nonplanner ideators were just as
likely to attempt suicide as were planners and that they also had additional
risk factors.
7. Lack of social supports/peer conflicts
70% of psychological autopsy subjects exhibited antisocial behavior versus
24% of controls (CV)
Isolation, alienation, socially withdrawn
Precipitating factors – breakup with boyfriend, intense attachment (AG),
trouble with a teacher, failing grades, parental trouble
Gould cites recent breakup with girlfriend, excessively dependent relationship
more prone to suicide.
Earlier suicide ideation/ prior attempts*
Males who have made prior attempts are more predictive of completing
suicide than females.
The prediction is that past behavior predicts future behavior. Only with half
of all suicide completers is it verified that they made prior suicide attempts
before their death.
Estimates of the percentage of attempters across all ages repeating an episode
within one year of the first attempt range from 14%-26%.
In a Finland study 5% of adolescent repeaters had completed suicide to only
1% of “first timers”
Substance abuse/dependence is the probable reason that adolescence
attempts are more lethal. When substance abuse is present with mood disorder
there is a fifty times increase with risk for suicide. Recommend abstinence for
safety reasons.
In a study of adolescent substance users, suicide attempts are found to occur at
rates of three times those of controls. The “wish to die” increases dramatically
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after the onset of substance use. Substance use relates to lethality Active
substance abuse at the time of death is associated with completed suicide
8. Cognitive distortions/hopelessness about the future –Learned Optimism
Seligman (ABC) . The goal is to increase the teenager’s capacity to generate
alternative solutions (Brent 12-16 weeks manualized treatment) This entails
monitoring and modifying automatic thoughts, assumptions and beliefs.
9. Exposure to other peers’ suicidality. Sometimes completed suicides can act
as a deterrent as the adolescent can see how devastated the family is by the
death.
10. Temper/aggression- strong relationship between aggressive behavior of first
degree relative and suicide attempts in adolescents
11. A much-debated risk factor of suicidality is whether an adolescent is gay or
lesbian. Russel and Joyner provide the most thorough analysis. In the twenty
prior studies, there were no heterosexual control groups and the studies relied
on convenience samples. In Russel study they drew on nationally
representative data that included other critical adolescent suicide risk factors
(hopelessness, substance abuse, and weighed those risk factors ).
The study looked at the two questions: Are youths who report same sex
sexual orientation at greater risk for suicidal thoughts and suicide attempts
than their peers?
Are these youth still at greater risk than their peers after critical adolescent
suicide risk factors are taken into account?
6254 adolescent girls 5686 adolescent boys
Youth with same sex orientation are two times more likely than their same sex
peers to attempt suicide but depression and alcohol use are precursors to
suicidality. Also it is key to emphasize the fact that 85% of same sex
orientation teenagers have not considered suicide at all. (72% of females 85%
of males) (Victimization Teacher –sexual deviant-, project 10 east ETOH and
depression suicide attempts acceptable for desperation).
12. Assess Impact of Cultural Factors. Suicide risk of African American rose
dramatically after 1986 but since then rates have declined. African American
heritage of the blues, religious perspective that it is a sin to be suicidal,
depression is often seen as a personal weakness. There is not much history of
associating with mental health services and a level of distrust (Pouissant Lay
My Burden Down). The difficulty of commanding respect at all costssuffering in silence also can lead to the internalization of racist stereotypes
that may have led to the rise in self destructive behavior. Pouissant linked
black suicide rates with the high rates of homicide and substance abuse among
blacks, which he identified as other manifestations of self destructive
behavior. He suggested that feelings of low self worth –expression of rage are
turned inward or outward. He raised the concern that blacks seek treatment
much later and this is a result of their general skepticism/fearful of the
medical establishment.
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B. Response to a Young Person at Risk for Suicide: Referral and Monitoring
Introduce follow up care early in assessment – suicide attempt can mobilize or
effect changes, create and strengthen connections- but it also highlights the child’s
vulnerability.
A suicidal attempt emphasizes the need to increase the safety net.
Prevention is resource dependent-there is an urgent need to customize prevention
strategies that match adolescents’ experience (basic trust- jump)
Assessing need for involuntary hospitalization can be problematic as there are no
randomized controlled trials that demonstrate that hospitalization improves
outcome. If a patient has an abnormal mental state and is psychotic, clearly the
patient needs to be hospitalized for containment. Sometimes brief hospitalization
can communicate to parents and children the seriousness of the action and
sometimes in the insurance game can access needed home based services that are
difficult to get as outpatient . The difficulty is that hospitalizations are often brief
and in geographically distinct areas from where the patient lives and different
staff provide follow-up. (AL)
Usually the patient is discharged from inpatient 24 hour supervision to outpatient
treatment once a week therapy rather than to an intermediate level of care
(e.g.step-down unit or partial treatment). The high reattempt rate among
hospitalized suicide attempters suggests need for a greater intensity of treatment
than once-a –week
Menu of school-based support, after-school partial programs,flexible funding
C. Follow-up Action Plan/Continuum of care
1. Arm patients and families with prevention knowledge such as suicidal
ideation as an indicator of mental illness, alcohol use increases risk of
depression, the value of reaching out to others to evaluate their problems, the
importance of not isolating and building coping strategies.
2. It is useful to give reassurance that depressed people do benefit from treatment
(AR-depression timeless quality) Elkind describes the imaginary audience,
personal fable.
3. Maintain regular communications with family.
4. Even when knowing the referral network in your area there is the difficulty of
accessing services, building infrastructure within the school and getting
around budgetary allocation, SBHC, Sped and work with inpatient hospitals).
5. Maintain regular collaboration with mental health provider (obtain releases at
discharge if possible. It is difficult when family doesn’t allow access to
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hospitalization information, and it is then helpful to create policy for school
based evaluation to determine safety to return to school ).
Only a relatively low proportion of suicide victims were identified as ever
having had mental health treatment (33%-50%) and a much smaller
proportion (15%) were actually in treatment at the time of death (Brent). ) One
study (Spirito) drop out ranged from 35-40% for adolescents in treatment after
suicide attempt with three visits, 58% to 78% dropped out within nine visits.
6. Check on status of referral/s.
7. Identify someone in school who periodically reevaluates suicidality/suicidal
risk. Be careful of pathologizing kids that they are “resistant” –timing key and
often therapy is used as a form of castigation or shaming by family (MS,
Haitian family).
8. There are structural barriers against family treatment but family treatment
helps to shift the focus from the “identified patient” to potentially toxic
environment. There can be family barriers to treatment such as transportation
difficulties, language problems, parent or adolescent ambivalence about
treatment, cost of treatment and scheduling difficulties. There can also be
service barriers-delays in getting an appointment, being placed on a waiting
list, inability to switch therapists due to agency policy and problems with
insurance coverage.
Offer looked at help seeking behavior of teenagers and teenagers usually
identified friends or parents. Few studies exist that have assessed adolescents’
perceptions of the helpfulness of the helping agents. Out of 497 adolescents,
two thirds of disturbed adolescents had not sought help. Usually it is the
parents’ initiative to get their child or adolescent help. Further barriers to
seeking help (Girl Val with gun and insurance) Also critical to find support
within environment (MSPY program). Advocacy work is critical and
leveraging (MM
VI.
Treatment
1. In the absence of “best” therapy clinicians may chose to
a. Treat any associated psychiatric disorder
b. Teach the family to recognize and then avoid or diffuse conflict
c. Therapy that helps build self acceptance, train the patient to avoid situations that
trigger negative moods, increase tolerance of distress
d. Classical approach with therapy is to try to determine maladaptive patterns that
stem from unconscious conflicts
e. Group approaches
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2. Medications
We all know that there is no “anti-suicide pill”. It is generally recognized that it is
critical to treat underlying pathology with medication.
In Shaffer group only 10% adolescents had been treated with antidepressants and
even fewer adolescents were in substance abuse programs
Symptom reduction may occur with medication, for example it can alleviate
psychomotor retardation and increase capacity to verbalize. I often refer to “safety
nets” and “jumpstarts”.
Although bipolar is difficult to diagnose in this population, with bipolar 44%
attempted suicide. Lithium or depakote are first line with bipolar patients. Treatment
is protective with antisuicidal, antiaggressive properties in adults (Baldessarini)
Lithium greatly reduces the rate of both suicide and suicide attempts in adults with
bipolar disorder.
If an adult patient is bipolar, discontinuing Lithium is associated with increases in
suicidal morbidity. There are no studies on bipolar children and adolescents on the
impact of Lithium on suicidality. With children and adolescents, there are many
other anticonvulsants that are being used (Lamictal, Trileptyl, Topamax, Neurontin).
In epidemiologic studies (not controlled studies) reduction in suicide among patients
treated with antidepressants was demonstrated.
The decrease in the suicide rate between 1988 to 2000 coincides with a substantial
increase in the prescribing of antidepressants for the general population. Isacson et al
(1996,1997) showed in Sweden that there were more SSRI-treated adults in Sweden
and that this was much higher than the rate of SSRI-positive autopsies among
persons who committed suicide, suggesting that SSRIs were protective of suicide
from depression.
SSRI –selective serotonin re-uptake inhibitors (Although usually highest risk
patients are excluded from rigorous trials). 30-40% of adults and adolescents with
major depression are treatment refractory and don’t respond. A poor response to
SSRI can be predicted if there is a history of chronic depression, comorbidity
(substance abuse), family discord, history of sexual abuse and parental mental illness
For patients that are treatment resistant there are several options:
Increase dose of current antidepressant
Change to another SSRI
Change to another class or agent particularly if patient failed two trials of SSRI (Can
use venflaxine or buproprion)
Augment, boost treatment with Lithium
Key to recognize side effects from SSRIs (Walkup research)
SSRIs usually take one month to reach consistent blood level – two months to leave
system.
Also other antidepressants are Effexor, Wellbutrin, Remiron, Trazadone and Serzone
**** There are potentially subtle side effects with SSRIs . Usually doctors review
physical side effects of SSRIs although it is important to be aware of possible
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complications of treatment as well as behavioral changes that can emerge from
taking medication.
Activation – increase in activity level that does not include any real change in mood,
impulse control. Patient may not note this and activation is most often seen early in
the course of treatment or soon after a dose increase. Young patients more than
adolescents (response dose reduction or medication discontinuation)
Bipolar switching predisposition – not only a change in activity level but also
includes a prominent change in mood, behavior, and impulse control. Activation –
too much of the same child, versus bipolar switching “ he has never been like this
before. More likely to appear after the child has been on the medication for awhile
Celebration – anxiety and avoidance move to more capability, elation and parents
are confused with think manic reaction.
Dimensional Issues or Comorbid disorders. More energy for oppositional and
conduct, cautious with those kids with risks for conduct disorder. Parents and
teachers need to be prepared to set boundaries and redirect energy.
Evolving psychopathology – anticipate problems (recent patient hospitalized)
Frontal Lobe-type symptoms such as apathy. More common at higher than lower
dose and does not necessarily go away with time. Emotional numbness or blunting,
not caring about anything, inertia, passivity, and feeling flat. Decreasing dose can
sometimes make a significant difference. (Give example of junior who was treated
with depression, difficulty applying herself, sleep, dropping AP classes, stopped
medications)
Gastrointestinal symptoms
Hey what happened to my sex life? -problematic trying to figure out
Advising presence of consistent adult, “Creating Caring Institutions”, “Empty Rhetoric or
Meaningful Relationships?”
In Passion for the Possible ,William Sloane Coffin recognizing that each of us plays a
critical role in keeping our children safe, exhausting and exhilarating.
Importance of self-care, written to a friend that was suicidal (Galway Kinell Wait)
“Hope makes us persistent when we can’t be optimistic, faithful when results elude us.
For like nothing else in the world, hope arouses a passion for the possible, a
determination that our children not be asked to shoulder burdens we let fall..”
Wait, by Galway Kinnell
Wait, for now
Distrust everything, if you have to
But trust the hours. Haven’t they
Carried you everywhere, up to now?
Personal events will become interesting again
Hair will become interesting
Second hand gloves will become lovely again;
Their memories are what give them
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The need for other hands. And the desolation
Of lovers is the same;that enormous emptiness
Carved out of such tiny beings as we are
Asks to be filled;
The need for new love is faithfulness to the old
Wait
Don’t go too early
You’re tired. But everyone’s tired
But no one is tired enough
Only wait a little, and listen
Music of hair
Music of pain,
Music of looms weaving all our loves again.
Be there to hear it, it will be the only time
Most of all to hear
The flute of your whole existence
Rehearsed by the sorrows, play itself into total exhaustion.
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