Depression and suicide risk in adolescents

1. Depression and suicide risk in adolescents Elizabeth Kline, LMSW, CAADC debra Miller, LMSW

2. Fact or Fiction? • Adolescents with depression are easy to identify due to head down body language, seeming lethargic, withdrawn, and looking sad. • FICTION: Depression is being increasingly identified in children, particularly with youth who have above average intelligences, stable family situations, many friends and appropriate social behavior (American Psychiatric Association) • Depression is diagnosable in children as young as 6 • Depression does not equal “sadness to the extreme” • A good mental health assessment is the best way to identify signs and symptom, particularly in youth

3. Fact or Fiction? • An estimated 2 million adolescents aged 12 to 17 in the United States had at least one major depressive episode in the past year with severe impairment. • FACT: In 2014, 2 million adolescents (8.2% of the U.S. population aged 12 to 17) had at least one major episode of depression with severe impairment (National Institute of Mental Health, 2014) • Locally, an increase in depression has been identified through the youth developmental asset survey; 17% or 969 students (Legacy Center, 2016) • Major depression with severe impairment is depression symptoms AND at least four other symptoms that reflect a change in functioning, such as problems with sleep, eating, energy, concentration, and self-image • These are the kids at highest risk, due to severity of symptoms and impact on functioning

4. Fact or Fiction? • Depression is only a medical disease, much like diabetes • Fiction: Pharmaceutical company ads would have us believe this, perhaps, however depression is understood in a more complex way • Depression has psychological, social and biological roots • Medication alone has a slower rate response in treating depression (Psychcentral, 2009)

5. Fact or Fiction? • Depression is treatable • FACT!!!!! • One of the largest, broad based studies of adolescent depression, Treatment for Adolescents with Depression Study (TADS), concluded positive treatment results, particularly safest with a combination of medication and psychotherapy • Psychotherapy and medication combinations can address biological and psychosocial components to depression and improve functioning • Treatment in youth should be inclusive of their family and social systems, in order to be most effective, long term

6. Fact or Fiction • All suicide data is accurate and there are no limitations • Fiction-All suicide data represents data that was identified as a death by suicide (evidence that the injury was self inflicted and intended to cause death) and a suicide attempt (there is intent or desire to die associated with the act). There are times physicians, medical examiners and other providers might indicate the death or the visit in a different manner due to stigma or they do not have evidence to support that it was intentional vs unintentional.

7. Fact or Fiction

8. Suicidal Behavior Statistics In addition to the thousands of people who die by suicide every year, many more attempt suicide but do not die. For every suicide death, there are approximately: 3 hospitalizations for a suicide attempt 10 emergency department visits for a suicide attempt 33 attempts that do not result in hospitalizations or emergency department visits

9. 969 Students 2016 Profiles of Student Life:Attitudes & Behaviors Study Survey completed by the Legacy Center in conjunction with Midland Public schools and funded by Herbert H and Grace A Dow Foundation and Mid State Health Network. The results for Midland County Public school students 6-12 graders. Survey developed by the Search institute, Minneapolis. The results included an increase in depression and attempted suicide (attempted one or more times). 798 Students

10. Fact or Fiction • Only Mental Health Professionals should assess for suicide risk in youth? • Fiction-Primary Care Physicians, Urgent Care, Emergency room departments and school staff have a greater opportunity for intervention then mental health professionals do. • In 2011, 70% of young adults aged 19-25 reported that they had visited a physician in the past 12 months and 23% had visited an emergency department (Kirzinger, Cohen, Gindhi 2010). • About 77% of youth who commit suicide, visited their primary care physician within the previous year and 45% had contact 1 month prior to their death. (Luoma, Martin, Pearson, 2002 • In the same study, it was reported only one third of suicide decedents had contact with mental health services within the year of their death, while over 75% had contact with primary care physicians. • The current standard of practice in primary care physician offices and emergency room departments is to assess for depressive symptoms and during sports physical there are no current questions being asked about suicide or depression. • Some primary care physicians are completing Beck Depression Inventory-Primary Care Version (BDI-PC) and asking youth if they have been feeling down, or hopeless. Some also utilize Patient Health Questionnaire-depression module (PHQ-9) • Zero Suicide initiative recommends suicide assessment and follow up after discharge and one suggestion for sports physicals and primary care offices is Ask Suicide Screening Questions (ASQ) developed by National Institute of Mental Health (NIHM).

11. Fact or fiction • Depression is the biggest predictor for suicide? • Fiction- While depression is a significant risk factor for suicide, it is not the only one. Mental disorders such as anorexia nervosa, schizophrenia and borderline personality disorder increase suicide risk. Additional risk factors include stressful life events (such as a death, divorce or job loss), access to firearms and historical factors, including a family history of suicide, previous attempts and childhood abuse. More than one in 10 suicides are related to chronic or terminal illness. (Joiner, 2010).

12. Risk factors in youth • Withdrawing from friends and activities that they used to enjoy • Neglecting personal hygiene • Insomnia or difficulty sleeping • Being preoccupied by death in writing, conversation and drawing • Running away from home • Physical and sexual abuse • Bullying behavior in school • Risk taking behavior such as driving recklessly, use of substances, sexually promiscuous • Uncertainty around sexual orientation • Traumatic events-major disruption to life (divorce of parents, frequently moving, loss of a family member, witness to violence etc.)

13. Model of suicide risk (joiner, 2006) Desire for suicide Perceived Burdensomeness Acquired capability for suicide Thwarted Belongingness High risk for completion or attempt

14. Suicide assessment-SAFE-T • SAFE-T (Suicide Assessment Five Step Evaluation and Triage) (American Psychiatric Association). • Identify Risk Factors- feeling like a burden to family/friends, connectedness, suicidal attempts/self injurious behavior history, key symptoms (insomnia, chronic pain, hopelessness, anhedonia, anxiety), family history, precipitants/Stressors/Interpersonal, change in treatment, access to means • Protective Factors-Internal (ability to cope with stress, religious beliefs, reasons for living etc.). External-(responsibility to children, pets, social supports, positive therapeutic relationships). • Suicide Inquiry- • Ideation-Frequency, intensity, duration. • Plan-timing, location, lethality, availability, preparatory acts • Behaviors-past attempts, aborted attempts, rehearsals • Intent-Extent to which person expects to carry out the plan and believes the plan to be lethal vs self injurious • Risk Level/Intervention-Hospital, crisis residential, outpatient therapy, youth intervention specialist services • Document-Risk level, treatment plan to address current risk (means restriction) and follow up crisis plan. Who is going to lock up what, assess/plan for barriers in following through with this plan.

15. Means Restriction • Means restriction is one of the few empirically based strategies to substantially reduce the number of suicide deaths (American Journal of Preventive Medicine) • The proportion of deaths varies dramatically across methods, ranging from a high of 85-90% for firearms to a low of 1-2% for the methods most commonly used in attempts-medication overdoses and sharp instrument wounds(Spicer, 2000). • Interventions that work- • Education on removing firearms during a crisis situation and locking up guns/ammunition separately all the time. • Locking up medications in a cabinet including aspirin and vitamins with iron. • Disposing off unused pain medications at the Law Enforcement Center or at Dump your Drugs event(s)(Sept 17 from 9-11am at Farmers Market. Dump your Drugs is an ongoing initiative for the Coalition Alliance 4 Youth Success. • Lock up potentially harmful common household products and cosmetics. • Lock up alcohol/drugs (could lead to impulsive behavior). • Parents should not share with children where the items are locked up or where they hide the key.

16. Depression and risk for Suicide – how can you help? • Understand that depression is a complex disorder that can be hard to identify in adolescents • Consider learning more about how to intervene, e.g. Mental Health First Aid • Identify needs and support opportunities for youth to have assessment and treatment • Get involved! Many community efforts are underway to address mental health needs in Midland County (Safe Communities Initiative-Mental Health gaps: Jail Diversion, school interventions, evaluation at emergency room/primary care offices) • Youth intervention Specialist-Jackie Warner

17. Links and Resources • Community Mental Health for Central Michigan 989-631-2320, 24-7 crisis services • American Foundation for Suicide Prevention www.afsp.org • National Suicide Prevention Lifeline Available 24/7 1-800-273-TALK • The Trevor Project (gay/lesbian/bi-sexual/transgender and questioning youth) 866-488-7386 www.trevorproject.org • Suicide Prevention Resource Center www.sprc.org • Marsha Linehan www.behavioraltech.org • Survivors of Suicide is an ongoing support group for families and friends bereaved by suicide. First and Third Thursdays of each month, 7-8:30pm. • Barb Smith sosbarb@aol.com 989-781-5260, also provides training for first responders, ASIST (Applied Suicide Intervention Skills Training), safeTALK (suicide alert for everyone) and Yellow Ribbon Best Practice. • Zero Suicide Initiative-zerosuicide.sprc.org • Cheryl King-University of Michigan-research studies • Mental Health Town Hall Meeting-October 4th 6:30-8:30, Towsley Auditorium • App for iphone-Virtual hope box (recommend not putting pictures of significant other on the app).

18. References • Centers for Disease Control and Prevention. (2000). WISQARS leading causes of death reports. • Crosby, A., Gfroerer, J., Han, B., Ortega, L., & Parks, S. E. (2011). Suicidal Thoughts and Behaviors Among Adults Aged> ̲18 Years--United States, 2008-2009. US Department of Health and Human Services, Centers for Disease Control and Prevention. • The Legacy Center for Community Success, (2016). Profiles of Student Life: Attitudes and Behavior Study • Gindi, R. M., Cohen, R. A., & Kirzinger, W. K. (2010). Emergency room use among adults aged 18–64: early release of estimates from the National Health Interview Survey, January–June 2011. National Center for Health Statistics. • Luoma, J. B., Martin, C. E., & Pearson, J. L. (2002). Contact with mental health and primary care providers before suicide: a review of the evidence. American Journal of Psychiatry, 159(6), 909-916. • Beck, A. T., Guth, D., Steer, R. A., & Ball, R. (1997). Screening for major depression disorders in medical inpatients with the Beck Depression Inventory for Primary Care. Behaviour research and therapy, 35(8), 785-791. • Kroenke, K., & Spitzer, R. L. (2002). The PHQ-9: a new depression diagnostic and severity measure. Psychiatric annals, 32(9), 509-515. • Horowitz, L. M., Bridge, J. A., Teach, S. J., Ballard, E., Klima, J., Rosenstein, D. L., ... & Joshi, P. (2012). Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. Archives of pediatrics & adolescent medicine, 166(12), 1170-1176. • Joiner, T. E. (2010). Myths about suicide. Harvard University Press. • American Psychiatric Association. (2006). American Psychiatric Association Practice Guidelines for the treatment of psychiatric disorders: compendium 2006. American Psychiatric Pub. • Schechter, M., Lineberry, T. W., Goldblatt, M. J., & Maltsberger, J. T. (2011). Self‐Harming Behavior and Suicidality: Suicide Risk Assessment. Suicide and Life-Threatening Behavior, 41(2), 227-234 • Hawton, K. (2005). Restriction of access to methods of suicide as a means of suicide prevention. Prevention and treatment of suicidal behaviour from Science to practice, 279-291. • Spicer, R. S., & Miller, T. R. (2000). Suicide acts in 8 states: incidence and case fatality rates by demographics and method. American Journal of Public Health, 90(12), 1885. • Grohol, J.M (2009) 7 Myths of Depression. http://psychcentral.com/blog/archives/2009 • Salvatore, A.J. (2006) Adolescent Depression: Myths and Realities. Principal, www.naesp.org. • Questions and Answers aboout the NIMH Treatmen for Adolescents with Depression Study (TADS). www.nimh.nih.gov/funding/clinical -research/practical/tads/questions-and-answers