Factors that influence adolescent behavior and how they may be mitigated Confidence comes with every card

By Dr. Beecroft . M.D

Teenage and adolescent suicide is a very serious issue in the United States. Suicide is the second leading cause of death for young people 12 to 18. Each day in the U.S. there are, on average, more than 5,240 suicide attempts by young people grades 7-12. The National Center for Health Statistics, in 2003, reported the suicide rate was 7.3 per 100,000 among youth aged 15-19, making it the third leading cause of death among adolescents at that time showing an increasing During a recent continuing medical education conference sponsored by Harvard medical school, Marisa Silveri, Ph.D., a behavioral neuroscientist at McLean Hospital, shared some insights about why adolescents may be particularly vulnerable to suicidal thoughts and actions. We develop additional myelination of neurons as we age and for this age group this enhances the connection between the amygdala and the frontal lobe, Silveri said. This connection enhancement helps modulate the impulsiveness and “right now” thinking that characterizes adulthood. This helps us think through the consequences of actions rather than just act. Having more life experiences and learning from consequences of earlier decisions also helps us problem solve the options available to us as we age, she explained. This experience isn’t usually available to teenagers as they haven’t been exposed to as many life lessons and, therefore, have fewer options to choose from. The stresses on teenagers are immense. Pressure from peers, parents, siblings, bullying, news media, social media, as well as educational and vocational expectations can seem overwhelming. This is especially true if there is an unforeseen circumstance that occurs to derail future plans.

Prediction of suicidal behavior has been the subject of multiple studies over the past 50 years, but there’s no definitive method of determining with certainty if a person is going to attempt suicide. The Columbia-Suicide Severity Rating Scale has become the gold standard for the

Assessment of suicidal ideation and behavior in clinical trials. This evidence suggests that the Columbia-Suicide Severity Rating Scale is conceptually and psychometrically flawed and doesn’t map to the U.S. Food and Drug Administration’s new standards. A new gold standard for assessment of suicidality may be warranted.

So how are we to predict adverse outcomes of adolescents when it comes to suicide assessment? One promising method of assessing and detecting suicide risk is the Signs of Suicide program, or SOS. This is a detection and prevention program primarily used in schools. It was developed by the same group organizing the National Depression Screening Day.

The two-year study involves more than 2100 students in five schools.  It utilizes a curriculum that educates about suicide issues and risks along with screening tools for depression and other mental health issues. Although in your practice there is no definitive tool that can measure suicide intent or predict suicide completion, information from the SOS suicide prevention program shows you can identify members at risk. Often, signs of concern mimic typical teenage behaviors. However, if multiple signs persist over a period of time and the behavior is a significant change in usual behavior, then closer attention is warranted. Look for family patterns of mood disorder. Listen to what your patients are saying. Stories of bullying or social media pressure may not be easy to elicit.

Using depression and anxiety screening tools for all of your patients can be the start of a dialogue with them about their mental health needs. Inferring family stress or communications

difficulty by listening independently to different members of the family could clue you in to one or more members that need some type of intervention. This may warrant a longer session to explore what is happening in their lives and possibly paving the way for a more specialized psychological or psychiatric evaluation. You may have a psychiatrist, psychologist or therapist that could give you a ‘curbside’ consult as to next steps while waiting to have them evaluated.

The use of antidepressants in adolescents has its place, despite black box warnings that use of these medications by adolescents can increase suicide risk. A review article in a recent American Journal of Psychiatry compared the industry-funded studies and the National

Institutes on Mental Health-funded studies and concluded, “The NIMH-funded studies demonstrate a good efficacy for antidepressant medications in pediatric depression and

should be heavily weighted in any review of the literature.” Each person’s treatment plan needs to be individualized, recognizing the risks and benefits of treatment. Therapy as a primary treatment and no treatment each carry risks in the vulnerable patient. Clozaril and lithium have been known in the medical lore to decrease suicide risks but aren’t generally considered first line treatments for depression or mood disorders and have significant risks themselves.

Generally, initial treatments of mood disorders still include psychotherapy with or without antidepressants. If you suspect bipolar illness, you might consider prescribing a mood stabilizer before an antidepressant. Referral to a specialist is a good idea but can take some time. If it’s obvious that the member can’t wait for an outpatient appointment, there are partial hospitalization programs around the state that can see the member relatively quickly and provide intensive diagnosis and treatment interventions while the patient is still living at

home and potentially going to school. The amount of therapeutic work a patient can achieve in a partial hospital program in a week is about what can be achieved in an outpatient setting in a month.

Family therapy is another very helpful tool especially if communication has been strained or broken down within the family unit. Short-term residential treatment may be of help but only if the program involves families early and often and provides comprehensive treatments including group, individual and medication assisted treatments.

Suicide detection and prevention takes a lot of interested individuals to facilitate. The primary care provider is a pivotal resource person for the individual patient and the entire support system of the individual. Initial interventions and screening are very important. Listening to your patients and looking for veiled requests for help are crucial.

 

1 https://www.cdc.gov/injury/wisqars/

2 Mann, J.J.; Apter, A.; Bertolote, J.; Beautrais, A.; Currier, D.; Haas, A.; Hegerl, U.;

Lonnqvist, J.; Malone, K.; Marusic, A.; et al. 3 Innov Clin Neurosci. 2014 Sep-Oct; 11(9-10): 66–80. Published online

Sep-Oct 2014. 4

Aseltine RH, DiMartino R: An outcome evaluation of the SOS suicide prevention

program. American Journal of Public Health. 2004, 94: 446-451. 5

1. J. Psychiatry 174:5 May 2017; pp430-437