Adolescent Suicidal BehaviorEvaluation and TreatmentConsiderationsGabriel Kaplan, M.D.Bennett Silver, M.D.
Conference AgendaDr. Gabriel Kaplan•EpidemiologyDr. Bennett Silver•PsychopathologyDr. Gabriel Kaplan•Risk Assessment•Pharm...
Bennett Silver, MDACADEMIC CREDENTIALS•Board Certified Adult Psychiatrist▫ American Board of Psychiatry and Neurology, INC...
Gabriel Kaplan, MDACADEMIC CREDENTIALS•Board Certified Child Psychiatrist, American Board of Psychiatry and Neurology, INC...
EpidemiologyGabriel Kaplan, MD
DefinitionsSuicidal Ideation Thoughts of harming or killing oneself.Suicidal Communications Direct or indirect expressions...
Trends in Suicide Rates Ages 10 Years andOlder, by Sex, 1991–2009Centers for Disease Control:www.cdc.gov/ViolencePreventio...
Rates have increased since 2004• Influence of internet social networks• High suicide among young U.S. troops• Higher rates...
Percentage of Suicides Ages 10 Years andOlder, by Sex and Mechanism, 2005–2009Centers for Disease Control: www.cdc.gov/Vio...
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 t...
Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App
Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App
Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App
Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App
H S Students Considering, Planning, orAttempting Suicide in Past 12 Months 2009Centers for Disease Control: www.cdc.gov/Vi...
Suicide Rates Ages 10–24 Years, byRace/Ethnicity and Sex, 2005–2009Centers for Disease Control: www.cdc.gov/ViolencePreven...
Risk AssessmentGabriel Kaplan, MD
Common school suicidal situations• A note is found• A student overhears another student• A student confides in a guidance ...
Risk Factors• History of depression or other mental illness▫ Psychiatric disorder is present in up to 80-90% of adolescent...
What to do?• A plausible suspicion must be assessed immediately▫ A usually happy go lucky 7 year old crying “I want todie”...
Evaluation• Adolescent suicidal behavior is a medical emergency thatmust be assessed by highly qualified professionals:▫ C...
Expert evaluation• Comprehensive psychiatric examination• Includes medical history• Patient, family, teacher input require...
Expert will assess• Presence of mental illness▫ Large majority of patients who suicide suffer frommental illness▫ All psyc...
Suicide ContinuumPassiveDeathWishSuicidalIdeationwithoutmethodSuicidalIdeationwithmethodSelf-Injuriousbehaviorwithuncleari...
Focused assessment of continuum• It is vital to assess what the adolescent is thinking• In order to determine strengths an...
Examples of Suicide Continuum• Passive death wish▫ I wish God took me away• Ideation without method▫ I feel bad and have t...
Attempt vs. Gesture• SUICIDE GESTURE:▫ Self-injury in which there is unclear intent to die but instead an intent togive th...
High Risk• 16 year old male• Abuses alcohol• Treated for bipolar disorder• History of suicidal ideas• Recent loss of mothe...
Medium Risk• 17 year old female• History of self mutilation without intent to die• Family history of completed suicide• Do...
Low Risk• 9 year old male• Parents recently separated• Stays with grandmother very often• Doing well in school and liked b...
Risk And Disposition• High Risk▫ Inpatient treatment▫ If condition relapses, next time discharge to structuredsetting, pos...
Psychopathology of SuicideBennett Silver, MD
How it HappensAlex was a 17 year old high school senior. He was awarm, sensitive, quiet young man; a high honor rollstuden...
Why it HappensIn order to understand why tragedies like this occur, wemust understand the psychopathology from which itste...
Suicide as a Symptom• Suicide is to the psychiatrist as cancer is to the internist• The psychiatrist may provide optimal c...
Causes of Depression• Depression has no single cause. Genetics/Biology definitely play a role (family history)• The enviro...
Biological Theories About Suicide• Genetic factors predispose to suicide – clusters of families with both mooddisorders & ...
Low Brain Serotonin, Impulsivity and Suicide• More violent suicide attempters/completers(guns, jumping) lower levels ofser...
Biopsychosocial Theories• Stress plays a role in development of depression, addiction and otherpsychiatric disorders• Cort...
Suicidal Behavior• More than 90% of all completed suicides in adolescents (andadults) are individuals with psychiatric dis...
The Suicidal Crisis• Often, a crisis situation, what one author called a “stateof perturbation,” occurs in a vulnerable ad...
Mood Disorders and Completed Suicide60-70% of suicide victims were suffering from a significantclinical depression at the ...
Some Facts About Bipolar Disorder• Prevalence in America of approx 1% to 4%• Equally in men and women• 60% onset before ag...
Characterized by Recurrent Mood Episodes• Major Depressive Episode• Manic Episode• Mixed Episode• Hypomanic Episode
Manic EpisodeA. Distinct period of persistently elevated, expansive, or irritablemood –causes marked impairment in functio...
Mixed and Hypomanic Episodes• During a Mixed Episode manic and depressivesymptoms may occur simultaneously or in quicksucc...
Suicide Risk in Bipolar Disorder and MajorDepression
Other Factors That Increase Suicidal Actsin Depressed and Bipolar Patients• Severity of depression• Age of onset (younger ...
Comorbid Substance Abuse• Prevalence of comorbid substance abuse in bipolar I andbipolar II disorder is as high as 61% and...
Accurate Diagnosis and Early Intervention• Bipolar Disorder is difficult to diagnose in adolescence, due tonature of adole...
Major depression in adults and adolescentsAt least 5 of these symptoms must be present to the extent that they interfere w...
Signs and Symptoms of Covert DepressionOften Seen in Adolescents• The quiet, perfectionistic “good boy” who never gets int...
Relapse is Common in Major Depression• After one episode 50%• After two episodes >70%• After three epsodes >90%• Relapse i...
Symptoms and Signs of Psychiatric IllnessAre Present Prior to SuicideAlthough the bereaved parents of adolescentsuicide vi...
Pharmacological ApproachGabriel Kaplan, MD
Pharmacology is just One of Many Toolswithin a Comprehensive Approach• Individual psychotherapy• Group psychotherapy• Fami...
Medication Classes Used in Suicide• Antidepressants• Antipsychotics• Mood Stabilizers• Only one medication has been proven...
AntidepressantsSerotonin Enhancers -SSRI’s• Prozac (Fluoxetine)• Zoloft (Sertraline)• Lexapro (Escitalopram)• Celexa (Cita...
Side-effects of AntidepressantsMost adolescents do not have side-effects. If they dooccur they are usually mild and transi...
Antidepressants Are Compatible WithStudent Performance in School• Low incidence of side-effects• Usually not sedating• Onc...
How Effective Are Antidepressants ?In an important recent study funded by the NIMH(TADS) on adolescents with moderate to s...
Do Antidepressants make people suicidal?• 2003 the maker of Paxil disclosed that clinical trial data had found anincreased...
Black Box Controversy• Data from the CDC show that between 1992 and 2001, the rate of suicideamong American youth ages 10 ...
Data Reanalyses• FDA studied only short term data• Data were reanalyzed adding longitudinal information, extending theobse...
Mood Stabilizers• USED FOR BIPOLAR DISORDER• LITHIUM:▫ Lithium Carbonate (Eskalith,Lithobid)• ANTICONVULSANTS:▫ Valproic A...
Lithium• Oldest mood stabilizer• Improves depression and mania• Helps prevent future episodes• Narrow dosage range (blood ...
Anticonvulsants• Improve depression and mania• Lamictal especially good for depressive episodes• Help prevent future episo...
Antipsychotics• TYPICAL▫ Haloperidol (Haldol) Less sedating, muscle rigidity, Tardive Dyskinesia▫ Chlorpromazine (Thorazin...
Antipsychotics• Improve depression (as add on) and mania (combined ormonotherapy)• Control delusions & hallucinations (psy...
Bennett Silver, M.D.Psychosocial Approach andPrevention
Getting the Right Help Can Prevent Suicide• > 80% of adolescent suicide attempters/completers communicate suicidalideation...
Psychotherapy for Suicidal Patients• Short-term, group, behavioral, interpersonal,psychoanalytically oriented, and multipl...
Cognitive Therapy• Cognitive theory emphasizes the psychological significance ofpeople’s beliefs about themselves, their p...
Thinking Patterns Targeted by Cognitive Therapy• Dichotomous (black-white) thinking• Cognitive rigidity and constriction• ...
Critical Role of Early Intervention andParent Education• The earlier the intervention in the course of suicidality,the gre...
Bullying and Suicide• Recent bullying related suicides and school shootings in the US andin other countries have drawn att...
New Jersey Anti-Bullying Bill of Rights Act• 2011, toughest in country-extension of original anti-bullying law enactedin 2...
How to Deal with a Suicidal Adolescent• First, a person in crisis needs someone to listen and hear what theyare saying• Al...
How to Deal with a Suicidal Adolescent - 2• Be firm but supportive – give the impression that youknow what you are doing a...
How to Deal with a Suicidal Adolescent - 3• Act Specifically – do something tangible, parents must be called in,arrange fo...
Postvention in the School Setting• Prevention measures implemented after a traumatic event to reduce riskto those who have...
National Suicide Prevention Strategy• Sept 10, 2012, U.S. announced $55.6 million in new grants for suicideprevention prog...
Elements of the National Strategy• Health professionals are not adequately trained for proper assessment, treatment andman...
Other Broad-Based Strategies• Develop strategies to reduce stigma for consumers ofmental health/substance abuse/suicide pr...
Suicide Prevention Checklist for Schools• Does school provide information to staff about the impact/prevalence ofadolescen...
Suicide Prevention Checklist for Schools• Does school provide parents with list of community resources if theysuspect thei...
Traditional Treatment Model for Depressed,Suicidal, Vulnerable Adolescents
Integrated School ModelNew Alliance AcademyThe most effective treatment for these emotionally fragile adolescentsrequires ...
Suicidal behavior-in-adolescents
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Suicidal behavior-in-adolescents

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Presentation by Drs. Gabriel Kaplan and Bennett Silver presented at the 11th annual Sage-NAA Conference

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  • Add threat (verbal or written) Note that self-injury does NOT fall within the continuum.
  • Suicidal behavior-in-adolescents

    1. 1. Adolescent Suicidal BehaviorEvaluation and TreatmentConsiderationsGabriel Kaplan, M.D.Bennett Silver, M.D.
    2. 2. Conference AgendaDr. Gabriel Kaplan•EpidemiologyDr. Bennett Silver•PsychopathologyDr. Gabriel Kaplan•Risk Assessment•Pharmacological ApproachDr. Bennett Silver•Psychosocial Approach and Prevention Programs
    3. 3. 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 patientsPUBLICATIONS/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
    4. 4. 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 JerseyPUBLICATIONS/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 ofArt Reviews (AM:STARs). Spring 2013 (in Press)
    5. 5. EpidemiologyGabriel Kaplan, MD
    6. 6. DefinitionsSuicidal Ideation Thoughts of harming or killing oneself.Suicidal Communications Direct or indirect expressions of suicidalideation 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, usedwith intent to change the behavior of otherpeople.Suicide Attempt A non-fatal, self-inflicted destructive act withthe explicit or inferred intent to die.Suicide Fatal self-inflicted destructive act with explicitor inferred intent to die.Suicidality All suicide-related behaviors and thoughtsincluding 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.
    7. 7. Trends in Suicide Rates Ages 10 Years andOlder, by Sex, 1991–2009Centers for Disease Control:www.cdc.gov/ViolencePrevention/suicide/statistics/
    8. 8. 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 ofrecent “black box” warnings on antidepressants—apossible unintended consequence of the medicationwarnings, required by the FDA in 2004
    9. 9. Percentage of Suicides Ages 10 Years andOlder, by Sex and Mechanism, 2005–2009Centers for Disease Control: www.cdc.gov/ViolencePrevention/suicide/statistics/
    10. 10. Leading Causes of Death by Age
    11. 11. 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 thatcontribute markedly to the leading causes of death, disability,and social problems among youth and adults in the UnitedStates• The YRBSS includes national, state, territorial, tribalgovernment, and local school-based surveys of representativesamples of 9th through 12th grade students. These surveys areconducted every two years, usually during the springsemester.
    12. 12. Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App
    13. 13. Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App
    14. 14. Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App
    15. 15. Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App
    16. 16. H S Students Considering, Planning, orAttempting Suicide in Past 12 Months 2009Centers for Disease Control: www.cdc.gov/ViolencePrevention/suicide/statistics/
    17. 17. Suicide Rates Ages 10–24 Years, byRace/Ethnicity and Sex, 2005–2009Centers for Disease Control: www.cdc.gov/ViolencePrevention/suicide/statistics/
    18. 18. Risk AssessmentGabriel Kaplan, MD
    19. 19. 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
    20. 20. Risk Factors• History of depression or other mental illness▫ Psychiatric disorder is present in up to 80-90% of adolescentsuicide victims and attempters Most common psychiatric conditions are mood, anxiety, conduct, andsubstance 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
    21. 21. What to do?• A plausible suspicion must be assessed immediately▫ A usually happy go lucky 7 year old crying “I want todie” because another student took a toy away does notneed 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 andrefer a.s.a.p.
    22. 22. Evaluation• Adolescent suicidal behavior is a medical emergency thatmust be assessed by highly qualified professionals:▫ Child Psychiatrist,▫ Psychiatrist,▫ Non-MD with training and experience in theassessment of suicidal behavior• If an adolescent actively threatens suicide, an assessmentmust be conducted asap in the Emergency Room setting
    23. 23. Expert evaluation• Comprehensive psychiatric examination• Includes medical history• Patient, family, teacher input required• Evaluation focused on determining potential risk anddisposition• May include rating scales
    24. 24. Expert will assess• Presence of mental illness▫ Large majority of patients who suicide suffer frommental illness▫ All psychiatrically ill adolescents are high risk• Presence of aggravating circumstances▫ Loss, bullying, substance abuse• Suicide continuum stage
    25. 25. Suicide ContinuumPassiveDeathWishSuicidalIdeationwithoutmethodSuicidalIdeationwithmethodSelf-InjuriousbehaviorwithunclearintentAttempt Completion
    26. 26. Focused assessment of continuum• It is vital to assess what the adolescent is thinking• In order to determine strengths and weaknesses, difficultquestions must be asked centered on degree of desire todie• Questions must be very specific. Trying to assesssuicidality without asking about death is like trying todetermine appendicitis without asking “does it hurthere?”• There is ample evidence that asking about suicide doesnot “put” ideas in any adolescent’s mind
    27. 27. 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
    28. 28. Attempt vs. Gesture• SUICIDE GESTURE:▫ Self-injury in which there is unclear intent to die but instead an intent togive the appearance of a suicide attempt in order to communicate withothers (Nock & Kessler Journal of Abnormal Psychology 2006, Vol. 115, No. 3, 616 – 623)• SUICIDE ATTEMPT:▫ Potentially self-injurious behavior with a nonfatal outcome, for whichthere is evidence (either implicit or explicit) that the person intended atsome 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 thatthose who engage in suicide gestures also carry a higher risk of completion.• Those who “gesture” must be taken seriously
    29. 29. 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
    30. 30. 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 wasoverheard voicing wish to die
    31. 31. 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, toldgrandmother nobody likes him and he wishes todie
    32. 32. Risk And Disposition• High Risk▫ Inpatient treatment▫ If condition relapses, next time discharge to structuredsetting, 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
    33. 33. Psychopathology of SuicideBennett Silver, MD
    34. 34. How it HappensAlex was a 17 year old high school senior. He was awarm, sensitive, quiet young man; a high honor rollstudent and a gifted young writer. He had been acceptedto an excellent college, and a promising, successfulfuture seemed assured. Yet one late afternoon in April,upon returning home from work, his horrified motherdiscovered him on the floor of his bedroom. Alex hadkilled himself with a gunshot to the head.How is it possible that this young man, who seemed tohave everything to live for, would take his own life?
    35. 35. Why it HappensIn order to understand why tragedies like this occur, wemust understand the psychopathology from which itstems.
    36. 36. 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 dieby suicide nonetheless• Suicide is best viewed as a symptom of an underlying disease ratherthan a disease per se• The underlying disease is usually some type of depression, oranother psychiatric disorder and therefore is highly treatable
    37. 37. 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, romanticbreakups, 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 andsuicide• Sometimes no clear triggering eventA bio-psycho-social model provides the best understanding of depression
    38. 38. Biological Theories About Suicide• Genetic factors predispose to suicide – clusters of families with both mooddisorders & 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 mentalstate most often underlying suicide• Deficiency of neurotransmitters like norepinephrine/ serotonin at criticalsites in brain resulting in depression• Many studies indicate a lower level of serotonin in brains of thosewho suicided and in cerebrospinal fluid of depressed individuals whohave attempted suicide than in depressed patients who are not suicidal
    39. 39. Low Brain Serotonin, Impulsivity and Suicide• More violent suicide attempters/completers(guns, jumping) lower levels ofserotonin 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 controlwhich increases suicidal behavior.• Alcohol lowers serotonin at same sites in brain as seen in depressedpatients. Alcohol is a disinhibiter that increases impulsivity and greatlyincreases risk of suicide in depressed patients.• One third of adolescents who suicide are legally intoxicated at the time ofdeath
    40. 40. Biopsychosocial Theories• Stress plays a role in development of depression, addiction and otherpsychiatric disorders• Corticotrophin releasing factor (CRF), a key brain hormone in the stressresponse, is implicated in the physiology of both depression & Substanceuse disorders (SUDs)• Elevated CRF concentrations found in the brains of suicide victims• Early life stress (physical/sexual abuse/neglect) and chronic stress causesustained elevations of CRF, causing long term damage to brain pathways(neuroadaptation) which increases susceptibility to depression andsubstance use• This provides the biological underpinnings of the well-establishedrelationship between early life adversity and depression, suicide and SUDsin adolescents and adults
    41. 41. Suicidal Behavior• More than 90% of all completed suicides in adolescents (andadults) 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 moreimportant as cofactors rather than primary in themselves. Co-existent high anxiety, panic, or substance use, accompanying majordepressive disorder or schizophrenia markedly increase suicide risk
    42. 42. The Suicidal Crisis• Often, a crisis situation, what one author called a “stateof perturbation,” occurs in a vulnerable adolescent with apsychiatric disorder and that crisis converts a state ofpotential risk into an actual suicidal act• The most common precipitating events are break-ups,episodes of perceived humiliation, academic orextracurricular failures, school disciplinary/legalproblems, or sexual assaults
    43. 43. Mood Disorders and Completed Suicide60-70% of suicide victims were suffering from a significantclinical depression at the time of their deathsCompleted Suicide Lifetime SuicideAttemptBipolar Disorder 10-20% 29%Major Depression 5-12% 16%General Population <.0002%(16/100,000).02%Any PsychiatricDisorder4%
    44. 44. 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 depressiongo on to develop Bipolar Disorder• Residual symptoms between episodes common, and 60%experience chronic interpersonal and school difficultiesbetween episodes• Strong genetic influence-one of most familial psychiatricdisorders
    45. 45. Characterized by Recurrent Mood Episodes• Major Depressive Episode• Manic Episode• Mixed Episode• Hypomanic Episode
    46. 46. Manic EpisodeA. Distinct period of persistently elevated, expansive, or irritablemood –causes marked impairment in functioningB. 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) orpsychomotor agitation7. Excessive involvement in activities with high potential for negativeconsequences (e.g., buying sprees, sexual indiscretions)
    47. 47. Mixed and Hypomanic Episodes• During a Mixed Episode manic and depressivesymptoms may occur simultaneously or in quicksuccession.• During a Hypomanic Episode, symptomssame as during Manic Episode, but less severe -do not cause marked impairment in functioning.
    48. 48. Suicide Risk in Bipolar Disorder and MajorDepression
    49. 49. Other Factors That Increase Suicidal Actsin 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
    50. 50. Comorbid Substance Abuse• Prevalence of comorbid substance abuse in bipolar I andbipolar II disorder is as high as 61% and 48%respectively• This is greater than the prevalence of substance abuseseen with any other psychiatric conditions, includingschizophrenia, panic disorder, dysthymia and unipolardepression• Comorbid substance use increases the risk for suicide inmood disorders
    51. 51. Accurate Diagnosis and Early Intervention• Bipolar Disorder is difficult to diagnose in adolescence, due tonature of adolescent moodiness, and similarities with conditionssuch as ADHD, Schizophrenia, and Addiction• Bipolar Disorder has a spectrum of severity and milder forms oftenmissed or misdiagnosed.• Misdiagnosis leads to delayed or incorrect treatment• Early intervention/treatment improves long – term outcome,reduces suicidal risk for teens
    52. 52. Major depression in adults and adolescentsAt least 5 of these symptoms must be present to the extent that they interfere with daily functioning overat least 2 weeksAdults AdolescentsDepressed mood most of the day Irritable mood; preoccupied with songlyrics that suggest life is meaninglessDecreased interest/ enjoyment in activities Loss of interest in sports, video games, activities withfriendsSignificant weight loss /gain Failure to gain normal weight ; anorexiaor bulimia; frequent complaintof physical illnessInsomnia or hypersomnia Excessive late night TV or computer; refusal to wake upfor school in morning in morningPsychomotor agitation/ retardation Running away from homeFatigue or loss of energy Persistent boredomLow self-esteem; feelings of guilt Oppositional and/or negative behaviorDecreased ability to concentrate; indecisive Poor performance in school; frequent absencesRecurrent Suicidal ideation or behavior Recurrent suicidal ideation or behavior (writingaboutdeath ; giving away favorite objects or possessions
    53. 53. Signs and Symptoms of Covert DepressionOften Seen in Adolescents• The quiet, perfectionistic “good boy” who never gets intotrouble but who cannot maintain the level of perfection thathe or others expect of him• Boys with conduct disturbances who become depressed andact out impulsively• Boys who abruptly develop conduct disturbances as their wayof expressing depression• Changes in school performance or friends• Beginning to abuse substances
    54. 54. 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 beforethe age of 20 years
    55. 55. Symptoms and Signs of Psychiatric IllnessAre Present Prior to SuicideAlthough the bereaved parents of adolescentsuicide victims frequently insist that their childwas totally free of any symptoms prior to thesuicide, this appears rarely true on closerexamination, and may reflect the parents’ denialor their inability to recognize the signs ofdepression
    56. 56. Pharmacological ApproachGabriel Kaplan, MD
    57. 57. Pharmacology is just One of Many Toolswithin a Comprehensive Approach• Individual psychotherapy• Group psychotherapy• Family therapy• School Interventions• Medication• Therapeutic school placement such as New Alliance Academywhich can utilize all of above approaches
    58. 58. Medication Classes Used in Suicide• Antidepressants• Antipsychotics• Mood Stabilizers• Only one medication has been proven to decrease suicide in adultschizophrenia and is FDA approved specifically for suicide▫ Clozapine (antipsychotic)• There is ample evidence for other medications in adults▫ Lithium (mood stabilizer)▫ Antidepressants
    59. 59. AntidepressantsSerotonin 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)
    60. 60. Side-effects of AntidepressantsMost adolescents do not have side-effects. If they dooccur they are usually mild and transient.▫ Headaches▫ Upset stomach▫ Decreased appetite▫ Flushing and sweating▫ Mild sedation▫ Jitteriness▫ Abnormal dreams▫ Rash▫ Sexual▫ BLACK BOX WARNING
    61. 61. Antidepressants Are Compatible WithStudent Performance in School• Low incidence of side-effects• Usually not sedating• Once daily dosing (morning or nighttime)• Usually compatible with other medications
    62. 62. How Effective Are Antidepressants ?In an important recent study funded by the NIMH(TADS) on adolescents with moderate to severedepression : 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 inrelieving depression as the placebo or psychotherapy aloneMarch J. TADS JAMA. 2004 Aug 18;292(7):807-20.
    63. 63. Do Antidepressants make people suicidal?• 2003 the maker of Paxil disclosed that clinical trial data had found anincreased risk of suicidality in youth.• FDA concluded that for every 100 treated patients, 1 to 3 patients might beexpected 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 identifiedsuicidality 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 adolescentdepression: fluoxetine (Prozac) and escitalopram (Lexapro).
    64. 64. Black Box Controversy• Data from the CDC show that between 1992 and 2001, the rate of suicideamong American youth ages 10 – 19 declined by more than 25%• The dramatic decline in youth suicide rates correlates with the increasedrates of prescribing antidepressant medication (particularly SSRI’s) toyoung people• Since the black-box suicide warnings appeared on the labels ofantidepressants, antidepressant use among teens plummeted. At the sametime, the suicide rate among U.S. teens rose sharply – bucking a decadeslong trend• There are no statistical data yet linking the black box to increasedsuicidality but suspicion is high amongst academicians that this may havebeen an unintended consequence of the warning
    65. 65. Data Reanalyses• FDA studied only short term data• Data were reanalyzed adding longitudinal information, extending theobservational period beyond the short term study end point timeframesassessed by the FDA.• For adult and geriatric patients medication actually decreased suicidalthoughts and behavior. The protective effect was mediated by decreases indepressive symptoms with treatment.• For youths, however, although depression also responded to treatment, nosignificant effects of treatment on lowering suicidal thoughts and behaviorwere found, although reassuringly, there was no evidence of increasedsuicide 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.
    66. 66. Mood Stabilizers• USED FOR BIPOLAR DISORDER• LITHIUM:▫ Lithium Carbonate (Eskalith,Lithobid)• ANTICONVULSANTS:▫ Valproic Acid (Depakote)▫ Carbamazepine (Tegretol)▫ Lamotrigine (Lamictal)
    67. 67. 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, increasedthirst, increased urination,thyroid underactivity,weight gain
    68. 68. 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 mixedstates• Side – effects: Nausea, headache, doublevision, sedation, liver enzymeelevation, weight gain, hormonechanges in women (Depakote, e.g.,absence of menstruation)
    69. 69. 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 antidepressantproperties▫ Olanzapine (Zyprexa) – Very effective, but significant weight gain, metaboliceffects (blood sugar, cholesterol)▫ Ziprasidone (Geodon) – Weight neutral, less sedating▫ Clozapine (Clozaril) – Most effective, weight gain, metabolic effects, risk for severewhite blood cell suppression requires regular blood tests. Used when othermedications fail.
    70. 70. Antipsychotics• Improve depression (as add on) and mania (combined ormonotherapy)• 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
    71. 71. Bennett Silver, M.D.Psychosocial Approach andPrevention
    72. 72. Getting the Right Help Can Prevent Suicide• > 80% of adolescent suicide attempters/completers communicate suicidalideation prior to the attempt• Majority of youth suicide attempters/completers have seen a doctor/mentalhealth worker in 3 months prior to the suicidal behavior• Few individuals with Major Depressive Disorder receive adequate treatmentfor depression before and after a suicide attempt• Only 20-40% of suicidal patients continue outpatient treatment afterpsychiatric hospitalization-treatment dropout another suicide risk factor• Recent Study of 102 people who killed themselves revealed more than half hadvisited mental health specialist during the year prior to death• Only 5% had contact with addiction services, even though 2/3 suffered fromsubstance abuse as well as depression - need better integration of mentalhealth and addiction services
    73. 73. Psychotherapy for Suicidal Patients• Short-term, group, behavioral, interpersonal,psychoanalytically oriented, and multiple otherpsychotherapy approaches have all been employed withreported success• However, Cognitive Behavioral Therapy (CBT) by far thelargest evidence base of its effectiveness• Dialectical Behavioral Therapy (DBT) particularlyeffective with suicidal Borderline Personality Disorderpatients
    74. 74. Cognitive Therapy• Cognitive theory emphasizes the psychological significance ofpeople’s beliefs about themselves, their personal world (includingthe people in their lives), and their future – the “cognitive triad”• Maladaptive emotional distress linked to biased beliefs about thiscognitive triad of self, world, and future• E.g., clinically depressed people may believe that they are incapableand helpless, view others as judgmental, and the future as bleak andunrewarding• Cognitive therapy modifies these maladaptive beliefs to help theperson gain a more objective view of their problems and theirpotential solutions
    75. 75. 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 experiencescannot be used as references for effective coping strategies• Impaired problem solving• Hopelessness/helplessness-negative expectations about thefuture• “locked-in” to current perceptions, unable to imaginealternatives• View death in a favorable light• Have difficulty generating reason for living
    76. 76. Critical Role of Early Intervention andParent 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’ssuicide attempts (more lethal methods with repeatattempts)• Parents are 3 times more likely to take protective actionswhen parent education is provided
    77. 77. Bullying and Suicide• Recent bullying related suicides and school shootings in the US andin other countries have drawn attention to the connection betweenbullying 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 and160,000 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
    78. 78. New Jersey Anti-Bullying Bill of Rights Act• 2011, toughest in country-extension of original anti-bullying law enactedin 2002• Defines bullying: any harmful action towards another student or anyaction that creates a hostile school environment or infringes on astudent’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 trainedto identify/respond to bullying• All schools anti-bullying specialist/school safety team
    79. 79. How to Deal with a Suicidal Adolescent• First, a person in crisis needs someone to listen and hear what theyare 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 givenpermission to talk about it• Do not be misled by the suicidal person’s comment that he is alrightand past the crisis – follow-up is crucial to insure good treatment
    80. 80. How to Deal with a Suicidal Adolescent - 2• Be firm but supportive – give the impression that youknow what you are doing and that you intend to doeverything possible to prevent him from taking his life• Evaluate the resources available – inner psychologicalresources such as intellectualization that can bestrengthened & outer resources such as counselors,relatives, clergy and others who can be called in
    81. 81. 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 personbrought to an emergency room for evaluation• School staff cannot assume that a student’s family will take positivesteps to respond to the situation, especially in dysfunctional familiesand must insure that at risk students receive the necessary services• Don’t be afraid to ask for assistance and consultation – call uponwhomever is needed. Don’t try to handle everything alone
    82. 82. Postvention in the School Setting• Prevention measures implemented after a traumatic event to reduce riskto those who have been affected by the tragedy• The suicide, violent or unexpected death of a student, teacher, even acelebrity 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 notdramatize/romanticize, leading to additional suicides• Establish school- based suicide prevention programs & crisis responseplans including educational activities that encourage students torecognize and find help for emotional issues
    83. 83. National Suicide Prevention Strategy• Sept 10, 2012, U.S. announced $55.6 million in new grants for suicideprevention programs• First new national strategy plan in over a decade• Promotes new Facebook service-users can report suicidal commentsthey see online from friends-website sends the potential victim an emailurging a call to hotline/chat online with a counselor• New technologies-mobile apps to connect people with counselingresources• Plan highlights the 23 million veterans (17,754 veteran suicide attemptslast year- 48 per day) and efforts to identify soldiers at risk, reducestigma and encourage them to seek help
    84. 84. Elements of the National Strategy• Health professionals are not adequately trained for proper assessment, treatment andmanagement of suicidal individuals, or know how to refer them properly forspecialized assessment/treatment• Provide targeted education for suicide identification and referral to key gatekeeperssuch 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 minimumstandard 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 adecrease in deaths by carbon monoxide poisoning
    85. 85. Other Broad-Based Strategies• Develop strategies to reduce stigma for consumers ofmental health/substance abuse/suicide preventionservices• Increase community linkages with mental health andsubstance abuse services• Improve portrayals of suicidal behavior, mental illness/substance abuse in entertainment/news media- avoiddramatization to reduce suicide contagions• Promote/support research on suicide/suicide prevention
    86. 86. Suicide Prevention Checklist for Schools• Does school provide information to staff about the impact/prevalence ofadolescent suicide?• Does school have policies and procedures in place concerning suicideissues?• Does it have support from superintendents/principals/teachers for suicideprevention program?• Does school have links to the community to help with a suicidal student andare staff educated about how to contact them?• Does your school have a crisis response plan/team that meets on a regularbasis?School-Based Youth Suicide Prevention Guide of University of South Florida
    87. 87. Suicide Prevention Checklist for Schools• Does school provide parents with list of community resources if theysuspect their child is considering suicide?• Does school inform parents about risk factors and restricting access tolethal means (firearms)?• Is school staff aware of legislation on liability for suicidal behavior instudents?• Is school aware that while students are in school, the school must act in locoparentis, or as reasonably as a concerned parent?School-Based Youth Suicide Prevention Guide of University of South Florida
    88. 88. Traditional Treatment Model for Depressed,Suicidal, Vulnerable Adolescents
    89. 89. Integrated School ModelNew Alliance AcademyThe most effective treatment for these emotionally fragile adolescentsrequires a highly integrated (under one roof), multi-pronged treatmentteam approach in order to prevent poor or tragic treatment outcomes

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