Successfully Dealing With Teen

Self-Harm BehaviorOregon School-Based

Health Care Network

Annual Institute

October 12, 2007

Kirk D. Wolfe, M.D.

Goals

To Recognize:

– The Major Impact of Youth Depression

And Suicide on Our State– Risk and Protective Factors With Suicide– Keys in Evaluating a Suicidal Student– Keys to Treating Suicide/Depression

Oregon Youth Suicide Facts- 1990’s

Rate Was 30-40% Above The US Average Rate Increased 400% In 40 Years #2 Cause of Death 75 Suicides Every Year 2/3 With Firearms

Oregon Youth Suicide Facts-1999-2005

~63 deaths per year- 16 % decrease

Why the decrease?

Youth Risk Behavior Survey-2005

U.S. High School Students, Past Year:

28.5% Depressed 2 Weeks or Greater 17% Seriously Considered Suicide 13% Report Specific Plan 8.4% Suicide Attempt 2.3% Attempt Leading to Medical Attn

U.S. Youth Suicide Facts-1990-2003

#3 Cause of Death Highest Psychiatric Risk- Major Depression Peak rate- late 1980’s 28% Decrease in Rate through 2003 Why the decrease?

U.S.Youth Suicide Facts-2004 vs. 2003

8% Increase, largest in 15 years

76% Increase, Females aged 10-14 yrs 32% Increase, Females aged 15-19 yrs 9% Increase, Males aged 15-19 yrs

Why the increase?

U.S. Youth Suicide Facts- Rates per 100,000, Females, 2004 Ages 10-14 years: All methods 0.95 Hanging/suffocation (72%), poison (16%)

Ages 15-19 years: All methods 3.52 Hanging/suffocation (49%), firearm (28%)

Ages 20-24 years: All methods 3.59 Hanging/suffocation (34%), firearm (32%)

U.S. Youth Suicide Facts-Rates per 100,000, Males, 2004 Ages 10-14 years All methods 1.71 Hanging/suffocation (73%), firearm (27%)

Ages 15-19 years All methods 12.65 Firearm (51%), hanging/suffocation (37%)

Ages 20-24 years All methods 20.84 Firearm (53%), hanging/suffocation (32%)

Risk Factors for Youth Suicide

Later adolescence/young adult Male Ethnicity- Highest Rate- Native American Greatest Number- Caucasian Stressful Life Events Previous Attempt(s) Access to Lethal Means Contagion/ Imitation Chronic Physical Illness (esp. epilepsy)

Risk Factors for Youth Suicide Youth Psychiatric Disorder - Major Depressive Disorder - Substance Abuse - Bipolar Disorder - Conduct Disorder- Aggressive/Impulsive Physical/ Sexual Abuse Hopelessness or Isolation Sexual Orientation FH of mood disorders/suicide/substance abuse

Protective Factors

Family Cohesion Good Coping/Problem-Solving Skills Help-Seeking/ Advice-Seeking Academic Achievement Social Integration Access/care for mental/physical/subst. d/o’s Responsibility for others/pets Religion/spirituality

Teen Psychological Autopsy-Case-Control Study

Brent et al, JAACAP, 1993,32,3:521-529 Psychiatric Risk Factors for Teen Suicide:

(1) Major depression (OR=27.0) (2) Bipolar mixed state (OR=9.0) (3) Substance abuse (OR= 8.5) (4) Conduct disorder (OR= 6.0)

~31% depressed suicide deaths- depressed <3 months

Columbia Teen Screen-Screening for Suicide Focus: on depression, suicide, substance use Need parental and student consent - Brief self-report screen (Teen Screen) - DISC if positive screen - Clinical interview if DISC positive - Make referral for further assessment 74% teens with SI not of concern to school 50% with prior attempt not of concern to school 30% of highest risk unknown to school or MHP www.teenscreen.org

Evaluating a Suicidal Student-Thorough Assessment Essential (1) Evaluate the suicide attempt thoroughly

(2) Evaluate for underlying mental illness- this will determine treatment (3) If no underlying mental illness- - still need to take safety precautions - get second and third sources to corroborate - need to look for underlying cause(s) - look to support the student (and family) - remain vigilant with close follow up

MDD/Suicide Risk Tip Offs

Major Problems Home/School/Peers/Job/Hygiene Overall Very Negative Presentation History of Loss, Abuse, Exposure to Violence,

Significant Life Stress “Superachievers” With Vegetative Changes Hallucinations Substance Abuse FH Mood/Anxiety Disorders, Suicide, Substance Abuse, Jail

Impact Of DepressionEmotional

Youth Family Peers Classroom Workplace Juvenile Justice System

Physical Effects

Obesity Smoking Alcohol Drugs Heart Disease

Financial

19 Million Americans Yearly More Than 1 In 5 Oregon Youth $23.8 Billion in Absenteeism And Lost

Productivity Education System SOSCF OYA Medical Costs

Possible Signs Of Depression

Low Self Esteem Anger Management Problems Alienation Or Withdrawal From Others Running Away School Avoidance Decreased Or Failing Grades Cruelty To Animals

Possible Signs Of Depression

Gang Involvement Violent Behavior Fire Setting Legal Problems Early Pregnancy Nutrition Problems / Obesity Physical Health Problems

Possible Signs Of Depression

Becoming A Smoker Using Alcohol Or Drugs Homicide Attempts Death By Homicide Suicide Attempts Death By Suicide

Why Youth Become DepressedBiopsychosocial Approach

Biological Psychological Social

Depression Is A Medical Illness

Evaluating Suicidal Thinking Look for in times of stress- empathic connection-

“Some teens will think about hurting or killing themselves.”

“Have you ever felt like hurting yourself?” “Have you ever felt like killing yourself?” “Have you ever wished you were dead?” Look at non-verbal cues in response “Ever had a plan? Would you be able to?” “What kept you from doing it?” “Ever try to kill yourself?Tell me what happened.” “Anyone in your family attempt / die by suicide?”

Evaluating a Suicide Attempt Connect in non-judgmental manner What was done? Lethality? Perceived lethality? When? Where? With whom? CONTEXT OF RELATIONSHIPS Why then? IDENTIFY STRESSOR(S) How long planned? The final straw? What did student hope would happen? Who else knows? CUTTING BEHAVIOR- TIP OF ICEBERG

Evaluating Past Attempts

Identify each attempt

-lethality

-context of relationships

-theme with stressors

-awareness/reaction of others?

-receive treatment?

-type of treatments? Compliant? Helpful?

Evaluating a Suicide Attempt

Getting a Second (and third) Informant Issues of Safety- Loss of confidentiality yet need to maintain alliance Empathic Connection with Student- Can student put self in parent/peer/school shoes in looking at student’s self-harm? Want student to understand why you are looking to get support for the student

Major Depressive Episode

Represents A Change 2 Weeks Or Longer Depressed Or Irritable Mood Loses Interest In Most Activities Most Of The Day, Nearly Every Day Causes Problems Need 5 Or More Symptoms

Depressed Or Irritable Mood

Easily Irritated Rebellious Behavior Rarely Looks Happy Crying Spells Wears Somber Clothes Music Has Depressing

Or Violent Themes Friends Are Depressed

Or Irritable

Decreased Interest

“I’m Bored” Spends Much Time In Their Room Declining Hygiene Changes To More Troubled Peer Group Or

Activity

Change In Appetite Or Weight

Being A Picky Eater Eats When Stressed Quite Thin Or Overweight

Changes In Sleeping Patterns

Delayed Sleep Multiple Awakenings Sleeps More Than Normal

Psychomotor Agitation Or Slowing

Agitated Always Moving Around Moping Around The House Or School

Fatigue Or Loss Of Energy

Too Tired To Do Schoolwork, Play or Work Comes Home From School Exhausted Too Tired To Cope With Conflict

Feelings Of Worthlessness Or Inappropriate Guilt

Sees Self As “Bad” Or “Stupid” No Hope Or Goals For The Future Always Trying To Please Others Blames Self For Causing Divorce Or Death

Decreased Concentration

Often Responds “I Don’t Know!” Takes Much Longer To Get Work Done Drop In Grades Headaches, Stomach aches Poor Eye Contact

Recurrent Thoughts Of Death Or Suicide

Giving Away Personal Possessions Asks If Something Might Cause Death Wanting To Join A Person In Heaven “I’m Going To Kill Myself” Actual Suicide Attempts

The Blues vs. Depression

Normal Reaction Hours-Days Affects Mood Briefly

Not Cause Suicide Good Listener Helps

Medical Illness Weeks-Years Mood, Thinking, Body

Functions Possible Suicide Needs Psychiatric

Treatment

Evaluation Of Depression Biopsychosocial Approach is Essential Identify Interests/Strengths and Use in Tx Distinguishing Normal vs. Abnormal is Critical

(e.g. sleep, bereavement, problems created) Determine (Impairment of) Function in Settings-

home, school, peer activities, job Recognize Cultural Context Who Does the Student See as an Ally? Ask About Mania FH Can Make a Big Difference- now and in future

Substance Use/Abuse/Dependence In utero Exposure? Cigarettes/Alcohol/Drugs Current Extent of Use/ Most Recent Use Specific Use With Suicidal Ideation/Action Problem Pattern of Use - Legal Problems - Failure to Fulfill Roles - Recurrent Use Despite Problems

Like Fuel to the Fire of Depression!

Completing The Evaluation

Screening Q’s- Anxiety Disorders Psychosis ADHD Autism Spectrum Disorder Conduct Disorder Eating Disorder Sleep Disorder Personality Traits

Completing The Evaluation

Past Psychiatric History Medical History- updated complete PE Developmental History Family History- Psychiatric and Medical Social History Mental Status Exam

Case Study

High school student, h/o ADHD C.C.: gradual decline academically h/o B/C’s, now D/F’s stimulant med since age 8, helpful now withdrawn, sad, poor hygiene Goth attire, hair dyed black Diagnosis?

Evaluating Risk for Suicide-Look at the Big Picture

Low or Moderate Risk

- May have voiced suicidal thoughts but no plan or access - No past attempts - Minor impairment in functioning - Actively involved parents, good support

Evaluating Risk for Suicide-Look at the Big Picture

Extreme Risk

- Voiced active intent - Had recent serious attempt - May or may not have had past attempts - Severe impairment in functioning - Has access to lethal means - Stressed family

Completing The Evaluation

Sharing Your Impression Recognizing This is a Tough Time What Happened Was Serious Help Student Understand Support Needed Student Needs to Keep Self Safe Treatment Will Be Essential Will Need to Notify Parents, School Admin How is Student Responding to Discussion?

Documentation

Needs to be timely and legible Estimate: -degree of risk -known data -basis for diagnosis -planned interventions (e.g., consultation, referral, notify parent/admin, med, follow-up) Develop (or update) treatment plan

TreatmentSafety

Eliminate Access To Guns And Sharp Objects All Medications In Locked Cabinet Eliminate Hanging Materials Appropriate Support and Supervision Psychiatric Hospitalization May Be Necessary Intensive Services May Be Needed Don’t rely on a “safety contract”

Treatment- Safety on Ongoing Basis

Close and Frequent Reassessment Has the student and family kept their word? Recognize the Teen Life and Mind-

NOT STATIC! Anticipate Future Stressors- preparing the

student to react safely

Treatment

Reestablishing Connections:

- with family, school, friends (psychosocial)

- between neurons (biology)

Treatment- Focus on Relationships

Utilizing Interests/ Strengths Individual / Family / Group Therapy Identify Possible Depression In Other Family

Members School Support

– Appropriate Expectations– Peer Mentor– Eliminate Harassment if Present– Special Education

Treatment

Develop Interests Physical Exercise Good Role Models Spiritual Support The Dougy Center Support Groups

(e.g. OFSN, NAMI)

Treatment- Sleep

Good night’s rest essential Review what’s normal vs. abnormal, how impacts the student (and others) Focus on reprioritizing student’s life to get sleep Focus on good sleep hygiene If not improving, consider medication

TreatmentMedication

Rarely “The Answer” Keep In Mind Target Goals Takes Weeks To Months Fluoxetine Other SSRI’s Wellbutrin SR/XL Others

Prescribing Meds in Children

Signs and Symptoms Should:

-Cause significant disturbance or distress

-Clearly impair expected, developmentally

appropriate functioning

-Be able to respond to medication

intervention based on research literature

Key PrinciplesMonitoring Meds in Children

PARQ conference essential, need to document Meds should never be the sole treatment if problems exist Recent complete physical exam essential Psychotropic treatment begins with appropriate diagnosis and symptom assessment Regular appts., good student/parent and practitioner communication encouraged

Key PrinciplesMonitoring Meds in Children

Start low, go slow, encourage patience Don’t stop halfway with treatment if no side effects Regular communication with tx providers Multiple meds may be the norm when functioning severely impaired Parents should be involved with monitoring

Treatment of AdolescentsWith Depression Study (TADS)

439 teens, ages 12-17 Dx of MDD at consent and baseline, at least 2 of 3 contexts for >5 weeks Excluded dx’s: bipolar, thought d/o, PDD, substance abuse/dependence Excluded if hosp for danger within 3 months or “high risk” related to SI/attempt Excluded if past poor response to CBT or fluoxetine

TADS

Randomized - Cognitive behavior therapy (CBT) - Fluoxetine (initial 10mg/d, up to 40mg/d) - CBT and fluoxetine - Placebo Outcome: CDRS, CGI, SIQ-Jr Baseline, week 6, week 12

TADS

Major Depressive Disorder - 71% improved with both - 61% improved with fluoxetine alone - 43% improved with CBT alone - 35% improved with placebo

Baseline: 29% had significant SI End of study: 10% had SI No deaths by suicide

Antidepressants in Teens

Prozac (fluoxetine)

- FDA- approved in teen depression

- more effective than placebo

- low lethality in overdose

- FDA- approved for anxiety (OCD)

Antidepressants in Teens-Black Box Warning

Review of 23 Clinical Trials, 4300 kids Studies Involving Nine Antidepressants Spontaneous Sharing of Suicidal Thoughts

- 2% on placebo had SI/behavior

- 4% on antidepressants had SI/behavior

- NO deaths by suicide

Antidepressants in Teens

Tricyclic antidepressants (Imipramine, Desipramine, Amitriptyline)

- No more effective than placebo for

depression

- May be lethal in overdose

- Avoid with suicidal teens

FDA- Black Box WarningAntidepressants in Teens

- Must balance risk with clinical need - When started or dose increased, observe closely for worsening, suicidality, unusual behavior change - Advise students/families of need for close observation and communication with prescriber - Applied warning to all antidepressants

Treatment- Cutting BehaviorWithout Underlying Illness Do family, school, peers confirm: - no underlying mental illness? No suicidal intent? - no past suicide attempts? No access to means? - underlying reason(s) for cutting? Address these. - consider psychiatric consultation Discuss cutting negatives: - damage, infection, scar Discuss safe ways of expression Determine how to motivate change- -e.g. poor judgment so no driving privileges Remain vigilant, close follow up

Hesitant Families

Don’t Recognize The Warning Signs Believe It’s Part Of Normal Adolescence Believe There Is A “Good Reason” To Be

Depressed Might Be Viewed “Crazy” Or “Weak” Lack Insurance Youth Refuses Treatment

Conclusions

Youth Depression/Suicide Have a Major Impact on Oregon

Make Use of Risk and Protective Factors of Suicide

Evaluate the Suicide Attempt and Underlying Mental Illness

Focus on Safety and Reestablishing Connections Remain Vigilant and Supportive Youth Suicide Can Be Prevented!

References Gould, M., Greenberg, T., Velting, D., & Shaffer, D.(2003), Youth suicide risk and preventive interventions: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 42:386-405. Muzina, D.J. (2007), suicide intervention: How to recognize risk, focus on patient Safety. Current Psychiatry 6:30-46.

References Centers for Disease Control and Prevention, Suicide Trends Among Youths and Young Adults Aged 10-24 Years- United States, 1990-2004. MMWR 2007; 56:905-908. - 2005 Youth Risk Behavior Survey www.cdc.gov/HealthyYouth/yrbs - 2005 Violent Death Reporting System www.oregon.gov/DHS/ph/ipe/nvdrs/index.shtml

References

2007 Oregon Healthy Teen Survey: www.dhs.state.or.us/dhs/ph/chs/ youthsurvey/index.shtml

2005 Adolescent Suicide Attempt Data www.dhs.state.or.us/dhs/ph/chs/data/ arpt/05v2/chp8toc.shtml

References Lazear, K., Roggenbaum, S., & Blasé, K. (2003). Youth suicide prevention school- based guide-Overview. Tampa, FL: Dept. of Child and Family Studies, Division of State and Local Support, Louis de la Parte Florida Mental Health Institute, U. of South Florida.

Special thank you to Lisa Moody, Oregon Family Support Network