Avicii (Tim Bergling), Chester Bennington, Kate Spade, Mark Salling, Robin Williams, Anthony Bourdain: All names in media for the unfortunate fame of recent suicides. Similarly, TV shows such as “13 Reasons Why” (released to Netflix in 2017) and pop songs like “1-800-273-8255” by Logic (featuring Alessia Cara and Khalid), shed light on the persistent and ever growing issue of adolescent depression and suicide. There has been heated national debate regarding the effect media has on perpetuating suicidal thoughts versus raising awareness. Whether by parental choice or not, the discussion of mental health and self-harm has made its presence known to the public eye of children with these big names of Hollywood and pop culture. Just as it is important to address gun violence covered by media, pediatricians and parents must take strong roles in approaching the sensitive subject of depression. Suicide is itself a very private matter, however more recently it has become publicized, glorified, and often shamed. In light of these portrayals, it is crucial to remember it for what it is: a mental health illness.

According the CDC 2018 Vital signs, suicide rates across ages continue to rise with a significant jump by 30% from 1996 to present, in half the US states [1]. Suicide remains the 3rd leading cause of death in children 10-14 years of age, and (since 2016) the 2nd leading cause of death in adolescents 15-24 years of age. Looking state specifically, Texas falls in the range of 19-30% increase in suicide rates. Fortunately, amongst adolescents, attempt rates and health injury caused by suicide attempts, remains relatively stable between 2013-2015, according to Youth Risk Behavior Survey [2]. The disappointing reality exists that even under the watchful eye of healthcare providers, 77% of those who complete suicide have been seen by a primary care provider, and 40% have been seen by an emergency care provider in the year leading up to their suicide [3].

What can be done? And how do we intervene? Initial screenings are not only welcomed by adolescent patients [4] but also effective in providing a backbone for further follow up [5]. Systematic tracking of endorsed suicidality, with formulas/surveys such as the PHQ-9, help to quantify mental health and to make screening easier for the providers.

For parents and pediatricians alike, anticipatory guidance during adolescent well child exams or sports physicals can serve as a time to review key topics such as:

• Warning signs of depression:
  • social withdrawal, loss of interest in prior hobbies, hopeless talk, extreme or labile emotions/mood swings, verbal outcries on social media
• Open communication:
  • encouraging parent-teen relationships, providing attention and empathy before patient outcries (http://www.bethe1to.com/), avoiding shame, expressing concern about the patient
• Access to guns/medications/drugs at home:
  • removing adult (or child) medications that can be abused, removing and locking away guns (4-10x higher likelihood of suicide in households with gun access) [6]
• Cyberbullying:
  • Limiting social media use, monitoring internet searches on suicide (more than 5 hours of internet use daily associated with higher rates of suicide) [7]
• When to escalate and who to reach out to with concerns:
  • primary pediatrician, mental health professional, suicide hotline, Trevor project, calling 911/emergency services, or other local resources

By initiating a conversation early on with parents and adolescents alike, pediatric providers may alter the perspective on mental health. Pop culture media is not required to uphold the ethics of beneficence or non-maleficence. Ultimately, it is the responsibility of the pediatrician and the community at large to invest in the future of its young adults. We can do this by advocating for improved funding (in light of budget cuts to mental health services), and perpetuating positive and open dialogue early on regarding mental health and depression.

~Alisha Wang, MD

 

References:

[1] Suicide Rising Across the US: https://www.cdc.gov/vitalsigns/suicide/

[2] Trends in the Prevalence of Suicide-related Behavior: https://www.cdc.gov/healthyyouth/data/yrbs/pdf/trends/2015_us_suicide_trend_yrbs.pdf

[3] Parkland Leads Way Nationally with Innovative Suicide Screening Program: https://www.parklandhospital.com/phhs/news-and-updates/parkland-leads-way-nationally-with-innovative-suic-769.aspx

[4] To Ask or Not to Ask? Opinions of Pediatric Medical Inpatients about Suicide Risk Screening in the Hospital. Journal of Pediatrics. Mar 2016. https://www.jpeds.com/article/S0022-3476(15)01464-X/pdf

[5] Suicide Screening in Primary Care: Use of an Electronic Screener to Assess Suicidality and Improve Provider Follow-Up for Adolescents. Journal of Adolescent Health. Feb 2018. https://www.jahonline.org/article/S1054-139X(17)30466-4/fulltext

[6] With Suicide Now Teens’ Second-Leading Cause of Death, Pediatricians Urged to Ask About Its Risks. AAP. Jun 2016. https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/With-suicide-Now-Teens%E2%80%99-Second-Leading-Cause-of-Death-Pediatricians-Urged-to-Ask-About-its-Risks.aspx

[7] Suicide and Suicide Attempts in Adolescents. AAP. Jun 2016. http://pediatrics.aappublications.org/content/early/2016/06/24/peds.2016-1420