Wednesday, November 01, 2006

Anti-depressants, suicide, and teen-agers

I first posted about a teen and suicide a few months ago.

The subject never really disappears for therapy docs, but it’s back in the news again. So I’ll be hearing about it at the office today. People will be asking me questions.

Not to digress too far, but it is the elderly, not ironically, that is the population most at risk for suicide. One becomes less newsworthy after 65.

But back to teens. The research flips back and forth, but my understanding of the problem is as follows:

Teenagers are at risk for suicide in general, primarily due to pressure about academics. Pressure about school and grades underlies most teenage suicide. This is the reason that I emphasize that parents NOT pressure their children about grades.

Pressure them about curfew, pressure them about relationships, pressure them about morals. When I say pressure I mean talk. Talking to teens is often interpreted as pressure. They already know where we stand on most things, so they put us in the category of white noise.


You don't have to pressure if you make your child’s academic progress one of his or her first big decisions. You can offer to pay for tutoring. You can intervene if a teacher is too hard on your kid. You can help with the homework if you're really, really helping.

But make the child do the work himself and make it okay not to do SO well. You had your chance to go to school.


Teenagers do express suicidal ideation, some for attention, others to be cool, some because they are really depressed and do think they would be better off dead. Caring parents bring these young people to therapy and participate in it themselves. They’ll do anything to be sure their child is safe.

A busy adolescent-centered practice draws a few dozen cases like this a year. Many therapy docs won’t see adolescents because teens are tempted to try on different behaviors in their search for identity, some of them really dangerous. They’ll explore risky deviant sexual behaviors like pillow sex (suffocation). They’ll experiment with drugs, cut themselves, etc. Docs are afraid of being sued if anything happens.

So those of us who do see wily teenagers watch them carefully. And if we refer for medication, we make sure that the prescribing physician doesn't just put a child on anti-depressants and say, Have a nice day.

That's what they found in the original studies of teenagers on anti-depressants. They were usually prescribed "harmless" SSRI’s, a class of anti-depressant medication. But once they felt better, they were set free and some did kill themselves (between visits). Their doctors had let up, stopped seeing them weekly after the symptoms of depression abated. The decision may have been based upon the economics of medicine and managed care that managed too tightly.

We have known for a long time that some of the SSRI’s (Prozac was the devil) could trigger a psychotic episode in people with bi-polar disorder. The mania and Prozac didn't jive. But now Paxil is commonly used, often as a "life-saver" in the treatment of bi-polar disorder. Patients are watched closely, of course.

I am not a medical doctor and cannot prescribe medication for my patients. But I will tell you that I feel that I have to recommend medication evaluations for very depressed patients at all ages. It's simply the rule. Not doing a med eval is like washing the floor without sweeping.

If a medical doctor says that no, the patient does not need medication, then fine.

We insist upon a med eval because empirical study by the National Institute of Mental Health has consistently indicated that anti-depressants relieve the symptoms of depression. Once the physiological symptoms are gone (see more on this on another post), it’s much easier to change the dynamics that are contributing to the disorder.

The very best treatment, proven time and time again, is a cocktail of cognitive therapy AND medication.

Depression is a physiological condition.

And everything psychological is also biological. Thus medical intervention will effect negative symptoms, i.e., lethargy, lack of focus, confusion, etc. (see other posts on depression on this blog).

When a patient is really depressed, just participating in talk therapy, or working on reversing negative thoughts, changing behavioral patterns, can be futile, more painful because it may not work.

The quick and dirty? Don’t be afraid to see a physician about medication. But don’t walk away with a prescription and avoid real treatment. Treatment implies therapy, at least weekly in the beginning, sometimes more often. Sometimes I'll know that a patient needs to be in the hospital right away.

Unless your family physician is going to follow your child closely (or has someone like me doing that), get a psychiatrist to do the medication evaluation. The primary care doctors need to be informed, obviously.

And by the way. If your therapist is like me, he or she may see a tremendous amount of latitude here, may see cognitive, behavioral, family treatments, etc. as better options than medication in many, many cases. But if we say you need a medication evaluation? You do.

Copyright 2006, TherapyDoc


Julie said...

I really love this blog and I read every post! I especially could relate to the beginning of this post about parents and pressure and grades... Education was always (and still is) a big thing in my family and a lot was expected from me and my siblings when we were in elementary and high school. I just wish someone could have reinforced the fact that life is not about getting A's to me back then. It would have made school a little bit more enjoyable!
Excellent blog!

Therapy Doc said...

Thanks Julie. I really appreciate your feedback. School should be about establishing good friendships and learning how to learn.

Who knew?

Brony said...

Great advice.

Mark Brown said...

Gaining an education and getting excellent grades are looked at as the same thing in many families and society in general. I agree that although it is tempting to pressure a person to achieve high grades, the truth is at the end of the day it is not the grade that matters, it is the gaining of the wisdom to understand how to best use the knowledge being taught which is the desired result. One thing I learned a few years back is that when a child does get a good grade, say "You should be very proud of yourself" notice you are not saying that you are proud, you are reinforcing the self pride, self image and confidence. This takes the pressure to please Mom and Dad away from future achievements and places the pressure/pleasure of achieving good future grades on the child. I believe that the reason that most teen suicides are a result of academic pressures is because the child does not want to disappoint the parent.

Katy Murr said...

mark brown -

you probably won't check this again to read it, but I'll reply incase you do. :)

I'm with you 100% about the 'you should be very proud of yourself' - my parents are really great in the way that although I am academic, they don't really add extra pressure, such as economic incentives to get the best grades/ economic punishment if you don't (which a lot of my friends' parents do). I've always got a 'well done, that's really great, you should be proud', or something along those lines, and maybe a couple of chocolates or my favourite dish cooked one night. Oh, and I get a book allowance, which is pretty cool, and encourages me to read, even though I don't need encouragement, because I enjoy it anyway!

Sadly, depending on the school, the knowledge often isn't what's being taught; but rather, as a result of so much examination, what is often taught is merely how to pass the exam; to fake-it, if you like. This makes enjoying learning difficult for anyone.

I think it's quite difficult for people generally to work out what they want and need, to separate this from parents' wants and needs for them, or that of their peers.

We're all afraid of disappointing people to some extent, aren't we? It's about how we learn to accept that a bit of that's normal, but that when it gets too much we need to try and manage it, so that it doesn't take over.

therapydoc said...

Fantastic, Katy.

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