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.

BUT DON’T PRESSURE THEM ABOUT THEIR GRADES.

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.

BACK TO DRUGS.

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