Successfully Dealing With Teen Self-Harm Behavior

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Successfully Dealing With TeenSelf-Harm Behavior

• Oregon School-Based
• Health Care Network
• Annual Institute
• October 12, 2007
• Kirk D. Wolfe, M.D.

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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

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Oregon Youth Suicide Facts- 1990s

• 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

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Oregon Youth Suicide Facts-1999-2005

• 63 deaths per year- 16 decrease
• Why the decrease?

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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

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U.S. Youth Suicide Facts-1990-2003

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

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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?

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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)

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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)

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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)

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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

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Protective Factors

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

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Teen Psychological Autopsy-Case-Control Study

• Brent et al, JAACAP, 1993,32,3521-529
• Psychiatric Risk Factors for Teen Suicide
• (1) Major depression (OR27.0)
• (2) Bipolar mixed state (OR9.0)
• (3) Substance abuse (OR 8.5)
• (4) Conduct disorder (OR 6.0)
• 31 depressed suicide deaths-
• depressed lt3 months

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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

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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

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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

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Impact Of DepressionEmotional

• Youth
• Family
• Peers
• Classroom
• Workplace
• Juvenile Justice System

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Physical Effects

• Obesity
• Smoking
• Alcohol
• Drugs
• Heart Disease

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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

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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

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Possible Signs Of Depression

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

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Possible Signs Of Depression

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

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Why Youth Become DepressedBiopsychosocial
Approach

• Biological
• Psychological
• Social

Depression Is A Medical Illness
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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?
  

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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

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Evaluating Past Attempts

• Identify each attempt
• -lethality
• -context of relationships
• -theme with stressors
• -awareness/reaction of others?
• -receive treatment?
• -type of treatments? Compliant? Helpful?

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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 students self-harm?
• Want student to understand why you are
  looking
• to get support for the student

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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

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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

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Decreased Interest

• Im Bored
• Spends Much Time In Their Room
• Declining Hygiene
• Changes To More Troubled Peer Group Or Activity

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Change In Appetite Or Weight

• Being A Picky Eater
• Eats When Stressed
• Quite Thin Or Overweight

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Changes In Sleeping Patterns

• Delayed Sleep
• Multiple Awakenings
• Sleeps More Than Normal

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Psychomotor Agitation Or Slowing

• Agitated
• Always Moving Around
• Moping Around The House Or School

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Fatigue Or Loss Of Energy

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

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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

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Decreased Concentration

• Often Responds I Dont Know!
• Takes Much Longer To Get Work Done
• Drop In Grades
• Headaches, Stomach aches
• Poor Eye Contact

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Recurrent Thoughts Of Death Or Suicide

• Giving Away Personal Possessions
• Asks If Something Might Cause Death
• Wanting To Join A Person In Heaven
• Im Going To Kill Myself
• Actual Suicide Attempts

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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

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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

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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!

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Completing The Evaluation

• Screening Qs- Anxiety Disorders
• Psychosis
• ADHD
• Autism Spectrum Disorder
• Conduct Disorder
• Eating Disorder
• Sleep Disorder
• Personality Traits

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Completing The Evaluation

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

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Case Study

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

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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

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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

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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?

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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

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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
• Dont rely on a safety contract

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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

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Treatment

• Reestablishing Connections
• - with family, school, friends (psychosocial)
• - between neurons (biology)

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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

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Treatment

• Develop Interests
• Physical Exercise
• Good Role Models
• Spiritual Support
• The Dougy Center
• Support Groups
• (e.g. OFSN, NAMI)

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Treatment- Sleep

• Good nights rest essential
• Review whats normal vs. abnormal, how
• impacts the student (and others)
• Focus on reprioritizing students life to get
• sleep
• Focus on good sleep hygiene
• If not improving, consider medication

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TreatmentMedication

• Rarely The Answer
• Keep In Mind Target Goals
• Takes Weeks To Months
• Fluoxetine
• Other SSRIs
• Wellbutrin SR/XL
• Others

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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

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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

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Key PrinciplesMonitoring Meds in Children

• Start low, go slow, encourage patience
• Dont 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

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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 gt5 weeks
• Excluded dxs 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

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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

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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

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Antidepressants in Teens

• Prozac (fluoxetine)
• - FDA- approved in teen depression
• - more effective than placebo
• - low lethality in overdose
• - FDA- approved for anxiety (OCD)

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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

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Antidepressants in Teens

• Tricyclic antidepressants (Imipramine,
• Desipramine, Amitriptyline)
• - No more effective than placebo for
• depression
• - May be lethal in overdose
• - Avoid with suicidal teens

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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

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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

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Hesitant Families

• Dont Recognize The Warning Signs
• Believe Its Part Of Normal Adolescence
• Believe There Is A Good Reason To Be Depressed
• Might Be Viewed Crazy Or Weak
• Lack Insurance
• Youth Refuses Treatment

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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!

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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 42386-405.
• Muzina, D.J. (2007), suicide intervention
• How to recognize risk, focus on patient
• Safety. Current Psychiatry 630-46.

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References

• Centers for Disease Control and Prevention,
• Suicide Trends Among Youths and Young
• Adults Aged 10-24 Years- United States,
• 1990-2004. MMWR 2007 56905-908.
• - 2005 Youth Risk Behavior Survey
• www.cdc.gov/HealthyYouth/yrbs
• - 2005 Violent Death Reporting System
• www.oregon.gov/DHS/ph/ipe/nvdrs/index.shtml

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References

• 2007 Oregon Healthy Teen Survey
• www.dhs.state.or.us/dhs/ph/chs/
• youthsurvey/index.sh
  tml
• 2005 Adolescent Suicide Attempt Data
• www.dhs.state.or.us/dhs/ph/chs/data/
• arpt/05v2/chp8toc.sh
  tml

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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