Physicians’ Perspective
Mental Illness & Suicide in Teens: Myths, Facts and Solutions
by Dr. Rick Bayer

During winter holidays when most were in high spirits, the New England Journal of Medicine (NEJM 12/28/2006) launched a sobering issue about the epidemic of mental illness in teens, risk factors for teen suicide, and the quandary of antidepressants for adolescents.

Suicide Background
Richard Friedman, MD, reminds us suicide is the 3rd leading cause of death among persons 15 to 19. The US Centers for Disease Control and Prevention reported in 2005 that 17% of high school students seriously considered suicide and 8% attempted suicide at least once during the previous year. Friedman recommends mental health screening in public school because the median age for onset of mental illness is 14. The median age for onset of anxiety disorders and impulse control disorders is the young age of 11, while the median age for onset of substance abuse is 20, and mood disorders is 30. Preliminary screening shows parents are unaware of 90% of teen suicide attempts and the vast majority of teens who attempt suicide give no warning.

Although true that suicides can cluster or be “contagious”, it is a myth that asking about suicidal thoughts plants ideas. After they were asked about suicidal thoughts, high-risk teens actually reported feeling less depressed and less suicidal. My experience is that appropriate empathy helps patients feel safer and more willing to work on difficult problems.

Physicians David Brent and John Mann write about risks for suicidal behavior, including genetic vulnerability and environmental triggers. Suicidal behavior under age 25 has a significant genetic component. A major risk is “impulsive aggression, defined as the tendency to respond to provocation or frustration with hostility or aggression”. Psychological testing, brain imaging, and biochemical testing demonstrate abnormalities in persons with suicidal behavior and impulsive aggression. For example, a naturally occurring mood-controlling brain hormone called serotonin is predictably lower in persons with suicidal behavior or impulsive aggression than in healthy persons. Childhood abuse or neglect increases risk of suicide. Risk factor evaluation is imperfect at predicting suicide; but impulsive aggression, poor judgment with poor interpersonal skills, and family adversity should be targets for prevention and treatment.

At the NEJM website www.nejm.org, Cynthia Montgomery discusses the loss of her 14-year-old son to suicide. She relates his early behavioral changes and her efforts to get help for her son. Her moving interview emphasizes the seriousness of an illness too often fatal—even when treated by child psychiatry specialists at Harvard-affiliated Massachusetts General Hospital.

Gregory Simon, MD, concludes this special section of the NEJM by discussing antidepressant medication in adolescents. In 2004 and 2005, the US Food and Drug Administration (FDA) issued public health advisories regarding worsening depression, suicidal thoughts, and suicidal behavior in some patients treated with antidepressant drugs. The FDA issued warnings because medication studies suggested antidepressants were associated with an increased risk of suicidal behavior in children and adolescents. But other studies show that risk of suicide attempt lessens with drug treatment. And, the increasing use of antidepressants in children and adolescents has not resulted in increased suicide rates. In spite of risk and uncertainty with drug treatment, Simon recommends confirming the diagnosis of depression. Then, if choosing drug treatment, start with Fluoxetine (brand name Prozac) as it is the only consistently effective FDA-approved drug for treating depression in children and adolescents. Sadly, appropriate antidepressant therapy does not guarantee good results.

University of Washington (Seattle) psychologists Katherine Anne Comtois and Marsha M. Linehan reviewed psychosocial treatments of suicidal behavior in the February 2006 Journal of Clinical Psychology. They found “a number of outpatient and often quite brief psychological treatments to be effective for patients following a suicide attempt or other self-inflicted injury, including and maybe even particularly for individuals at high risk of repeat self-injury.”

Mental and Physical Health/Universal Healthcare
How does this information translate to care of Oregonians? Specialists concentrate in urban centers while much of Oregon is rural. Oregon’s new mental health parity law now means mental health is treated the same as physical health—but only by group insurance plans. Those with individual policies or no insurance were left out of this partial solution. And, those who think they are now covered face “medical necessity” denials from the insurer. In other words, even after parity, there remains a patchwork of healthcare out of reach for many Oregonians.

In all fairness, mental healthcare should have always had parity with physical healthcare. But, even parity is a small patch on a huge failed system. A recurring theme of the NEJM authors and psychologists is the value of follow-up care. They uniformly say that nothing works well if patients don’t take their medicine or don’t see their doctors. Without healthcare for everyone, how can teens continues care when they are young adults and how can families of teens get family counseling? Our failed healthcare system is the reason outcomes for depression treatment have not improved over the last 20 years.

In my opinion, piecemeal healthcare reform without universal coverage is a mistake because we always leave someone out while losing both the public health advantages and cost-savings of a single-payer universal healthcare system. For example, administrative costs in the “for-profit” sector can be 5 to 10 times higher than in America’s 40-year-old experiment with our single-payer system called Medicare. American history shows that when healthcare is treated like a consumer good, profits always trump health. For example, it is shameful that healthcare costs are the most common cause for bankruptcy in the US. For those who seek more evidence, we only need look at better health outcomes for citizens in countries with universal healthcare. If Americans were serious about preventing teen suicide, we would demand universal healthcare from our politicians immediately. Neither teenagers nor anyone else should die waiting for Big Insurance and Big Pharma to reach financial satiety or, even less likely, decide to support the common good through sustained generosity. Until we have universal healthcare, activists and politicians are applying another small patch on a life-threatening hemorrhage.

To learn more about universal healthcare, see Physicians for a National Health Program www.pnhp.org including the link to HR 676. In Oregon, former Governor John Kitzhaber MD is proposing universal healthcare via the Oregon Better Health Plan www.WeCanDoBetter.org.

Richard “Rick” Bayer, MD, FACP is board-certified in internal medicine, a Fellow in the American College of Physicians (FACP), practiced, and lives in Oregon. He is member of Physicians for a National Health Program www.pnhp.org