Two of my patients, both teenage girls, were hospitalized for suicide attempts within the same week. Both had a history of depression, substance use and suicidal ideation, but both were seeing therapists at our practice and seemed to be stable.
At our small family medicine health center in Brooklyn, a satellite of a larger federally qualified health center system, the medical and mental health departments are remarkably integrated. Morning huddle often includes a minute or two dedicated to general updates on patients who are shared between the medical side and the behavioral health side. I usually love these moments because I learn about the human psyche and my own interactions with patients. However, hearing about the suicide attempts by two intelligent, promising young women first thing in the morning set a gray tone I couldn't shake.
That was four months ago. Since then, I learned both girls are safe. Our mental health clinicians monitored their transition from hospital to outpatient program closely. Both have clear and regimented plans with lots of family support. Recently, I had a follow-up visit with one of the girls and we talked about her experience. (She agreed to let me use her story for this post.)
This suicide attempt was her first, but she said she had seriously thought about it before. In March, she started to drink heavily, triggered by the loss of a friendship. One day, in a drunken state, she took an entire bottle of antidepressants, which she previously took appropriately. She does not think she would have taken the pills if she had been sober.
She was hospitalized for a month, then sent to a partial hospitalization program (usually six hours a day, five days a week), and is now in a day program (four hours a day, four days a week) that seems to be going well. Her relationship with her parents has changed for the better, a change she says was catalyzed by the suicide attempt. She still expresses a continued "sense of loneliness," and some days feels "deeply suicidal," but now has stronger connections to lean on in those moments.
During our conversation, I mentioned that I started reading more about teen suicides after her admission to the hospital. I shared a recent JAMA report indicating that suicides among adolescents have increased to their highest point since 2000.
"Do you think the increase is due to the political climate?" she asked. "I know that for me, the future seems hopeless sometimes."
I was surprised to hear my patient think of the political climate as a risk factor, although it is an idea I have heard before: Greater internet access to mixed media and political messages on cultural, racial and gender identity, climate change, and personal safety could lead to more uncertainty, depression and anxiety for today's youth.
Suicide in teens is usually correlated with factors such as depression; anxiety; school pressures; social media use; substance abuse; and exposure to violence, trauma, mass media and cyberbullying. Even television has been suggested as an influencing factor.
After the release of the second season of Netflix's 13 Reasons Why, a show about a teenage girl who commits suicide and leaves behind the 13 reasons she did it, the AAFP aggregated resources for teens and their parents who have questions about suicide. The show garnered a lot of attention as a potential influence for teens with suicidal ideation or plans. In fact, a study published in the Journal of the American Academy of Child & Adolescent Psychiatry in April concluded that the show correlated with a significant increase in monthly suicide rates among adolescents ages 10-17, although causation could not be determined. The study advised caution in exposing youth to the show. (My patient said she does not watch the show but has heard about it and knows peers who watch and enjoy it.)
Regarding social media use, I asked if my patient had considered shutting down her Facebook and Instagram accounts. She wasn't surprised I suggested it, but she was incredulous that I would ask her to get rid of her primary connection to the world.
"I mean, I really only use it to keep in touch with my friends," she said with a wry smile. "But maybe (getting off social media) is a good idea."
Our chat spilled over into my next patient's appointment time. The lack of time was frustrating for me, but I knew her day program would be a more consistent source of therapy and counseling. I asked her and her mother to follow up in one month, just to give her additional support before school started again in the fall.
I usually reserve talking about depression and anxiety for adolescent annual visits. During those visits, I -- like many other family physicians -- ask whether my patients are using substances such as alcohol, opiates, marijuana or other mind-altering agents. I ask about bullying at school; feelings of safety; unwanted and uncomfortable touch; violence in the home; feelings of sadness, loneliness and worry; and thoughts of self-harm. I also purposefully review topics such as sexual consent and what to do if a friend talks about depression or thoughts of hurting him- or herself. But I know when I am in a rush, I fly through these talking points, and the gravitas that helps relay their importance is not always there.
Because of our practice's specific interest in mental health (with readily available interventions and resources in the form of access to psychiatry and therapists), we are good at screening all age groups for depression and anxiety with the PHQ-9 and the GAD-7 scales. I have mixed feelings about these screenings because some patients find that completing the screening tool makes them realize how depressed they are. That realization brings a lot of concern and worry to the forefront. For the most part, however, I'm thankful I have the opportunity to address anxiety and depression, especially when I can connect patients to the appropriate resources and treatment.
In this patient's case, she was already connected to these resources and was in treatment for her longstanding depression even before her suicide attempt. I asked if there was something we could have done to prevent it. She felt the attempt was inevitable, and that in a way, for things to change for the better, it needed to happen.
Somewhat shocked by her comment, I tried to have her consider other ways to express her desire for change. I wanted her to know that her health care/mental health professionals, parents and teachers could be advocates for her if she was having trouble communicating her frustration. I wondered to myself if there were more pointed questions that I could have asked beforehand, or perhaps additional support we could have given her. In retrospect, I'm not sure I could have prevented this attempt. I'm simply thankful that it didn't end in death.
At the end of our follow-up, with Mom back in the room, I told my patient that if she is ever feeling overwhelmed again, she can always come to our practice. She is familiar with the suicide hotline and is no longer drinking alcohol or using any other substances. Things seem to be better. I hope they stay that way.
Lalita Abhyankar, M.D., M.H.S., is a family physician practicing in New York City. You can follow her on Twitter @L_Abhyankar.