Will's Choice

by Gail Griffith

  No discussion of depression and mental illness is complete without taking into account the role played by genetics. During the nineteenth and early twentieth centuries, vast repositories of the mentally ill were homeless, destitute, or confined to asylums. Stories about a “crazy” aunt or uncle locked away in a closet upstairs wound their way through family lore. Almost every family had one such tale. By the middle of the twentieth century, effective treatments became available for people suffering from debilitating mental illness, and for the first time the mentally ill began leading more normal lives. As lives improved, so did attitudes about the mentally ill. But not entirely.

  Today, people with chronic mental illnesses, such as bipolar illness or major depression, anxiety disorders, and even schizophrenia, are marrying, raising children, and living productive lives—and passing genetic predispositions for mental illnesses along to future generations.

  Much more work will have to be done by scientists and the medical establishment, along with a more concerted effort by parents and educators, to build support for a rigorous public policy debate to determine why we are seeing an increase in major depressive disorder in teens. It is a horrific problem with far-reaching consequences and it is not going to vanish in our lifetime. The causes may indeed be physiological or biological; illness may be a function of genetics or it may be the social ecology. I argue it is no one thing; it is an anomaly: depression is a combination of all of these factors and it will require monumental and collaborative efforts on the part of the medical and therapeutic communities, the government entities charged with protecting the public welfare, and educators to come up with dynamic new initiatives to tackle the problem.

  Identifying and diagnosing teen depression presents an entirely different and more complex set of challenges than diagnosing depression in the adult population. Adolescents’ inclinations toward impulsivity, volatility, and delusional thinking (particularly about death and their own mortality) challenge conventional depression treatment regimes designed for adults. And initiatives designed to preclude suicidal teens from taking their own lives must be tailored to adolescents with a natural predilection for engaging in risky behavior.

  In order to reduce the number of teen suicides, a number of steps must be taken, but first and foremost among them is accurate diagnosis.*

  I have watched family and friends struggle to ferret out what is really going on with their teenagers, and I have concluded that parents today are ill-equipped to steer their children through the rugged terrain of mental illness. Worse still, we have so little confidence in our judgment about what is best for our children that our anxiety over doing the “right thing” often results in doing nothing at all.

  In a 2003 survey of American families, ninety percent of parents indicated they were “confident in being able to tell if their child was depressed or thinking about suicide.”11 But in reality, the findings go on to state that “only one-third of teens with mental health problems are known to parents or any adult.”12

  Sometimes families of troubled teens refuse to accept the overwhelming evidence pointing to a child with depression when it is right in front of them. Drugs and/or alcohol abuse, risky sexual behavior, truancy, petty larceny, and self-mutilation (including eating disorders) are all in their own way a cry for help; take two or more of the behaviors together and alarm bells should go off.

  Often, parents confronted with the challenge of handling a troubled adolescent see the problem as a reflection of their own parenting skills—or lack thereof. They worry they will be judged harshly by the community if they own up to a “failing” kid. Some families worry that if they tag a child with a “mental illness,” the label will stick and preclude the teen from reaching the heights the parents envisioned before the illness struck.

  How can a parent, who professes to “want the best” for his or her child, believe the problem is better ignored than tackled head on? Maybe, by denying it exists, you hope it will just go away of its own accord. All of us engage in a bit of denial when it comes to raising our children, but as most of us have learned the hard way, the problem almost never recedes on its own—and it usually gets worse before it improves.

  Even parents adroit at intuiting the magnitude of their child’s malaise would rather wish the problem away, but if you suspect your teen is depressed, doing nothing is a luxury you cannot afford.

  Look at the statistics on teen suicide and they paint an ominous picture. Over two thousand American teens, aged thirteen to nineteen, commit suicide each year.13 Include young people up to age twenty-four and the number of suicides doubles. Of the approximately 2 million young Americans who attempt suicide in a given year,14 girls are two to three times more likely to attempt suicide than boys, but teenage boys are four times more likely to die from an attempt than teenage girls.15

  All suicide attempts should be taken seriously. Each year almost seven hundred thousand teens receive medical attention for suicide attempts;16 but there is a presumption among the medical community that suicide attempts by girls are more often a “cry for help,” whereas boys’ attempts are riskier, more impulsive, and hence more lethal. And it is telling to note that nearly sixty percent of completed suicides committed by young males are carried out with firearms or explosives.17 Is it any surprise that in the United States firearms are the most common method of suicide for both genders and all ages and ethnic groups?18

  If you break the statistics down by gender—how adolescent males versus females approach suicide—the facts speak to the fundamentally different ways in which we raise boys versus girls in our culture. Despite the fact that the suicide rate for young males is higher than for girls,19 over the last two decades we have seen a marked increase in self-destructive behavior among adolescent girls, initially showing up as eating disorders or sexually risky behavior. Most recently, depression in teenage girls has taken shape in the form of self-mutilation, or “cutting.”

  You do not need to be a member of the psychiatric establishment to presume that these grotesque manifestations of self-loathing stem from low self-esteem. Our teenage daughters are struggling to calculate their worth in a society replete with mixed messages.

  It also reflects poorly on our society that gay, lesbian, and bisexual teens are more likely to attempt suicide than their straight counterparts. This group is subjected to a multitude of risk factors (depression, substance abuse, sexual victimization, family conflict, and ostracism at school).20

  But here is the clincher: whether male or female, gay or straight, a teen who has made a previous attempt at suicide is “100 times more at risk of completing a suicide than one who has not made an attempt.”21 Often the second attempt follows in close proximity to the first and is much more serious.

  This last statistic is particularly worrisome for parents of depressed teens. In 1999, roughly one of every thirteen high school students in the United States reported making a suicide attempt the previous year.22 Dr. David Shaffer, of Columbia University and a leading authority on teen suicide, suggests that roughly twenty percent of high school students will have contemplated suicide in any given year.23 Given that there is sufficient anecdotal evidence to suggest that only a fraction of teens report making a suicide attempt, how are we to know whether or not a child has made a previous attempt—or two or more?

  There is yet another and perhaps more troubling pattern among suicidal teens. It turns up more often, but not exclusively, in adolescent males, and has been underexamined and underreported. I call them the “stealth” candidates for suicide—the kid next door who appears to be doing just fine, the type of kid my son Will appeared to be.

  How often have we seen media reports of the “star athlete” or “president of the student council,” or the kid voted “most likely to succeed”—the teenager with everything going for him—who comes home on a Saturday night and with no warning loads a gun and shoots himself? If there is a suicide note, it is vague in the extreme—“Sorry for the inconvenience,” or �
�I just couldn’t handle stuff anymore.”

  This type of kid typically closets emotions, while aiming at goals and self-imposed standards that are impossible to meet; he is a “high-achieving, anxious, or depressed perfectionist,” writes Kay Redfield Jamison. She concludes:

  It may be difficult to determine the extent of such a child’s psychopathology and mental suffering, due to the tendency to try to appear normal, to please others, not to call attention to oneself.24

  While one category of depressed teens resorts to angry, explosive, oppositional behavior or demonstrable self-abuse, another masks feelings and emotions. Both pose challenges to proper diagnosis and treatment.

  Finding a doctor, a psychiatrist, to treat a young person is a huge challenge. The reality is harsh: psychiatry is the poor cousin of the medical establishment, and within the practice of psychiatry, few doctors sign up for child and adolescent specialties.

  Beyond four years of medical school, it takes a doctor at least two or more years to be trained in psychiatry. But once qualified to practice, psychiatrists are constrained by the health care system from achieving financial parity with their peers in pediatrics, or gerontology or other specialties, because of a punishing insurance reimbursement schedule biased against the treatment of mental illness. It is no surprise that so few doctors elect to practice adolescent psychiatry.

  Adequate mental health care for families and adolescents will only be achieved by forcing insurers to treat mental illness on a par with physical ailments. Bipartisan congressional legislation to address insurance parity is slowly making its way through the U.S. Congress. Although the legislation does not stand much chance of passing in the near term, there is an ever-growing recognition by our politicians that health plans need to cover the treatment of mental illness.

  Statistics vary, but the mental health community argues that only ten percent of depressed adolescents receive proper diagnosis and treatment. When parents suspect a child is crossing that fine line between “normal” adolescent behavior and something more troubling, their first stop is often the family doctor or pediatrician. Some general practitioners are excellent at diagnosing depression in children; others are not. It takes skill and practiced observation, which I argue comes after years of practice in the field of mental health.

  If the family is lucky, the general practitioner will refer the child up the food chain to a specialist to render an accurate diagnosis—and prescribe a course of treatment. But again, because of the contractions in the health care system, which have occurred over the past decade, younger patients are rarely seen by a mental health clinician or psychiatrist. Unless a parent directly requests a referral, most doctors are too busy or lack the skills to pick up a signal or symptom.

  Oftentimes parents are dissatisfied with the care their teenagers receive from mental health clinicians. More often, the teenager mistrusts the intervention of a psychiatrist or psychologist. But since it’s much harder to track recovery from mental illness than, say, a broken collarbone, patients and parents who don’t see immediate improvement often fault the doctor.

  Clearly, if your child refuses to communicate honestly and openly with his or her doctor, and after six or more months your child shows no signs of a recovery, there is a problem. And a good doctor knows to keep an ongoing dialogue with the parents, too. If you’re not receiving regular status reports on your child’s progress (or lack of progress), do not hesitate to demand more frequent communication. For treatment to succeed, everyone—the child, the doctor, and the parents—needs to be on board with the treatment regime.

  Movement is afoot to allocate more government funds for accurate diagnosis and treatment of young people in an effort to reduce the number of teen suicides.

  One ambitious new program that will benefit from the congressional funding is Columbia University’s TeenScreen, developed by Dr. David Shaffer and his colleagues working in the field of adolescent depression and teen suicide. The program, run by Laurie Flynn, a leading children’s mental health advocate, works with state and local communities to promote and provide a “mental health checkup” for high school–aged kids. By the end of 2004 TeenScreen was active in nearly three hundred communities nationwide.

  Unfortunately, mental health screening has run into a buzz saw of criticism from conservative elements who characterize screening as an unwarranted breach of family and privacy rights by federal and local officials. But if we screen school-age children routinely for vision, hearing, and physical well-being, why shouldn't we screen for their emotional well-being as well?

  TeenScreen’s model involves a two-step test, administered with parental notification and parental consent, that includes a prescreening questionnaire followed by a computerized interview program. Because studies show that young people are far more willing to submit to a computerized probe of their emotions than a face-to-face interview with a counselor, TeenScreen’s interactive methodology finds teens are more inclined to answer the computer questions honestly.

  The initial concern that screening adolescents for suicide was harmful and would lead to an increase in suicidal thinking among suggestive teenagers was examined by a team of child and adolescent psychiatrists. Their findings were surprising and counterintuitive. “High-risk” teens—kids with symptoms of depression or a prior suicide attempt—who were asked outright whether they were harboring thoughts of killing themselves “were neither more suicidal nor distressed than high-risk youth in the control group; on the contrary, depressed students and previous suicide attempters in the experimental group appeared less distressed and suicidal respectively, than high-risk control students.”25

  As a parent, it's hard to know what to make of these findings. Perhaps by broaching the worry head-on and asking your child directly, “Are you thinking of killing yourself,” you are breaking the shell of taboo and discomfort—for both of you. Perhaps it provides an opening or even a measure of relief that allows the depth of the pain to be expressed bluntly, directly.

  After scrutinizing suicide awareness programs for teen populations, Dr. Shaffer concluded that programs designed to counsel and educate adolescents about suicide often fail to address the root cause of the problem: undiagnosed and untreated depression. In fact, research shows that school-based suicide awareness programs (as opposed to programs designed to teach adolescents how to recognize depression) are not always beneficial.26 Opening up the classroom to a general discussion of suicide “makes some kids more likely to try to kill themselves.”27 Since “suicide clusters” or copycat suicides often follow a single tragic incident that subsequently receives excessive media or community attention, a thoughtful dialogue between students and educators (and/or health professionals), emphasizing the markers and triggers for teen depression over suicide, better serves our children and helps prevent susceptible adolescents from being sucked into the vortex of suicide.

  Programs are underway to develop curricula28 for family practitioners and pediatricians that will help sharpen their tools for diagnosing and treating young people at risk of suicide. But if we really hope to save the lives of children and adolescents, everyone in the community—school counselors, teachers, clinicians, public health and welfare agencies, and volunteer organizations—will have to pitch in and collaborate.

  In 2004, a landmark funding bill was enacted, allocating $82 million over three years for mental health screening at the state and local level. Monies are being distributed through the Center for Mental Health Services of the U.S. Department of Health and Human Services. Compare $82 million to billions spent on military spending and disaster relief. It’s a drop in the bucket, but it’s a start.

  If there is a hurt more wrenching than watching your child suffer, I do not know it. There is no doubt that we are raising our kids in a difficult time—we are in uncharted territory. But there is “normal” adolescence and there are teenagers who suffer from depression. The two are very different.

  Time is the antidote for the bruising volatilit
y of adolescence. If your teenage children are safe and relatively content, chances are by the time they’re in their early twenties you can begin to relax. But if your child were battling cancer, you would not sit by and wait for the disease to run its course. And if your teen is depressed, he or she is up against a life-threatening illness and you need to seek help. Immediately.

  3

  TUNNEL VISION

  Three days after his suicide attempt, Will was admitted to the Psychiatric Institute of Washington for the second time in two months. I sat next to him on a couch in the dreary, dimly lit lobby with his four suicide notes in my purse, ready to turn them over to Dr. Salerian. The letters were the hard evidence linking him to his “crime,” and for his transgressions he would pay the price: involuntary commitment to a mental hospital. As a society, we are notably lacking a better solution to treat a suicidally depressed person—either an adult or a child.

  I have thought long and hard about how this setting—any institutional setting for the treatment of mental illness—could be improved upon. Shouldn’t there be generous amounts of natural light and pleasant music? Certainly. Something pleasing to look at, such as an aquarium, an aviary, or a garden, instead of a droning television in a common room? Exercise, meditation, and fresh air? Maybe a cruise ship with no specific destination, just blue sky and water? Bed linens that don’t imprison you in the smell of institutional detergents? Perhaps even little chocolate mints on the pillows? (Please, no Enya tapes.) A staff that radiates kindness and good health and a knowledgeable kitchen chef adept at preparing meals people actually want to eat? And, while I fully understand the need to protect suicidal individuals from doing harm to themselves with sharp objects, how many of us really enjoy eating with plastic utensils unless we are required to do so by aviation authorities while airborne?