I know what it's like to be falling. Now that I'm on solid ground, I can't stop, won't stop, trying to lift others up.
In 2016, suicide was a leading cause of death in the United States—tenth overall, second for ages 10-34, and fourth for ages 35-54—and there were twice as many suicides as homicides (1). The rate of suicide increased 28% from 1999 to 2016 (2).
My patients, many of whom suffer from anxiety, depression, bipolar disorder, or substance abuse issues, are often plagued with suicide ideation and suicide attempts. No demographic is spared. Suicide intentions are a common discussion point in my office. Just yesterday, a 12-year-old and a 19-year-old were in the throws of intense suicide ideation and we spent the sessions (along with a parent for the 12-year-old) figuring out ways for the young people to distance themselves from those life-ending considerations.
Given the tragic and heartbreaking suicides of Kate Spade and Anthony Bourdain this week, I wanted to offer one of my psychiatric perspectives on suicidal thoughts, perhaps it can contribute a little to the conversation. When patients with anxiety and/or depression reveal active suicide ideas or plans, or a history of, I teach them that suicidal thoughts are their mind’s red flag, a warning that they’re completely overwhelmed and need to ask for help, not a literal edict to kill themselves. I will start the discussion with something like this, “I’m so sorry you’re having these scary suicidal thoughts. I know they seem unavoidable but let’s take a step back for a bit, ok? What if I told you the suicidal thoughts are your mind’s red flag and it’s waving it, shouting, ‘Hey! Stop! You haven’t asked for help with all the spiraling negative thoughts and feelings and now you’re completely overwhelmed! I need some relief, I need to feel in control. Please get some help, ASAP!’ What if I told you that not only are your suicidal thoughts a red flag but also your mind’s secret code, and that you and I can decipher the code and get to the real issues, which are NOT anything that involve killing yourself. Imagine if you had asthma and you were around smoke or allergens, you’d probably cough or wheeze, right? The coughing and wheezing are symptoms of the asthma when you are around an irritant. Similarly, the suicidal thoughts are a symptom of your anxiety and depression when you are overwhelmed and haven’t expressed your true thoughts and feelings to others, which we’ve been working on in therapy but takes awhile to master. It’s important that you don’t act on the suicidal thoughts, but accept that they are your mind’s tricky signal that you need to figure out what’s really going on. Let’s do that now. Tell me about…”
Depending on the age of the patient, I will make the above discussion more or less sophisticated. It is wonderful when patients have their aha moment with suicidal thoughts being a red flag, and not a word for word command.
Suicide prevention is multifaceted. Here are some basics that I hope everyone becomes familiar with:
Know the sign and symptoms of someone thinking about suicide. Examples include: talking about wanting to die or kill themselves, talking about feeling hopeless or having nothing to live for, making plans or researching ways to kill themselves, talking about feeling shame, unbearable pain, or being a burden to others, using drugs or alcohol more often, acting different (more anxious, agitated, or withdrawn), more intense mood swings, giving away possessions, or saying goodbye.
Know the risk factors. Common ones include: depression, other mental disorders or substance abuse disorders, some medical conditions, chronic pain, a prior suicide attempt, family history of a mental disorder, substance abuse, or suicide, family violence and/or abuse, having guns in the home, or being exposed to others’ suicidal behavior (like a family member, friend, or celebrity).
Have an action plan.
Ask them if they are thinking about killing themselves. Don’t worry, asking directly “Are you thinking about killing yourself?” doesn’t make them do it.
If the suicidal person has a plan, try to get them away from lethal items or places.
Listen and talk to the person. This will not increase suicidal thoughts, but rather the opposite.
National Suicide Prevention Lifeline 1-800-273-TALK (8255)
Family member or friend
Mental health professional
Keep in touch with them if possible.
1 Centers for Disease Control and Prevention WISQARS Leading Causes of Death Reports
2 Centers for Disease Control and Prevention Fatal Injury Data Visualization
My teenager looked over my shoulder as I finished typing the first draft of this blog post. She proceeded to roll her eyes and mutter, “Ugh. This is our household.”
I smiled a satisfied smile to myself because, yes, this is our household.
Outside of my household, I’m a child and adolescent psychiatrist and I have the privilege of guiding young people through individual talk therapy to help them overcome mental health issues such as anxiety, depression, eating disorders, post-traumatic stress disorder, reactive attachment disorder, etc. Sometimes there are also complex family dynamics at play that require specific family interventions such as parent education or family therapy.
Over the years of doing individual child and adolescent talk therapy and family therapy, I’ve found that without a certain baseline, non-negotiable structure at home, therapy isn’t as effective or lasting. Because without this basic structure, it is that much more challenging to navigate the muddy waters of mental illness and that much more challenging to even begin to negotiate normal social, emotional, physical, and/or intellectual developmental tasks. Without limits and rules at home they may become even more entrenched in their mental illness. And a lack of boundaries doesn’t just affect youth with mental illness. It can negatively impact any young person.
So what is this baseline, non-negotiable structure I recommend? It’s three simple rules for children and adolescents that parents can enforce.
Social media and screen time - 2 hours a day maximum, but less is better.
Uninterrupted sleep time - 9-10 hours each night.
Family meals - eat together as often as possible.
I apply these rules to my own tween and teen. I recommend the rules for all youth in general, as well as for the youth I treat. Let me give you a bit more detail on each rule.
Social Media and Screen Time
More studies are coming out about the detriment of social media and prolonged screen time. The bottom line is that excessive electronics isolates and prevents youth from learning about normal face-to-face interactions with people, which are an important part of development and happiness. The worst case scenario regarding isolation is that it is a risk factor for suicide. But being plugged in for two or more hours a day can also lead to a significant increase in suicide risk factors.
When youth have their heads buried in screens they are not self-reflecting or thinking independently. It’s not their fault that they want to stare at all the dazzling images and words on their screens. See youth do not have fully developed abstract thinking so they are more vulnerable than adults to being swayed by what flashes before their eyes. That’s also why they are more susceptible to peer pressure. So they see these fancy, filtered images and words and they may become convinced that they have to look and behave that way. They may think they have to get a certain amount of comments and likes to be worthy. They may engage in excessive texting or messaging that doesn’t allow them to learn the nuances of social communication (facial expressions, tones in voice, etc.). They may be vulnerable to online bullying. They may be constantly thinking they are missing out. They may live through their screens instead of in the moment. All of this can impair their ability to move through the normal stages of social, emotional, and intellectual development.
Incidentally, I quit social media. My tween and teen are not allowed to have social media. I figure I should practice what I preach, right?
Poor sleep in youth can lead to negative outcomes such as struggles in school, car crashes, and/or depression. Numerous studies have shown that 9-10 hours of uninterrupted sleep is optimal for youth, especially teens because they are in an intense stage of physical, intellectual, and emotional growth.
It is helpful to remove all electronics from their bedroom at bedtime (except a good, old fashioned alarm clock) because teens will often surreptitiously use these devices in the middle of the night. They are not bad for doing this. Testing boundaries is part of normal teen development and it is up to parents to set and enforce the limits to help guide and teach them.
Most kids will not happily go to bed early, my kiddos included. They will most likely complain and fight it. They may also panic because they haven’t finished their homework. But in the long run, sleep is more important. Parents can rest assured that despite what their youth say, setting strict bedtimes helps with brain development and teaches youth to make more efficient use of their time. It may even bring up the issue of cutting back on extracurricular activities if there really isn’t enough time to get homework done. This raises another issue—that youth need time to be bored to help with their normal emotional and intellectual development. But that’s for another blog post.
Eating Meals As a Family
In this day and age of being overscheduled, I cannot overemphasize the importance of eating meals together as a family. I recommend decreasing youth activities if this will allow for more meals together. That’s how important it is. Eating meals together, especially dinners, teaches kids about face-to-face communication. It also can lead to better family relationships, improved nutrition and enjoyment of food, boosted grades and vocabulary, decreased depression and stress, increased ability to bounce back from bullying, improved overall mood, and fosters a positive outlook of the future.
As a side note, there is a trend in our society to eliminate more and more types of food from our diets. The science behind this “purer” eating is not crystal clear. There are many factors besides food that contribute to overall health and longevity. Still, it is not uncommon for people who don’t have medical reasons for dietary restrictions to cut out all meat, gluten, dairy, sugar, etc. For adults, this is a personal choice and I’m not addressing that right now. But children and teens have different nutritional needs than adults and it can be dangerous for youth to be eating “pure,” “clean,” vegan, or some other restrictive diet unless they are properly monitored by a parent who can make sure they are getting enough calories, protein, vitamins, and minerals. Chronic lack of these nutrients can lead to medical problems and organ damage.
A typical example I see in my practice is the teen girl athlete who restricts her food intake and then doesn’t get enough calories to maintain her high activity level. She loses weight and stops having her period. Contrary to what some people think, it isn’t normal for a girl athlete to not have a regular menstrual cycle. Also parents need to be aware that restrictive diets can be a guise for eating disorders. In fact, "healthy," restrictive eating is the most common trigger for eating disorders in teens that present to my office. Eating disorders are complex and can have devastating consequences, including death.
If the family does not have long established exclusionary food preferences or practices (such as for religious or diagnosed medical reasons), I recommend that youth not be allowed to suddenly follow any restrictive diets. They can make up their own minds when they are eighteen but until then parents can protect them by normalizing inclusive, structured eating- regular meals and snacks, normal portions, preparing and offering a variety of foods, not making negative comments about certain foods, ingredients, or bodies. This makes it less likely that the youth will have disordered eating when they grow up. This makes it less likely that the youth will link food with control and self-worth. They will be more likely to grow up with the understanding that food is simply fuel and nourishment, not a means to happiness, and most certainly not who they are.