Three articles available free from the December 28, 2006, issue of the New England Journal of Medicine deal with the troubling issues around mental illness in teenagers, including suicide.

Screening

“Uncovering an Epidemic—Screening for Mental Illness in Teens,” by Weill Cornell Medical College professor Richard Friedman, describes TeenScreen, a school-based mental health screening program that was developed at Columbia University and consists of having teens fill our a short questionnaire and then participate in an interview with a master’s level social worker or clinical psychologist, who attempts to determine if the questionnaire responses are “clinically significant.” If they are believed to be so, the clinician recommends a more comprehensive psychiatric evaluation to the teen and his parents. In 2005, TeenScreen screened 55,000 young people in 42 states and found that about one-third rated positive on the questionnaire. Half of those—about 17 percent—were referred for further evaluation after the clinical interview.

Dr. Friedman notes that although the screening is voluntary and requires active consent of the parents and assent of the teen, “Not everyone approves of screening teens for psychiatric illness.” One congressman has, in fact introduced legislation to ban the use of federal funds for such screening, on the grounds that the real goal is to make screening mandatory.

There is also concern about the high sensitivity but relatively low specificity of the screening instruments, a combination that leads to many false positive results. Friedman suggests, however, that the potential consequences of falsely identifying a teen as needing psychiatric evaluation “seem less dire than those of failing to identify a suicidal teenager. Stigma is real, but unlike suicide, it doesn’t kill.”

Families and Suicidal Behavior

In a second article, “Familial Pathways to Suicidal Behavior,” Doctors David Brent and J. John Mann, of the University of Pittsburgh School of Medicine and Columbia University College of Physicians and Surgeons, examine the role of familial transmission of vulnerabilities in teen suicides and conclude that, in combination with stressors, family characteristics (such as suicide by a parent or sibling) may predispose to suicidal behavior. They note that studies of adopted children and twins show that suicidal behavior is explained by both genetic and environmental factors, with the familial influence strongest in persons under the age of 25.

It’s hard to settle on the cause of a suicide because our knowledge of what leads up to suicidal behavior is so limited, the authors say, but they mention that “impulsive aggressive traits appear to be transmitted from parent to child, along with a tendency toward suicidal behavior,” probably because such traits make it more likely that a person will act on suicidal thoughts. And they doubt that imitation is what causes a young person to commit suicide, since often in studies the family member who did so was not even known to the teen.

That leaves the genetic component, and the authors are careful to say that current findings are insufficient to predict accurately who will commit suicide. They suggest, however, that “impulsive aggression, neurocognitive difficulties, and family adversity” might be good places to start in treating someone who has attempted suicide. “In fact,” they say, “some promising treatments that reduce the recurrence of suicidal behavior focus on enhancement of the regulation of emotions, tolerance for distress, and cognitive flexibility in order to improve the efficacy of generating viable alternatives to suicide during a crisis.” Mood stabilizers such as lithium prevent suicide in some populations and deserve further study, the authors say, because even though they have undesirable side effects, they do positively affect decision making or impulsive aggression.

The Antidepressant Quandary

In the third article, Dr. Gregory Simon of the Center for Health Studies at Group Health Cooperative in Seattle, notes that in March 2004, the federal Food and Drug Administration (FDA) issued a public health advisory regarding worsening depression and suicidal thoughts and behavior in patients treated with the newer antidepressant drugs fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), escitalopram (Lexapro) bupropion (Wellbutrin), venlafaxine (Effexor), nefazodone (Serzone), and mirtazapine (Remeron). In February 2005, the FDA extended the warning to all antidepressant drugs, noting that placebo trials had shown antidepressants are associated with increased risk of suicidal behavior in children and adolescents.

That is leaving a lot of uncertainty about how to treat depressed children and adolescents, since the FDA did not actually advise against the use of antidepressants in that population but simply recommended more frequent follow-up visits. Despite the long list of suspect antidepressants, only one of them—Fluoxetine—is currently approved in the United States for treating depression in children and adolescents. “For the time being,” Dr. Simon says, “physicians who are considering the treatment of depression in a child or adolescent must make recommendations to patients and families in an environment of considerable risk and uncertainty.”

He cites some figures to point up the problems facing practitioners. “Among 10,000 children and adolescents who begin taking antidepressants for depression, approximately 6 will die by suicide during the next 6 months and another 30 will be hospitalized after a serious suicide attempt. Of those 10,000 children and adolescents, approximately 3,000 will stop taking their medication within a few weeks, 4,000 will never return for a follow-up visit, and 6,000 will not recover from depression during the next 6 months.

“Our treatment of depression is growing wider, but it is often only inches deep,” Dr. Simon says.

The article “Uncovering and Epidemic—Screening for Mental Illness in Teens,” can be accessed at http://content.nejm.org/cgi/content/full/355/26/2717?query=TOC.

The article, “Familial Pathways to Suicidal Behavior—Understanding and Preventing Suicide among Adolescents,” can be accessed at http://content.nejm.org/cgi/content/full/355/26/2719?query=TOC.

The article, “The Antidepressant Quandary—Considering Suicide Risk When Treating Adolescent Depression,” can be accessed at http://content.nejm.org/cgi/content/full/355/26/2722?query=TOC..

See also:
Parents Resource Center: Suicide and Suicide Prevention
http://www.healthinschools.org/parents/suicide.htm

Screening High School Students for Suicide Risk: A Report on the Suicide Risk Screen
http://www.healthinschools.org/ejournal/2006/feb2.htm

InFocus: Adolescent Depression and Mental Health Services
http://www.healthinschools.org/focus/2002/no5.htm