In the largest newspaper in the world this week, one of the largest problems in the world was proposed as having a very simple solution.
There are few problems more heartbreaking and excruciating than the growing epidemic of youth (and adults) taking their own precious lives. So it’s understandable that we all continue putting significant attention towards solutions that can make a difference.
In response to this urgent challenge, psychiatrist Richard A. Friedman asked in a recent New York Times op-ed: “How is it possible that so many of our young people are suffering from depression and killing themselves when we know perfectly well how to treat this illness?”
Do we? That’s certainly a widely shared perception among many in the general public today. But are the answers really so crystal clear?
Dr. Friedman certainly thinks so, suggesting that little more needs to be discussed: “The good news is that we don’t have to wait for all the answers to know what to do. We know that various psychotherapies and medication are highly effective in treating depression.”
While it’s true there are different therapies and treatments that have been helpful for many, there are also wide-ranging debates that continue today about inadvertent consequences associated with some of the most commonly used treatments — over both the short and long term. Shouldn’t we be weighing those in the balance? And what else could be done to help more people find sustainable healing over time?
Instead of having that important (more complex) conversation, we continue to be invited into a much simpler discussion: How do we get more people to be able to access more treatment?
After noting that rates of youth treatment are significantly below treatment rates for adults, Friedman goes on to suggest that the pathway ahead is obvious: “We just need to do a better job of identifying, reaching out to and providing resources for at-risk youths.”
On its face, this seems a clean and compelling solution: just get these kids some more help!
How could we not simply rally around that?
Because that’s what we’ve been rallying around for many years now.
The other day, I sat in a suicide prevention presentation in my home state where the speaker advocated the same solution: “the biggest need is to get more teens access to treatment.”
I raised my hand during the Q/A and asked my sincere question: “Haven’t we been doing that for quite a while already? If so, are there other questions we should be considering?”
A 2011 report released by the National Center for Health Statistics (NCHS) showed that the rate of antidepressant use in this country among teens and adults (people ages 12 and older) had increased by almost 400% between 1988–1994 and 2005–2008 — with estimates of one in every 10 Americans now taking an antidepressant. (During this same period, rates of psychotherapy usage have not increased in corresponding fashion — with some studies finding these rates decreasing in recent years).
If getting more teens more help was really the answer, wouldn’t we have reasonably seen a measurable decrease in suicide, depression and anxiety by now? In striking contrast, the rates of these concerning numbers have increased markedly during this same period.
Indeed, these troubling numbers have reached such historic levels that one would think it was time to reassess and reevaluate a lot of things: from the way we conceptualize these problems, to what we’re doing about them (and what we’re not doing about them).
Instead of this kind of a pause for reflection, all across America what we see today is a doubling down of the approach we’ve taken for the last twenty years. Is this a responsible way to respond to the suicide crisis among our youth (and our adults too)?
No, it’s not. And it’s time for a bigger conversation about not only suicide, but mental health care in America today.
It will likely be the voices of people who are seeking and finding healing in their own lives that lead the way in this conversation. Too often, it’s the professionals who orient us back towards something more narrow. As Dr. Friedman himself wrote to his worldwide audience, “Our collective failure to act in the face of this epidemic is all the more puzzling” — even asserting, “Teenagers and young adults in the United States are being ravaged by a mental health crisis — and we are doing nothing about it.”
Not true, Dr. Friedman. We have done something about it. And it’s just not working.
During this same period of time in which antidepressant rates have soared, depression, anxiety and both suicidal ideation and suicidal completion have continued to increase. I was so troubled by this counterintuitive pattern that I reviewed the research and found seven different lines of evidence that confirm a concerning linkage between antidepressants and suicidality — especially among youth. To provide just one illustration, a 2017 study in Sweden that examined 483 suicides from young women between 1999-2013 (representing 93% of all confirmed suicide for this subgroup) explored treatment they received 6 and 12 months before the suicide.
Not only did antidepressants not “lead to a drastic reduction in suicide rates,” the author, Dr. Larsson, noted: “On the contrary, it was found that an increasing tendency of completed suicides follow the increased prescription of antidepressants,” adding, “This analysis shows a covariance between increased prescription of antidepressants and an increasing trend in the number of suicides among young women.”
This is not an anomaly, but one of many examples in a broader pattern hardly receiving attention in America’s mental health conversation today. And perhaps that shouldn’t be surprising, since it runs in the face of the conventional wisdom taken for granted not only by psychiatrists like Dr. Friedman, but by many faith and community leaders across the United States today: that the real issue in this crisis is “undertreatment.” A great deal of rigorous scientific, epidemiological, clinical and randomized-controlled trial data — not to mention the precious lives of our youth today — call for much greater care in making such a conclusion.
It’s not just caution we need, however — it’s hope. And it’s important to note that the same research literature is remarkably full of solid reasons to hope. Alongside the encouraging understanding that continues to emerge from neuroplasticity and epigenetic studies, there is a vast research literature documenting hundreds of lifestyle adjustments that can make a difference in reducing emotional pain over the long term.
And not just for mild cases. A Pubmed search of “suicide” and “risk factors” reveals well over 15,000 scholarly articles documenting a dizzying array of possible contributors. Factors commonly cited as making a likely contribution to increasing suicide rates among youth include a more pervasive social media and digital presence, widespread sleep deprivation and a nutrient-deficient American diet, growing cyber-bullying and social anxiety, the unsettling influence of compulsive pornography use, and the uniquely painful trauma of sexual abuse or assault.
After examining cases of suicide in our own state, one state suicide research summarized: “Our investigation showed that suicide is complex and youth can experience multiple risk and protective factors. No single behavior or risk factor could explain all the reasons for the increase we’ve seen.”
If that’s true, then there are a lot of things we can do in response. And that’s the good news hidden in all this: there’s so much we can act on and do something about!
Starting with better protecting our youth from early trauma and abuse. Underscoring perhaps the most important theme across studies, a 2014 Utah summary of factors involved in youth suicide notes that “Suicide is also often preceded by a lifetime history of traumatic events.”
We can do a better job of protecting our youth — rallying together to help provide them with the kind of lives overall that don’t drive them to despair. And we’ve got a lot of options to do just that: improvements in a nutritious diet, more time outside in nature and away from screens, physical activity, better connection with those who love them the most, discussions that bring them greater meaning and purpose. And yes, in cases of previous abuse, finding ways to increase access to trauma-oriented therapy is crucial.
When asked what the alternative to standard care was for teens for whom the medications weren’t working, another leading psychologist responded simply: “all of life!” This is precisely what the research also confirms — with a large wealth of possible adjustments showing up that can make a measurable difference for anyone, especially over time.
So no, Dr. Friedman, the answer to our suicide crisis among youth is not to rally more force of will (and legislative dollars) to encourage more teens to embrace more treatment. It’s to have a little — or a lot — more humility about what is facing us. To breathe deep, and to pursue multifaceted answers to a complex, multifaceted problem.
It’s time to do just that, uniting around the precious youth who depend on the steps we take next.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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