[Originally published: Sept. 9, 2019. Updated: April 14, 2023]
Every October, after school starts—and each May, as it ends—there is a spike in the number of teenagers who go to the Yale New Haven Children’s Hospital (YNHCH) emergency department because they are considering suicide. They may or may not have struggled with a mental health issue before. But they often have a story: Bullies are harassing them, their parents are divorcing, or the academic pressure is crushing them. For some, it’s gender concerns—they have come out as trans or non-binary, and their peers are shutting them out.
“It’s everything—all the pitfalls of being a teenager,” says Kirsten A. Bechtel, MD, a Yale Medicine specialist in the YNHCH, where she says 900 of the 40,000 patient visits a year come in for care for anxiety, depression, and other mental health and behavioral problems, and about half of those have suicidal thinking or behavior. In some cases, there may be no clear reason at all, she says.
In February, the Centers for Disease Control and Prevention (CDC)’s biannual Youth Risk Behavior Survey showed the situation is worsening throughout the country, with girls faring worse than boys. Based on data from 2021, the report showed that 57% of teenage girls had “persistent feelings of sadness or hopelessness” that year—the highest level reported in the past decade—and as many as 30% had seriously considered suicide. (The suicide rate is up almost 60% from a decade ago.) More than half of LGBQ+ teens who took the survey reported they had recently experienced poor mental health in the previous 30 days, and 22% said they had attempted suicide in the past year. But the report was clear that teenagers in all categories have been struggling.
Talking to a trusted adult, such as a parent, teacher, or health care provider, can be lifesaving for these children and adolescents. In some cases, going to the Emergency Department for an acute evaluation and stabilization is necessary, Dr. Bechtel says, adding that even a single suicide attempt is a preventable tragedy.
Yale Medicine pediatric specialists answered questions about the latest data and the work that is being done at Yale and at the YNHCH Level 1 pediatric trauma center, which provides subspecialty care for vulnerable children.
Why are more teens thinking about suicide?
Experts aren’t sure why more teens say they have thought about suicide, although some think the isolation many teenagers experienced during the pandemic helped exacerbate some mental health problems.
Social media also comes under discussion. “There is tantalizing data as far as the effects of social media, but I don’t think we have a good grip on that association,” says Yann Poncin, MD, a Yale Child Study Center (YCSC) psychiatrist and medical director of youth services and the Children’s Day Hospital. Dr. Poncin has noticed that many teenagers with depression—especially girls—turn to the online world. “I think the use of social media in a teenager with pre-existing [mental health] concerns does fuel the fire a bit,” he says.
Although Dr. Bechtel has seen cases where social media has been used to alert friends and family that a teenager was in crisis, Facebook and Instagram can also drive a vulnerable teen to despair, she explains. “The negative feedback teenagers get about what they said, what they wore, and who they are is so intense,” she says.
However, some of the biggest issues teens face are not new, Dr. Poncin says. A common one is loss—a romantic breakup, the end of a friendship, a death or divorce in the family—combined with underlying psychiatric disorders, such as anxiety, depression, and bipolar disorder, which are also on the rise. Another is bullying: In a 2008 study, Yale researchers reviewed studies from 13 countries and found a connection between bullying and suicide. This has been supported by other studies since then.
The CDC report showed another issue that comes up for girls is sexual violence and what it describes as “forced sexual abuse”: Eighteen percent of girls reported experiences of sexual violence in the past year, while 14% had ever been forced to have sex. Both of these figures showed significant increases over 2019 data.
How do you know a teenager is in trouble?
One thing experts agree on is that teenagers look at the world differently than adults do. “Psychologically, teenagers tend to have more absolutist views. They see things in starker, more rigid colors and fewer gray areas,” says Eli Lebowitz, PhD, the director of the YCSC Anxiety & Mood Disorders Program. “This view can make a problem seem more daunting and a solution seem less likely, where a more mature person might be more accustomed to realizing that life has a combination of good and bad.”
Lebowitz tells parents who are worried to look at their teen’s ability to function. “‘Normal’ is ultimately the ability to function in a way that is in line with expectations for someone of a similar age,” he says. For a teenager, that means attendance, performance, and the ability to get along with others at school, he explains. It is having a satisfying social life in and out of school and the ability to participate in a reasonably functioning family life (whether or not it is devoid of conflict). It includes the “ability to eat, sleep, and get through a day feeling OK,” he says.
Jennifer Dwyer, MD, PhD, co-founding director of the YCSC Pediatric Depression Clinic, says parents should pay attention if their teenager is chronically angry, cranky, or irritable, as teen depression may manifest through these behaviors rather than strictly through sadness or crying. But sadness can be a symptom, too, she adds. Parents also should note if teenagers are isolating themselves from friends, in constant conflict with family or peers, having mood swings, giving away their belongings, or increasing their use of alcohol and drugs, she says.
Should you ask if they are thinking about suicide?
Suicidal ideation—essentially thinking about suicide—is not uncommon; in fact, most teenagers probably have thoughts, even if they don’t try it, Lebowitz says. But he says that many parents are hesitant to ask their teenager the direct question: Are you thinking about hurting yourself? “Not asking is usually a mistake. You are not likely to cause suicidal behavior if you ask about it,” he says. If the answer is yes, Lebowitz says the parent can follow up with additional questions:
- How often do you think about it?
- When do you think about it (all the time or only when you are really angry)?
- Do you want to do it?
- Do you have a specific plan?
If the teenager answers yes, the parent should seek help, Lebowitz says. “If the answer to the last two questions is yes, that would show the highest level of risk,” he adds. “Even if the answers to those are no, if a teenager thinks about it often, and not only when they are very angry or frustrated, then seeking help is recommended because it would indicate a high level of distress.”
These questions can also help diffuse the situation, Lebowitz says. “If you are alone thinking about suicide and you’re not able to talk about it, and nobody is asking you, that puts you at higher risk. If someone asks, even if you don’t like that person, it can reduce that sense of isolation. It’s just a fact in the life of a teenager that when somebody does care, it will reduce the risk,” he says.
What treatments are available to prevent suicide?
Treatment for suicidal ideation starts with understanding the underlying concerns. Individual therapy, medication management, and a combination of the two could be appropriate, depending on the circumstances. Medicines that treat depression can often include a selective serotonin reuptake inhibitor (SSRI) such as Prozac or Zoloft. The medication can be combined with cognitive behavioral therapy (CBT), which involves regular meetings with a therapist to explore thoughts, feelings, and behaviors to better manage problems. “You can teach someone to recognize their own thinking patterns,” Lebowitz says. “It’s not instantaneous. But you can train the brain to recognize that pattern and say, ‘Oh, I’m falling into my thinking trap.’”
“A lot of times, the relationship with the therapist you are seeing is a good predictor of how therapy might work,” says Dr. Dwyer. “It should be someone the child and the parents feel comfortable bringing their concerns to, and who the child can stick with even when discussing difficult topics.”
Still, about 40% of teenagers fail to respond to medication, and half of that 40% don’t respond even when they switch to another medication and add psychotherapy, says Dr. Dwyer. “There aren’t a lot of great guidelines or algorithms after you’ve not had success with two medication trials and a trial of evidence-based psychotherapy,” she says.
Given the seriousness of adolescent treatment-resistant depression and suicide, novel treatments are currently being investigated. Ketamine is an anesthetic that has made headlines for its surprising antidepressant effects in adults. Esketamine, a related compound delivered as a nasal spray, is approved by the Food and Drug Administration (FDA) for treatment-resistant depression in adults. This medication works rapidly, within 24 hours, to reduce depressive symptoms compared to SSRIs, which take weeks to work. Ketamine is also associated with reduced suicidality in adults, even after controlling for any improvements in depressive symptoms.
Ketamine and esketamine are currently undergoing testing for adolescents with treatment-resistant depression and suicidality in randomized clinical trials (RCTs). A small RCT at Yale showed a positive effect of a single ketamine infusion in adolescents with treatment-resistant depression compared to a placebo, but this study only looked at short-term (two-week) outcomes.
Unfortunately, single doses of ketamine typically do not lead to sustained antidepressant responses, and Yale researchers are now conducting a larger, National Institute of Mental Health-sponsored trial looking at a limited number of repeated ketamine doses (which are associated with prolonged antidepressant effects in adults) in adolescents with depression and suicidal thinking. But caution is warranted, Dr. Dwyer says, noting that some animal studies suggest that younger ages may be more susceptible to damage to the brain from a high dose of ketamine. It’s important to realize that ketamine is still considered an experimental treatment at this time for pediatric patients, she emphasizes. “I’m hopeful, but I’m also cautious about it because I think the issues of effective and safe dosing paradigms in the adolescent population still need to be worked out,” says Dr. Dwyer.
What are we learning about the teenage brain?
Neuroscientists are looking for clues in the brain which, in teens, is still developing. “Adolescence is a time when suicidal thoughts and behaviors can start to emerge,” says psychiatrist and neuroscientist Hilary Blumberg, MD, director of the Mood Disorders Research Program at Yale School of Medicine. She uses magnetic resonance imaging (MRI) to take pictures of the brains of adolescents and young adults with bipolar disorder who are at especially high risk—an estimated 50% of whom will attempt suicide at some point.
“We’re identifying the brain circuitry that underlies suicidal thoughts and behaviors, how its trajectory of development differs in adolescents at risk for suicide, and how this can be helped,” says Dr. Blumberg, who has seen subtle variations in the prefrontal cortex of young people who have attempted suicide. (The prefrontal cortex has such executive functions as regulating emotions and impulses, as well as decision-making and planning. It can be compromised by various kinds of child abuse, substance abuse, and other stressors.) She and her research team have also observed subtle differences in the prefrontal structure in teens who go on to make suicide attempts. “This provides us with new leads about how to generate targeted interventions to prevent suicide,” she says.
Dr. Blumberg is also studying Social Rhythm Therapy (SRT), an approach that she says is showing early promise for improving the functioning of the brain circuitry that regulates emotions and preventing suicide. SRT is designed to improve mood by regulating emotions and regularizing daily “rhythms”—an example of the latter is sleep patterns. “In order to help people have more regular sleep, you have to look at potential issues that may be causing the disruption. Their issues could be tied to social interactions and activity throughout the day, and a therapist can help them problem-solve around that,” Dr. Blumberg says. “We are encouraged by preliminary results where, after 12 weeks of regularizing daily rhythms, we see reductions in symptoms and suicide risk, as well as improvements in related brain circuitry.”
“The field has made important progress, but more research is needed,” Dr. Blumberg says. She is the U.S. lead of an international research consortium studying the brain scans of thousands of young people around the world who have suicidal thoughts and behaviors. She notes that the research is promising and may also turn out to be helpful to people who have bipolar disorder, as well as depression and other mental illnesses. “The future is very hopeful. We already have some strategies to prevent suicide, and it is especially hopeful that researchers from different disciplines are coming together in global efforts to discover new ways to reduce suicide.”
What if you are worried about suicide now?
Of course, many families need help immediately. If this is the case, Maryellen Flaherty-Hewitt, MD, a Yale Medicine pediatrician, recommends talking to the family pediatrician. “We routinely ask questions about access to guns, medications in the home, video games teenagers are using, and if they are exposed to violence,” says Dr. Flaherty-Hewitt. The pediatrician should be alert to teenagers with no history of mental illness but who may be having difficulty coping with, say, feelings about sexuality, bullying at school or online, or the transition from one school to another, she says.
“When you have a child who has suicidal ideation, it’s a crisis, and pediatricians want to be part of this conversation. We want to make sure we bring the right people into the mix right away,” Dr. Flaherty-Hewitt says.
If the crisis warrants going to the Emergency Department, one of the first things that will happen is a milieu counselor, a specialist who assists with crisis intervention (but doesn’t provide direct treatment), will sit with the teenager and listen to their concerns. They will also be evaluated by a social worker and/or a child psychiatrist to determine if hospitalization is warranted. In some cases, the patient will be referred to YNHCH’s Partial Hospitalization Program or Intensive Outpatient Program.
For most young patients, thoughts of suicide are manageable, specialists say. It may be a lifelong vulnerability, but there are many people who used to have an anxiety disorder or depression and have learned to manage their condition with treatment, says Lebowitz. “We need to foster a belief in treatment and the understanding that having these problems can be part of life," he says.
Contact the 988 Suicide & Crisis Lifeline if you are experiencing mental health-related distress or are worried about a loved one who may need crisis support. Call or text 988. Chat at 988lifeline.org. Connect with a trained crisis counselor. 988 is confidential, free, and available 24/7/365. Visit the 988 Suicide & Crisis Lifeline for more information at 988lifeline.org.