Plenary session P5 Mental Health

Chaired by Eric Taylor - Institute of Psychiatry London

and Daniel Hardoff - Tel Aviv Israel

Teenage suicide. Richard Brown

Good morning. It’s really a pleasure to be here and have an opportunity to speak to you about depression and suicide in adolescents. I worked for 30 years in San Francisco since the flower power area, during the Vietnam war and also through different epics and advance in San Francisco and I’ve been 20 years at San Francisco General Hospital which is an inner city programme with adolescents involved with gangs and marginalised situations, and homeless and runaway youths in central part of the city. So that’s the orientation I really bring to talk to you.

Maria was a 16 year old woman  who was found in the hallway drunk at Mission High School with a girlfriend and they had drunk a whole pint of brandy. So here they were found in the hallway by the teachers at the high school and hauled over to emergency area for me to see at San Francisco general hospital. She was very inebriated and her girlfriend was similarly. So we had to start an IV, she’d been really quite ill with the amount of alcohol that she’s taken. And as she came around she wanted to die, I don’t want to leave, I want to die. So it was a befuddlement, why a young woman who was obviously quite suicidal would have done what she did with a girlfriend and then be brought in to the hospital. Very public, very kind of unsuicidal type of behaviour, very disconcerting to us to know what this is all meaning. And without having a guessing game it was all very inexplicable when we found out how the story emerged.

The story was that after her mother came in was that she had lived with her mother alone for some years and about 2 two years previous to this a boyfriend moved in to the home within an angelic beautiful young daughter, a perfect daughter. And Maria was a young Latino wanting to begin to date at Mission High School staying out a little too late at times and in this very traditional family it was seen as a slut, rejected furiously dealt with by this father who saw her as a very bad girl and he had this beautiful perfect little girl. And as the years went by, these 2 years, she increasingly became rejected, not going to school all the time, and was increasingly isolated. So the issue that Bob Blum spoke about so eloquently about connectedness was destroyed. And she then drank this brandy. Why did she drink the brandy? This father that she was so furious at was a recovered alcoholic, a total teetotaller. He was furious with other people who drank, he could not tolerate anything like this. If there be a way to push the button she knew it. She knew how in this public demonstration to push the button and bring everybody roaring in to the hospital furious, upset, but she was getting attention. Brilliant. Maria knew how to do it and unfortunately I had to face the father. The father had come in and I had to talk to him. And he of course was extremely enraged about what she had done and only validated all the more the obstreperousness of this young woman and her beligerence and what she was doing, but it brought attention to her situation and she got care and she got help and she did do much better I need to say to end the story. This is an introduction to talk a little bit about some psychodynamic issues around suicidal behaviour in adolescents.

A first principle is that there is often a long-term and I have hand-outs for people, I am going to have to ask people to share afterwards, I made a pile of 2 different hand-outs that you can have after my presentation. There is characteristically a long history of suicidal behaviour with adolescents and she had a tenuous long history with just her mother and then this father moving in, so there were a couple of years there where there was a break-down and alienation. And she had really experienced some of the great fears of adolescents. What are the great fears of adolescents?

The worst one of all it’s what Bob spoke about which is isolation and rejection. This is the most profound fear. And for all human beings when I talk about adolescents, I say adolescents are not different than adults in all they are more. Adolescents are just more, you name it they are just more. And there is moreness at back to her situation - she was increasingly isolated,  a tremendously fearful thing.

The other fear is loss of control. And indeed increasingly without support, without structure and loving and caring, without limits setting really there was increased loss of control and things were really  out of hand.

The other fear is that of hopelessness. One of the tasks of adolescents is to hope for the future and I think we’ve heard that articulated here over and over again is the sense of what they had in a general affirmation in life is a really important goal. And of course for her it was despair, there was very little prospect of hope for her and helplessness is another great fear.

The fourth great fear is a mutilation, a body alteration and as you all know adolescents are imminently sensitive to their body, every detail, every little things and so when you examine then there is just this one little zit, one breast is a little bigger than the other, one testicle is hanging a little lower than the other and it’s bowels zones and it smells and all these things, isn’t it? So this body awareness and a fear of any kind of mutilation and that’s why with teen pregnancy part of psychodynamic issues of that is a change in a body and often adolescents try to cover themselves up because of the alteration. So body alteration is a great fear. And so Maria really illustrated some of those great fears.

And also adolescents will often demonstrate in public ways and hers was a dramatic public way. Imagine with her peer group in the hallway in the high school, this is an ultimate public demonstration. It is a real cry for help issue with her in that way. And also are ingenious as to how to push a button even though it is results in a very negative response from her family, it brought attention to her despair and her rage and she got help. So those  were some of the elements  about Maria.

Depression is a basic part of the human condition and a basic part of adolescents. There are normally a wide variety of mood swings through adolescence and they are closely tied with the normative changes that occur. So we all are very experienced with adolescent depression, we just know that that’s inevitable. We also know that we work with an adolescent we have to assess the degree of the depression. And sometimes when a young person is in an identity crisis or some personal struggle you can feel the depression just really lift during an interview, they do better and by the end of the interview they are really less depressed. If you do an interview though and you are depressed at the end of the interview then there is a message there. Then you need to really look at this in detail and always the essence of it is we have to ask questions. There are certain sensitive questions in adolescents that they are not going to bring to us. We have to be there for them and open to them and it’s a variety, I’ll give you a list of those that we have to speak to them and one of them is the difficult question of do you want to die have you thought, can  be direct sometimes, in certain  interviewing skills we want to be kind of subtle and all but we have to sometimes really ask this directly.

The other issue about enquiry into suicide behaviour is that this is not a confidential topic. And in the relationship with young people we need to define those things that are confidential and protect them and all and there are some very in our laws are defined and where we live in terms of confidentiality. This is one of a few areas that is not confidential: homicidal behaviour, suicidal behaviour, severe mental illness is not confidential and then abuse, such as sexual abuse and incest and all are really not confidential as far as the young person is concerned. So this is not. And the experience in the literature is that this is never a deterrent to the relationship, I mean young people don’t run away. And for the most part there is a real strong cry for help element in a young person who has become suicidal. So we do need to look for evidence of desporia, severe mood swings, we also need to look for a potential severe mental illness. A phenomenon that we see clinically is that first psychotic breakdown right in our clinical setting you probably have experienced this where the young person is basically doing OK and then suddenly they are psychotic and the stresses of adolescence can push a young person over to that.

Just a few weeks ago I had a young Indonesian, a young woman who came in with both of her parents  they’d recently come from Indonesia, the mother had died of cancer 2 years previously and the father had found a new lovely Indonesian woman and they had immigrated to San Francisco and the young woman was straight A student and then during the summer she started hearing voices and withdrawing and there were voices for her to jump out of the window. Suddenly in the midst of a very stable family where parent were very concerned, they were very sophisticated and very interested and baffled by these actions. But the stresses upon her which are the loss, the grieving for her mother, the movement to San Francisco, the stress around her school performance and all and her isolation were those things probably that triggered her towards the first psychotic break. So this is something very important to look towards.

Another element is looking for the interject. Do you know about the interjection? Interjection is a phenomenon in which a person takes hook line and sinker an idea about themselves. So as Diana was speaking out this morning people can get in a vicious abuse cycle in which they take on the identity of bad things that are described upon them from their unsafe environment and they learn then to see that they are bad, they are furious, they feel rejected and they begin to act out and you get an acting out cycle and one of those can be suicidal behaviour. And it is something like, you are just like your father, you are starting to stay out late at night, I know you had alcohol on your breath, he is an alcoholic, you are just like him, must be genetic, I don'’ know what to do with you, you are just nothing but trouble, ever since you turned 13 you are just trouble. That young person takes that on often in the lack of resolution of the omnipotence they really take that on as part of their identity and it’s a very destructive, negative assumption. It’s an interjection, it is taking into themselves an idea and of course one of our tasks clinically is to question that interjection, be able to move out and so better.

There are many factors in the literature which lead to a suicidal behaviour. And my hand-out has some of those, I think in this time I will not go over them you can see them but to go on with the stages of suicidal behaviour that’s what I want to complete with. The first one as I said is a long history. So Maria did have the series of years that were difficult for her. The second is a period of escalation that there is, young people begin to have a lot of stress, first signs might be school failure, teen pregnancy and symptoms can develop. And this reflects the issue of how sensitive or how resilient the young person is. Because I’ve seen young people who have had tremendous escalating type of events in their life but they are not suicidal. And I’ve seen other young people like a third year student that gets a B and they become suicidal. So there is an issue of a different issues of personality. But there is characteristically an escalating period, it’s not really predictive but it’s important to define in history. That’s stage two.

Stage three is a period of adaptive failure and this is actually the point where the young person is seen in a clinical setting or in the school counselling setting or in with the social worker, whatever. Things begin to crumble and fall apart. Helplessness begins to take its toll. Coping mechanisms beginning to fail and symptoms develop. Family conflict begins to occur, social isolation begins. And as it goes on becomes more severe, sometimes they are giving away objects, talking about planning to die, talking about running away, actually running away, possibly doing self-destructive acts during this time, becoming accident-prone, increasing use of substances, of alcohol, severe school issues and drop out, anxieties, expressions of sadness, this is really the really breaking down part and it’s so important because this is indeed the moment that we might see the young person. And most young people that go on to suicide behaviour actually appear seeking help at this time.

Then the  final, the rationalisation is the fourth phase and this is that there is no help in the world that there is nothing that is really going to, there is no consolation, there really is no caring and loving. There is no support, the problems just progressively result in isolation and then something happens. And an illustration of this was at Berkley There was a young man who had killed himself, he was discovered three weeks later in the dorm from the smell in the hallway in the dorm. It illustrates that for three weeks not a soul on this earth thought to inquire or look at this young man, there was a very dramatic illustration of the horrific isolation that can occur leading to this.

I need to conclude. I want to talk a little bit about intervention. And intervention needs to be very immediate and very intense, it often does need to have some psychiatric involvement immediately. For runaway and isolated young people they must have an on-going abiding connection during the time that they have suicidal ideation. Another thing that I want to say that we need to look, gestures and attempts are not good terms for adolescents with this, because many times they can be quite suicidal and they slit their wrists. So it’s not a lethal thing but they can be very suicidal. Or they can take a bottle of iron tablets which may have a lethality to it but it was just attention getting. And so we need to look at how public or private the activity is and how lethal it is. So with Maria we can see that it was a very public demonstration, but there’re also private ones as well. The young person at home, in the house alone, going downstairs and putting a gun to his head. And maybe leaving a note. This is an illustration of a private act. So we need to look at the thoughts in terms of how public or private they are. So this is a very major topic but I did want to present it to you from a psychodynamic point of view today illustrating the precursors, the underlying issues, the sequence of events that occur and give some illustrations and some sense of the emotional enormity of what happens with young people who become suicidal. Thank you very much.

Chairman. Differentiation of different tracks into disorder. Now we do have time I think for one or two questions.

Question -perhaps you did not emphasis the fact that  mother had suddenly got a man in her house. I can well remember adolescent coming into my large group and lying on the floor mother had remarried it is quite interesting how they need treatment.

Chairman. Thanks very much for that question. It’s in some ways more of a comment than a question.  We have a question about substance abuse.

Dick Brown. From adolescent medicine view we often look at substance use as self treatment an attempt to deal with emotions. The choice of substances are parallel there, there are also ways of masking other issues such as a psychotic break. I hope to express the enormity of emotion that young people are feeling, substances are often a hint to try to ameliorate or to try to deal with these very severe emotions of loss, grieving, rage, sadness, just the whole spectrum of difficult emotions often experience in this process towards suicide behaviour, so substances are often self-treatment. Or it can be as it was with Maria a way of pushing the button.

Chairman. Thanks very much, if there are no more questions we should thank Richard Brown again.  Now Doctor Simon Clarke from Sydney, Australia, he is a paediatrician and adolescent medicine physician, he developed, is running and directing extensive adolescent medicine services in Sydney and he will share with us his experience in attention deficit disorders.

Attention Deficit Disorder  Simon Clarke

Thank you very much. We are, I was going to stick up a formal committee definition of ADHD, all fourteen points and ask you to commit them to memory, I can’t spell either. Well, I won’t do that, basically these are the main point of symptoms of ADHD and the interesting thing is the contrast between ADHD and ADD where you take away the impulsivity and the hyperactivity and I don’t know about other people but we seem to be running into a lot of problems in Sydney where everybody has an adolescent son who doesn’t do quite as well as he should at school and has an ADD. I was taught in America in Boston where the belief is that everybody has their learning style and you’re entitled to have your own learning style and that within 10 years the diagnosis of ADD won’t exist but that is extremist. I think it’s an interesting point.

ADHD or the old hyperactive attention deficit disorder has been with us forever, I have not gone to pre-biblical times but certainly there were descriptions from Germany in the 19^th century. From England descriptions of people who had most of the symptoms of ADHD following head injuries in the 1^st World War, the flu epidemic of 1919 seem to leave a lot of people with a lot of these symptoms, then in 1950 searching for a term, I think a most unfortunate term it was called minimal cerebral dysfunction which possibly described the person doing the description rather more than describe the kid I mean how can you call somebody minimal cerebral dysfunction? You either have it or you don’t have it. Then came hyperkinetic or hyperactive and in light of what’s coming through now from certain people I am not sure that wasn’t a bad description and these were your fidgety boys, you knew how to treat them, you’ve stuck them on stimulants and they got better  and you are happy and they were happy. Subsequently the field has become very confused.

But recently this year an interesting academic Joe Sergeant from Amsterdam feels that in fact the essence of ADHD really is loss of inhibition of motor activity and that the inability to moderate motor activity, to automate responses and to memorise patterns may be in fact what these kids are suffering from so that they continue to make the same mistakes. Again that’s an interesting theory. So perhaps the wheel has turned the full cycle.

Where does ADHD actually occur? Well, it occurs in every population so far studied. It’s interesting that it occurs in some say 3% some say higher 9%.  In other words this is what we are looking at the end of a spectrum: on one end of the spectrum you have your Nintendo playing couch potato to whom physical activity is an anathema and on the other end you have a kid who can’t sit still for a second. So it’s a spectrum and you should be allowed to have a spectrum. What makes ADHD a problem when fidgety Phil is so disruptive in the classroom with his constantly getting up, talking, fidgeting, etc. And at home that he’s driving everybody bananas and that’s when you are in trouble and that’s where ADHD becomes a problem. So at one end of the spectrum, and we often say this to parents, yeah, your kid has got mild ADHD and they say, What do you recommend, and I say, what about more soccer. In other words get this kid out, have you ever thought of living in a house with a bigger yard. They need more activity and they will do well.

I worked with an Irish psychiatrist once and we were talking about this and she said, ah, now I understand why sister Mary used to send Maureen run around the school twice every quarter of an hour, and sister Mary used to say, Maureen, and Maureen would get up, run around the school twice and sit down again. And that was a very affective cure for ADHD, no riddle in this. So what Maureen’s mother and father did I don’t know, but in fact one of the funniest people I’ve ever had was a mother who said, you know I find when my kid walks home from school he is much better, I think that a good 2 to 3 km walk preferably uphill on the way home from school, you don’t have to buy your house up the hill but a hill does help.

Males to females: it depends on what population you study. Some people say 3 to 1. If you are talking about ADD it’s closer to 3 to 1, if you’re talking about ADHD we certainly see far more males than we see females. The females we see seem to have lower self-esteem, have more problems in relationships, seem to be more perhaps more damaged than the males. So it depends. By definition it should have come on about 7, but we see a number of kids who present in adolescence, don’t forget it does come and they do come along in adolescence for the first time. Why then, why the circumstances change? For a variety of reasons, but they can present for the first time in adolescence and you need to be aware that they are there.

Now. there’s some very interesting stuff coming out now on the aetiology of ADHD. There are some very good twin studies showing a much higher incidence, 60 to 80% in identical twins as opposed to 10 to 20% in non-identical twins, those are American, Swedish, English and American studies. So, it’s very good information coming through. Regarding the inheritance of DR for dopamine receptors that’s what we are looking at when we are treating people with stimulants and the studies are there but they need to be bigger. There are only 50 patients at the moment. The incidence or coincidence of learning disabilities with ADHD is 40%. There are some good brain studies done by Rappaport and her group which showed 4 areas of the brain are smaller. One area inhibits motor activity, these areas help to automate motor actions. A lot of this is speculation but the fact that these 4 areas are smaller in kids with ADHD seems to point to the basis of a genetic inherited polygenetic, a number of genes.

EEGs, these are the tests we do if we think the kid is fitting and has epilepsy. So any classic EEG, you look at the brain wave, you look for that classic spike and wave. Now, what we did and what Settafield first did in 1973 was to break the wave forms down and what he found was a relatively immature form and that in a way makes sense. Because what you are looking at with ADHD is a relatively immature pattern. In other words this kid’s fidgeting, this is 16 year old with a fidgety index of a 12-year old. Or an 8 year old who looks like a 6 year old. And very often you get kids who are developmentally delayed. And the parents come along and they say, he’s like a 5 year old, they are so active all the time. This shows that immature patterns in these kids is persistent.

Now literally hot off the press from work we’ve done looking at Gamma. Now this is a wave form we are measuring with electrodes all over the brain, we are measuring the brain and we are measuring the fastest form, it’s been done a number of times before but what happened was we’ve not only measured the 40 Hertz cycles but then developed a mathematical model to look at how well those cycles co-ordinated in the brain and guess who didn’t co-ordinate - the ADHD.

We  then go back to the same kids, we had 52 in this sample to look at their Beta, and these are the normal kids Beta and these are ADHD kids Beta with their immature pattern still returning a high Beta right there over the pre-frontal region and there we looked at their skin conductance levels, in other words looked at their autonomic nervous system and showed that right throughout their thinking pattern these things interfered with their thinking pattern. So that’s where our group’s going at the moment. I just wanted to show you a brief glimpse of where we are trying to add some science to what is sometimes an area where there is not very much science or the science is confused.

So when you diagnose this a long history is essential, psychometric testing, you must know how intelligent the kid you are calling ADHD is. Look always at school reports, because I am always struck by people who come to see me when they are talking about their kid having ADHD because the next door neighbour’s kid has got it, that’s generally how it goes, suburb by suburb, and when they come in to talk about ADHD and you go through their school reports and the kid has not changed and the reports are absolutely superbly symmetrical so these kids’ performance has always remained as is. What’s your differential diagnosis for ADHD? Never forget learning disabilities, because 40% of them have it anyway and if you miss that you are doing the kid a disservice. These are the differential diagnosis but it’s also the co-morbidities, in other words the whole lot can exists with ADHD and that’s the problem and that’ why we are trying to develop an organic brain measure that actually says, well you’ve got this and yes the kid’s oppositional and now his conduct disordered, depressed and angry, abusing cigarettes or marihuana. The parents, every parent has inappropriate expectations. Doctors generally worse than most. And so the kids can actually come in with all of those at the one time and that’s sorting that out that’s a problem.

How do we manage this? Well, the stimulants in 70 to 90% of kids moderate to severe ADHD the stimulants are still very useful. We use Ritalin, Dexamphetamine, and we find antidepressants particularly Imipramine with your angry adolescent male are effective. I was talking to Gail Slap last night and she also has found that those kids responded to antidepressants. There are some very good programmes and they actually have them in most cities now. In Sydney the parenting behaviour programmes, family therapy programmes, these kids’ families often have gone wrong for so long. The school, how do you place this kid at school, how do you alter the work given to him, how do you praise this kid a lot, how do you get those teachers on side, you must communicate with the school right from the word go. I think the best one was when I put this kid on medication having listened to this tearful mother and the principle rang me 4 days later and said, Doctor, why did you put the nicest kid in school on medication? And I said, I guess you’re telling me something, and he said, I am telling you something, so I rang the mother we revised the diagnosis. So it was a learning pattern for me.

You need to see if you can the kid into a group programme for kids where they stop. Look and think, in other words anything to slow down that impulsive process.

Chairman: we can take 2 questions.

Question - How early can add arise?

S.C. The classics are when the mother says to you, you know this kid kicked me to death in the womb and another mother says, this one can’t stop swimming, the funniest description that I’ve heard, the kid’s still swimming by the way. Most people say it has to be present, if it is organic problem it must be present by 7, but it’s not always and for variety of reasons you need not diagnose till adolescence. And it does not stop at adolescence, it goes right through to adult life in I think probably 60 to 70%. The point is it ameliorates as you get older, so your adolescent will fidget a lot but won’t be moving around the classroom, but in your adult life it will still be the few with things right through adult life. Very important to form a good liaison with an adult psychiatrist because the co-morbidities of adolescents become even more marked in adulthood and so you’ve got to form a liaison with somebody who’s going to take this kid over.

Question - what you do with kids who are in a care situation or from a very chaotic background.

S.C. What I do with those kids is try to get them into child and adolescent psychiatric institution near me as soon as possible to stabilise them in some way, just a glimpse of what a kid looks like in a stable situation with the family’s needs being met often resolves things. Another situation might be when you take that kid out of family and put that kid into an institution, medicate him and do that way. And you see every other kid in the family becomes normal. So I’ve had that happen as well so I mean it’s better if you can get somewhere you can just get a look at the kid away from that chaotic family.

Chairman: Thank you very much. It may sound like we are going to the opposite end of the spectrum from talking about hyperactive kids to kids with chronic fatigue. There probably is quite a bit in common, not least that the areas where mental health and physical health need to work together very creatively. They say that people are like their subjects that people study, their subject because they like it, I don’t think that’s true, I am sure Dr. Clarke is very focused and Dr. Viner is very energetic.