Matthew Wintersteen, Ph.D., returned to the FCP Behavioral Health Workshop series with an update on  his presentation entitled: “Depression, Suicide, and Related Mood Disorders in Adolescents.” As in the past, his easygoing and relaxed style allowed his mastery of the material to quickly become obvious. Using appropriate humor (considering the topic), and quickly moving through any material that may have otherwise been redundant for most of the audience, Dr. Wintersteen’s three-hour presentation went by quickly.

The workshop goals included:

• List etiologies of mood disorders in adolescents
• Name factors that contribute to suicide risk in adolescents
• Describe effective and efficient safety plans for youth who may be at risk for suicide

These goals were all met during this workshop.

Dr. Wintersteen briefly discussed etiology and prevalence of depression and other mood disorders. Yes, he did present some slides showing statistical trends and analysis of suicidal thoughts and behavior. As in his past workshops, he was also guilty of talking about effective techniques to reduce suicidal thoughts and ideation with adolescents. Dr. Wintersteen said that Psychoeducation, Psychotherapy (CBT, DBT), Family Therapy, and Psychopharmacology were effective in treating mood disorders. Research has demonstrated that psychotherapy and pharmacology combined were most effective. In his discussion of bipolar disorder, Dr. Wintersteen mentioned that those with bipolar II, had a higher incidence of suicide, because these individuals were less likely to seek treatment. He respected the professional level of his audience and did not attempt to re-teach basic mental-health skills.

Statistically, Dr. Wintersteen reported that:

• Suicide is the 2nd leading cause of death from birth to age 46
• 78% of all U.S. suicides are completed by men, 89% of which are white men
• Woman make 3 times as many attempts as men
• Approximately 1.2 million suicide attempts occur annually in the U.S
• Approximately 9.4 million Americans seriously considered suicide in 2014
• 90% of individuals who die from suicide had a diagnosable psychiatric disorder

As presented by Dr. Wintersteen, suicide rates for adolescent boys were highest from age 15 to 25. He also mentioned that there has been an increase in suicide rates during the past few years. While girls show more suicide attempts, boys are more likely to die due to lethality of method. Firearms are the most common method in successful suicides.

Dr. Wintersteen presented biological etiology for mood disorders in adolescents as:

• Largely Genetic
• Subcortical and prefrontal processing and regulation differences
• Reduced volume in the amygdala
  • Developmental delay in gray matter and subcortical region
  • Delay in prefrontal development
• Cognitive deficits including visuospatial memory, verbal memory, executive functioning, and attention set-shifting.

He also said that research suggests increased negative information availability through social media may contribute to the increase in suicidal thoughts for children and young adults.

During his discussion of suicide risk with adolescents, Dr. Wintersteen said assessment should include:

• Suicidal Desire and Ideation
  • Thoughts or images of suicide
  • Wanting to be dead
  • Connectedness to others
  • Perceived as a problem to others
• Resolved plans and preparations
  • How long to suicidal thoughts last
  • How strong is the intent
  • History of suicidal behavior
  • Specific plan
  • Means and opportunity
  • Preparations made
  • Time-frame established
  • Fearlessness
• Other Significant findings
  • Precipitant stressors
  • Hopelessness
  • Impulsive Behavior
  • Presence of psychopathology

Dr. Wintersteen provided references for two suicide risk assessment instruments, The “Columbia Suicide Severity Rating Scale” (C-SSRS), and the “Suicide Risk Assessment.” Information for these is available here: http://cssrs.columbia.edu/ 

While not going into detail due to time limitations, Dr. Wintersteen presented the steps required for a safety plan to be effective with adolescents. A general “no-suicide” contract is not usually helpful. An effective suicide safety plan is a list of coping strategies and resources for use during a suicidal crisis. The plan is typically developed collaboratively between the clinician and the youth, sitting side by side. Elements of the plan include:

• Step 1: Recognizing Warning Signs
  • How will the person know when the plan should be used
  • Write down the warning signs using the person’s own words
  • Negative thoughts about self (a nobody, failure, worthless, hopeless)
  • Images (flashbacks)
  • Thought Process (racing thoughts, many problems)
  • Mood (depressed, worried, intense anger)
  • Behavior (crying spells. Isolation, drugs)

• Step 2: Using internal Coping Strategies
  • List activities to do alone
  • What worked before? (going for a walk, music, playing an instrument, hot shower)
  • List potential roadblocks
  • Collaborative problem solving to overcome roadblocks

• Step 3: Socializing with Family Members or Others
  • List family, friends or others who may offer support or distraction from the crisis
  • List several people in case first is not available

• Step 4: Contacting Family Members or Friends for Help
  • Use if step 3 does not work
  • How willing is adolescent to contact these
  • Identify obstacles and problem solve ways to overcome them
  • Always include adults on the list

• Step 5: Contacting Professionals and Agencies
  • Use if step 4 does not work
  • List clinicians, urgent care & crisis numbers, National Suicide Prevention Hotline (1-800-273-TALK)

• Step 6: Reducing the Potential for Use of Lethal Means
  • Ask adolescent what means they would use
  • Always ask about access to a firearm
  • Ask adolescent to eliminate access to low-lethal means
  • Collaboratively work with a responsible person to secure high-lethal means

The Audience at today’s workshop appeared receptive and quiet. Most questions were short and relevant to the topic.  Dr. Wintersteen was able to quickly answer most questions. He repeated the questions for the audience.  In general, today’s workshop was very satisfying. It provided me with useful information for my practice. Any other thoughts on this workshop?