DYING YOUNG: DEPRESSION, SUBSTANCE USE DISORDERS AND SUICIDE

Introduction

For about 6 months, it was increasingly common for 15-year-old Tyson to have mood swings and bouts of sadness or anger–but lately, they seem to be occurring much more frequently. “What’s wrong honey?” his mother would ask. “Nothing” he’d snap — “I’m just having a bad day.” On these days Tyson would either stay in his room and “veg out” on video games, sleep, or go to hang out with his friends.

Over the following 5 months his mother chalked these “bad days” up to the pressures of high school. His guidance counselor told her that many kids experience difficulty adjusting to high school and that being 15 is an awkward age. “Just give him time,” she said. So she did–until one day when Tyson came from school and began cursing and slammed his bedroom door. When his mother came in his room she found her son sobbing uncontrollably. “What’s wrong honey–did you have another bad day?” “Mom” he replied, “I’m having a bad life—I wish I were dead”.

Tyson’s mom called the pediatrician and immediately and made an appointment for the following week. But that weekend, Tyson tried to kill himself by overdosing on hydrocodone and Zolpidem (Ambien) both of which he found in his parents medicine cabinet. Fortunately, his mom found him unconscious and called 911. The Emergency Department physicians were able to save Tyson. But the real challenge was still ahead.

There is no easy way for a parent to tell the difference between a bad case of the blues, adolescent “growing pains”, substance abuse, or symptoms of depression in their children. So when feelings of sadness, loneliness, confusion, or anger persist, it may not be “just a phase” they will simply grow out of–it may be a serious and potentially fatal brain disease.

Suicide

Suicide is now the second leading cause of death for children, adolescents, and young adults age 5-to-24 years old in the United States. Data from the World Health Organization indicate that suicide is the leading cause of premature death in teens and young adults worldwide, with a global incidence rate of 16 per 100,000 people. This adds up to more than a million people committing suicide each year. Accidents, another common cause of death for adolescents and young adults, are also sometimes suicide. Drug overdoses, often considered accidental, are also commonly suicide attempts.

The majority of persons who attempt or commit suicide have a serious mental illness, namely depression, especially among 20-40 year olds. In addition, Substance Use Disorder (c), especially opioid misuse and addiction is directly associated with a 200% increase since 2000, and more than 33,000 deaths in 2015 alone. Which begs the question, why is depression and overdose from drugs, especially opioids, seemingly so prevalent?

The answers are complicated and not well understood. In general, suicide attempts among children, teens and young adults are often an impulsive response to an acute stressor, or a chronic, seemingly unchanging stressor, such as addiction, in which they see no way forward. These young people experience intense sadness, confusion, hopelessness, grief and anger, and most do not have the internal coping skills to manage these feelings or the external assets to seek help or to change their circumstances.

Depression is a multifaceted brain disease, of which the exact cause is unknown. Certainly, painful circumstances in one’s daily life- loss and grief, social rejection, and bullying are all external stressors that children and teens identify when describing their depression. But neurobiological processes, hopelessness and genetic vulnerability are also confirmed risk factors for depression.

The American Academy of Child and Adolescent Psychiatry has identified the most common risk factors for suicidality. They include:

• Family history of suicide attempts
• Exposure to violence
• Impulsivity
• Aggressive or disruptive behavior
• Access to firearms
• Bullying
• Feelings of hopelessness or helplessness
• Acute loss or rejection

For children and adolescents, making statements or comments such as, “I wish I was dead,” or “I won’t be a problem for you much longer”, are serious warning signs and should never be taken lightly. Other warning signs may include:

• Loss of interests, friends, “face” or standing amongst peer.
• Changes in eating or sleeping habits (loss of appetite and insomnia are more commonly observed than overeating and hypersomnolence)
• Frequent or pervasive sadness, crying
• Withdrawal from friends, family, and regular activities
• Frequent physical complaints and symptoms such as stomachaches, headaches, fatigue
• Declining interest and performance in schoolwork or extracurricular activities
• Physical or emotional pain
• Preoccupation with death and dying

People who are contemplating suicide often have on-line evidence for depression, anger, despair, and stop talking about the future, or cease making any long term plans. They may give away important possessions to those they care about.

Substance Use Disorder and Suicidality

Depression is the number-one risk factor for suicide, but alcohol and drug abuse are a close second. The best available evidence has established that drug and alcohol abuse during adolescence is a major risk factor for depression. Specifically, persons with substance use disorders are approximately six times more likely to commit suicide than the general population.

Substance Use Disorders (SUDs) not only increase the likelihood that a person will take their own life, but also provides the means for committing suicide. Approximately one-third of suicides are committed under the influence of drugs or alcohol. Most recently, opiates, such as oxycodone or heroin (often cut with fentanyl), are associated with both accidental overdose and suicide. Often, it’s difficult to determine if an OD was intentional or not. Yet, in 2015, over 33,000 Americans died from misusing opioids.

We do know that men with an opioid use disorder were twice as likely to commit suicide compared to same age men without opioid use disorder. It’s even worse for women. Recent data informs us that these opioid abusing women are eight times more likely to commit suicide compared to age matched cohorts. In general, opioid misuse is associated with a 40%-60% increased risk for suicidal thought, and a 75% increased likelihood of a suicide attempt.

What’s the connection?

The oldest theory asserts that substance abusers incur so much failure in their life and loss of important relationships that in their minds, suicide is a viable means to end their suffering and the differing of those who love them. In addition, we have established the causal effects of intoxicants and neuroadaptive changes within the brains pleasure and reward systems, as well as degradation to the neural circuity involved in mood and inhibitory control.

Genetics: We know that the risk for both SUDs and depression are heritable, and thus more likely to manifest in the children of parents with either disorder. Notice we didn’t say “cause” we said increase the “risk”. However, the combination of a genetic risk, plus the exposure to intoxicants, especially early in life, dramatically increases the risk of developing either or both disorders. In fact, the concordance rate for SUDs and Depression is bi-directional and somewhere between 45-65 percent. Among the treatment population, the risk is closer to 70 percent. The risk is even greater when a parent or sibling experiences one or more psychotic episodes.

Neurobiology

Both SUD and depression are thought to be rooted in the activity of specific neurotransmitters called catecholamines (dopamine, epinephrine, and norepinephrine, as well as serotonin in the midbrain, frontal and prefrontal areas). Dysfunction in neurotransmission involving these neurotransmitters are implicated in neurologic and neuropsychiatric disorders including SUDs, Depression and Bi-Polar disease, Anxiety, Psychosis and even Parkinson’s Disease.

Collectively known as the reward center or reward pathway, drugs of abuse impact the volume and activity of the aforementioned neurotransmitters. Many drugs of abuse have chemical structures similar to endogenous neurotransmitters and bind to selective protein receptors that are reserved for transmitting dopamine, noradrenalin, and serotonin. When this occurs, the brain has been usurped by exogenous and toxic substances which produce acute euphoria, but in the process, degrade the normal and essential neuronal signaling between important centers in the brain and the body. Therefore, addiction and mental illness commonly co-occur and must be addressed and treated aggressively.

But which came first the addiction or the depression?

The answer is “it doesn’t matter”. Good medicine understands that co-occurring illness must be treated concurrently. In the case of SUDs, untreated or underrated depression leads to relapse, remorse, shame and increases the risk of suicide.

Evaluation and treatment must be multimodal. Patients who are dually diagnosed with depression and SUD’s are at increased risk for suicide and should be treated as such until stabilized. It takes a highly trained doctor, boarded in psychiatry and addiction medicine, or addiction psychiatry to effectively care for an individual with dual disorders. Equally important is the work of the therapist with the family in understanding the stressors that can be modified, especially when the patient is a teen or young adult.

Evaluation

A psychiatric evaluation is conducted for any patient that has been treated for, or attempted suicide. Because the concordance rate between SUDs and depression is so high, depression should be thoroughly assessed throughout the treatment process. Many depressed teens get a cursory evaluation and quickly find themselves prescribed antidepressants. The goals of the psychiatric evaluation include;

• Getting a complete Family Medical and Psychiatric History
• Physical, Psychoeducational and Neurological examination-evaluation looking for diseases which might cause anhedonia, depression, loss of energy, as well as for medical mimics of psychiatric disease
• Identifying family expectations, educational and other goals and comparing them to the child’s goals, aptitudes, and testing
• Identifying Drug and/or Alcohol abuse or dependence. Determining the risk of subsequent suicide attempt or suicide completion
• Identifying sexual or emotional trauma, familial, environmental and other predisposing stressors and precipitating factors that can be treated or modified
• Psychological treatment for depressed and stabilized dually disordered persons may include Cognitive Behavioral Therapy
  (CBT), Dialectical Behavioral Therapy (DBT), Motivational Interviewing (MI) and structured, symptom driven treatment (inpatient, partial hospital, or outpatient care)

As mentioned, a psychiatric assessment should be performed by clinicians with specialized training and experience in adolescent psychiatry, as well as addictive disease whenever possible.

The process gathers essential information from several sources including the family, previous psychiatric evaluation or assessments, school or EAP assessments, patient interviews and testing as well as family members. This is most productive when family interviews are conducted with the patient present and separately. This technique reveals important family and relational dynamics.

Suicidal ideation, suicide plan and intent are considered a medical emergency. Urgency and timeliness is the key. On demand psychiatric triage for these emergencies and same day appointments after acute care has been the most efficacious model, especially among the student population utilizing campus mental health centers. Evaluating suicidality, lethality and the risk for future attempts is a critical component of individualized, patient centered care. Information regarding concurrent psychiatric, medical or substance abuse diagnoses and a thorough understanding of the precipitating or inciting event is critically important when assessing coping skills, resilience and risk.

Treatment

Once evaluated, treatment should begin immediately with regularly scheduled re-assessments of symptoms. If SUD is diagnosed— a program that employs dually credentialed (psychiatry and addiction medicine) physicians is essential.

Both depression and SUDs are serious and life threatening disorders of the brain— but are also highly treatable. Early recognition is critical. On the prevention side, it’s equally important to teach parents and school personal about both disorders, how to identify risk factors, and how to intervene when symptoms occur.

Dr. Mark S. Gold is Chairman of the RiverMend Health Scientific Advisory Boards. He is an award-winning expert on the effects of opiates, cocaine, food and addiction on the brain. His work over the past 40 years has led to new treatments for addiction and obesity which are still in widespread use today. He has authored over 1000 medical articles, chapters, abstracts, journals, and twelve professional books on a wide variety of psychiatric research subjects, including psychiatric comorbidity, detox and addiction treatment practice guidelines. www.rivermendhealth.com

Dr. Drew Edwards is a behavioral medicine/addictive disease researcher, clinician, author, medical writer, and clinical consultant. He has published over 250 peer-reviewed and popular articles on behavioral medicine obesity, addictive disease, parenting and youth culture, as well books on childhood depression, and instilling self-esteem in children. He is a certified forensic expert in the neurobiology of addictive disease, providing expert testimony in capital cases involving drugs and alcohol. He is a graduate of the University of Minnesota, received his Master of Science from the University of No. Florida and earned his doctorate at Nova Southeastern University. www.drdrewedwards.org