tag:theconversation.com,2011:/global/topics/suicidal-thoughts-16773/articlesSuicidal thoughts – The Conversation2024-02-01T13:30:51Ztag:theconversation.com,2011:article/2166032024-02-01T13:30:51Z2024-02-01T13:30:51ZSuicide has reached epidemic proportions in the US − yet medical students still don’t receive adequate training to treat suicidal patients<figure><img src="https://images.theconversation.com/files/562904/original/file-20231201-17-ssns1k.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C5982%2C3997&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Every year, more than 12 million Americans have suicidal thoughts.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/tired-and-downcast-man-holding-head-with-hands-royalty-free-image/1472116942?phrase=suicide&searchscope=image%2Cfilm&adppopup=true">Djavan Rodriguez/Moment via Getty Images</a></span></figcaption></figure><p>Suicide in the U.S. is <a href="https://www.mentalhealthfirstaid.org/">a societal epidemic</a> and a <a href="https://www.kff.org/mental-health/issue-brief/a-look-at-the-latest-suicide-data-and-change-over-the-last-decade/">staggering public health crisis</a> that demands attention from medical experts.</p>
<p>In 2021, <a href="https://www.cdc.gov/suicide/suicide-data-statistics.html">someone in the U.S. died by suicide every 11 minutes</a>, according to the Centers for Disease Control and Prevention. That rate equates to nearly 50,000 Americans every year. Another 1.7 million people in the U.S. attempted suicide in 2021, and over 12 million more had suicidal thoughts. </p>
<p>And the numbers appear to be getting worse: Preliminary numbers for 2022 show a <a href="https://www.nytimes.com/2023/08/11/well/mind/suicide-deaths-2022-cdc.html">2.6% increase in suicide deaths from 2021</a>. </p>
<p>Suicide particularly affects younger people – it remains one of the top three causes of death for those between ages 10-34. High school students identifying as lesbian, gay, bisexual, transgender, queer and questioning, or LGBTQ+, attempt suicide <a href="https://www.thetrevorproject.org/resources/article/facts-about-lgbtq-youth-suicide/">four times more often than heterosexual students</a>. </p>
<p>These statistics make it clear that far more attention needs to be given to how to talk about suicide, both with loved ones and in medical and other professional settings. </p>
<p>As <a href="https://medicine.fiu.edu/about/faculty-and-staff/profiles/office-of-medical-education/rbonnin.html">a team of experts</a> <a href="https://medicine.fiu.edu/about/faculty-and-staff/profiles/psychiatry-and-behavioral-health/gralnikl.html">who educate medical students</a> <a href="https://medicine.fiu.edu/about/faculty-and-staff/profiles/psychiatry-and-behavioral-health/ndesmara.html">on how to identify</a> and treat suicidal patients, we are well aware that most medical schools <a href="https://doi.org/10.1097/ACM.0000000000004008">do not yet adequately address the topic of suicide</a>. </p>
<p>In turn, many of their students, once they become physicians, are not adequately equipped to identify, assess and refer suicidal patients. Yet, these health care providers are expected to <a href="https://doi.org/10.3389/fmed.2022.892205">play a key role</a> in the battle to prevent suicide. But as the numbers make clear, this approach is not enough.</p>
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<figcaption><span class="caption">The signs of someone considering suicide include giving away possessions and abusing drugs or alcohol.</span></figcaption>
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<h2>Destigmatizing suicide</h2>
<p>Suicide has a long history of stigma, made worse by how it’s <a href="https://theactionalliance.org/messaging/entertainment-messaging/national-recommendations">portrayed in the media</a>. Often, when someone dies by suicide, the media uses euphemistic phrases such as “no foul play suspected,” rather than clear and accurate language describing the death as a suicide. This type of coded language implies the subject of suicide should not be addressed directly and <a href="https://link.springer.com/chapter/10.1007/978-3-030-26840-4_1">leaves questions about what actually happened</a>. </p>
<p>When a person takes their own life, the phrase <a href="https://www.dailymail.co.uk/news/article-12856353/Emily-Matson-Pennsylvania-suicide-train.html">“committed suicide” is often used</a>, as if it were a sin or a crime. This is partly because, historically, most religions have considered suicide to be sinful and as a result it is <a href="https://doi.org/10.1111/1467-9566.12224">treated as taboo</a>. Although laws against suicide have been <a href="https://ethics.journalism.wisc.edu/2023/03/10/a-guide-to-responsible-reporting-on-suicide/">repealed in the United States and many other places</a>, attempted suicide is still <a href="https://www.law.cornell.edu/wex/suicide">considered a crime in some states</a>. </p>
<p>The verb “commit” in the context of suicide can <a href="https://twitter.com/APStylebook/status/1160941325073731584">suggest a criminal act</a>. In contrast, using language such as “died from suicide” or “took her own life” is less stigmatizing and more neutral, which is why these phrases are <a href="https://www.hse.ie/eng/services/list/4/mental-health-services/nosp/resources/language-and-suicide/">recommended by advocates of mental health</a> as best practices. Consistent with this approach, many media organizations have developed specific guidelines for reporting about suicide. For example, the Associated Press Stylebook recommends <a href="https://www.apstylebook.com/ap_stylebook/suicide">avoiding use of the phrase “committed suicide</a>.” </p>
<p>Similarly – largely because of the societal and historical stigma surrounding suicide, which medical education is not immune to – medical schools do not equip up-and-coming doctors with the language and skills needed to recognize it and properly address it with their patients.</p>
<h2>Shortage of mental health care</h2>
<p>The first point of contact for patients seeking treatment for mental health conditions is usually their primary care physician. About 44% of those who died by suicide worldwide between 2000 and 2017 had visited their primary care provider <a href="https://doi.org/10.1177/1403494817746274">within one month of their death</a>. </p>
<p>This could be due to a combination of factors, including the continued stigma of mental health, <a href="https://theconversation.com/as-the-mental-health-crisis-in-children-and-teens-worsens-the-dire-shortage-of-mental-health-providers-is-preventing-young-people-from-getting-the-help-they-need-207476">limited access to mental health professionals</a> and ease of access to and comfort with their primary care practitioner as a first step. Research shows that gaps between general medical services and specialty mental health options are preventing adults and kids from <a href="https://doi.org/10.1016/j.apnu.2019.08.001">getting the mental health care</a> they need.</p>
<p>In addition, the vast majority of patients with depression are treated by their primary care physicians rather than psychiatrists. </p>
<p>The shortage of available psychiatrists means that primary care physicians provide treatment and prescribe mental health care by default, especially for children, adolescents and geriatric patients. In fact, primary care providers – in other words, practitioners who are not psychiatrists – prescribe more than half of all psychiatric medication. And a 2023 study found that approximately one-third of patients received <a href="https://doi.org/10.1007/s10488-023-01290-x">mental health care from their primary care provider</a>. </p>
<p>Finally, many psychiatrists in private practice do not accept insurance, including Medicare and Medicaid, leading to <a href="https://doi.org/10.1001%2Fjamapsychiatry.2013.2862">reduced availability of psychiatric care</a>. </p>
<p>Thousands of additional lives might be saved if primary care physicians and other practitioners who are not psychiatrists were better trained to ask the vitally important questions about suicide. In addition, better recognition of the warning signs of suicide, readily available psychiatric care and the elimination of stigma of mental illness would facilitate better quality of care. </p>
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<figcaption><span class="caption">Psychiatry and behavioral health professors Rodolfo Bonnin and Nathaly Shoua-Desmarais talk about the urgent need for suicide education for all doctors, not just psychiatrists.</span></figcaption>
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<h2>Training the next generation of doctors</h2>
<p>Why do so many Americans take their lives shortly after seeing a primary care provider? </p>
<p>It may be because many doctors are <a href="https://doi.org/10.1027/0227-5910/a000555">unprepared or uncomfortable discussing suicide</a> or don’t pick up on the signs of <a href="https://pubmed.ncbi.nlm.nih.gov/33351435/">suicidal ideation</a>. It’s also possible that the doctors simply don’t have the necessary time to spend with the patients, even when intervention is needed. </p>
<p><a href="https://medicine.fiu.edu/about/departments/psychiatry-and-behavioral-health/">At Florida International University</a>, we train all medical students, beginning in the first year, on how to discuss suicide with patients. This helps to normalize the topic as just another part of their medical training, which, in turn, destigmatizes it. </p>
<p>We then emphasize the need for comfort and familiarity with the topic, as well as the many myths surrounding it. For example, there’s a false belief that asking a patient about suicide will increase the likelihood they will act upon the suicide. <a href="https://doi.org/10.1080/13811118.2020.1793857">Research indicates otherwise</a>. </p>
<p>Finally, students are told that doctors must create a safe environment for their patients to be open about discussing sensitive topics. In short, doctors must ask questions about suicide in a way that’s not pejorative or dismissive. They must not apologize to the patient or shy away from the subject.</p>
<p>Statements like “I’m sorry to have to bring this up” or “I’m sorry if this question seems too personal” can be an indication of discomfort or uneasiness. Instead, doctors should ask direct and specific questions like “Have you had any thoughts about ending your life” or “Are you having any thoughts of suicide?” </p>
<p>After a risk assessment is completed, then a patient would be hospitalized if they are at risk – there is no mandate for doctors to report on or act on depression.</p>
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<figcaption><span class="caption">Suicidal ideation is an emergency.</span></figcaption>
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<h2>The need for universal suicide screening</h2>
<p>Although universal suicide screening has yet to be made the best practice nationally, there are multiple reasons why a standard screening process would be beneficial. Training in suicide assessment and prevention can be made mandatory for medical license renewal, which would include universal screening practices. </p>
<p>For example, <a href="https://www.pewtrusts.org/en/research-and-analysis/articles/2023/04/19/health-care-providers-laud-universal-screenings-to-help-reduce-suicide-risk">adopting best practices</a> could include offering suicide screening during routine health care visits to identify people at risk who might not otherwise be identified. </p>
<p>Another example: More than half of 15,000 children and adolescents who were seen in a pediatric hospital emergency room for nonpsychiatric reasons between March 18, 2013, and Dec. 31, 2018, were also <a href="https://doi.org/10.1176/appi.ps.202100625">experiencing suicidal ideation and behaviors</a>. These examples emphasize the critical need to train doctors in suicide assessment and prevention. Currently there are fewer than 10 states that <a href="https://www.datocms-assets.com/12810/1577013724-afsphealthprofessionaltrainingissuebrief6-7-19.pdf">require any training on suicide assessment and prevention</a> for doctors to renew their medical license.</p>
<p>In addition, doctors can use empathy, compassion and a nonjudgmental approach, rather than making the patient feel like they are being cross-examined by a lawyer. Interacting empathically leaves the patient feeling more understood and comfortable disclosing sensitive information. </p>
<p>There is a growing movement <a href="https://doi.org/10.1097/ACM.0000000000004008">toward addressing mental health issues</a> in medical schools. Our program prioritizes training a new crop of physicians who will be prepared and motivated <a href="https://doi.org/10.1007/s40596-021-01485-0">to discuss suicide with their patients</a>. </p>
<p><em>If you or someone you know is considering suicide, please <a href="https://988lifeline.org/">call or text 9-8-8 for confidential, free support</a>.</em></p><img src="https://counter.theconversation.com/content/216603/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Close to half of those who die by suicide saw a primary care doctor within a month of their death.Rodolfo Bonnin, Assistant Dean for Institutional Knowledge Management and Associate Professor of Psychiatry and Behavioral Health, Florida International UniversityLeonard M. Gralnik, Chief of Education and Associate Professor of Psychiatry and Behavioral Health, Florida International UniversityNathaly Shoua-Desmarais, Assistant Dean for Student Success and Well-Being and Associate Professor of Psychiatry and Behavioral Health, Florida International UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1909502022-09-22T18:08:48Z2022-09-22T18:08:48ZKetamine paired with looking at smiling faces to build positive associations holds promise for helping people with treatment-resistant depression<figure><img src="https://images.theconversation.com/files/485716/original/file-20220920-14233-xe0rz7.jpg?ixlib=rb-1.1.0&rect=10%2C0%2C6699%2C4476&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some of the positive photos used in the study were similar to this one -- a group of smiling strangers.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/successful-business-team-taking-selfie-royalty-free-image/1132119295?adppopup=true">Luis Alvarez/DigitalVision via Getty Images</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em></p>
<h2>The big idea</h2>
<p>Simple computer exercises using positive words and images designed to boost self-worth can prolong the antidepressant effects of ketamine in people with depression. That’s what my research team and I found <a href="https://www.doi.org/10.1176/appi.ajp.20220216">in our new study</a>.</p>
<p>Over two decades ago, researchers serendipitously discovered that intravenous ketamine, a widely used anesthetic medication that has been <a href="https://doi.org/10.1111/j.1365-2044.2007.05298.x">shown to be safe</a> when administered under medical supervision, had <a href="https://doi.org/10.1016/s0006-3223(99)00230-9">rapid-acting antidepressant effects</a> when given at lower doses than is used for anesthesia. </p>
<p>Our study included 154 adult patients with depression. One-third received a single infusion of ketamine and returned a day later to begin four consecutive days – about 30 to 40 minutes total each day – of our novel digital exercises. That is, we showed them repeated pairings of self-related words and images – such as the letter “I” and photos of the patient – paired up repeatedly with positive cues. These include positive words like “good,” “sweet” and “lovable” as well as photos of strangers smiling.</p>
<p>We targeted this period of time within five days of ketamine because we expected ketamine would quickly help restore the brain’s healthy capacity to adjust and learn in response to the environment. The specific exercises we used were designed based on our prior work showing that, shortly after a ketamine infusion, thought patterns related to oneself <a href="https://doi.org/10.1002/da.22253">may become less “stuck”</a> and be more malleable, creating a window of opportunity to improve a person’s sense of self-worth.</p>
<p>The other two-thirds of patients went into one of our two control groups: those who received ketamine followed by a neutral, or placebo, version of computer training, and those who received a saline infusion followed by the real training exercises. </p>
<p>We found that after just a single intravenous infusion of ketamine, patients experienced relief from depression symptoms for at least one month as long as they were assigned to the group that completed the digital exercises within the first five days. Compared with those in the control saline group, both of the groups that received a ketamine infusion experienced substantial relief from depression on the first day, prior to any computer training. </p>
<p>However, whereas the control group who went on to receive the “sham” computer training began to experience the return of depression symptoms in the subsequent 1.5 weeks or so, the group that received ketamine followed by exposure to positive conditioning continued to report decreased depression severity all the way out to the last follow-up interview, one month after ketamine. </p>
<p>The people who got digital training in the absence of ketamine had very little relief from their depression.</p>
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<figcaption><span class="caption">More than 20 million U.S. adults and 4 million adolescents have had at least one major depressive episode, according to the National Institute of Mental Health.</span></figcaption>
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<h2>Why it matters</h2>
<p>Depression is a highly prevalent and disabling condition that exacts a staggering burden on patients, families and communities. </p>
<p>Globally, <a href="https://www.who.int/news-room/fact-sheets/detail/depression">an estimated 280 million people</a> experience depression. There are <a href="https://doi.org/10.7326/AITC202105180">numerous effective treatments</a> for depression, including <a href="https://www.nice.org.uk/guidance/ng222">antidepressant medications and psychotherapy</a>. </p>
<p>However, unfortunately, not all patients <a href="https://doi.org/10.1176/ajp.2006.163.11.1905">are helped by such treatments</a>. And accessing them initially, as well as maintaining them over the long haul can be challenging for many patients.</p>
<p>The discovery of ketamine’s rapid-acting antidepressant effects opened up a brand new possibility within psychiatry to begin relieving symptoms within a day. Conventional treatments typically take six to eight weeks to reach a therapeutic effect.</p>
<p>However, a key question is how to keep that relief going without relying solely on repeated ketamine infusions. These can be burdensome and costly for patients and health care systems, and it is important to consider <a href="https://doi.org/10.1176/appi.ajp.2014.13101434">possible risks</a>, such as the potential for drug misuse. </p>
<p>Our study is the first to demonstrate that the rapid effects of ketamine can be made more enduring with simple, portable and automated techniques that would be relatively easy to provide to patients in a wide range of settings. </p>
<h2>What’s next</h2>
<p>Our initial findings suggest the positive conditioning exercises tripled – at a minimum – the duration of ketamine’s effects. But we don’t yet know how much longer the relief from depressive symptoms may have continued. </p>
<p>Patients in our trial will continue to complete questionnaires about their depression symptoms for an entire year following the infusion, enabling us to gain an initial understanding of just how long this benefit may endure.</p>
<p>Ongoing research is exploring whether <a href="https://clinicaltrials.gov/ct2/show/NCT04578938">similar techniques might help ease suicidality</a>, in the hopes of providing relief in the midst of a suicidal crisis that is both immediate and enduring. Other future research may expand these techniques to additional common forms of psychological suffering, such as anxiety, disordered eating and more.</p><img src="https://counter.theconversation.com/content/190950/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rebecca Price receives funding from the National Institute of Mental Health.
Dr. Price is the named inventor on a University of Pittsburgh–owned provisional patent filing related to the combination intervention described in this report.</span></em></p>In a new study, a single infusion of the antidepressant – along with repeated exposure to positive imagery – significantly reduced symptoms in depressed patients in a clinical trial.Rebecca Price, Associate Professor of Psychiatry and Psychology, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1674362021-09-07T20:10:22Z2021-09-07T20:10:22ZMore children are self-harming since the start of the pandemic. Here’s what parents and teachers can do to help<figure><img src="https://images.theconversation.com/files/419694/original/file-20210907-13-1z0fnk2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-asian-preteen-teenager-boy-hugging-1476187649">Shutterstock</a></span></figcaption></figure><p>There has been a reported spike in young people attending emergency departments for self-harm and suicide during the pandemic. In New South Wales, <a href="https://www.smh.com.au/national/it-s-completely-shocking-when-it-s-your-child-what-s-driving-the-youth-mental-health-crisis-20210902-p58oa5.html">presentations to emergency departments</a> for self-harm and suicidal thoughts are reportedly up by 47% since before the pandemic. </p>
<p>In the year to July 29 2021, there were <a href="https://www.smh.com.au/national/nsw/more-than-40-nsw-children-and-teenagers-rushed-to-hospital-for-self-harm-every-day-20210827-p58mg7.html">8,489 presentations to NSW emergency departments</a> for self-harm in people aged up to 17. This was up from 6,489 presentations in the year to July 20 2020. </p>
<p>A <a href="https://about.unimelb.edu.au/newsroom/news/2020/december/study-finds-some-primary-school-aged-children-self-harm,-as-experts-call-for-earlier-intervention">study published in December 2020</a> found children as young as in primary school are harming themselves intentionally.</p>
<p><a href="https://www.smh.com.au/national/calls-to-kids-helpline-surge-in-melbourne-and-sydney-20210813-p58ijs.html">Services like</a> <a href="https://www.abc.net.au/news/2021-08-04/lifeline-records-highest-daily-calls-on-record/100350522">crisis help lines</a> and emergency departments are <a href="https://www.theage.com.au/national/victoria/system-overload-why-victoria-s-health-network-is-on-its-knees-20210901-p58nry.html">not meeting the increased demand</a> for mental health support.</p>
<p>If you are a parent or teacher, there are several things you can do when you learn your child or student has self-harmed.</p>
<h2>What is self-harm?</h2>
<p>Self-harm, also known as self-injury or non-suicidal self-injury, describes people’s intentional acts to inflict harm on their own body. Self-harm includes cutting skin, burning, self-hitting and scratching skin — or <a href="https://headspace.org.au/young-people/understanding-self-harm-for-young-people/">any other behaviours</a> that cause body injury, pain and wounds.</p>
<p>People who <a href="https://www.lifeline.org.au/get-help/information-and-support/self-harm/">intentionally harm themselves</a> do so to relieve stress, anxiety and sadness, to bring their attention to the present moment or to punish themselves because of self-loathing and self-hatred. </p>
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Read more:
<a href="https://theconversation.com/why-do-people-intentionally-injure-themselves-90451">Why do people intentionally injure themselves?</a>
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<p>Self-harm may be something a young person does once, twice or repeats over and over. Young <a href="https://headspace.org.au/young-people/understanding-self-harm-for-young-people/">people who repeatedly self-harm</a> often have other mental health problems or have experienced significant stress in their life.</p>
<p>As <a href="https://au.reachout.com/articles/what-is-self-harm">self-harm is often a response</a> to mounting stress and uncertainty, it’s not surprising rates have gone up during the pandemic. Self-harm can be a means to cope and establish control over emotions. </p>
<p>Self-harm and physical pain <a href="https://au.reachout.com/articles/what-is-self-harm">can provide a sense of relief</a> from emotional pain.</p>
<h2>What can you do?</h2>
<p>If you know a child who is harming themselves, there are some things you can do.</p>
<p>First, it is <a href="https://raisingchildren.net.au/teens/mental-health-physical-health/mental-health-disorders-concerns/self-harm">essential parents and teachers</a> do not respond with shock, horror, anger or judgement when they identify their child or student has self-harmed. Young people often report feeling shame after they have intentionally harmed themselves which leads them to hide their wounds under clothing and jewellery. </p>
<p>Many may not participate in activities which might reveal their wounds, such as swimming or other sports.</p>
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<a href="https://images.theconversation.com/files/419704/original/file-20210907-13-1da6pcf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Father with his arm around his son." src="https://images.theconversation.com/files/419704/original/file-20210907-13-1da6pcf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/419704/original/file-20210907-13-1da6pcf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/419704/original/file-20210907-13-1da6pcf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/419704/original/file-20210907-13-1da6pcf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/419704/original/file-20210907-13-1da6pcf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/419704/original/file-20210907-13-1da6pcf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/419704/original/file-20210907-13-1da6pcf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">It’s important not to react with judgement if you find out a child has been intentionally harming themselves.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/father-parenting-his-son-535653202">Shutterstock</a></span>
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<p>The second thing you can do as a parent or teacher is remove objects which may be used to self-harm. The purpose of this should not be to punish or shame the child but to remove a child’s easy access to things that could be used to inflict injuries. And you can remind the child you are not removing these objects to punish, but rather to help them.</p>
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Read more:
<a href="https://theconversation.com/its-not-only-teenage-girls-and-its-rarely-attention-seeking-debunking-the-myths-around-self-injury-120214">It's not only teenage girls, and it's rarely attention-seeking: debunking the myths around self-injury</a>
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</p>
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<p>When treating young people who self-harm we instruct them to <a href="https://www.orygen.org.au/Training/Resources/Self-harm-and-suicide-prevention/Guidelines/Coping-with-Self-Harm-Guide-for-Parents-and-Carers/Orygen-coping-with-self-harm-web">create a delay</a> between the urge to self-harm and the act of self-harm. Removing implements used to self-harm can help to do this too.</p>
<p>Activities to <a href="http://www.selfinjury.bctr.cornell.edu/perch/resources/distraction-techniques-pm-2.pdf">distract young people</a> from self-harm, such as cooking and exercise, is another highly recommended strategy to prevent further injury. </p>
<p>Some recommend so-called “<a href="http://www.selfinjury.bctr.cornell.edu/perch/resources/distraction-techniques-pm-2.pdf">substitution activities</a>” for self-harm such as holding ice or snapping a rubber band on your wrist. But <a href="https://www.talkspace.com/blog/time-retire-self-harm-alternatives">these are controversial</a> as they come from the same self-destructive mindset and are similar behaviours, just in a different wrapper. </p>
<h2>How to treat a child’s wounds</h2>
<p>It is important parents, a school nurse or school first aid trained staff have an opportunity to inspect and treat a child’s wounds. Parents and school staff should be <a href="https://www.self-injury.org.au/t-respond-to-adolescents">pragmatic, sensitive and show unconditional positive regard</a> for their child and students during this interaction.</p>
<p>This can include comments like: “Can you tell me a little bit about what happened?”; “Have you ever done this before?”; “Where on your body did you do this?” and “How many times did you do this?” </p>
<p>Finally, <a href="https://www.taylorfrancis.com/chapters/oa-edit/10.4324/9781003025955-13/self-injury-response-intervention-policy-emily-berger-janis-whitlock">parents and school staff should ask</a>, “How do you normally care for the wounds?”</p>
<p>Understanding how young people care for their wounds and teaching them about wound care, as well as the importance of seeking help after self-harm, should be the goal of these interactions.</p>
<p>Parents and school staff can then make decisions about the next stages of action. This can be discussed with their child to allay any fears they may have about seeking further help from medical or mental health services. It may include booking a session with the child’s GP or psychologist.</p>
<p>A mental health professional will be able to help address the underlying feelings that led the young person to self-harm and provide the young person with different ways of coping. They will also be able to determine whether the young person is also having suicidal thoughts.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-every-teacher-needs-to-know-about-childhood-trauma-132965">Why every teacher needs to know about childhood trauma</a>
</strong>
</em>
</p>
<hr>
<p>A <a href="https://www.taylorfrancis.com/chapters/oa-edit/10.4324/9781003025955-13/self-injury-response-intervention-policy-emily-berger-janis-whitlock">recently published policy</a> for schools has outlined other ways for teachers to respond after a student has self-harmed. All schools should have a self-harm policy to support teachers by telling them what steps to follow if they become aware a student has self-harmed.</p>
<p>A school policy on self-harm should include information about how to support students, how to talk to parents, how to minimise contagion of self-harm between students, and how to support teachers managing the issue of self-harm of students.</p>
<p><em>If you or anyone you know has self-harmed or thought about it, contact <a href="https://www.lifeline.org.au/">Lifeline</a> on 13 11 14 or <a href="https://kidshelpline.com.au/">Kids Helpline</a> on 1800 55 1800.</em></p><img src="https://counter.theconversation.com/content/167436/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emily Berger does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Self-harm is often a response to mounting stress and uncertainty. So it’s not surprising rates have gone up during the pandemic. Self-harm can be a means to cope and establish control over emotions.Emily Berger, Lecturer, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1523112021-04-19T17:16:41Z2021-04-19T17:16:41ZSuicide prevention during COVID-19: The healing power of connection and mutual support<figure><img src="https://images.theconversation.com/files/387580/original/file-20210303-14-shq5h.jpg?ixlib=rb-1.1.0&rect=2%2C0%2C1994%2C1535&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There are many complex pandemic-related risk factors for suicide, and suicide prevention is a crucial public health response to COVID-19.</span> <span class="attribution"><span class="source">(Pixabay/Canva)</span></span></figcaption></figure><p>The mental health crisis is a <a href="https://doi.org/10.1016/S1473-3099(20)30797-0">parallel pandemic</a> of COVID-19 across the globe. There are increased concerns about <a href="https://www.cbc.ca/news/canada/calgary/covid-19-pandemic-distress-centre-calls-calgary-suicide-1.5826497">pandemic-related risks of suicide in Canada</a> and <a href="https://www.washingtonpost.com/health/2020/05/04/mental-health-coronavirus/">elsewhere</a>. Studies from different countries present a complex picture with <a href="https://doi.org/10.1136/bmj.m4352">varying suicide trends</a>, but increased rates of <a href="https://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/publications-and-technical-guidance/noncommunicable-diseases/mental-health-and-covid-19">depression, anxiety and suicidal ideation</a> were found to be consistent across countries. </p>
<p>Data from previous pandemics show a significant positive association <a href="https://www.mentalhealthcommission.ca/sites/default/files/2020-11/covid19_and_suicide_policy_brief_eng.pdf">between pandemic and suicide</a>. The Toronto Transit Commission reported a nearly <a href="https://www.theglobeandmail.com/canada/toronto/article-suicides-on-the-ttc-have-risen-sharply-over-the-last-eight-months/">one-third increase of suicide attempts or fatalities</a> during the first eight months of the pandemic. Suicide prevention is a critical public health response to COVID-19.</p>
<p>There are many complex pandemic-related <a href="https://www.mentalhealthcommission.ca/sites/default/files/2020-11/covid19_and_suicide_policy_brief_eng.pdf">risk factors</a> for suicide: </p>
<ul>
<li>Anxiety and <a href="https://doi.org/10.1002/brb3.1745">fear of being infected</a> and becoming a contagion for one’s family; </li>
<li>Financial stressors; </li>
<li><a href="https://doi.org/10.2196/21279">Decreased social interactions</a> with friends and community activities, disruption of life goals and normal activities; </li>
<li><a href="https://thepsychologygroup.com/catastrophic-thinking-during-the-coronavirus-pandemic/">Catastrophic thinking</a>; </li>
<li>A sense of <a href="https://dx.doi.org/10.1016%2Fj.nepr.2020.102780">hopelessness and helplessness</a>; </li>
<li>Increased <a href="https://doi.org/10.1080/15487733.2020.1776561">family stressors</a> due to working/schooling from home; </li>
<li><a href="https://globalnews.ca/news/7188797/divorce-couples-coronavirus/">Relationship conflicts and break-ups</a>; </li>
<li>Increased risk of <a href="https://dx.doi.org/10.1111%2Finm.12735">family violence</a>. </li>
</ul>
<p>A recent study shows that <a href="https://www.cbc.ca/news/canada/british-columbia/quarantine-mental-health-1.5809865">people in quarantine</a> are twice as likely to have suicidal thoughts. </p>
<h2>Vulnerable populations</h2>
<p>Front-line <a href="https://www.psychiatrist.com/JCP/article/Pages/covid-mental-health-and-suicide-risk-among-health-care-workers.aspx">health-care providers</a> are also at increased risks of mental health distress. Furthermore, usual adaptive and coping resources <a href="https://globalnews.ca/news/7393817/ontario-social-support-covid-19-pandemic/">may be decreased</a> — less social support from friends and family, limited or no access to primary care, community support, health-care services and social recreational activities.</p>
<figure class="align-center ">
<img alt="Illustration of hands inside a circle" src="https://images.theconversation.com/files/393941/original/file-20210408-15-10ymakz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/393941/original/file-20210408-15-10ymakz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/393941/original/file-20210408-15-10ymakz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/393941/original/file-20210408-15-10ymakz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/393941/original/file-20210408-15-10ymakz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/393941/original/file-20210408-15-10ymakz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/393941/original/file-20210408-15-10ymakz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People with pre-existing mental illness are more likely to experience deteriorated physical and mental health.</span>
<span class="attribution"><span class="source">(Unsplash/Tim Mossholder)</span></span>
</figcaption>
</figure>
<p>The impact of diminished coping resources is particularly critical to <a href="https://cmha.ca/wp-content/uploads/2020/06/EN_UBC-CMHA-COVID19-Report-FINAL.pdf">vulnerable populations</a> experiencing pre-existing social, economic and health inequities. Elderly people are cut off from supportive programs and in-home services, and those in <a href="https://doi.org/10.1503/cmaj.201860">long-term care homes</a> have had family visits restricted. </p>
<p>People with <a href="https://doi.org/10.1016/S2215-0366(20)30421-1">pre-existing mental illness</a> are more likely to experience deteriorated physical and mental health. Some <a href="https://www.ctvnews.ca/health/is-your-child-getting-zoom-burnout-what-is-happening-and-how-you-can-help-1.5171975">children and youth</a> are beset by the uncertainty of learning modes and disruption of social connections; many report experiencing <a href="https://theconversation.com/having-trouble-concentrating-during-the-coronavirus-pandemic-neuroscience-explains-why-139185">difficulty focusing</a> on online learning. </p>
<p>For Indigenous, Black and racialized communities, pre-existing social inequities are translated into <a href="https://www.cbc.ca/news/canada/toronto/toronto-covid-19-data-1.5669091">disproportionate burden of COVID-19 cases</a> related to increased risk of workplace exposure, inadequate housing and reliance on public transportation. For <a href="https://www.cbc.ca/news/canada/new-brunswick/newcomers-canada-social-isolation-covid19-1.5637275">immigrants and refugees</a>, disruption of community support and limited access to linguistically appropriate services are worsened during the pandemic. </p>
<figure class="align-right ">
<img alt="Illustration to two clasped hands" src="https://images.theconversation.com/files/375847/original/file-20201218-13-ld1k25.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/375847/original/file-20201218-13-ld1k25.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/375847/original/file-20201218-13-ld1k25.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/375847/original/file-20201218-13-ld1k25.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/375847/original/file-20201218-13-ld1k25.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/375847/original/file-20201218-13-ld1k25.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/375847/original/file-20201218-13-ld1k25.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A recent study showed people in quarantine are twice as likely to have suicidal thoughts.</span>
<span class="attribution"><span class="source">(Unsplash/Tim Mossholder)</span></span>
</figcaption>
</figure>
<p>These increased stressors and decreased coping resources may interact to escalate the <a href="https://cmha.ca/news/warning-signs-more-canadians-thinking-about-suicide-during-pandemic">risk of self-harm and suicide</a>.</p>
<p>The following vignettes are anonymized composites of cases based on real clinical presentations. They provide a human story behind the complex issues at hand:</p>
<h2>Ms. Smith</h2>
<p>Ms. Smith is a veteran intensive-care nurse. She presented to the emergency department with worsening depression and suicidal thoughts, with an unsuccessful overdose attempt after a recent breakup. She feels that her partner did not show understanding when she came home from her shift exhausted, and they had frequent fights. She suspects that her partner is abandoning her to avoid the risk of infection. </p>
<p>Every day, work is like a war zone, always short-staffed, and the manager seems heartless. She is resentful that many colleagues are taking sick time, and that the system learned nothing from the first wave. She cannot take care of patients like she used to due to isolation precautions and work demands, and she is feeling numb facing so much illness and death. </p>
<p>While she gives reassurances to anxious families and dying patients, she feels like a fraud and a failure, ashamed of her own helplessness and hopelessness. She blames herself for not having more positive thoughts and not doing more meditation, and has begun to use alcohol to fall asleep at night.</p>
<h2>Ms. Chan</h2>
<p>Ms. Chan is a 75-year-old widow living alone with multiple medical illnesses. She does not speak English. All her regular community activities and medical appointments have been shut down and she has been feeling terrified because of her high-risk COVID-19 category. </p>
<p>At the beginning of the pandemic, most people were not wearing masks and gave her dirty looks for wearing one. She was anxious about people disregarding elevator capacity at her apartment, sometimes seeming to crowd around her deliberately. Once, while lining up at the grocery store, the person behind her yelled at her to go back to her home country. She was so shocked that she left her cart there and headed straight home. </p>
<p>She began to feel useless and hopeless. Her daughter started dropping off food for her at the door weekly. She tried to get her daughter to come in to listen to her fears, but her daughter angrily told her that she could not take any more stress and stormed off. Ms. Chan asks if she can get medically assisted suicide to end her meaningless suffering.</p>
<h2>Proactive outreach</h2>
<p>These brief composite cases illustrate the complex contextual determinants of suicide risk. People become vulnerable when multiple internal and external factors conspire to overwhelm their capacity to cope. There is a need to proactively reach out to those who are isolated, disadvantaged and marginalized, as well as to front-line health-care workers at high risk of burnout. </p>
<p>Suicide prevention is possible through increased public awareness of the <a href="https://projectprotech.ca/staying-healthy/giving-help-support/suicide-prevention/">warning signs</a>, responsive mental health care and access to comprehensive interventions that address the complex psychosocial and <a href="http://doi.org/10.1001/jamanetworkopen.2020.20104">structural determinants</a>.</p>
<figure class="align-center ">
<img alt="Illustration of two outreached hands" src="https://images.theconversation.com/files/393939/original/file-20210408-22-194cgdc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/393939/original/file-20210408-22-194cgdc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/393939/original/file-20210408-22-194cgdc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/393939/original/file-20210408-22-194cgdc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/393939/original/file-20210408-22-194cgdc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/393939/original/file-20210408-22-194cgdc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/393939/original/file-20210408-22-194cgdc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Increased stressors and decreased coping resources intensify depression, anxiety, obsessions and psychotic symptoms, which may interact to increase the risk of self-harm and suicide.</span>
<span class="attribution"><span class="source">(Unsplash/Tim Mossholder)</span></span>
</figcaption>
</figure>
<p>In response, our <a href="https://projectprotech.ca/">PROTECH</a> (Pandemic Rapid-response Optimization To Enhance Community resilience and Health) team has applied our resilience-building Acceptance and Commitment to Empowerment model to address pandemic stress and sense of hopelessness associated with suicide. The <a href="https://projectprotech.ca/working-together/pacer-training/">PACER online intervention</a> integrates <a href="https://contextualscience.org/act">Acceptance and Commitment Therapy</a> and <a href="https://www.catie.ca/en/pif/fall-2016/champ-mobilizing-people-living-hiv-and-allies-champion-hiv-prevention-and-care-ethno-r">social justice-based Group Empowerment Psychoeducation</a>, comprising six self-guided reflective online modules with live video group conferencing. </p>
<p>Participants are encouraged to acknowledge and make room for their distressing thoughts and feelings without believing in them, while finding renewed value and meaning in their life. The group sessions facilitate social connection and mutual support. The social justice perspective supports participants to make sense of their suffering in a larger social context, enabling them to engage in “self-care” and “we-care” actions that promote personal and collective resilience. </p>
<p>Since June 2020, we have implemented 12 cohorts of PACER (Pandemic Acceptance and Commitment to Empowerment Response) training with two priority populations: front-line health-care providers and the Chinese/Asian Canadians who experienced COVID-19 related racism. Our preliminary results showed significant reduction in distress and increased resilience. </p>
<p>We have used the train-the-trainer approach and mentored 20 PACER graduates to become co-facilitators. We will continue to start new <a href="https://projectprotech.ca/working-together/pacer-training/">PACER</a> cohorts biweekly over the next six months with a goal of delivering 30 additional cohorts.</p>
<p>The global pandemic has had a devastating impact on us all. To combat catastrophic demoralization, it is critical to proactively support people to reconnect with their values, meaning of life, one other and the larger world. Our spirit to survive and thrive collectively is bigger than the virus.</p>
<p><em>If you are experiencing suicidal thoughts, you need to know you’re not alone. If your life or someone else’s is in danger, call 911 for emergency services. For support, call Canada Suicide Prevention Service (CSPS) at 1-833-456-4566. Visit <a href="https://www.crisisservicescanada.ca/en/">Crisis Services Canada</a> for more resources.</em></p><img src="https://counter.theconversation.com/content/152311/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kenneth Po-Lun Fung received funding from New Frontiers in Research Fund (NFRF) and Mount Sinai Hospital–University Health Network Academic Medical Organization (MSH-UHN AMO), and the Canadian Institute of Health Research (CIHR). He is affiliated with the University of Toronto, Asian Initiative in Mental Health (AIM) at Toronto Western Hospital, and Society for the Study of Psychiatry and Culture (SSPC).</span></em></p><p class="fine-print"><em><span>Josephine Pui-Hing Wong received funding from the New Frontiers in Research Fund (NFRF) and Mount Sinai Hospital – University Health Network Academic Medical Organization (MSH-UHN AMO ), and the Canadian Institute of Health Research (CIHR). She is affiliated with the Sex Information and Education Council of Canada (SIECCAN), and the Committee for Accessible AIDS Treatment (CAAT). </span></em></p>Combating catastrophic demoralization and suicidal thoughts during COVID-19 means supporting people to reconnect with their values, with meaning in life and with others.Kenneth Fung, Associate Professor, Department of Psychiatry, University of TorontoJosephine Pui-Hing Wong, Professor & Research Chair in Urban Health, Toronto Metropolitan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1487212020-12-21T13:05:44Z2020-12-21T13:05:44ZNew antidepressants can lift depression and suicidal thoughts fast, but don’t expect magic cures<figure><img src="https://images.theconversation.com/files/374930/original/file-20201214-20-vhn4py.jpg?ixlib=rb-1.1.0&rect=302%2C33%2C2899%2C1918&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Alleviating major depression for the long term involves more than just drugs.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/worried-woman-royalty-free-image/563853729">Rafa Elias via Getty Images</a></span></figcaption></figure><p>Depression is the <a href="https://www.who.int/news-room/fact-sheets/detail/depression">most common cause of disability</a> in the world. Chances are high that you or someone you know will experience a period when depression gets in the way of work, social life or family life. Nearly two in three people with depression will experience <a href="https://www.nimh.nih.gov/health/statistics/major-depression.shtml#part_155030">severe effects</a>.</p>
<p>As a <a href="https://scholar.google.com/citations?user=5DzjK7QAAAAJ&hl=en">psychiatrist</a> specializing in behavioral neuroscience, I help patients who suffer from mood disorders. Many have “<a href="http://doi.org/10.1016/s0193-953x(05)70283-5">treatment-resistant</a>” depression and are on a nearly constant search for relief. </p>
<p>There have been some exciting developments in treating depression recently, particularly new rapid-acting antidepressants. But it’s important to understand that these medications aren’t cure-alls.</p>
<p>The new treatments for depression <a href="https://www.nytimes.com/2019/03/05/health/depression-treatment-ketamine-fda.html">promise</a> to relieve distressing symptoms, including <a href="https://www.npr.org/sections/health-shots/2020/08/07/900272454/nasal-spray-is-a-new-antidepressant-option-for-people-at-high-risk-of-suicide">suicidal thinking</a>, faster than any previous treatment. They include ketamine, an anesthetic that is also abused as a street drug, and a derivative of ketamine called esketamine. These drugs have been shown to help relieve symptoms of depression <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6534172/">within hours</a>, but each dose only works for a few days. <a href="https://doi.org/10.1080/15622975.2020.1836399">They also carry risks</a>, including the potential for drug abuse.</p>
<p>With the <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6932a1.htm">coronavirus pandemic taking a toll</a> on mental health, patients are looking for fast relief. Medication can help, but to effectively treat depression long term, with its mix of biological, psychological, social and cultural components, requires more than just drugs. </p>
<h2>Depression medications have evolved</h2>
<p>The early history of depression treatments focused on the psychological components of illness. The goal in the early 20th century was for a patient to understand unconscious urges established during childhood. </p>
<p><a href="http://library.law.columbia.edu/urlmirror/CJAL/14CJAL1/shock_i.htm">Biological treatments at the time</a> seem frightening today. They included insulin coma therapy and primitive, frequently misused versions of a modern lifesaving procedure – electroconvulsive therapy.</p>
<p>In the middle of the 20th century, medicines that affected behavior were discovered. The first medicines were sedatives and antipsychotic medicines. <a href="https://pubmed.ncbi.nlm.nih.gov/16433053/">Chlorpromazine</a>, marketed as “Thorazine,” led the way in the 1950s. In 1951, imipramine was discovered and would become one of the first antidepressants. The <a href="https://archive.fortune.com/magazines/fortune/fortune_archive/2004/06/28/374398/index.htm">“blockbuster”</a> antidepressant Prozac, a selective serotonin reuptake inhibitor, or SSRI, was approved in 1987. </p>
<figure class="align-center ">
<img alt="Man in therapy session." src="https://images.theconversation.com/files/374921/original/file-20201214-15-6n0f22.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/374921/original/file-20201214-15-6n0f22.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/374921/original/file-20201214-15-6n0f22.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/374921/original/file-20201214-15-6n0f22.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/374921/original/file-20201214-15-6n0f22.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/374921/original/file-20201214-15-6n0f22.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/374921/original/file-20201214-15-6n0f22.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The physician-patient relationship can help ensure all components of major depression are being addressed.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/youre-not-alone-royalty-free-image/1048189084">SolStock via Getty Images</a></span>
</figcaption>
</figure>
<p>It’s been over 30 years since we’ve seen a novel class of antidepressant medicine. That’s one reason rapid-acting antidepressants are exciting.</p>
<h2>What depression looks like inside the brain</h2>
<p>Medical treatments for depression affect certain processing cells in the brain area above your eyes and under your forehead. This area, called the prefrontal cortex, processes complex information including emotional expressions and social behavior. </p>
<p>Brain cells called neurons are chemically controlled by <a href="https://thebrain.mcgill.ca/flash/i/i_01/i_01_m/i_01_m_ana/i_01_m_ana.html">two opposing messenger</a> molecules, glutamate and gamma-amino-butyric acid (GABA). Glutamate works like a gas pedal and GABA is the brake. They tell the neurons to speed up or slow down.</p>
<p>Rapid-acting medicines for depression decrease the action of glutamate, the gas pedal. </p>
<p>Other treatments have been developed to rebalance GABA. A neurosteroid called <a href="https://doi.org/10.3389/fendo.2020.00236">allopregnanolone</a> affects GABA and applies the brake. Both allopregnanolone and esketamine have federal approval for treatment of depression, allopregnanolone <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-first-treatment-post-partum-depression">for postpartum depression</a> and esketamine for <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-new-nasal-spray-medication-treatment-resistant-depression-available-only-certified">major depressive disorder and suicidal thinking</a>.</p>
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</figure>
<h2>Not so fast</h2>
<p>Around 2016-2017, young psychiatrists like myself were rushing to implement these novel antidepressant treatments. Our training supervisors said, “not so fast.” They explained why we should wait to see how studies of the new drugs turn out.</p>
<p>Several years before, the medical community experienced similar excitement over Vivitrol to treat opioid addiction. Vivitrol is a monthly injected form of naltrexone, an opioid-blocking medicine. </p>
<p>Clinical trials are executed in a highly controlled and clean environment, while the real world can be highly uncontrolled and very messy. Without risk reduction, education and psychosocial treatment, the potential <a href="https://www.vivitrol.com/important-safety-information">risks of medications like Vivitrol</a> can be magnified. Vivitrol can help reduce relapses, but isn’t a panacea on its own. The National Institute on Drug Abuse <a href="https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/principles-effective-treatment">recommends integrated treatment</a> for addiction. </p>
<p>Treating depression may be <a href="http://doi.org/10.1176/appi.ajp.2015.15040476">similar</a>. Medication and psychological support together work better than either on its own.</p>
<h2>The risks</h2>
<p>In depression, the more treatments a person tries that don’t work, the less likely that person is to have success with the next treatment option. This was a main message of the largest clinical trial studying depression medications, the <a href="https://www.nimh.nih.gov/funding/clinical-research/practical/stard/index.shtml">National Institutes of Health-directed STAR-D study</a>, completed in 2006.</p>
<p>Providing a more effective option for patients who don’t respond to a first or second antidepressant may turn that STAR-D message on its head. However, when dealing with an illness that is affected by <a href="http://doi.org/10.2174/1570159x1304150831150507">external stress</a> like trauma and loss, treatment is more likely to succeed with both medication and psychological support. </p>
<p>A real-world treatment approach called the <a href="https://www.psychiatrictimes.com/view/can-we-salvage-biopsychosocial-model">biopsychosocial paradigm</a> accounts for the wide range of relevant biological, psychological and social components of mental illnesses. The patient and physician work together to process the patient’s problematic experiences, thoughts and feelings. </p>
<p>A hyperfocus on novel drugs may overlook the importance of addressing and monitoring all those components, which could mean problems surface in the future. Medications like opiates or other substances that provide rapid relief of physical or psychological pain can also be physically and psychologically addictive, and novel rapid-acting antidepressants <a href="http://doi.org/10.1177/0897190014525754">can have the same risks</a>.</p>
<p>Rapid-acting antidepressants can be powerful tools for treating major depression when used with other forms of therapy, but are they the answer? Not so fast.</p>
<p>[<em>Get facts about coronavirus and the latest research.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=coronavirus-facts">Sign up for The Conversation’s newsletter.</a>]</p><img src="https://counter.theconversation.com/content/148721/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicholas Mischel receives or has received funding from the American Heart Association, National Institutes of Health, and Wayne State University. He is employed by Wayne State University and member of the American Psychiatric Association, Society of Biological Psychiatry, North American Neuromodulation Society, the Clinical TMS Society, and the American Society of Ketamine
Physicians, Psychotherapists & Practitioners.</span></em></p>Drugs like ketamine can relieve depression symptoms, including suicidal thoughts, within hours, but they also carry risks that patients need to understand.Nicholas Mischel, Assistant Professor of Psychiatry and Behavioral Neurosciences; Director, Interventional Psychiatry and Neuromodulation Research Program, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1421272020-07-26T11:27:30Z2020-07-26T11:27:30ZMental health impact of coronavirus pandemic hits marginalized groups hardest<figure><img src="https://images.theconversation.com/files/349289/original/file-20200724-37-bdj63o.jpg?ixlib=rb-1.1.0&rect=5%2C5%2C1985%2C1526&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Mental health issues resulting from COVID-19 and efforts to contain it are the fourth wave of the pandemic.</span> <span class="attribution"><span class="source">(Pixabay, Canva)</span></span></figcaption></figure><p>The mental health consequences of COVID-19 can be described as <a href="https://www.healthing.ca/diseases-and-conditions/coronavirus/doctors-brace-for-fourth-wave-of-the-pandemic">the “fourth wave” of the pandemic, and are projected to result in the greatest and most enduring health footprint</a>. </p>
<p>Canadian data show growing mental health concerns across the country. In April 2020, the Angus Reid Institute found that <a href="http://angusreid.org/covid19-mental-health/">50 per cent of Canadians felt their mental health had worsened during the pandemic, indicating high levels of worry and anxiety</a>. The following month, Statistics Canada reported only <a href="https://www150.statcan.gc.ca/n1/pub/45-28-0001/2020001/article/00003-eng.htm">54 per cent of Canadians identified their mental health as “very good” or “excellent</a>” in 2020, compared to 68 per cent two years earlier. </p>
<figure class="align-center ">
<img alt="Graph with four lines showing pandemic waves: acute COVID-19 illness, impact of resource restrictions on other urgent conditions, impact on care for chronic conditions and impact on mental health" src="https://images.theconversation.com/files/346449/original/file-20200708-3978-1cqmxtb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/346449/original/file-20200708-3978-1cqmxtb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=352&fit=crop&dpr=1 600w, https://images.theconversation.com/files/346449/original/file-20200708-3978-1cqmxtb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=352&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/346449/original/file-20200708-3978-1cqmxtb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=352&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/346449/original/file-20200708-3978-1cqmxtb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=442&fit=crop&dpr=1 754w, https://images.theconversation.com/files/346449/original/file-20200708-3978-1cqmxtb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=442&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/346449/original/file-20200708-3978-1cqmxtb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=442&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Four waves of the COVID-19 pandemic.</span>
<span class="attribution"><span class="source">(Victor Tseng)</span>, <span class="license">Author provided</span></span>
</figcaption>
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<p>As mental health researchers working in collaboration with groups who have long experienced health and social inequities, we know that general population data do not tell the whole story. The toll of the pandemic is not distributed equally.</p>
<h2>Root causes and differential mental health impact</h2>
<p>Growing mental health challenges amid the pandemic illustrate how profoundly population-level mental health is shaped by the social determinants of health — the everyday conditions in which we live. Increases in mental health challenges have been <a href="https://cmha.ca/news/cmha-calls-for-more-mental-health-support-to-help-the-most-vulnerable-cope-during-covid-19-and-beyond">attributed to months of physical distancing, growing job loss, economic uncertainty, housing and food insecurity and child care or school closures</a>. Many of us are attempting to balance far too much, and it is taking a toll. </p>
<p>Our research, done in partnership with the <a href="https://cmha.ca">Canadian Mental Health Association</a>, adds new and concerning nuances to these trends. </p>
<p>During the first phase of the economic reopening in May, we conducted a <a href="https://news.ubc.ca/2020/06/25/covid-19-survey-highlights-growing-suicide-and-mental-health-risks-across-various-groups/">nationally representative survey of 3,000 adults over 18 years old in Canada</a>. Thirty-eight per cent of the general population reported experiencing <a href="https://cmha.ca/wp-content/uploads/2020/06/EN_UBC-CMHA-COVID19-Report-FINAL.pdf">a deterioration in mental health since the onset of the pandemic</a>. This effect was more pronounced in specific groups: 59 per cent of those with a pre-existing mental health condition reported this experience, 48 per cent of those with a disability, and 44 per cent of people living in poverty.</p>
<h2>A rise in suicidal thoughts</h2>
<p>Our research also shows a significant jump in suicidal thoughts or feelings arising from the pandemic, with six per cent of the general population reporting this compared to <a href="https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/healthy-living/suicide-canada-key-statistics-infographic/pub-eng.pdf">2.5 per cent in 2016</a>.</p>
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<img alt="A young Black man looking pensive, with one hand on his forehead and the other cradling his face" src="https://images.theconversation.com/files/347463/original/file-20200714-70463-cklare.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/347463/original/file-20200714-70463-cklare.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=916&fit=crop&dpr=1 600w, https://images.theconversation.com/files/347463/original/file-20200714-70463-cklare.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=916&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/347463/original/file-20200714-70463-cklare.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=916&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/347463/original/file-20200714-70463-cklare.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1151&fit=crop&dpr=1 754w, https://images.theconversation.com/files/347463/original/file-20200714-70463-cklare.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1151&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/347463/original/file-20200714-70463-cklare.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1151&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">High unemployment, closure of schools and childcare centres and social distancing are some of the issues that have contributed to increased mental health problems in the wake of the pandemic.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>Again, the impact is greater on groups marginalized by social circumstances and stigma, with 18 per cent of those who reported a pre-existing mental health condition identifying suicidal thoughts/feelings — nearly one in five people. Sixteen per cent of those who identified as Indigenous reported experiencing suicidal thoughts, as well as 14 per cent of people with a disability and 14 per cent of those identifying as LGBTQ+. This sobering finding has been <a href="https://doi.org/10.1016/j.psychres.2020.113104">linked to extraordinarily high rates of unemployment and economic instability</a> and aligns with respondents’ greatest sources of stress: financial concerns, including job insecurity. </p>
<p>Our study further identified food insecurity as a considerable concern and potential challenge to mental health. Specifically, 18 per cent worried about having enough food for their family. This concern was magnified to affect 37 per cent of those living in poverty, 28 per cent of those with a disability, 26 per cent of racialized people and 25 per cent of Indigenous people. The <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-1102">relationship between food insecurity and mental challenges is well established</a>. </p>
<p>Additionally, our study identified that fear of domestic violence was high, with nine per cent of respondents reporting this concern. This was twice as likely (18 per cent) among racialized people and also high (14 per cent) among Indigenous people. This consequence has been <a href="https://www.unwomen.org/en/news/stories/2020/4/statement-ed-phumzile-violence-against-women-during-pandemic">described as a “shadow pandemic,”</a> with implications for persistent adverse mental health outcomes, particularly for women.</p>
<h2>Equity must be part of the equation</h2>
<p><a href="https://cmha.ca/news/warning-signs-more-canadians-thinking-about-suicide-during-pandemic">Our research confirms that the toll of the pandemic is not distributed equally</a> and is among the first to show that those who are systematically oppressed due to their mental health or disability status, income, ethnicity, sexuality or gender have borne the brunt of the pandemic’s mental health consequences. This will continue unless we frame our public health and policy responses towards equity.</p>
<p>We need an overhaul in our approach to mental health. </p>
<p>When last estimated, costs associated with <a href="https://www.canada.ca/content/dam/phac-aspc/migration/phac-aspc/publicat/hpcdp-pspmc/28-3/pdf/cdic28-3-2eng.pdf">mental health challenges in Canada topped $51 billion annually</a>. As well, our <a href="https://www.mentalhealthcommission.ca/sites/default/files/2016-06/Investing_in_Mental_Health_FINAL_Version_ENG.pdf">mental health system is insufficient in addressing demand</a> and not equipped to respond to the everyday conditions responsible for many mental health challenges, particularly as they relate to the pandemic. </p>
<p>We need a comprehensive and equity-oriented mental health strategy that not only includes prevention and treatment, but also promotion.</p>
<p><a href="https://cmha.ca/wp-content/uploads/2019/05/MHP-Full-Paper-FINAL-EN.pdf">Mental health promotion</a> is a strengths-based approach that emphasizes healthy public policy. Characterized by “<a href="https://www.who.int/healthpromotion/conferences/previous/adelaide/en/index1.html">explicit concern for health and equity in all areas of policy</a>,” it enhances community and population-level mental health responses, especially for those experiencing the greatest risk. </p>
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Read more:
<a href="https://theconversation.com/how-to-build-a-better-canada-after-covid-19-transform-cerb-into-a-basic-annual-income-program-140683">How to build a better Canada after COVID-19: Transform CERB into a basic annual income program</a>
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<p>In the case of COVID-19, this includes <a href="https://www.bbc.com/worklife/article/20200624-canadas-forgotten-universal-basic-income-experiment">poverty reduction strategies, such as universal basic income</a>, to mitigate the effects of job loss and economic hardship to prevent suicide and further mental health decline. </p>
<p>Also important are <a href="https://equiphealthcare.ca/toolkit/trauma-and-violence-informed-care/">trauma- and violence-informed</a> mental health supports, developed in collaboration with communities that will access them. It includes dedicated efforts to safely reopen schools and childcare centres, <a href="https://www.theglobeandmail.com/opinion/article-education-is-a-human-right-but-it-certainly-hasnt-been-a-covid-1/">delivering programming to support children’s social-emotional development, and often providing safety, food security and mental health supports</a> as well as respite for struggling parents.</p>
<p>Now more than ever, public health and mental health strategies need to align to address the impact of the pandemic. An equity-oriented response is the only solution for a sustainable recovery.</p><img src="https://counter.theconversation.com/content/142127/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emily Jenkins receives funding for other mental health studies from the Canadian Institutes of Health Research, Public Health Agency of Canada, Michael Smith Foundation for Health Research and Community Action Initiative. </span></em></p><p class="fine-print"><em><span><a href="mailto:anne.gadermann@ubc.ca">anne.gadermann@ubc.ca</a> has received funding for other mental health related research from the Canadian Institutes of Health Research, Michael Smith Foundation for Health Research, and Social Sciences and Humanities Research Council. </span></em></p><p class="fine-print"><em><span>Corey McAuliffe does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The pandemic’s mental health toll is not distributed equally. Its impact is disproportionately felt by racialized groups, Indigenous Peoples, people with disabilities and those experiencing poverty.Emily Jenkins, Professor of Nursing, University of British ColumbiaAnne Gadermann, Assistant Professor, School of Population and Public Health, University of British ColumbiaCorey McAuliffe, Postdoctoral Fellow, School of Nursing, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1039232018-10-15T14:52:33Z2018-10-15T14:52:33ZSuicide behaviour in social circles increases risk for Kenyan men<figure><img src="https://images.theconversation.com/files/240398/original/file-20181012-119117-1ie1xwy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Suicide is increasingly recognised as a global health challenge.</span> <span class="attribution"><span class="source">Love the Wind/Shutterstock</span></span></figcaption></figure><p>Suicide is increasingly <a href="http://apps.who.int/iris/bitstream/handle/10665/131056/9789241564779_eng.pdf;jsessionid=1FDF22B5BA397898180800C77638BA6D?sequence=1">recognised</a> as a global health challenge by the World Health Organisation who call for society-wide efforts to prevent suicide. </p>
<p>In a <a href="https://www.ncbi.nlm.nih.gov/pubmed/29192523">recent study</a>, we set out to understand the drivers of suicide for young men in Meru county, in central Kenya. We wanted to know whether young men in the region were more at risk of contemplating suicide if they have more friends and family who have attempted, or committed, suicide. </p>
<p>Previous <a href="http://journals.sagepub.com/doi/abs/10.1177/0022146514568793">research</a> has found that incidents of suicide and emotional states <a href="https://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.160.8.1525">contribute</a> to suicidal thoughts passing among networks of friends and within families. Part of the familial link may be genetic, but <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/bjp.12134">evidence shows</a> that social pathways – like the transmission of considering suicide as a viable option and devaluing one’s own life as a result of a peer’s self destructiveness – also exist. </p>
<p>If we identify factors that predict why young men consider suicide as an option, we can potentially stop suicides before they happen. </p>
<h2>Contemplating suicide</h2>
<p>Using surveys, we randomly interviewed 514 young men (aged 18-34 years) in the Igembe sub-counties of Meru County. We used the <a href="http://okmis.com/forms/Charting/20160118183859_Modified_Scale_for_Suicidal_Ideation_20150126.pdf">Modified Scale of Suicide Ideation</a> – a scale that assesses the presence or absence of suicidal thoughts and how severe suicidal ideas are – and coded for only the most severe cases. </p>
<p>We found that, over two days, around 12% of men engaged in severe suicide ideation – they prepared a plan to end their lives, and considered their own death with concerning intensity or frequency. Though global lifetime <a href="https://www.tandfonline.com/doi/abs/10.1080/13811110500182018">estimates</a> of considering suicide range between 14%-33%, our survey specifically screened for more severe suicide ideation, as opposed to more common passing thoughts about ending one’s life.</p>
<p>Among young men who reported that none of their friends had completed suicide, the percentage who had contemplated suicide was 5%. This is much lower than the percentage of respondents who engaged in severe suicidal ideation if they had one friend who completed suicide (17%), and higher still if respondents knew two or more friends who completed suicide (32%). </p>
<p>Similarly, the prevalence of suicidal thoughts increases with the number of friends who attempt, but don’t complete, suicide. If a family member completed suicide during the respondent’s first 18 years of life, the risk for present suicidal thoughts increases by 20% in the respondent’s young adulthood. These patterns are consistent regardless of education, age and household wealth.</p>
<h2>Explanations</h2>
<p>Consistent with other studies, we found a relationship between self-esteem, loneliness and suicide that may explain this pattern. Men who <a href="http://faculty.psy.ohio-state.edu/crocker/lab/documents/CSEscale_general_version.pdf">reported</a> more suicide among friends and family, reported lower social self-esteem, a predictor of suicide behaviour. Men who <a href="http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.825.5782&rep=rep1&type=pdf">reported</a> lower self-esteem also reported more loneliness – described as the pain felt when they believed they didn’t belong socially and emotionally. </p>
<p>The image is therefore that men who have experienced suicide in their social groups think their social groups are less valuable and experience loneliness. <a href="https://link.springer.com/article/10.1007/s10902-018-0017-9">They then</a> experience less meaning in life and thoughts of ending their own life can begin to form. </p>
<p>Prior research also <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/bjp.12134">finds</a> that our thoughts about ourselves are influenced by the self destructive behaviours of our peers. We can internalise their emotions and behaviours as though these emotions and behaviours were our own through a process called projective identification. </p>
<p>Peer suicide doesn’t affect the majority and identifying social and psychological factors that lead to resistance needs more investigation, and <a href="https://academic.oup.com/bjsw/article/43/2/317/1671401">likely includes</a> making meaning from the tragedy. </p>
<h2>Implications</h2>
<p>The implications of this research are multi-fold. </p>
<p>As with many countries, <a href="https://www.ncbi.nlm.nih.gov/pubmed/20671901">Kenya lacks</a> enough mental health resources to meet the demand for services. Resources to prevent suicide in the future should target young men who are friends or children of those who have attempted or completed suicide in the past. This includes identifying and following-up with friends of suicide attempters who come to emergency health centres. </p>
<p>Efforts should focus on group support and gratitude interventions which encourage people to remember at least one thing they are thankful for each day by writing or drawing it down. Gratitude interventions <a href="https://www.sciencedirect.com/science/article/pii/S0092656613000597">can improve</a> one’s sense of meaning in life and reduce suicidal thoughts.</p>
<p>Faith, community, education and other leaders should be sensitised to the challenges faced by those who remain behind after a loved one’s suicide. </p>
<p>And finally, media campaigns should be promoted that improve awareness and reduce stigma related to mental health issues.</p><img src="https://counter.theconversation.com/content/103923/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Goodman receives funding from the University of Texas Medical Branch in Galveston, TX. He is affiliated with Sodzo International. </span></em></p>Young men in Kenya are more at risk of contemplating suicide if they have friends and family who attempted or have gone through with it.Michael Goodman, Instructor, Social Epidemiology, The University of Texas Medical BranchLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1032062018-09-18T22:11:35Z2018-09-18T22:11:35ZWhy Canada needs a ‘Children’s Charter’<figure><img src="https://images.theconversation.com/files/236319/original/file-20180913-177956-1qu6llc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It is estimated that 1.2 million children in Canada live in low income households and 10 per cent of families with children under the age of six report some degree of food insecurity. This places kids at increased risk of developmental vulnerability.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Canadian kids might not be doing as well as we think they are, according to the recent report, <a href="https://static1.squarespace.com/static/5669d2da9cadb69fb2f8d32e/t/5b8e12e121c67c87038b4cbf/1536037605886/Raising+Canada+Report.pdf"><em>Raising Canada</em></a> from the <a href="http://www.obrieniph.ucalgary.ca/">O’Brien Institute for Public Health</a> at the University of Calgary and <a href="http://www.childrenfirstcanada.com/">Children First Canada</a>. </p>
<p>Canada consistently ranks poorly against other developed countries, when comparing <a href="https://www.unicef-irc.org/publications/pdf/RC14_eng.pdf">child health statistics</a>. Injury and suicide are the <a href="https://www150.statcan.gc.ca/n1/en/pub/89-503-x/2015001/article/14680-eng.pdf?st=6gVdMKjz">two leading causes of death</a> among Canadian children and youth. Canada also has one of the <a href="http://www.oecd.org/els/family/CO_4_4_Teenage-Suicide.pdf">highest teenage suicide rates</a> internationally. </p>
<p>I am an assistant professor in the departments of obstetrics and gynecology, medicine and community health sciences at the University of Calgary. My <a href="https://research4kids.ucalgary.ca/profiles/amy-metcalfe">research uses large datasets to examine trends in maternal and child health</a> and the effectiveness of different interventions to ensure that kids get the best start in life.</p>
<h2>Hospitalizations for self-harm</h2>
<p>High rates of teenage suicide are just the tip of the iceberg. The <em>Raising Canada</em> report profiles evidence from the Canadian Institute for Health Information and the 2012 Canadian Community Health Survey which show that <a href="https://secure.cihi.ca/free_products/Public_Summary_Intentional_Injuries_EN.PDF">hospitalizations for self-harm</a> in Canada increased 90 per cent between 2009 and 2014. And that 14 per cent of children and youth reported they had <a href="https://www150.statcan.gc.ca/n1/en/pub/82-003-x/2017001/article/14697-eng.pdf?st=xjIZQoEj">suicidal thoughts</a> at some point. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/236317/original/file-20180913-177938-1gkk883.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/236317/original/file-20180913-177938-1gkk883.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=437&fit=crop&dpr=1 600w, https://images.theconversation.com/files/236317/original/file-20180913-177938-1gkk883.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=437&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/236317/original/file-20180913-177938-1gkk883.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=437&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/236317/original/file-20180913-177938-1gkk883.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=549&fit=crop&dpr=1 754w, https://images.theconversation.com/files/236317/original/file-20180913-177938-1gkk883.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=549&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/236317/original/file-20180913-177938-1gkk883.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=549&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Teenage boys throw rocks in the Attawapiskat First Nation in northern Ontario, in April 2016.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette</span></span>
</figcaption>
</figure>
<p>Individuals who contemplate or commit suicide often struggle with mental health issues, and up to one in five children may <a href="https://www.cihi.ca/en/child-and-youth-mental-health-in-canada-infographic">develop a mental health disorder</a>. Sadly only 20 per cent of them are able to access <a href="https://www.mentalhealthcommission.ca/English/what-we-do/children-and-youth">appropriate treatment</a> for mental health problems. </p>
<p>Between 2007-08 and 2016-17 there was a <a href="https://www.cihi.ca/en/child-and-youth-mental-health-in-canada-infographic">66 per cent increase in emergency department visits and a 55 per cent increase in hospitalizations</a> for mental health issues amongst children and youth aged five to 24. </p>
<p>Many other issues related to poor mental health may never lead to children and youth seeking help. </p>
<h2>From cyberbullying to food insecurity</h2>
<p>Surveys indicate that 20 per cent of internet users aged 15 to 29 report personal experience of <a href="https://www150.statcan.gc.ca/n1/en/daily-quotidien/161219/dq161219a-eng.pdf?st=PYosIUjR">cyberbullying, cyberstalking</a> or both. One-third of Canadian adults report that they <a href="https://www.canada.ca/en/public-health/services/health-promotion/stop-family-violence/problem-canada.html?_ga=2.162634684.125106970.1528920153-1668390544.1528920153">experienced some form of abuse</a> before they turned 16. </p>
<p>Ensuring that our kids have the best chance in life is about more than just health and health care. It is estimated that 1.2 million children in Canada live in <a href="http://www12.statcan.gc.ca/census-recensement/2016/as-sa/98-200-x/2016012/98-200-x2016012-eng.pdf">low-income households</a> and 10 per cent of families with children under the age of six <a href="https://www.statcan.gc.ca/pub/82-625-x/2013001/article/11889-eng.htm">report some degree of food insecurity</a>. </p>
<p>Poverty places kids at increased risk of developmental vulnerability. One study shows <a href="https://secure.cihi.ca/free_products/Children_Vulnerable_in_Areas_of_Early_Development_EN.pdf">34.9 per cent of children from low-income neighbourhoods to be vulnerable in at least one area of development</a>, compared to 19.5 per cent of children from high-income neighbourhoods. These areas of vulnerability include communication skills, emotional maturity, physical health, social competence and language and cognitive development.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/236318/original/file-20180913-177950-16emwtw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/236318/original/file-20180913-177950-16emwtw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/236318/original/file-20180913-177950-16emwtw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/236318/original/file-20180913-177950-16emwtw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/236318/original/file-20180913-177950-16emwtw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/236318/original/file-20180913-177950-16emwtw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/236318/original/file-20180913-177950-16emwtw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Candles are seen in front of a picture of bullying victim Amanda Todd during a memorial for her in Surrey, B.C., Oct. 19, 2012. Todd is one of a rapidly increasing number of Canadian teens who have taken their own lives.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jonathan Hayward</span></span>
</figcaption>
</figure>
<p>Some may ask, what do these numbers mean to my kids and my community? Sadly, the answer to that question often depends on where your community is located. </p>
<p>While infant mortality rates nationally are at their lowest point in history, substantial variation exists based on geography. For example, <a href="https://www150.statcan.gc.ca/n1/en/pub/89-503-x/2015001/article/14680-eng.pdf?st=6gVdMKjz">infant mortality rates</a> are approximately five times higher in Nunavut than they are in British Columbia. <a href="https://www12.statcan.gc.ca/census-recensement/2016/dp-pd/dt-td/Rp-eng.cfm?TABID=2&LANG=E&A=R&APATH=7&DETAIL=0&DIM=0&FL=A&FREE=0&GC=01&GL=-1&GID=1159582&GK=1&GRP=1&O=D&PID=110266&PRID=10&PTYPE=109445&S=0&SHOWALL=0&SUB=0&Temporal=2016&THEME=119&VID=0&VNAMEE=Age%20(8)&VNAMEF=%C3%82ge%20(8)&D1=0&D2=0&D3=0&D4=0&D5=0&D6=0">Childhood poverty rates</a> are 50 per cent higher in Nova Scotia and New Brunswick than they are in Alberta. </p>
<h2>The success of children’s charters</h2>
<p>As health, education and social programs generally fall under provincial jurisdiction, without federal standards geographic disparities are likely to persist. </p>
<p>Children First Canada has <a href="https://www.childrenfirstcanada.com/canadian-childrens-charter/">called for the implementation of a Canadian Children’s Charter</a>. It has also called for the establishment of an independent national commission for children and youth to advocate for children’s rights within the federal government. </p>
<p>Similar children’s charters have been <a href="https://ec.europa.eu/info/policies/justice-and-fundamental-rights/rights-child_en">established in several countries</a> to set up national goals for child health and well-being, engage key stakeholders and develop an action plan to ensure each child is able to reach their full potential.</p>
<p>Most kids in Canada grow up healthy and safe. However, this data shows us that there’s still considerable room for improvement. </p>
<p>As parents, neighbours, teachers and friends, it’s important to watch out for our kids — to help connect them with appropriate resources when they’re struggling and to encourage them to take simple preventative actions (like wearing their bike helmet and getting vaccinated) to make sure that they stay safe. </p>
<p>Together, we can help change the direction of the statistics and change the narrative so that Canadian children can eventually have some of the best health outcomes internationally.</p><img src="https://counter.theconversation.com/content/103206/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amy Metcalfe receives funding from the Canadian Institutes for Health Research, the MSI Foundation, Alberta Innovates - Health Solutions, Alberta Children's Hospital Research Institute, O'Brien Institute for Public Health, and Cumming School of Medicine.</span></em></p>From food insecurity to cyberbullying and teenage suicide, Canada scores low on child health.Amy Metcalfe, Assistant Professor of Obstetrics & Gynecology, Medicine, and Community Health Sciences, University of CalgaryLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/900082018-01-30T22:21:54Z2018-01-30T22:21:54ZLet’s Talk about the mental health of young immigrant and refugee men<p>In the past few years the world has seen the <a href="http://www.unhcr.org/pages/49c3646c11.html">largest displacements of people</a> since the end of the Second World War. And, according to the World Health Organization, “<a href="http://www.who.int/dg/speeches/2015/migration-and-health/en/">the scale of anti-migrant sentiment is equally unprecedented</a>.” In Canada, around <a href="http://www.statcan.gc.ca/daily-quotidien/171025/dq171025b-eng.htm">one in five people were born outside of the country</a>. </p>
<p>How do these experiences of immigration, and of anti-migrant sentiment, impact upon mental health?</p>
<p>This question motivates my research as a PhD candidate in the School of Nursing at the University of British Columbia, where my work has focused on <a href="http://journals.sagepub.com/eprint/jFBVFAVApmT9msXZ9xwr/full">mental health from the perspectives of immigrant and refugee young men</a> in Greater Vancouver. </p>
<p>During my research I interviewed 33 young men (aged from 15 to 22 years) — from various countries and with different immigration backgrounds — about their everyday experiences in relation to their mental health.</p>
<p>My PhD committee and I analysed interview data for narratives that described the experiences of the participants. Three main narratives emerged, those of: <em>Searching for a better life</em>, the pressure of <em>living the immigrant dream</em> and <em>starting again, from way below</em>. </p>
<p>The interviews also revealed experiences of discrimination and of “glass ceilings” in work and career opportunities. One participant attributed some of his frustration to the notion of being a “perpetual foreigner,” which has been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3092701/">linked to lower sense of belonging, lower life satisfaction and greater depression for some groups</a>. </p>
<h2>Safety, security, opportunity</h2>
<p>The first theme that emerged — of searching for a better life — was linked to safety, security and opportunity. Despite experiences of loss and trauma, particularly for those who were refugees, the participants described a strong sense of hope. For many, the hope for a better life was an impetus for migration. </p>
<p>Canada was often portrayed as “a better country overall” compared to countries from where some of the young men moved. Opportunity was described in terms of employment and freedom to travel. As 19-year old Luke explained, “being on a South African passport, travelling is impossible. [Becoming a Canadian citizen] is really kind of my ticket out of all of that.” </p>
<p>This narrative referred to experiences of navigating global class systems while also reinforcing a view of North American superiority over other countries.</p>
<p>At the same time, the sense of hope for safety, security and opportunity seemed to impact the young men’s mental health in a positive way. For example, some of the participants described their experiences of living through war. Although there was worry about family members “back at home,” they felt safer — and more hopeful — in Canada.</p>
<h2>Financial hardship and suicidal thoughts</h2>
<p>In the second narrative of living the immigrant dream, interviewees focused on the stress of financial hardship and the pressure this created for the participants to succeed in school. </p>
<p>For 18-year-old Aaron from Bosnia, the pressure to complete school led to several years of suicidal ideation:</p>
<blockquote>
<p><em>I know I’m obligated to [my parents] just ‘cause I feel like I owe them that much at least - so when I do poorly… it really stresses me out and um it kind of just gets all the bad thoughts coming… you just want it to end and how else is it going to end, right?</em></p>
</blockquote>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/204089/original/file-20180130-38209-740211.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/204089/original/file-20180130-38209-740211.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=323&fit=crop&dpr=1 600w, https://images.theconversation.com/files/204089/original/file-20180130-38209-740211.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=323&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/204089/original/file-20180130-38209-740211.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=323&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/204089/original/file-20180130-38209-740211.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=405&fit=crop&dpr=1 754w, https://images.theconversation.com/files/204089/original/file-20180130-38209-740211.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=405&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/204089/original/file-20180130-38209-740211.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=405&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Discrimination within systems, such as schools, can contribute to feelings of failure.</span>
<span class="attribution"><span class="source">(Pexels/ Min An)</span></span>
</figcaption>
</figure>
<p>Here, individual failures were emphasised over the role of systems and institutions to support immigrant and refugee youth.</p>
<h2>Discrimination and vulnerability</h2>
<p>The third narrative was that of starting again, from way below. Here, the focus was on experiences of discrimination through mainstream views and institutional practices. </p>
<p>As Nabhan, a refugee from Afghanistan, recounted:</p>
<blockquote>
<p><em>My friends were just kind of – “Oh, you guys just wanna –,” like in Afghanistan and Iraq, and Gaza and those places, there was lots of fighting and he was like, “Why you guys don’t want peace in your country?” – I was like, “Well, you can’t just describe the whole country by one or couple people.”</em></p>
</blockquote>
<p>The devaluing of international credentials also came up several times. As 22-year-old Henry from China put it: “It was really hard to find jobs, especially when you were Asian at that time, because… they were more or less really focused on Caucasian people… [and] because [my parents’] credentials from their birthplace weren’t really transferable to here.” </p>
<p>Participants also described their own experiences of discrimination within systems like the schools. Joey (age 16, from China) said:</p>
<blockquote>
<p><em>“I don’t know if I’m supposed to say this but he [the teacher] is nicer to girls in general and he’s nicer to non-Asian, I mean non-Chinese people. Other students told me about this too. But then he’s not the only teacher who does that.”</em></p>
</blockquote>
<p>Experiences of discrimination and racism shaped their mental health and the extent to which they could seek support. Twenty-year-old Hedayat from Bangladesh described it this way: </p>
<blockquote>
<p><em>“For immigrants and people of colour there’s specific emotions that are hard to deal with… anger and pain and things that you’re not really allowed to show in the context of being vulnerable.”</em></p>
</blockquote>
<p>For many of these young men, distress was not allowed — in the context of feeling like “second-class” citizens within Canadian society. </p>
<h2>Talking about mental health</h2>
<p>Previous research has shown the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2747726/">negative effects of perceived discrimination on mental health</a>.
Discrimination can also shape <a href="https://link.springer.com/article/10.1007/s10865-008-9185-0#Sec11">access to mental health supports and the delivery of care</a>.</p>
<p>The findings in my study suggest that social context can make it difficult for immigrant and refugee young men to seek help for mental health challenges. </p>
<p>But some of the men did seek and receive support — from counsellors at their schools and at youth centres. Some described the important role that their youth settlement workers played in helping them adjust to Canadian society and to also deal with difficult experiences. Others turned to their partners, mothers and sisters as people they could trust and talk to. </p>
<p>My research with these immigrant and refugee young men suggests that the accessibility of services and talking about mental health are key. </p>
<p>In Hedayat’s words, “It needs to be okay to seek out these services…there needs to be a bigger dialogue.”</p><img src="https://counter.theconversation.com/content/90008/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Carla Hilario received financial support through a Strategic Training Initiative in Health Research Award from Knowledge Translation Canada and an internal research grant made possible by the UBC School of Nursing, the Men’s Depression and
Suicide Network, and and Movember Canada. She is on the Board of Directors for Next Gen Men, a nonprofit organization aimed at promoting healthy masculinities and gender equity with boys, young men, men, and people of all genders.
</span></em></p>Talking about mental health challenges is not always so easy for young immigrant and refugee men in Canada, according to research from the University of British Columbia.Carla Hilario, Doctoral Candidate in Nursing, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/860102017-10-23T15:32:30Z2017-10-23T15:32:30ZMore teenage girls are self harming than ever before – here’s why<figure><img src="https://images.theconversation.com/files/191350/original/file-20171023-1738-38f1w8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>A <a href="http://metro.co.uk/2017/10/18/charities-praise-self-harm-episode-as-hollyoaks-responds-to-backlash-7008647/">recent storyline on TV soap Hollyoaks</a> has been <a href="http://metro.co.uk/2017/10/17/why-the-hollyoaks-self-harm-episode-is-a-masterpiece-of-informative-television-for-young-people-6998411/">praised as</a> a “masterpiece of televion” after focusing on the issue of self harm in young people. </p>
<p>The show, which worked with charities Samaritans and Mind on the episode, broadcast a special edition, which looked closely at the journey of the character <a href="http://metro.co.uk/2017/10/12/hollyoaks-reveals-moving-self-harm-support-video-with-lily-drinkwell-6996669/">Lily Drinkwell</a>, and her friends Peri Lomax and Yasmine Maalik – as well as their parents and guardians – and explored themes of self harm and cutting among teenage girls.</p>
<p>It came as a recent report showed there had been a steep rise in incidents of <a href="https://doi.org/10.1136/bmj.j4351">self harm among teenage girls</a>. The findings, based on data from GP practices across the UK, show that self harm among girls aged 13 to 16 has risen by 68% in the past three years.</p>
<p>The study by researchers at the University of Manchester found that self harm was three times more common among girls than boys – and that those who self harm are at much greater risk of suicide. Self harmers are 50 times <a href="http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/self-harm.aspx">more likely to try to take their own lives</a>.</p>
<p>The research also revealed that it is socially deprived areas where the greatest increase of self harm is seen. These children are also less likely to be referred to mental health services within a year of their first incident compared with those children living in more affluent areas.</p>
<p>The UK now has the <a href="https://www.mentalhealth.org.uk/a-to-z/s/self-harm">highest rates of self harm in Europe</a>. And the NSPCC’s <a href="https://www.nspcc.org.uk/globalassets/documents/annual-reports/not-alone-anymore-childline-annual-review-2016-17.pdf">ChildLine Annual Review</a> lists it as one of the top reasons why children contact the charity.</p>
<h2>A cry for help</h2>
<p>Working directly with adolescences in therapeutic communities, I have seen self harm used by children time and time again as a form of communication – about their state of mind and inner world. They cannot always tell you, but they can show you their pain. </p>
<p>In this way, Armando Favazza, the US writer and psychiatrist <a href="https://jhupbooks.press.jhu.edu/content/bodies-under-siege">has explained how self-harm</a> can usefully be thought of as “a morbid form of self-help”. </p>
<p>And <a href="https://www.ncbi.nlm.nih.gov/pubmed/17014942">research has shown that</a>
the <a href="https://www.researchgate.net/publication/315772649_Emotion_dysregulation_as_a_mechanism_linking_child_maltreatment_exposure_and_selfharm_behaviors_in_adolescents">main function of self harm</a> is “affect regulation” – in others words, to manage chaotic and frightening feelings. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/PMPPgEyxxFc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
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<p>There is also a lot of <a href="https://www.amazon.co.uk/Body-Keeps-Score-Healing-Trauma/dp/0143127748">evidence that suggests</a> early traumatic memory from childhood is held in the right brain hemisphere, and cannot be accessed symbolically through language because of the immaturity of the infant brain. </p>
<p>The theory goes that memory of these traumatic experiences then tends to be become “somatised” or experienced within the body. So for children who have experienced abuse and mistreatment, self harm can be a method of externalising internal wounds by showing this on the surface of the body. </p>
<h2>Troubling times</h2>
<p>The fact that more of these harming behaviours are seen in teenage girls is of course concerning. But as the psychoanalytical psychotherapist, <a href="https://www.amazon.co.uk/Self-Harm-Psychotherapeutic-Approach-Fiona-Gardner/dp/0415233038">Fiona Gardener explains</a>: </p>
<blockquote>
<p>Self harm typically begins in adolescence, and is characterised by an adolescent state of mind.</p>
</blockquote>
<p>Adolescence itself is transitional, a period of uncertainty, and its duration has lengthened in recent years – with some girls experiencing their <a href="https://www.amazon.co.uk/Nature-Adolescence-4th-Society/dp/0415564204">first period as young as nine years-old</a>. At the other end, adolescence may be extended with many teenagers staying longer at home because of poor job prospects and rising rental and housing prices.</p>
<p>This means that children remain dependent on parents for longer and are instead compelled to explore their independence in the virtual world – and this of course has consequences. </p>
<h2>Anxious culture</h2>
<p>Children and parents now spend increased amounts of time online, which has led to a more <a href="http://edition.cnn.com/2017/05/09/health/parenting-burnout-professional-burnout/index.html">disconnected style of parenting</a>. And one of the other issues with more time spent online in chatrooms is that <a href="http://www.dailymail.co.uk/news/article-2480723/Chatrooms-raise-risk-teenage-self-harm-Vulnerable-youths-look-empathy-help-stop-online-forums.html">self-harming behaviours</a> can be “normalised” by peers. <a href="http://www.dailymail.co.uk/news/article-2480723/Chatrooms-raise-risk-teenage-self-harm-Vulnerable-youths-look-empathy-help-stop-online-forums.html">Previous research</a> has shown a “strong link” between using online forums and self harming teens.</p>
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<p>Then there is also the highly pressured and image obsessed world many teenagers are growing up in – which is <a href="https://www.theguardian.com/lifeandstyle/2016/oct/04/girls-as-young-as-7-feel-pressure-to-be-pretty-body-confidence-girlguiding-study-reveals">most acutely felt by girls</a>. Children these days live in an age of selfies, online status, updates and instant communication – with sites such as Instagram and Snapchat emphasising appearance over content. </p>
<p>The proliferation of self-images on these sites breeds a <a href="http://time.com/4793331/instagram-social-media-mental-health/">deeply competitive and anxious culture among teens</a>. And as any teenager can tell you, <a href="https://www.commonsensemedia.org/blog/how-girls-are-seeking-and-subverting-approval-online">more images are posted by girls</a>. </p>
<p>Bullying and pressure on social media is also an <a href="https://www.theguardian.com/uk-news/2017/aug/14/half-uk-girls-bullied-social-media-survey">ever present threat</a>. This is a threat that doesn’t just follow you home, but comes into your house with you, goes to bed with you and even on holiday with you – it is inescapable.</p>
<h2>Fighting the feelings</h2>
<p>What all this shows, is that children are being given too much of what they don’t need and very little of what they do. </p>
<p>This comes at a time that child and adolescent mental health services are inadequately resourced. If children get access to help they are often placed into short term cognitive behavioural therapy (CBT). But this isn’t always the answer, because self harm tends to be more about emotional difficulties than cognitive processes – which is what this type of therapy focuses on. </p>
<p>Ultimately though, this rise in self harm needs to be seen for what it is, a cry for help, and a way of communicating the pain and upset these teenagers are feeling. And given the scale of the problem, these heartbreaking figures speak volumes about the experience of growing up as a girl today. </p>
<p><em>If you have been affected by any issues in this story, or you need support and information, you can visit <a href="https://www.mind.org.uk/information-support/types-of-mental-health-problems/self-harm/?gclid=EAIaIQobChMIotaxxbaG1wIVTTPTCh3dgwFWEAAYASAAEgLHmPD_BwE#.We21s9OGODM">Mind’s website</a> or call their confidential helpline on 0300 123 3393.</em></p><img src="https://counter.theconversation.com/content/86010/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chris Nicholson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The UK has the highest rates of self-harm in Europe.Chris Nicholson, Deputy Head of Department of Psychosocial and Psychoanalytic Studies, University of EssexLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/763062017-04-27T20:06:25Z2017-04-27T20:06:25ZTeenagers who are both bully and victim are more likely to have suicidal thoughts<figure><img src="https://images.theconversation.com/files/166757/original/file-20170426-13422-1qnvhbs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Teenagers who bully also have a high risk of mental health issues. </span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>Most research into teen bullying tends to focus only on the victim. This means we know little about how the bully is affected. A <a href="https://www.ncbi.nlm.nih.gov/pubmed/28387535">new Australian study</a> shows that teenagers who have been both a victim and a bully are at greatest risk of mental health problems, including self-harm and suicidal thoughts.</p>
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<img alt="" src="https://images.theconversation.com/files/166934/original/file-20170427-1830-orvt4p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/166934/original/file-20170427-1830-orvt4p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=388&fit=crop&dpr=1 600w, https://images.theconversation.com/files/166934/original/file-20170427-1830-orvt4p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=388&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/166934/original/file-20170427-1830-orvt4p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=388&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/166934/original/file-20170427-1830-orvt4p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=488&fit=crop&dpr=1 754w, https://images.theconversation.com/files/166934/original/file-20170427-1830-orvt4p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=488&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/166934/original/file-20170427-1830-orvt4p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=488&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><span class="license">Author provided</span></span>
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<h2>Bullies are victims too</h2>
<p>When it comes to bullying, there is a common misconception that adolescents neatly fall into a category of bully, victim, or not involved. But this is not the case. </p>
<p>In fact, three-quarters of the adolescents who reported that they had bullied others were also victims of bullying. </p>
<p>The study asked 3,500 14-to-15-year-old Australian teenagers – who were participants in the <a href="http://www.growingupinaustralia.gov.au/">Longitudinal Study of Australian Children (LSAC)</a> – whether they had experienced any of 13 different types of bullying behaviour in the past month. </p>
<p>This included being hit or kicked on purpose, called names, or forced to do something they didn’t want to do. </p>
<p>The participants were asked if they had bullied anyone in the last month using the same bullying behaviours. </p>
<p>LSAC also included questions about whether teenagers had self-harmed, had suicidal thoughts, and whether they had made a plan to attempt suicide. </p>
<p>One-third of teenagers reported that they had either bullied, been a victim of bullying, or both (bully-victim). </p>
<p>On the whole, all three groups were more likely to report self-harm, suicidal thoughts and a plan for suicide than those who were not involved in bullying. </p>
<p>Among bullies only, one in ten had self-harmed and one in eight had thought about suicide in the past year. </p>
<p>Teenagers who were both the bully and the victim of bullying had the highest levels of self-harm (20%) and suicidal thoughts (20%). </p>
<p>Involvement in bullying was associated with two times the risk of self-harm and four times the risk of suicidal thoughts. This was the case even after taking into account other factors that might explain the findings, such as gender, single parent versus couple household, ethnicity and socio-economic status.</p>
<h2>Girls more likely to be affected</h2>
<p>Suicidal thoughts and self-harm were highest among girls involved in bullying. </p>
<p>More than one in three girls who were both the bully and the victim self-harmed (35%) and one in four had suicidal thoughts (26%).</p>
<p>The levels among boys who were bully-victims were 11% and 16% respectively. </p>
<p>However, even among teenagers not involved in bullying, self-harm or having suicidal thoughts were more common among girls than boys.</p>
<p>There were also gender differences in roles in bullying. Of those who were only victims 58% were girls, while 69% of those who were only a bully were male. </p>
<p>However, this is not the complete story. Boys represented a higher proportion of those who had a dual role as both a victim and a bully (61%).</p>
<h2>Who bullies?</h2>
<p>While we don’t know why teenagers bully, <a href="https://www.apa.org/pubs/journals/releases/spq-25-2-65.pdf">other research</a> suggests that children who bully are more likely to exhibit “externalising behaviours”. These are defined as: </p>
<blockquote>
<p>defiant, aggressive, disruptive and non-compliant behaviour.</p>
</blockquote>
<p>They were also more likely to have:</p>
<ul>
<li><p>negative thoughts, beliefs and attitudes about themselves and others </p></li>
<li><p>been negatively influenced by peers</p></li>
<li><p>lived in families where there were problems such as parental conflict.</p></li>
</ul>
<h2>What can be done?</h2>
<p>Our research highlights the fact that bullying interventions must recognise the often complex nature of bullying, and particularly the multiple roles that individuals may adopt. </p>
<p>Targeting victims of bullying only may miss opportunities to have a broader impact on bullying.</p>
<p>Reducing bullying requires a multifaceted approach focusing on individuals involved, parents, teacher and school climate. </p>
<p>Based on the results of multiple studies, it is estimated that school-based interventions can <a href="https://link.springer.com/article/10.1007/s11292-010-9109-1">reduce bullying behaviour by around 20%</a>.</p>
<p>Extrapolating from our findings, this would lead to an 11% reduction in the proportion of students who self-harm or have suicidal thoughts. </p>
<p>Some studies have shown that <a href="http://jamanetwork.com/journals/jamapediatrics/fullarticle/569481">whole-of-school interventions</a> that target school-wide rules and sanctions, teacher training, classroom curriculum, conflict-resolution training, and individual counselling yield better results than those that target only one component. </p>
<p>One of the other problems is that while school-based interventions may reduce bullying behaviour in the short term, the evidence for long-term behaviour change is limited. </p>
<hr>
<p>• <strong>This piece was co-authored by Dr Rebecca Ford, an intern at the Royal Melbourne Hospital.</strong></p>
<p><em>If you have been affected by any of the issues discussed, call Lifeline on 13 11 14.</em></p><img src="https://counter.theconversation.com/content/76306/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anne Kavanagh receives funding from the Australian Research Council and the National Health and Medical Research Council. </span></em></p><p class="fine-print"><em><span>Naomi Priest receives funding from the Australian Research Council (ARC) and the National Health and Medical Research Council (NHMRC).</span></em></p><p class="fine-print"><em><span>Tania King does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>When it comes to bullying, there is a common misconception that children neatly fall into a category of bully, victim, or not involved. This is not the case.Anne Kavanagh, Professor and Head, Gender and Women’s Health Unit, Centre for Health Equity, The University of MelbourneNaomi Priest, Fellow, ANU Centre for Social Research and Methods, Australian National UniversityTania King, Research Fellow, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/712862017-01-19T15:36:55Z2017-01-19T15:36:55ZHow social factors drive up suicide rates among pregnant women<figure><img src="https://images.theconversation.com/files/153211/original/image-20170118-3885-19e2yr9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pregnant women in South Africa who live in poor communities are more likely to consider or attempt suicide than the general population.</span> <span class="attribution"><span class="source">Mike Hutchings/Reuters</span></span></figcaption></figure><p>Pregnant women in South Africa who live in poor communities are more likely to consider or attempt suicide than the general population. That’s a <a href="http://link.springer.com/article/10.1007/s00737-016-0706-5">key finding</a> from a recent study we undertook at Hanover Park. </p>
<p>The research found 12% of pregnant women living in low-resource communities had thought of killing themselves during the previous month. In the same period, an additional 6% of pregnant women reported they had started to enact a suicide plan or attempted to end their lives. Rates of depression and anxiety were also found to be elevated among the pregnant women who took part in the study.</p>
<p>These findings mirror research about high rates of suicidal ideation and behaviour among pregnant women elsewhere in the world. A review of 17 studies in high- and low-income countries found the prevalence of suicidal ideation among pregnant and postpartum women ranged from 5% to 18%. Rates were higher among pregnant women living in <a href="http://link.springer.com/article/10.1007%2Fs00737-005-0080-1">low-income countries</a>.</p>
<p>Our study’s most-significant finding was that more than half of the pregnant women who were at risk of suicide did not have a diagnosable depressive or anxiety disorder. Their suicide risk was also associated with lower socioeconomic status, food insecurity, intimate partner violence and a lack of social support.</p>
<p>This suggests suicidal ideation among pregnant women is about more than mental illness. Past studies suggest suicide and mental illness are <a href="http://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-2393-11-57">strongly linked</a>. Pregnant women who are depressed or have problems with anxiety are more likely to experience thoughts of death and engage in suicidal behaviour compared with other pregnant women. </p>
<p>But our research shows social and economic context may be a much more important contributor to suicide risk than previously thought. </p>
<h2>Pernicious impact of adversity</h2>
<p>The findings show the pernicious impact of socioeconomic adversity, interpersonal violence and lack of social support on pregnant women’s wellbeing.</p>
<p>We found pregnant women who are the victims of intimate partner violence are twice as likely to engage in suicidal behaviour compared to other pregnant women. Those who experience food insecurity – either they go hungry regularly or they have considerable trouble feeding themselves and their families – are almost four times more likely to report suicidal behaviour.</p>
<p>Pregnant women who are not in a relationship are also more likely than other pregnant women to experience suicidal thoughts and attempt suicide. And we found suicide risk decreases as pregnant women experience more social support. </p>
<p>These findings add to the growing body of evidence showing that sociocultural and economic factors are important risk factors for suicide. Suicidal ideation and behaviour are not simply a symptom of mental illness. Suicide can be a reaction to living in a particular context or facing stressful circumstances.</p>
<p>So, our research supports the idea that suicide risk should be assessed independently of – and in addition to – depression and anxiety among pregnant women.</p>
<h2>Broader focus needed</h2>
<p>This is an important nuance. Suicide prevention initiatives have traditionally focused narrowly on identifying and treating psychiatric illness. Our findings suggest they should more broadly include interventions that tackle socioeconomic factors and adversity.</p>
<p>Interventions that focus exclusively on psychiatric determinants of suicidal behaviour are unlikely to be effective. This is especially true in low-resource settings. Contributing factors include a scarcity of mental health resources and factors that adversely affect people’s lives.</p>
<p>More work still needs to be done to identify effective suicide prevention interventions for pregnant women living in adverse conditions. This requires more collaboration between different sectors. Policymakers also need to tackle social ills and find ways to increase the level of support for pregnant women and mothers of young babies.</p><img src="https://counter.theconversation.com/content/71286/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jason Bantjes receives funding from the South African National Research Foundation and the South African Medical Research Council. </span></em></p><p class="fine-print"><em><span>Nnachebe Michael Onah receives funding from University of Waterloo and multilateral organisations. </span></em></p><p class="fine-print"><em><span>Simone Honikman receives funding from philanthropic organisations and trusts, the University of Cape Town, The Medical Research Council (SA), DFID (UK)</span></em></p><p class="fine-print"><em><span>Sally Field does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Depression may lead pregnant women to engage in suicidal behaviour. But the socioeconomic contexts pregnant women are in may also contribute to their suicide risk.Jason Bantjes, Senior Lecturer in the Psychology Department, Stellenbosch UniversityNnachebe Michael Onah, Doctoral Candidate, University of WaterlooSally Field, Project co-ordinator: Perinatal Mental Health Project, researcher, University of Cape TownSimone Honikman, Director of the Perinatal Mental Health Project; Senior researcher, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/418002015-05-18T10:17:23Z2015-05-18T10:17:23ZThe epidemic of burnout, depression and suicide in medicine: One doctor’s story<figure><img src="https://images.theconversation.com/files/81876/original/image-20150515-25417-i9ah9s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sometimes doctors need help too.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-114588181/stock-photo-thoughtful-surgeon-sitting-in-a-operating-room-with-his-hand-on-head.html?src=1_zQrKySwzCgRfuxMBWqNg-1-0">Surgeon image via www.shutterstock.com</a></span></figcaption></figure><p>The suicides of <a href="http://www.nytimes.com/2014/09/05/opinion/why-do-doctors-commit-suicide.html?_r=0">two medical residents in New York City</a> last fall have thrown a spotlight on a real problem among health care professionals, particularly physicians. <a href="http://www.ncbi.nlm.nih.gov/pubmed/22722352">Medical</a> <a href="http://www.ncbi.nlm.nih.gov/pubmed/16565188">students</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/15598920">residents</a> and <a href="http://www.amjmed.com/article/S0002-9343%2803%2900117-7/abstract">practicing physicians</a> commonly report symptoms of burnout and depression. Rates vary depending on the group, but range from 20-60%.</p>
<p>Frank suicidal ideations (when someone has serious thoughts or plans about suicide) are reported in 5-10% of physicians. </p>
<p>I was discussing this with a colleague who told me that four of his medical school classmates have taken their own lives. He graduated in a class of 160 students, so that means that more than 2% of class died by suicide.</p>
<p>Why is burnout – and suicide – so prevalent among medical students, residents and physicians? At least a part of the problem stems from the fact that people in general and physicians in particular are reluctant to be honest about such things for fear of consequences. Because there remains a remarkably stubborn kind of <a href="http://www.ncbi.nlm.nih.gov/pubmed/25650824">social stigma</a> associated with depression, those struggling often become more reticent to come forward and seek help. </p>
<p>Unless we can create safe space to seek help without fear of reprisal, nothing is going to change. It is with this goal in mind I decided to share my story.</p>
<p>When I was a young faculty member in my early 40s at the University of Florida College of Medicine, I had the deep sense that I was called to care for cancer patients, teach young physicians the art and science of medicine and do my best to advance the field in the area of clinical research. </p>
<p>I found great fulfillment caring for the bravest and most vulnerable of patients. I loved teaching medical students, residents and fellows and had a modest but successful clinical research program. </p>
<p>With four children, a wonderful wife and a group of very close friends, life felt pretty good. From the outside I was successful, although stressed. Who wouldn’t be, as a cancer doctor? </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/81903/original/image-20150515-25422-606ulx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/81903/original/image-20150515-25422-606ulx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/81903/original/image-20150515-25422-606ulx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/81903/original/image-20150515-25422-606ulx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/81903/original/image-20150515-25422-606ulx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/81903/original/image-20150515-25422-606ulx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/81903/original/image-20150515-25422-606ulx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Physicians may be reluctant to talk about feeling burned out or depressed.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-178817840/stock-photo-people-walking-in-modern-laboratory-abstract-blur.html?src=PbILW8N1D883MQ2DJ0KJTA-1-12">Man walking via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<p>As my responsibilities grew and the pace of life increased, life’s inevitable difficulties took their toll. I found myself less resilient to the stress of life, increasingly sleepless and short-tempered. And worse, I had to suppress a quiet sense of dread from surfacing multiple times a day. But I had a great support system and could handle it all with occasional periods of rest.</p>
<p>And then one of my closest friends lost a child unexpectedly. My wife sustained an injury, so I had to take on extra responsibility at home to help. Equally eroding was the loss of several patients to whom I was very close. </p>
<p>I felt trapped with nowhere to turn, without being cognizant of why. It seemed to me that everyone around me was also busy and stressed and I had been taught just to “suck it up” (to quote my chief resident as an intern) and go on. </p>
<p>Working hard during the day and caring for children each evening left little time to care for myself. Friends noticed I was troubled, but weren’t sure what to say or how to help. </p>
<p>I began imagining suicide as a path to freedom from the feeling of misery and pain but worried about the impact on those I loved. In fact, it was the fear of leaving my children fatherless that kept me going. Over my years of practice and pastoral care, I’d seen firsthand the pain inflicted on those left behind by suicide and wanted nothing of this for my family.</p>
<p>I have always had a pretty vivid imagination and come up with some pretty crazy ideas; and I would argue this is a central part of creativity. During this time however, I began to ask questions in my private internal dialogue such as, “Were I writing a novel, how could a character carry out the perfect suicide, making it appear an accident?” For some time it was just a game, but then as I slipped more deeply into despair, I began to imagine myself in these scenarios. </p>
<p>There would be advantages, after all. My family would be spared the crushing blow of deliberate abandonment, and life insurance would secure the family finances. My wife (whom my medical school classmates described as my “only redeeming quality”) was a marvelous woman and would have no trouble finding another soul mate. There would be a funeral, with mourning and recounting my virtues (that would take about 30 seconds) and a gracious overlooking of my innumerable failings. Then life would go on and everyone else would be fine. </p>
<p>The sorrow hung like a millstone around my neck, but I laid it aside to care for the others because that’s what you do as a physician. Yet, when I was alone, the sense of hopelessness was becoming insufferable. </p>
<p>The tipping point came in June 2002 when a lifelong friend and physics professor who was terminally ill died. A group of close college friends had gathered for his funeral and to comfort his widow. This group of friends had formed an intentional community in college and promised to care for one another and stay connected if possible for life. </p>
<p>Over a meal after the funeral, we began to share our struggles. There were children with serious issues, troubled marriages, strained family relationships and family members with serious illnesses. Some acknowledged turning to alcohol to numb the pain. All the while I sat mute, listening. </p>
<p>Then one of my friends turned to me and asked, “How about you, Jay; you’re awfully quiet?” I knew I had a chance to finally be honest, but I paused, looking down at the dingy carpet with tears clouding my vision. My wife touched my arm, sensing I was having trouble responding and I muttered something like, “Not too well, I think.” </p>
<p>It was in this safe place among those I knew loved and accepted me that I finally simply said, “I have been planning the perfect suicide.” This was the first time I’d admitted this even to myself, let alone anyone else. These friends gathered around me, expressed their genuine affirmation of me and prayed for me.</p>
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<img alt="" src="https://images.theconversation.com/files/81904/original/image-20150515-25412-1whpwob.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/81904/original/image-20150515-25412-1whpwob.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/81904/original/image-20150515-25412-1whpwob.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/81904/original/image-20150515-25412-1whpwob.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/81904/original/image-20150515-25412-1whpwob.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/81904/original/image-20150515-25412-1whpwob.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/81904/original/image-20150515-25412-1whpwob.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A safe place to talk.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-131244659/stock-photo-close-up-of-holding-people-hands.html?src=IOiNNJvtiFGqyUWcUHNbBw-1-4">Hands via www.shutterstock.com.</a></span>
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<p>As we traveled home, my wife and I talked about my sense of hopelessness, and I agreed to seek help. Not long afterwards, I was overcome with emotion when seeing a patient and realized I could no longer function without assistance. </p>
<p>I called a friend in psychiatry who saw me the next day. When asked to summarize why life was so painful, I didn’t have to even think. “All I do is disappoint people. No matter what I am doing, there is always someone angry or disappointed that I am not doing what I should for them.” </p>
<p>The answer to my prayers came in a way I did not expect, in the form of a caring, kind and well-trained psychiatrist who prescribed an antidepressant. My response to the medication was rapid. Within two weeks I felt as though someone had turned on a light in a very dark room. It wasn’t until I felt normal that I realized how dark my thoughts had become. </p>
<p>Depression and related maladies are fundamentally brain disorders. Our thinking, emotions, memories and actions are all mediated by chemicals in the brain called neurotransmitters. Therefore, medications directed toward correcting these imbalanced neurotransmitters are often a critical part of the best treatment. Over the years, appropriate adjusting of my medication has become a part of my ongoing care from my wonderful primary care physician. </p>
<p>Since we not only feel but also think with neurotransmitters, depression distorts our perceptions, disabling our ability to see ourselves clearly. Add to this blurry self-portrait the concern about loss of livelihood, fear of failure, and social stigma and it becomes easy to see why many do not seek the care they need. It took the love of family and community to help me see reality, and I had to learn humility in order to acknowledge their wisdom and follow their guidance. I have more gratitude than I could ever articulate for those who care about and therefore care for me.</p>
<p>The sense of freedom and joy that has followed has restored my enjoyment of life and those I love. As a result, I am more attentive to my own health and try to listen to those who love me. </p>
<p>One of the most curious ironies in reflecting upon my story was the fact that although I had helped numerous young distressed physicians get help and cared for innumerable patients struggling with depression, I was unable to see it clearly in my own life. And this is something that I think is easy for many physicians to experience.</p>
<p>When I shared this story with my church, people thanked me for being open about my troubles. Many were previously afraid to acknowledge their own similar struggles but became determined to be more open with others. My faith community has been central to my continued spiritual and emotional health. </p>
<p>According to George Weigel, the late Pope John Paul II believed that:</p>
<blockquote>
<p>“We all live…in a quotidian, yet deeply consequential, moral drama. Every day of our lives is lived in the dramatic tension between who we are and who we should be.” </p>
</blockquote>
<p>As I consider my own experience and speak to others, I have learned that the weight of this tension can be suffocating. </p>
<p>My medical treatment was a key part of my recovery, but equally important was the truth and grace I was shown. The health care community should be a safe place to admit difficulties and to care for one another so we can learn from and care for our patients. For any who find themselves slipping down the mountain, there is help available, and I encourage you to reach out for assistance. There is however, one proviso: None of this is possible without humility. As Thomas Merton observed, “Pride makes us artificial, but humility makes us real.” </p>
<p><em>If you or someone you know needs help, contact the National Suicide Prevention Lifeline: 1-800-273-8255.</em></p><img src="https://counter.theconversation.com/content/41800/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James W Lynch does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Unless we can create safe space to seek help without fear of reprisal, nothing is going to change. It is with this goal in mind that I decided to share my story.James W Lynch, Professor of Medicine , University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/413242015-05-08T09:53:32Z2015-05-08T09:53:32ZDepression common on college campuses; graduate students more at risk<figure><img src="https://images.theconversation.com/files/80736/original/image-20150506-10961-mkprvt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Suicides are the second leading cause of death on college campuses. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&search_tracking_id=PXYBTGr-noxxRYHvoh47xg&searchterm=depression&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=197995073">Girl Image via www.shutterstock.com</a></span></figcaption></figure><p>Graduate <a href="http://www.ncbi.nlm.nih.gov/pubmed/24711096">students experience significant stress </a> and are more prone to depression and anxiety than other groups of students. They report greater levels of eating disorders, substance abuse and feelings of hopelessness.</p>
<p>A recent report from the University of California, <a href="http://ga.berkeley.edu/wellbeingreport/">found</a> 47% of doctoral students and 37% of master’s degree students, who were surveyed, to be depressed. Furthermore, 64% of graduate students in arts and humanities <a href="http://ga.berkeley.edu/wellbeingreport/">showed higher levels</a> of depression and suicidal thoughts. Based on the university’s <a href="http://grad.berkeley.edu/admissions/rankings-stats/">enrollment data </a> from 2013, we can estimate 2,800 of the 6,000 PhD students to be clinically depressed.</p>
<p>This is a high number and not limited to the Berkeley campus. Other studies, too, have shown high rates of student depression. As a researcher working on suicide prevention programs, I have found this to be true for our own campus.</p>
<h2>Stressed students</h2>
<p>On a single day last fall, we randomly stopped students on our campus and administered a depression questionnaire. Of the approximately 250 students we contacted on this one particular day, no fewer than eight were having active suicidal thoughts. </p>
<p>While the students with suicidal thoughts received emergency counseling, another 12 scheduled appointments voluntarily after seeing their scores. Ten more students presented themselves over the next few days, saying that the questionnaire helped them realize they needed counseling. </p>
<p>This meant that 30 students, or 12% of the students we stopped, were experiencing depression serious enough to need intervention. </p>
<p>Relative to the total campus enrollment, these are small numbers, but in terms of the number of students we contacted, <a href="http://www.sprc.org/collegesanduniversities/scope-problem">they are higher than previously reported percentages</a> and quite probably more in line with reality. </p>
<p>Suicide is the <a href="http://www.suicide.org/college-student-suicide.html">second leading cause of death</a> for college students after <a href="https://www2.nami.org/Content/NavigationMenu/Find_Support/NAMI_on_Campus1/Mental_Illness_Fact_Sheets/Suicide.pdf">traffic accidents</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/80737/original/image-20150506-10937-fgpbif.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/80737/original/image-20150506-10937-fgpbif.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/80737/original/image-20150506-10937-fgpbif.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/80737/original/image-20150506-10937-fgpbif.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/80737/original/image-20150506-10937-fgpbif.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/80737/original/image-20150506-10937-fgpbif.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/80737/original/image-20150506-10937-fgpbif.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Students have a great deal of anxiety over job prospects after college.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&search_tracking_id=PXYBTGr-noxxRYHvoh47xg&searchterm=depression&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=94267417">Pencil image via www.shutterstock.com</a></span>
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<p>We do not have adequate data that separates the suicide rate of graduate students from that of under-graduates. But studies among graduate students show that a substantial percentage suffer from depression, anxiety and have suicidal thoughts. </p>
<p>According to <a href="http://www.ncbi.nlm.nih.gov/pubmed/24711096">one such study</a> where an email questionnaire was sent out to 301 graduate students nationally, 22% were found to be on medication for depression or anxiety and nearly 19% were in counseling. </p>
<p>At the University of Michigan, researchers <a href="http://psycnet.apa.org/psycinfo/2007-19519-005">found</a> nearly 2% of graduate students were having suicidal thoughts in the four weeks preceding a survey they conducted in 2007. </p>
<p>Other studies, too, have reported that <a href="http://psycnet.apa.org/psycinfo/2009-08599-001">4% of graduate students </a> and <a href="http://annals.org/article.aspx?articleid=742530">11% of medical students</a> having serious suicidal thoughts in the year prior to the studies. </p>
<h2>Anxiety over life after college</h2>
<p>The most common risk factors, as reported by researchers at the University of Michigan, for depression in graduate students include financial concerns, post-graduate job prospects, isolation and lack of social support. </p>
<p>We don’t know what makes the arts and humanities graduate students more vulnerable to depression and suicide. Since there are no other studies that point to these fields of study as having greater risk, it may be that this is simply coincidental or specific to the Berkeley campus, or their fears about post-graduate employment are realistic. </p>
<p>This is not to say that undergraduate students are not at risk. Data from the <a href="http://www.sprc.org/">Suicide Prevention Resource Center</a>, a federally-supported program, shows about 8% of college students (undergraduate and graduate) as <a href="http://www.sprc.org/collegesanduniversities/scope-problem">having</a> suicidal thoughts, about 2% making a suicide plan and about 1% making an attempt. </p>
<p>As not all universities respond to surveys about student suicide and in many cases suicidal thoughts or attempts go unreported, actual numbers are likely to be higher. </p>
<p>A university can be a stressful place. Students might feel <a href="http://www.sprc.org/sites/sprc.org/files/library/SuicideAmongCollegeStudentsInUS.pdf">overwhelmed</a>, hopeless, isolated and not able to cope at college. Under such circumstances, they may perceive suicide to be the only way out.</p>
<h2>Depression on campus</h2>
<p>So, what can colleges and students do?</p>
<p>University administrators and counselors should focus on <a href="http://www.ncbi.nlm.nih.gov/pubmed/24711096">developing mental health and wellness interventions</a>. College students in general and graduate students in particular need to be encouraged to seek help. </p>
<p>Additionally, students need to know there are a number of online resources available. </p>
<p>These resources include the <a href="http://www.sprc.org/">Suicide Prevention Resource Center</a>, the <a href="http://www.jedfoundation.org">Jed Foundation</a>, <a href="http://www.thetrevorproject.org">The Trevor Project</a>, <a href="http://www.nimh.nih.gov/index.shtml">The National Institute of Mental Health</a> and <a href="http://www.samhsa.gov">The Substance Abuse and Mental Health Services Administration</a>. Information can also be found on the <a href="http://www.apa.org">American Psychological Association</a> and the <a href="http://www.psychiatry.org">American Psychiatric Association</a> websites. </p>
<p>It is important to break the silence and to bring to public attention the problem of student depression, anxiety and suicide. The larger issue of lack of resources on some campuses needs to be addressed urgently.</p>
<p>Otherwise, the numbers will continue to rise.</p><img src="https://counter.theconversation.com/content/41324/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeannie D DiClementi receives funding from a Garrett Lee Smith suicide prevention grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) that is referenced in the article.</span></em></p>Suicidal thoughts among college students are more common than we think. Graduate students, especially those in the humanities, are at a greater risk.Jeannie D. DiClementi, Associate Professor of Psychology, Indiana UniversityLicensed as Creative Commons – attribution, no derivatives.