AAs a task force coordinator, I am sure you are aware of the many good web sites for suicide prevention information. In fact, if you send me a list, I will post them here. But you may also know that there has been very little success in predicting a suicide attempt. From the description in the article, it appears that the Burnhams did every thing a concerned parent could: therapy, medication, thinking cautiously about how to respond to problems etc. My only recommendation is that any troubled teen, be it depression, drug use, school failure, or sexual risk behavior, is at higher risk for suicide than teens not struggling with these kinds of problems. Therefore, along with discussion of other problems and challenges, we recommend frank and open communication about suicidal feelings. Parents need to make kids know that this is a topic they are willing to hear about if that is what the adolescent is pondering. Adolescents need to know that parents will listen to their despair in nonjudgmental, compassionate, and supportive ways. And support does not mean trying to fix everything for a teen. Support means conveying that the parent believes in the teen’s capacity to think about, discuss and explore difficult issues. Fundamentally, suicide is a problem of emotion regulations. Kids feel bad and cannot stop it. It becomes overwhelming and they want to escape. In contrast, when we can help our teens learn to talk about difficult feelings, express anger in direct ways, accept that ambivalent feelings are normal, and increase their capacity to tolerate difficult feelings, then teens are more likely to solve problems in less destructive ways.

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I am not sure that there is intention to hide these resources. For instance many schools have made a great effort to have suicide prevention on campus through the SAP programs. But yes, in general, suicide is a very difficult topic for the general public to discuss. Many worry that by discussing in, it will spread ideas, while others feel like the prevalence is low, there are other things to focus on. In addition, non mental health systems (e.g. school, primary care, probation), while concerned about mental health, are ambivalent about providing those services in their system. So suicide prevention is not at the top of their priority list. Should they do more? Yes! Do they have the training and resources to do more? Not usually. Better integration of mental health services with other child serving systems will require strong and courageous political leadership, and the public to make this issue better known.

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Impulsivity plays a large role in many suicide attempts and successes. Usually the foundation of distress or hopelessness is there, but the decision to attempt can often come without a premeditated plan. In fact, a high percent of adolescent attempters or completers did not even have depression before the event. But life became overwhelming and suicide seemed a reasonable solution. This is why keeping close tabs on your child and keeping open communication is essential. It is the only safety net we have.

As for the particular questions of this comment, it is hard to know what is behind persistent thoughts about a plan and about dying without knowing you better. If you are filled with despair, then suicide may seem like an escape or providing some relief. But suicide can also be an angry act. It inflicts such lifelong pain on those left behind that one wonders if this is the attempters/completers only way of expressing that anger. Still others have a profound sense of the fragility and temporary nature of life. A preoccupation with death comes to many sensitive and deep thinking souls who struggle with the meaning and futility of life. Ultimately, it is about choice. Human beings may be the only creature that can choose death, just as they are able to choose life. It is a profound burden and profound gift. We have to decide how to use this.

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The effectiveness of medication is complicated. There are a few studies now that show anti-depressant medication to be effective for adolescents with depression. The limited data we have however suggests that medication plus  psychotherapy is the most effective. Still, a recent report reviewed unpublished studies from the pharmaceutical companies. Only 17% of studies that showed no result for anti-depressants were published. So yes, the data to support the effectiveness of antidepressant medication for adolescents is equivocal. So what are we to think? Well, as a generality, the psychiatrists do what they are trained to do: prescribe medication. Psychologists, licensed social workers and other related disciplines are trained to provide psychotherapy. So depending on who you seek out for treatment, may impact what kind of treatment you receive. Current best practice guidelines however suggest that for adolescent depression, one should start with psychotherapy and then add medication if treatment does not seem to be working.

But the pressure to use medication is not just from the professionals. Many parents and adolescent see medication as a first response solution. While viewing depression as a medical disease has helped reduce some stigma, it also defines depression as a medical problem. And medical problems need medical solutions.

In contrast, we view depression in adolescents as an interpersonal problem. Yes, people have vulnerabilities to depression and often depression runs in families. But for adolescents, it is usually interpersonal problems that activate or cause the depression. Conflicts with parents, school failure, social isolation, as well as more traumatic events such as abuse, abandonment and neglect are the kinds of problems that we see as leading to maintaining depression. While
medication can help reduce some severe, debilitating symptoms of depression, it does not solve the kinds of interpersonal conflicts that drive the depression.