Spotting Trouble: The Debate Over Teen Suicide Risks

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The 13-year-old was a middle school student. He lived in Washington Heights. He wrote in his journal that he wanted to die by putting a plastic bag over his head. School-based health counselors contacted his guardian and referred him to an emergency room. He’s in counseling now, and alive. Score one for the city’s mental health network.

But because of funding constraints, it’s unclear that a student at a different school in the city would have had the same access to this level of help. And despite the growing consensus that teenage suicide is a public health problem, there is emotional debate over how best to combat it.

The federal Centers for Disease Control and Prevention estimates that suicide is the third leading cause of death for individuals between the ages of 10 and 24 nationwide. The number of 15-to-24-year-olds who committed suicide across the five boroughs declined from 52 in 2007 to 43 in 2008, according to New York City’s Office of Vital Statistics. But the Department of Health and Mental Hygiene’s 2008 youth risk behavior survey found that depression—the recurring precursor to suicide—was a “serious” area of concern.

After steadily rising for six years through 2005, the number of adolescents and teenagers who reported in the survey that they attempted suicide in the past year fell to 8 percent in 2007, but that number remains higher than it was nearly a decade ago.

Using its suicide prevention MySpace page, the Department of Health and Mental Hygiene (DOHMH) plans to launch a pilot program this fall in which counselors are made available after school via the website. And after the city’s youth risk behavior survey and figures from the CDC showed a higher tendency for attempted suicides among female Latino adolescents and teens, the New York State legislature allocated $1 million to the state Office of Mental Health to support a public awareness campaign focused on Latina teens. In April, an initiative dubbed Life Is Precious opened in Brooklyn after securing $167,000 in funding from Congresswoman Nydia Velázquez. The program, which is focused on Latina girls aged 12 to 17, uses a nonclinical approach to suicide prevention through the use of art therapy. But while outside efforts are important, the city’s school system is a likely place for teens with troubles to display warning signs that they might hurt themselves. One question is whether the capacity to provide help is there.

Inside New York City’s sprawling network of 1,600 public schools, about 250 of them—including about 100 high schools—have on-site health centers. The school-based health centers—or SBHCs—are staffed with medical professionals and social workers who tackle everything from toothaches to mental health needs in underserved neighborhoods. A broad network of community service providers— like the Park Slope Center for Mental Health in Brooklyn and the Children’s Aid Society in Manhattan —independently run the centers and are tasked with handling any number of mental-health-related concerns.

On-site health clinics first began to appear in a limited number of public schools across the country in the early 1970s. Similar to those in most jurisdictions nationwide, New York’s SBHCs are free of charge for enrolled students. Most SBHCs across the country are paid for by state government revenue. In New York, funding them is only partly done through Medicaid and third-party insurance companies. Individual grants and donations also help cover costs.

Unlike outpatient clinics, the city’s SBHCs aren’t presently eligible to receive Medicaid reimbursement payments for mental health services. And while a new plan was slated for adoption last March, it has since been delayed after the federal agency that distributes Medicaid expressed concerns about the manner in which New York State calculates its inpatient services.

“We have a dearth of mental health services in the schools and in the community. It’s a challenge everywhere,” explains Dr. Myla Harrison, assistant commissioner for child and adolescent services at DOHMH, which oversees the clinics.

New York’s SBHCs aren’t the only ones facing difficult financial hurdles. In Connecticut, Gov. M. Jodi Rell proposed last month that the state cut $1 million in funding for the state’s 75 SBHCs to help cover its budget deficit. And 150 SBHCs in California are struggling to find a consistent revenue stream for their operating costs in a state besieged by a host of budgetary challenges. As a result, SBHCs are increasingly seeking avenues for federal support. In the landmark health care legislation that passed in February, the SBHCs became federally authorized programs. But while $200 million for SBHCs over four years under the Patient Protection and Affordable Care Act will soon be distributed, those funds are solely to be used for the upkeep of the facilities as opposed to covering the center’s operational and programming costs.

Despite the funding challenges, Manhattan City Councilwoman Gale Brewer—an ardent SBHC supporter—contends that the clinics should be expanded to every school. Failing that, she contends, each school should be staffed with at least a social worker—which she estimates would cost the city $6 million annually. “There are so many young people with so many issues at home, and having someone to talk to is so important,” Brewer says.

The federal Substance Abuse and Mental Health Services Administration estimates that 2 million teens nationwide are suffering from depression. Depression is one among dozens of reasons most commonly cited by researchers in the medical community as contributing factors in youth suicide cases. The others range from environmental causes to the impact of substance abuse and anxiety to debilitating mental illnesses like bipolar disorder. Yet there’s no consensus as to which cause is more prevalent. “With suicidal behavior, it’s never due to just one thing,” says Dr. Alex Crosby, a CDC suicide expert. “We just don’t have the longitudinal studies that can allow us to say, ‘Well, clinical depression contributes to 50 percent of suicides.’”

Adjacent to the Audubon Ballroom in Washington Heights is the nondescript location of the Asociacion Comunal de Dominicanos Progresista, a community-based mental health service provider. “Depression is the most common diagnosis among the teenagers that we see,” says Howard Raiten, director of mental health services at the nearly 30-year-old organization. “You have to look at what is behind depression. There isn’t one explanation. There’s hostility, bullying, violence, questions over sexual identity and stress. Adolescence is a very difficult and trying stage of development.”

Last year, the U.S. Preventive Services Task Force recommended that children and teens between the ages of 12 and 18 undergo screenings for depressive disorders. However, that suggestion is generating its share of controversy among some observers, who worry that the methods used to detect depression and treat it do more harm than good.

In New York, schools with mental health programs run a number of screening programs—testing for depression, anxiety and a range of other disorders using a questionnaire tool whose guidelines are approved by the state Office of Mental Health. At 17 New York City–area high schools, screenings for depression take place through the use of questionnaires— distributed after securing parental consent—created by the TeenScreen National Center for Mental Health Checkups at Columbia University. The brief questionnaires ask about depression symptoms, past suicide attempts and drug and alcohol abuse. Students who test positive move to a second-stage screening interview with a mental health professional. If a student is deemed to be suffering from depression, then the parents are contacted and recommendations are made for the appropriate local mental health providers to contact. But critics charge that the tests are too susceptible to false positives. “There is no screen that prevents suicide. You won’t even find a single pharmacological drug that has on its label that it prevents suicide. So what is the screening all about?” asks Vera Sharav, president of the Manhattan-based advocacy group Alliance for Human Research Protection. “It’s all about turning kids into guinea pigs and generating business for the medical industry.”

Jerome Wakefield, a professor of social work at NYU who has probed depression studies, is also dubious. “We’re using instruments that are too broad to identify those who are truly at risk, so the false-positive rate is enormous,” he explains. “The public has been sold on this idea that it’s all depression, but there’s plenty of good evidence which shows that suicidal behavior, especially in adolescents, is triggered by stress of various kinds.”

For its part, TeenScreen stands by its testing procedures. “I would rather have a few kids who [falsely] score positive that we’ll catch during the second-stage interview than to have some kid score negative who actually needs help,” says Leslie McGuire, deputy executive director at TeenScreen.

Also controversial among some observers is the use of antidepressants—particularly psychotropic medications like Prozac, Paxil and Zoloft, which in some studies have been found to actually increase the potential for suicide among teens and young adults. Last February, Brooklyn Assemblyman Felix Ortiz reintroduced legislation to prohibit school personnel from recommending the use of psychotropic drugs. “A lot of parents in my district have complained about teachers who told them that child should be put on Ritalin and other medication,” says Ortiz, who now chairs the mental health committee. “It’s not the role of teachers to ever tell parents about medication. They ’re not doctors. That’s the responsibility of a health professional.” The bill has since been referred to the education committee.

“I think [antidepressants] are being prescribed too frequently and too automatically,” cautions Raiten. “With depression, the thing that we have to do is get to the underlying cause. Ultimately, it’s about dealing with those personal problems that led up to the depression in the first place.” A RAND study found that $1 billion was spent on psychotropic medication in 1998 for children and teens.

But experts contend that medication can bring relief to those who are suffering from a range of debilitating addictions. In a 2005 letter to the Food and Drug Administration expressing worry about the FDA’s 2004 warning on antidepressants’ risks to teens, the American Academy of Child & Adolescent Psychiatry wrote: “Several studies … have shown a combination treatment (medication and talk therapy) as being most effective for youngsters with depression—a course of treatment that would appear to be endangered by such a strong decline in the medication portion of therapy.” “The biggest threat to a depressed young person’s well-being is to receive no care at all,” the letter continued.

At colleges and universities, the discussion around suicide prevention isn’t quite as contentious as the intense debate now swirling around younger teens. Still, the conversation—and the response of many institutions— is often set against the unwelcome backdrop of highly publicized suicides on campus. New York University saw six students kill themselves on campus in 2003 and 2004. And while glass barriers have been installed along the railings of Bobst Library—where two suicides occurred in 2003—a College of Arts and Sciences junior killed himself after leaping from the library’s fifth floor last year. NYU administrators did not respond to City Limits requests for comment. University officials had previously expressed concern over media coverage of previous suicides, citing it as a catalyst for possible copycat incidents.

Even schools that haven’t suffered from suicides are moving to prevent them. Pace University received a $220,000 suicide prevention grant last year from the Substance Abuse and Mental Health Services Administration for its Project OPEN (Outreach, Prevention and Emergency Network) program. The initiative—which is intended to serve as a national model—is focused on raising mental health awareness among previously overlooked segments of the Pace population, including Muslims and Asians as well as gay, lesbian and transgender students. “Those students who write about suicide in their English assignments are more likely to come in for help,” says Richard Shadick, director of counseling services at Pace. “It’s really the students who are quiet about their pain that we’re trying to reach.”