Dr. Doug Gray
Child and Adolescent psychiatrist at the University of Utah
Interviewer : First of all let’s just talk about this um, supposed or perceived high rate of teen suicide here in Utah and particularly for males between 14 and 24. Um, could you put that in perspective for me and you had mentioned um, it really applies to the Rocky Mountains and address how that compares to the United States.
Dr. Gray : Yeah. Utah’s youth’s suicide rate is higher then the national rate but so uh, are the neighboring states. It turns out that the Rocky Mountain West and in some years Alaska have higher rates of both youth suicide and adult suicide, um, then the rest of the country. Some of this can be accounted for by firearm availability but some of it cannot be accounted for. And they’ve done some studies to try to sort out why, uh, the Rocky Mountain states have, have higher rates of suicide. And we still don’t know why, still question.
And talk about the differences between males and females, you’re talking about majority of females are attempters?
Yes, um, both males and females, of course, get suicidal when they’re have mental illness or under duress, stress. When you look at completed suicide it’s primarily males, 90% male. If you look at attempted suicide it’s primarily female, 90% female. Uh, males tend to use firearms. Of course there’s no second chances there. Females tend to use less violent means, such as overdose, which can be very dangerous but with our technology and our intensive care units now a days many of those kids can be uh, saved.
Okay, let’s talk about then why kids commit suicide or attempt to commit suicide. And in this we wanted to talk about mental health issues also.
Yes. Well if you look at teenagers that actually complete suicide, and even if you look at, sorry, let me start over. If you look at teenagers that complete suicide and if you look at those that make serious suicide attempts the one thing that all of them have in common is that over 90% of them have a mental illness. If you look at what’s different about the ones that complete and the ones that attempt, uh, the ones that complete tend to have multiple illnesses such as depression plus substance abuse. Um, combining mental illness plus alcohol abuse or some other type of drug abuse or dependence puts you in the highest risk cat, category. Um, so mental illness puts you at risk for suicide attempt and having mental illness plus substance abuse puts you in a higher risk group for completed suicide.
Let’s talk about mental illness just a little bit. Define it so that the kids know what we’re talking about.
Yeah, the most common uh, mental illness would be depression. Kids get sad and they don’t enjoy life day to day. They don’t enjoy the things they’ve always enjoyed. They start having sleep problems. They might wake up in the middle of the night and not be able to get back to sleep. Um, changes in appetite. They’re either eating a lot more then they used to or a lot less. Um, low energy, lack of uh, energy to really do the things that they used to do, may spend a lot of time sleeping, a lot of time in their room. They get guilty, they get down on themselves, very pessimistic, they look at the world differently. Um, have trouble concentrating, they may get through their school work but they’re struggling to focus and concentrate. Get agitated, have little outbursts. Um, and they get suicidal commonly with depression. Um, other types of illnesses include bi-polar disorder. A little less common but mood swings, I mean highs and lows. Um, anxiety disorders that can range from generalize anxiety, where you’re tense all the time and nervous, can’t relax to specific anxiety, types of anxiety like obsessive – compulsive disorder, where people are washing their hands uh, thirty times a day and having trouble um, with recurrent thoughts that they can’t get out of their head. Um, uh, so anxiety and depression are probably two of the most common. We do see some young people that have psychosis, that’s a strange word but what it means is you lose touch with reality. Uh, some people’s psychosis have, are developing schizophrenia which is a tough illness but we can treat it a lot better these days then we used to be able to. Um, and of course, substance abuse, the most common are alcohol and marijuana. Um, but then those are sometimes entry level drugs that get you into other more serious drugs like heroine and cocaine and methamphetamine, which are you know, even more dangerous so.
Just to finish off that thought, the differentiation between just a normal teenager and this, you’re not talking about just a normal teenager.
Yeah. Well sometimes people say “how do we know the difference between a normal teenager, because they get moody or a teenager that’s struggling with a mental illness?” Normal teenagers will slam a door. They’ll get mad when you tell them they can’t out or they’re restricted. Uh, they’ll be irritable sometimes. But generally you can see them enjoying life. They enjoy their friends. Uh, they seem to enjoy school, if not every aspect of school at least the majority of what’s there, their friends and, and a few of their classes. Uh, they enjoy some of the family outings, sometimes they don’t want to go on family outings but they, you know, and they fight about it but generally if you get them out they’ll have, have fun. Teenagers that are developing um, mental illness may isolate themselves in the room. They may turn down invitations from friends. If they skateboard, they, they’re not that interested anymore or they, they go through the motion, they look sad while they’re doing it. They don’t look happy like they really enjoying things. Uh, they may be a little explosive and blowup and over little things, not, not when you’re restricting them but just talking to them. And you notice that there differences, again in terms of their sleeping, appetite, energy, their concentration, their homework and they seem to be deteriorating. Those are some of the symptoms.
What are things that you could offer to teenagers as to when they should get help? In other words, if a teenager’s viewing this video, what are the signs that they should look at to say, “Oh, you know, maybe I better talk to somebody.’?
Yeah, some easy ones would be um, you know, think back over the last couple of weeks. What percentage of the time have you been happy? And if the majority of the time you say “yeah, I’ve been a happy person. I had that one day where I was upset and I didn’t do well but, you know, that’s a good sign. If it’s hard to remember when you were happy last, that’s a concern. Um, enjoyment. When’s the last time uh, you really enjoyed things day to day? And I’m talking about having a meal or having a shower, just simple day to day things or checking out uh, a comic book or a newspaper, uh, are you enjoying day to day activities? If you’re not that’s a concern. If you feel a lot of distress, if you feel stressed all the time, you can’t relax, you’re frustrated, uh, that’s a concern. Um, and if you’re not functioning the way you used to. If you used to be able to do well in school and you were doing well with your friends and you’re just not functioning in the same manner, that’s a concern.
We talked about stigma and stereotyping and you made three kind of delineations. You talked about the disease, then we talked about how Jeff asked people, "What’s your disease?" and then you also talked about the stigma keeping kids away from seeking help because they’re embarrassed. Will you talk about that for a second?
Sure. Stigma is a big issue with mental illness. And when we look at kids that die from suicide, most of them uh, were not in, actually very few of them were getting any treatment. And when we ask the parents and their friends what was going on they say “well they were embarrassed about having an illness.” They did not deny they had an illness um, they didn’t think treatment would work. And so stigma has really kept those kids from getting the help they need. Now, we come a long way, there’s less stigma now then there used to be. As a psychiatrist uh, when I started training uh, many years ago, if I saw a patient out in public, at a restaurant, course I wouldn’t acknowledge that I knew them, and they would acknowledge that they knew me. Nowadays if I go into a school or restaurant, other places, some of my patients will come up and say hi. They want me to meet their grandparents or who at the other table. Uh, and so you see that stigma starting to breakdown, it’s still there but it’s, it’s getting, uh, better. Uh, the goal, the goal would be that, uh, mental illness would be looked at just like other medical problems, like asthma and diabetes. Some people are very private about their diabetes. Other people talk to their friends about it. Hopefully some people will be private about their bi-polar disorder but some people will talk about it. Each person has to make their own decision about that, depending on their personality and what they’re comfortable with. But I hope that mental illness eventually is in that same category with asthma and diabetes and other types of illnesses.
What would you say to a teen that is having suicidal thoughts? A teen that is perhaps viewing this video. You have talked about treatment and maybe you can say something about treatment, but what initial thought would you offer to them?
Yeah, I think the first thing is, is uh, how serious those suicidal thoughts are. Sometimes when somebody’s under stress they have a daydream about suicide but they, they know they’d never really harm themselves and they have no intention of doing that and, it’s fleeting and they’re sort of back to normal pretty quickly. But if um, suicidal feeling persist and come and go and they’re not going away, especially if they’re getting worse, and especially if the person has distress and dysfunction from some type of illness going on with their brain, uh, they really need to get help. Some people, uh, will talk to a school counselor or maybe a clergy or bishop or somebody that they trust who’s an adult. Some people can go directly to their parents and their parents will need to be involved cause they’re the ones that will seek the treatment for them. But some people feel more comfortable, some teenagers feel more comfortable going to uh, some other adult they trust and having them approach the parents and then having a meeting and having a discussion and sort of having a somebody who’s an advocate kind of on their side. But eventually the parents need to be involved, it’s so important. If you’re, if you’re a parent, you want to be involved. And the parents are the ones that can seek treatment for the teenager.
What about kids that are afraid of the treatment. You know, I’ve heard some kids say “well, I’m afraid that everybody’s going to think I’m crazy and they’ll lock me up.”
Yeah, a lot of uh, teenagers are afraid of what will happen. Will they lock me up? Will I be in the hospital? What’s going to happen? I, I try to tell them that my job in outpatient, as an outpatient psychiatrist is to keep kids out of the hospital. We’re trying to help them and prevent a crises. The kids that end up in crises and in a hospital often are those that aren’t seeking treatment. They’re avoiding it and so then it all crashes down in a crises moment and they end up in the hospital. So if you come in for an outpatient evaluation basically we’re just going to sit and talk. We’re going to talk to your parents. We might get some information from a grandparent or someone else to and put all the information together and try to come up with a treatment uh, plan that’s specifically geared for you. Something that fits. You know what, we sit down and talk to the teenager. How does look? What do you think about this plan? We talk to the parents? What you do you think about this plan? Is this the right plan for your teenager? We try to come up with a plan that everyone agrees to. The teenager, the parents and the uh, psychiatrist so we’re all in the same page. We write that plan down and we follow it and kids get better. It’s amazing. I have medical students come work with me and pediatricians and they say “wow, all your patients are getting better.” And I went “yeah.” It’s really great. It’s a fun practice.
So what kind of, just to very briefly let teenagers know, what kind of treatments are involved? You said something about medications, something about maybe behavioral therapy, just very briefly give them idea of…
Well, just, just some ideas about treatment, one is we have uh, new medicines that uh, for depression, anxiety other disorders that work much better and have fewer side effects. And some, you know, generally don’t have any side effects. So we have, where we used to have one or two antidepressants, we have twelve to fourteen. We used to have one or two medicines for bi-polar, now we have gosh, twelve, thirteen medicines. So we have this toolbox full of tools in terms of medicine. We have new therapies, cognitive behavioral therapies for teenagers, group therapies that help them, uh, deal with anxiety or deal with depression, deal with substance abuse. Some teenagers I’ve seen are having trouble with their parents divorce, we’ve got specific help for that so that the parents keep the teenager out of , out of the middle. Um, some of the teenagers we see have learning disabilities and until we get the right school program, they’re going to continually frustrated during the school year. So we address the learning disabilities and so forth. So it’s really a comprehensive plan that looks at the whole teenager and tries to address all their needs.
We talked about the stigma, but can you talk a little bit more about how these kids are just normal kids, because sometimes people in the community or their friends may worry if they say “oh I have a mental illness” or conversely the kids may think “oh, if I let someone else know that I have a mental illness, they will not accept me”….so will you talk a little bit about that?
Yeah, these kids are just normal kids. They don’t look different then other kids and it might be your best friend or somebody you know at school who you really enjoy. When they’re ill they’re really struggling. When they’re treated they’re functioning just like everybody else. Some teenagers are coming forward now and speaking for us. We have uh, several programs, there’s Hope for Tomorrow where teenagers are speaking. First Lady Huntsman has a program Power in You. Some of these teenagers that are pretty brave are going to schools and talking about their illness and people are looking at them saying “wow, they look normal. They look like me” and uh, yeah, they do. And, and they’re brave in talking about it because there is still some stigma around mental illness but it’s helping to breakdown the stigma.
Let’s talk a little bit about the fact that sometimes suicide seems to be glorified or romanticized in the youth’s mind. Can you talk about that and why that’s a mistake?
Yeah. We’ve found that um, sometimes in movies or t.v. or other situations, suicide might be glorified and they might try to honor the person that suicided and you can understand trying to honor someone when you care about them and love them but suicides a mistake. Okay. There’s no question about it. A lot of the teenagers that suicide actually think that their family will be better off without them. And I hear that in my practice when somebody’s depressed or really struggling. And in fact, when you go and talk to families that have lost someone from suicide, they’re not better off. They’re much worse off. And people are, uh, not recovering from that kind of loss for, you know, many years. Well, they never recover but they, it takes a long time to get back to even functioning regularly. So there’s this misperception by some teenagers who are ill that everybody will be better off, it’s not true. It’s really a mistake. There’s treatment available. They can get help and they can get well and function like they used to again.
Talk about those consequences of suicide for the survivors and the impact on the family and friends and the community.
Yeah, I think that uh, we know that suicide, the main factor is mental illness that’s untreated. Um, people in treatment are doing well. But often times there’s a precipitating event um, that, kind of things that occur in every family every day, like a parent yelling at a teenager or teenager breaking up with a girlfriend or boyfriend and some people will think well, if I hadn’t yelled at my teenager cause they got in trouble that day or if their girlfriend hadn’t broke up with them, they’d still be around. But we know that everybody has romantic breakups, everybody gets yelled at by their parents sometimes so that really isn’t the cause of suicide. And yet after suicide everyone feels guilty. Well if I hadn’t done that or if I had done something different maybe Johnny would still be alive and so there’s a tremendous amount of guilt, survivor guilt. There’s a tremendous amount of uh, sadness. And then there’s this stigma on the family. Um, I’ve gone an talked to families who’ve lost a teenager by suicide and they’re, you know, the families I’ve talked to loved their kid, they’re wonderful families, they were supportive and yet people may look at the families and say well what’s wrong with them? Did they abuse their child? What were they doing wrong? So there’s this stigma upon the family even though they may have been really good parents and there’s this stigma upon the, you know, community and you know, what’s wrong with this school that they had a suicide? So there’s a mixture of all kinds of feelings but people don’t recover from this quickly. This is a long drawn out, uh, situation and again the big mistake is that teenager thought, well I’m too much of a burden. Well suicide is the burden.
That leads me into um, talking about this whole thing about the church and Jeff mentions that in his piece. The fact that sometimes um, in different theologies, they’ve look at mental illness (unintelligible) as um, being created or caused because it’s a sin (unintelligible). Can you address that?
Well I think if you talk to church leaders, whether it’s the L.D.S. church, the Catholic church, uh, any, any uh, church, you find that they understand that mental illness is not related to sin or uh, something like it. But there’s still some people actually believe there’s some connection with sin or making certain mistakes, you know, that are leading to mental illness uh, and or suicide and that’s really unfortunate, I mean, hundreds of years ago people were burned at the stake for having mental illness and we’ve obviously come a long way but we still have a ways to go to educate people. And you’ll, you’ll see in our community there have been efforts by uh, leaders to educate folks about this, that anyone can have mental illness. That it’s treatable but you have to get treatment. And that’s where the responsibility comes in. the, the, you have to go get treatment, get help.
So can um, the community, friends, family support someone who’s been through a difficult time with mental illness?
Well, I think if you have a friend that is struggling with mental illness you want to enjoy them the way you normally do, listening to music, hanging out with them, those kinds of things. I think you also want to check in with them from time to time, when you’re alone with them and say “how are you doing? Are you getting the help you need? Do you need me to help you access some help? Can I, you know, how are things going? Are you doing okay?” I think that’s important too.
Okay and then um, just bouncing a little bit off of something you said earlier, and I mentioned to you that several of the girls that have done pieces, excuse me, mentioned that in their past there’s abuse. And you touched a little bit on this that, that these families, there’s not always a precursor. Will you, you address that whole issue of, of um, them being higher risk but not necessarily everyone having abuse in their past.
Sure. Um, I get asked question about what’s the relationship between child abuse and suicide. Well, if you’ve been abused as a child, you are at increased risk for suicide. Um, you think about kids that have been abused in foster care and all the things they have to deal with that are stressful, however, the majority of kids who suicide have not been abused and when we did our suicide study and went into talk to families, we found out that they, you know, you walk into the teenagers room and there was the soccer trophy’s and the posters on the wall and photo albums and in talking with these families, these kids were loved and they were welled cared for and we need to breakdown that stigma too, that you can be a good family and a loving family and still have someone suicide if they have mental illness.
Okay and then lastly, what can we do in communities to help the kids, teenagers forego suicide and choose other alternatives?
Well there’s several things that we need to do in our community. The first one is to breakdown stigma. So if people are embarrassed about getting help and embarrassed about having a mental illness, they’re not going to want to seek treatment and they won’t tell people they’re in trouble, so we’ve got to work on that first and we are. We’re working on that. Once we breakdown the stigma we’ve got other barriers, for example, insurance companies. If you go see the pediatrician, you might have a fifteen dollar co-fee. If you go see a child psychiatrist, it might be fifty dollars and if you catch somebody from an insurance company they might admit to you that it’s meant to be a barrier. They’re trying to keep kids from getting the same kind of help they might get from medical problems to reduce cost. They’re not against these kids but they’re just trying to reduce costs. And we’ve gotta actually have insurance parody where if you have a fifteen dollar co-fee for pediatrics then you’re going to have a fifteen dollar co-fee for child psychiatry or child psychology. Um, and I think that’s, that’s going to be important. And I think the other one is people in the community being more aware of mental illness, being more aware that it’s treatable so that when they see someone in trouble they’ll start pushing them towards getting help, or help, you know, advocating for them so they can get the help they need.
I’ll just ask again. What can we, in our communities, do to help Utah teens forego suicide and choose healthy alternatives.
First thing we have to do is breakdown stigma. As long as there’s stigma and people are embarrassed about getting help, denying they have problems, uh, we won’t get anywhere. People have to start talking about these illnesses and looking them up and learning more about them and being more aware. Um, once we get past stigma, there are problems within the structure of how we deliver healthcare so that there’s no parody. Parody, you know, means equality. The, if you go to a pediatrician you may have a fifteen dollar co-fee but if you go to see the child psychiatrist it might fifty dollars. And that’s sort of meant to prevent people from getting mental health treatment to reduce costs, not because they don’t need help but to reduce costs. So we need what’s called mental health parody where the co-fee would be the same whether it’s mental health or physical health. And I just think we need an overall increased awareness so we pick up on teenagers that might, might not otherwise get help uh, and advocate for them and steer them in the right direction and that’s starting happen. It’s exciting, it’s an exciting time.
Let’s talk about the teens at highest risk.
The teenager that’s at highest risk for suicide is the teenager with mental illness plus substance abuse and especially if they have access to firearms. I’ve had teenagers tell me that they thought about suiciding in a moment and they actually looked for something, you know, to complete suicide and then the doorbell rang or a phone rang, something happened, distracted them, they ended up talking to somebody, getting help and they’re fine now. So it’s important to recognize is if somebody’s at risk, that parents voluntarily keep their home safe during that time. It’s a little different, I spun the gun thing.
That’s okay. I’ve got it.
I hadn’t mentioned really the gun safety.
Yeah. And it might destigmatize it a bit too.
And help people recognize that it is an illness.
People ask me uh, “can suicide be inherited?” well, increased risk for suicide can be inherited. We know from adoption studies that when someone who was adopted at birth, grows up and commits suicide and we look backwards, we found out that the family that raises them has no increase risk for suicide. None. But the family they never met has increase risks of suicide six fold from normal. So we’re trying to sort out what those genes might mean. We know that identical twins have higher rates of suicide if one suicides and the other then non – identical twins. Again, another factor telling us that there are some genetic influences. Part of that might be the genes for that illness, like schizophrenia, depression, bi-polar, and part of it might be other factors like impulsivity or anger, other things that might increase risk. And we’re sorting that out right now. Um, but if you have relatives who’ve suicided, it certainly doesn’t mean that it’s going to happen to you but you are at higher risk. Um, so there is something uh, that you can inherit in terms of an increased risk. I mean, that’s true with asthma too or any other illness.
