By Arne Vainio, MD
He wasn’t my patient, but he told his mother he was having suicidal thoughts and he needed to be seen right away. He had been started on an antidepressant by someone else a few weeks earlier and the new medicine made him feel better for a while, then he started having thoughts of harming himself.
He was a nice young man, age 16 and he was polite and respectful. He was with his mother and I introduced myself as I sat down.
“Tell me what’s going on.” I said.
He replied, “I was started on the new medicine and it seemed to help for a little bit, then I started to feel worse. I had thoughts initially of wishing I had never been born and then started thinking everyone would be better off if I wasn’t here. Then I started actually thinking about killing myself.”
“Do you have a plan for how you would do that?” I asked.
“No plan and I don’t allow myself to think about it enough to come up with one. I know how much it would hurt everyone if I did that. I just want to feel better.” He answered.
He was articulate and I could tell he was bright and I asked him, “How do you do in school?”
“Mostly As, some Bs, but they’ve been slipping this year.” He answered.
“And what do you want to do after you graduate?” I asked.
“I want to be a psychiatrist.” He answered.
“That’s an important field.” I said. “You could go anywhere and find work easily. Are you seeing a counselor?”
“I am.” He answered. “That’s been helpful and she told me to come in to talk with you.”
“I’m glad you did.” I told him. “I think we can help you. I don’t want to talk down to you and I don’t want to talk to you like you’re still too young to make decisions. I don’t want to make plans behind your back and I promise I won’t do that. I want to tell you my father committed suicide when I was four years old and that affected everyone in my family and it still has effects over fifty years later. At 16, the world is waiting for you and it can be an uncertain place, especially for someone as bright as you clearly are. I want to tell you some things I wish my father would have told me. In just a few short years, you have to be thinking about the direction you want your life to go. That’s a big responsibility and it’s a decision that requires some thought. You need to sort out sexuality and what that means for you in a society that thinks that’s their business. Social media is always there and reaches you in ways adults can’t even imagine. Bullies are out there and I have no doubt they were in middle school and in high school.”
I could tell by the look on his face I had struck a nerve.
“Bullies are still bullies in the adult world and all too often they get to be bosses, and they can make your life difficult. Paying rent and tuition and other stresses are in your future. Going to college when your friends have jobs and are making money is hard, and the temptation to quit will be strong. You need to look beyond and, in retrospect, that time will go fast.
The antidepressant you were started on is a good one and is one I would have chosen. Someone didn’t make a bad decision when they started it. If there was only one antidepressant that worked for everyone and didn’t have any side effects, this would be easy. Most primary care providers use just a few of them and are familiar with them. I’m going to give you your first pharmacology lesson.”
I went into a long and fairly technical explanation about serotonin release, receptor up regulation and down regulation and biological mechanisms for clearing neurotransmitters. I could tell he was interested in that conversation and that he understood it.
All of these medicines are going to have black box warnings in someone under 18 years of age. That means there is an increased risk of suicide with these medicines and you need to be aware of that. Those black box warnings make some providers reluctant to prescribe them. The fact that you need to be on one of these medicines increases your risk of suicide all by itself and we need to talk about suicide. Having a plan increases your risk of suicide and having the means to carry out that plan increases it more. Having a history of previous suicide attempts increases it even further. There is the suicide hotline at 1-800-273-TALK (8255) and that number is answered 24 hours a day, 365 days a year.
People are afraid to talk about suicide because they think they’ll put that idea in your head, but that idea is already there and talking about it helps.”
I asked him and his mom if anyone in their family had a problem with a particular antidepressant, or if anyone had particularly good luck with one of them. His aunt was on one that worked well for her for the past 5 years and they chose that one.
“All of these medicines work and they’ve been well studied.” I told them. “I don’t want you to get the impression we’re just putting you on a medicine to hide your problems. Having depression is more common than you know. Continuing to see the counselor is important and right now you need to be seen frequently. These medicines are safe and really have minimal side effects. They don’t make you look at the world through rose colored glasses and needing them is not a character flaw and taking them is not s sign of weakness. They are not addicting. These are a tool, just like a calculator or a pencil or a shovel. These are a tool to help you feel better and get some successes behind you. This medicine won’t make school work any easier and you still have to make up any classes you’re behind in. The bullies will still be bullies and you still have to figure out your goals.
Life can be difficult at times and everyone here recognizes that. We want to help you aim for your dreams and if there’s anything we can do to help you talk to someone at a college or medical school, we’ll do it. There are lots of hurdles on the path you’ve chosen and most of them we’ve seen before.
You will start feeling better soon and the circles you travel in will get better as you get better. You have a mother who clearly loves you and cares about you. Your goals are sensible and not everyone your age has such ambitions. I believe in you and we are always here to help you.”
I could see he and his mother felt better and I could see hope in the way they carried themselves as we ended the visit.
“Thank you, Dr. Vainio.” He shook my hand and looked directly into my eyes.
“One last thing.” I told him. “You come from people who survived incredible hardships and community is what has always kept us going. That resilience is in your blood. I know this is a lot to take in in a single visit, but I want you to know this. We need you more than we ever have. We need your youth and your dedication and your sense of direction. I don’t remember ever hearing my father’s voice, but this is what I would have wanted him to say.
“We need you.”
