Critical Issue Addressed with Insight and Expertise

Today’s workshop presented by Eric Lewandowski, Ph.D., and entitled: “Recognizing and Managing Depression and Suicidal Thoughts in Children and Teens” was an important start to the 2019/2020 FCP Behavioral Health lecture series. Dr. Lewandowski captivated his audience with a fast-paced presentation on an important topic. He had a direct but congenial style and showed a command of his topic throughout the presentation.

The Workshop Objectives included:

At the end of this activity the learner will be able to:
• Describe recent trends of youth depression and suicide
• Explain the theories of what underlies depression and suicide risk
• Name tools for identifying, assessing, and managing depression and suicide risk

Most of these objectives were met. Although there was not much discussion of recent trends of youth adolescent depression and suicide, Dr. Lewandowski started his presentation with a description of depression in youth saying that 1 in 5 has a depressive episode by age 20, and 3.1 million teens were diagnosed with a major depression disorder in 2016. He also said that only 40% received treatment of any kind. Among his opening remarks, Dr. Lewandowski mentioned that cooccurring disorders are common with depressed youth and many treatments are too complex for teenagers.

Dr. Lewandowski talked about trends in treatment for depression with adolescents. He presented research studies that demonstrated low effect size for several evidence-based treatments modalities. These studies indicated that treatments are not working as well as we want. He pointed out that many treatment models suggest that changing the mood or the cognition of depressed teen is the best way to change the behavior. Dr. Lewandowski disagreed. He explained that, the brain has 3 distinct neural circuits for motivated behavior in the subcortical system.

  • Approach-Ventral Striatum
  • Avoidance-Amygdala
  • Regulatory-Prefrontal Cortex

These systems are all immature in children and all mature in adults. Adolescents show mixed development with the prefrontal cortex less mature than the subcortical circuit. Dr. Lewandowski stated that the risk for depression is greater in adolescents because of greater influence of the approach system (intense feelings, risk taking behavior, altered reward processing) and less developed regulatory system (the “brakes”). He suggested that adolescents are more likely to change their mood, after a change in behavior, rather than after a change in cognition.

Dr. Lewandowski spent much of the first half of his workshop talking about Behavioral Activation (BA) as a treatment for depression and suicidal thoughts with adolescents. He mentioned that 17 studies with depressed adolescents have shown medium effect sizes at the end of treatment and at 1 to 3-month follow-ups with BA. The general framework of BA model of depression and Change includes four components:

  • A life that is not sufficiently rewarding is a risk factor.
  • Patterns of avoidance and withdrawal maintain depression.
  • Guided activation will help patients disrupt avoidance, improve mood and build a more rewarding life.
  • Idiographic focus on the individual’s values/interests.

Dr. Lewandowski added a quote stating, “The kid should not fit the treatment. The treatment should fit the kid”.

The BA model does not focus on the Content of thinking. Instead, BA focuses on the Context and Consequences of thinking. Regarding the persons thinking, BA asks:

  • When did it start?
  • How long did it last?
  • What were you doing?
  • How engaged were you with the activity?
  • What were the consequences?

Dr. Lewandowski said that BA has 10 principles starting with, “The key to changing how people feel is helping them change what they do”. He said that there is a manual, but it is more a statement of the principles than a cookbook for treatment. The structure of sessions includes an assessment, psychoeducation about the key concepts, skill training relevant to the adolescents experiences, “test it out” homework assignments, meeting with parents, and a preview of the next session. Dr. Lewandowski pointed out that other therapeutic models can sometime be helpful in conjunction with BA to facilitate new activities. Clinicians should not lose site of the BA model, however. He also said that a patient may need treatment for another disorder such as trauma, before they are ready to participate in BA treatment.

The second half of Dr. Lewandowski’s workshop was focused on suicide assessment and management. He said that 1 in 12 high school students attempt suicide each year, and 1 in 5 have considered suicide in the past year. He also pointed out that 20% to 40% of youth attempt suicide without prior planning. Dr. Lewandowski said that self-injurious behavior may or may not be suicidal.

An assessment for self-injurious behavior should always include”

  • What were you thinking?
  • How did you feel before? After?
  • What does cutting do for you?
  • Were you wishing you were dead?
  • Thinking about killing yourself another way?

Dr. Lewandowski provided a list of suicide risk assessments. These included:

  • Columbia Suicide Severity Rating Scale (C-SSRS)
  • Linehan Risk Assessment and Management (LRAMP)
  • Adolescent Suicide Questionnaire (ASQ)
  • Brief Suicide Safety Assessment (BSSA)

Interventions for suicidal youth should always start with restriction of the means for suicide. These include firearms, sharps, drugs and location access. It is important to maintain social access, and safety planning with a suicidal person. Dr. Lewandowski stated that safety planning includes developing a plan for recognizing and coping with stress or upsetting emotions. During his workshop, he presented a detailed description of a safety plan for suicidal patients. He pointed out that safety planning is not:

  • A one time thing, rather an on going process.
  • Just a list of coping skills.
  • Contracting for safety

According to Dr. Lewandowski, interventions for the suicidal adolescent include:

  • Restricting means of suicide
  • Maintain social connectedness
  • Safety planning
  • Cognitive Behavior Therapy (CBT)
  • Dialectic Behavior Therapy (DBT)
  • Collaborative Assessment& Management of Suicidal Risk (CAMS)
  • Augmented familial and social support

Dr. Lewandowski stated that there is a growing body of evidence supporting the effectiveness of the CAMs as both an assessment instrument and treatment approach for suicidal adolescents. He ended his workshop with slides showing that, as he said “Suicide risk does not rise out of the blue.” His slides demonstrated that stress is cumulative and can lead to a “boiling point” over time. Teens and parents can learn to avoid their boiling point with support from a mental health professional.

I found the workshop today to be very satisfying. It is difficult to squeeze a complex topic such as depression and suicide with teens into 3 hours. Dr. Lewandowski managed to do this well. His audience included mostly experienced mental health professionals. The audience was quiet throughout the presentation and had very good questions before the break and at the end of the workshop. Dr. Lewandowski gave expert response to all questions. I expect that Dr. Lewandowski will be invited back for more workshops in the future.

Any other thoughts?

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