Expert discusses increase in female teen suicide rates: An interview with Dr. James Greenblatt

By Al Saint Jacques, MDLinx
Published June 30, 2016

Key Takeaways

In April, the Centers for Disease Control and Prevention (CDC) published a report on the incidence of suicide in the United States between 1999 and 2014. Although a previous report looking at years 1986 to 1999 saw a steady decline in suicide rates, this recent report shows an increase since 1999. Among several statistics that are concerning is the increase in suicides and suicide attempts among females aged 10 to 14. The suicide rate for females aged 10 to 14 had the largest percent increase (200%) during the time period, tripling from 0.5 per 100,000 in 1999 to 1.5 in 2014. In this MDLinx Spotlight interview, James Greenblatt, MD, Chief Medical Officer at Walden Behavioral Care in Waltham, MA, discusses some potential causes for this increase.

MDLinx: Can you comment on the CDC report that was recently released on suicide?

Dr. James Greenblatt: It was pretty dramatic. The headline was that the suicide rate is rising. Overall, almost a 25% increase between 1999 and 2014. Some of the more dramatic findings had to do with the largest increases in middle-aged women. What got our attention and why people started contacting us was that young women, girls as young as 14 years old, had 3 times the incidence of suicide. Although the increase in suicide overall is dramatic, what it doesn’t capture is the increase in suicide attempts.

MDLinx: To what do you attribute this rise in the incidence of suicide and suicide attempts?

Dr. Greenblatt: I have my theories. Being in the field of eating disorders for 15 years in this world and population, we have known that eating disorders have the highest risk of suicide of any psychiatric illness. I have been dealing with young women not only attempting but completing suicides for 15 years out of my 30-year career. So it is clear to me, and the research is supportive, that malnutrition plays a part in it. Malnutrition is complicated for 10 to 14 year old children; and there are studies looking at junk food, increased rates of depression, and the most dramatic stuff that even the military is involved in is looking at the levels of omega-3 fatty acids. The healthy fats are being tied to suicide attempts and completion.

MDLinx: Are we talking about low levels of omega-3 fatty acids?

Dr. Greenblatt: Yes. Low levels and there is 10 years of research supporting that. I think it is an equation of 3 different things. Malnutrition in the 10 to 14 year old group is part of the risk we have seen in this group of traditional eating disorder patients and now that it is becoming global, I think that there are repercussions between the no-fat/low-fat and our obsessions as a culture with not eating fat.

MDLinx: What else enters the equation in this high-risk group?

Dr. Greenblatt: The second thing that is not discussed in any of the CDC information or the commentary, which seems so bizarre to me, is the use of antidepressants. All antidepressants have this black box warning that says “can cause suicide ideation.” And there is a marked increase and we are using these medications easily and very quickly on these 10 to 14 year old kids. So that is completely ignored by both the media and the researchers. In my experience, I have found that when the black box warning first came out for antidepressants I was treating very sick kids, not eating disorders, and I never saw that increased suicide ideation. And then with the eating disorders in girls, I started seeing it. You put them on antidepressants and they get these intense, intrusive suicidal thoughts. If you stop the antidepressants, it goes away. I believe, although there is no research to support it, there is a malnutrition part of the equation for the increase in suicide ideation.

MDLinx: Is it that these girls are not eating enough or is it what they are eating?

Dr. Greenblatt: They are probably not getting sufficient nutrients is my guess because they are globally malnourished. Part of it could be related to the fats and part of it could be related to other nutrients, but either way we have this clear FDA black box warning on increased suicidal risk with antidepressant medication.

MDLinx: You also mentioned social media having an impact. How is that having an impact?

Dr. Greenblatt: Yes, we use the metaphor about throwing gasoline on the fire. It is quite clear that social media supports the detachment, loneliness, and isolation of many of these young women. Cyber bullying has clearly been linked to suicide. We see it all the time in the girls who have committed suicide and attempted suicide. We know that victims of cyber bullying are twice as likely to kill themselves.

MDLinx: What do you think can be done to turn this around?

Dr. Greenblatt: We have risk factors and we know kids who are depressed. We have kids who have had attempts in the past we have a high-risk group that we need to flag but what I think is missing is this other few areas like monitoring the medications more closely, monitoring the online and cyber bullying issues, as well as understanding where malnutrition fits in. In the omega-3 literature, the bigger study was done by NIH and with the military and they are now repeating a multi-million dollar study looking at these low levels. We know the risk factors and I think if we are more aggressive, and not just focus on one area which too many of the prevention programs do, if we look at all of these areas, I think we can make a huge dent. With cyber bullying, there are now texting and online communities that are being supportive and this is actually showing some benefit in suicide prevention.

MDLinx: You also mentioned that there is a lack of funding for many of these areas.

Dr. Greenblatt: Nutrition research does not get well funded because it is not pharmaceutically driven. Thank God that the military got involved. The suicides in the military generated some of the impetus for finding more omega-3 studies. As far as the black box warnings by the pharmaceutical companies, again that research is hard to get done because of the pharmaceutical companies not wanting to do it.

There was an interesting study that recalled an earlier study. Paxil® is an antidepressant that is used for depression and it was early on, in 2004, that data came out saying that it is both safe and effective for depression in adolescents. Then, last year, a group of researchers went back and relooked at that study, calling it restoring study 329, and they actually found completely different results. Their study showed that it was not effective and that there was a dramatic increase in the incidence of suicide in those kids taking Paxil. This was 10 to 15 years later with scientists looking at the same data.

MDLinx: Why was there a discrepancy in the interpretation of results from this same study?

Dr. Greenblatt: Well, they took the data and looked at the same results and published it in the British Medical Journal. It was dramatic and it got a lot of press for that one day. To me, it should have woken up the world to the fact that certainly for kids these antidepressants have potential side effects. What they found in the reanalysis was a much higher incidence of self-injury and suicide.

MDLinx: What can clinicians do to reverse this trend in suicides?

Dr. Greenblatt: In my training as a child psychiatrist, we were taught that children 10 to 14 years old do not commit suicide. So I think the most important thing is that suicide can no longer be considered rare in pre-adolescence. That awareness means that we can ask the questions and not pass over it. We should apply some of these equations like social media, parents monitoring it and professionals asking the questions, because these sites encourage suicide and tell you how many pills you should take, and then these online chat rooms will support you. So there is a whole host of both professional and parental issues, the black box warning, and then diet. We are getting bombarded by diet and mood, but there is a particular interest in how it fits into prevention.

MDLinx: What can be done regarding diet?

Dr. Greenblatt: The only thing we have in the research is that processed junk food is associated with depression. There are a number of studies that clearly demonstrate that link. Then you have the low levels of the omega-3s—individuals who don’t have fish in their diets or other sources of omega-3 should probably supplement it in their diet. The other piece for professionals that needs to be incorporated is the fact that genetics is a huge factor and professionals should ask the questions. When you ask the questions initially—is anyone in your family depressed or have they committed suicide—you might not get an answer, but if you push it you are going to find aunts, uncles, relatives who might have committed suicide and that family history, I think, is significant.

MDLinx: How far should a clinician push when asking questions?

Dr. Greenblatt: We don’t ask our 10 to 14 year old kids if they think of suicide, so just asking the questions about suicide will help, asking the questions about depression, and then asking about the family history of the parents. I also think we need to be more aggressive about some of the known risk factors that aren’t always being discussed such as substance abuse, individuals who are using drugs that provide that disinhibition that we also get from social media.

MDLinx: Are there any other signs that clinicians can look for?

Dr. Greenblatt: In my world, we have also found, in terms of laboratory values in addition to low omega-3s, we can test for very low levels of vitamin D and B12, which are associated with depression and, in my experience, puts these kids at higher risk as well.

MDLinx: Looking forward, is there anything else can we do as far as research?

Dr. Greenblatt: We have data that say that suicide is increasing, we have data that show it is increasing more in women and then in these young girls. Perhaps we can look at more biomedical markers to put it into the medical community. To me, those biomedical markers would be nutrient deficiencies. We didn’t talk about inflammation. Inflammation has been implicated in increased suicide risk. A lot of the data are there and when you see it you wonder why this is not being addressed more aggressively. Maybe these statistics will wake people up. Depression is a common co-existing condition and rates of depression are increasing. Depression, within a few years, will be the number one cause of global disability, according to the World Health Organization.

References

Curtin SC, Warner M, Hedegaard H. Increase in suicide in the United States, 1999–2014. NCHS data brief, no 241. Hyattsville, MD: National Center for Health Statistics. 2016.

Le Noury J, Nardo JM, Healy D, et al. Restoring Study 329: Efficacy and harms of paroxetine and imipramine in treatment of major depression in adolescence. BMJ. 2015;351:h4320.

Umhau JC, George DT, Heaney RP, et al. Low vitamin D status and suicide: A case-control study of active duty military service members. PLoS ONE. 2013;8(1):e51543.

Brundin L, Erhardt S, Bryleva EY, Achtyes ED, Postolache TT. The role of inflammation in suicidal behaviour. Acta Psychiatr Scand. 2015:132:192–203.

Hibbeln JR. Depression, suicides and deficiencies of omega-3 essential fatty acids in modern diets. World Rev Nutr Diet. 2009;99:17-30.

James M. Greenblatt, MD, is a pioneer in the field of integrative medicine, having treated patients with mood disorders and complex eating disorders since 1990. He is a founder of Integrative Medicine for Mental Health, and currently serves as the chief medical officer and vice president of medical services at Walden Behavioral Care in Waltham, Massachusetts. Dr. Greenblatt is also an assistant clinical professor in the Department of Psychiatry at Tufts University School of Medicine in Boston. His new book, Breakthrough Depression Solution: Mastering Your Mood with Nutrition, Diet & Supplementation (Sunrise, May 2016), offers a personalized model for relief from depression.

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