The outpouring of discussion around stress, school, mental illness and the welfare of our teens has been tremendous these past few months. These discussions are critical for change and it is clear that change is happening. Comments have spanned the gamut of potential contributors to suicidal ideation, including mental illness, stress, social isolation and pressures, homework and school factors, sleep debt, family issues and societal expectations.
The Palo Alto Weekly's Jan. 30 editorial stated: "Suicidal ideation, they say, is not the product of too much homework, test anxiety, too little sleep or worry about college admissions, in spite of the stress they may cause." As an adolescent psychiatrist, it was my intention to address this piece since "they" referred to "mental health professionals." It seems unlikely that most health professionals would agree that stress (internal or from the environment) or sleep abnormalities do not play a role in contributing to mental illness or suicide.
Then, I came across a truly brave and vulnerable account of one student's experience and that teen said it all! The story is a reminder of the strengths in our midst, some of the contributors to great distress, and subsequent hope and health moving forward.
The teenager shared how stress in the family, school and social life eventually led to serious suicidal thoughts. Environmental stressors can absolutely contribute to mental disorder and are one of the first things medical professionals look for when trying to understand how to best help someone struggling with disease.
Stress causes the brain to release chemicals that drive a person to fight or flee the perceived problem. This can be life saving in the short term. The hormones can help a person perform well at certain things, such as getting through the SAT on time. These stress hormones make a person hyper-alert, ready for action, feeling less need for sleep or food, and more resistant to infections. But if the stressors are chronic or overemphasized as a danger in one's mind, the person's health deteriorates. Chronic stress affects many parts of the body, contributing to diseases, increased infection and mental illness. For the teen in this story, chronic stress kept them focused on fleeing the perceived threat. This fleeing was, for awhile, equated in their mind with dying to escape.
The teen noted that stress affected sleep and attitude. Sleep abnormalities are intricately connected with stress and mood. Stress hormones can make it difficult to fall asleep even when one is quite tired. The combination of high stress hormones and sleep deprivation can impair rational thinking and cause depressed or irritable moods.
Our brains can become hyper-focused and narrow-minded in the choices for dealing with stress -- or react impulsively without being able to analyze the consequences of the action. Teens are more susceptible to this as their brains are not fully developed in the executive functioning areas, the frontal lobes. This means they are less able to stop and think, prioritize solutions and plan before acting. It also means they can have more intense emotions, react more quickly and jump to conclusions more readily than adults. That can be useful or dangerous.
With lowered sleep, the frontal lobe functions even less well, impacting mood. In fact, two recent studies of thousands of teens showed those who slept seven hours or less a night and did not meet criteria for depression still had a two-fold increased risk of suicide compared to teens with normal sleep habits. Another study published this past month is the first of its kind to show smartphone usage causes increased disruption in teens' sleep and repeats what others have found: that electronic devices can be connected to sleep difficulties, which in turn were related to depressive symptoms.
For people with anxiety, depression and many other psychiatric conditions, sleep abnormalities are a common thread in the cluster of symptoms used to define disease. Like hypertension, which warns of the risk of heart disease and stroke, sleep problems can warn of the risk of mental disorders. Further, if hypertension or sleep problems go untreated, the health of the person is at risk.
Part of our teen's story referenced another student whose family courageously stepped out of their grief to share that their son was living with depression and despite help had been unable to conquer it, taking his own life. Severe cases of clinical depression are rare before puberty, but there is a drastic increase in the disease so that nearly 20 percent of the population has experienced a depressive episode when turning 18 years old. The co-morbidity of depression and sleep disorders in adolescence is very high, with 73 percent of depressed teens suffering from a sleep disorder. In fact, a large meta-analysis in 2014 "concluded that sleep disturbance rather acts as a precursor to the development of depression."
This is scary stuff when a person feels alone, with a bad attitude, stressed and sleep deprived. Even worse when people do not have others to help them see the big picture. Their mind is not working properly and thinks in ways that are abnormal. Perceptions are off and not necessarily legitimate.
Fortunately, this Palo Alto teen texted their concern to friends. Fortunately, compassionate friends responded and realized they are a part of a community. They called the school. Mental health services involved the family and engaged professionals to work with the teen. The teen no longer felt alone, which is a common contributor to suicidal feelings, and got needed help from their community. Further, the teen now realizes it is hard therapeutic work to understand the triggers leading to suicidal thoughts as well as to maintain healthier ways of thinking.
So how do we improve our community and the lives of teens around us? Try simple steps such as sleep hygiene, turning off electronic devices at night, getting eight hours of sleep (nine if you are a teen), counting how much time you or your child does work without electronic distractions, getting help when these things don't work, and understanding common diseases such as depression. By learning and applying these things to our own lives we are an example to others.
We can also look beyond mental illness to address what the Palo Alto Weekly suggested, "the happiness and well-being of all students in a hyper-competitive culture." Consider mindfulness or exercise as ways to decrease stress and improve clarity. Consider a change in course or workload or an emphatic shift from success in performance to relationships and connections. Consider collaborating with others to identify what areas need attention and improvement, then work towards those goals together as a collective community.
And when we feel we have given what we can to our hyper-competitive community, let us not forget the words of our teens, "We're all in this together." When we have learned and changed in our community, we can continue the work by stepping beyond ourselves to find that teen sleeping in the shopping cart. Remember, her story was also part of what saved our student's life. Let's focus on compassion and collective change, and when we have healed, spread our wings further.
Maria Daehler, M.D., is a PAUSD parent, adolescent psychiatrist and smartphone owner.