For three decades, the suicide rate in Indiana has steadily increased. According to the Centers for Disease Control and Prevention, suicide is the 11th leading cause of death in Indiana and second leading cause of death for Hoosiers between the ages of 10 and 34.
At the forefront of this issue is Kelly Donahue, PhD, a licensed psychologist and associate professor of clinical pediatrics in the Division of Adolescent Medicine at the Indiana University School of Medicine.
During college, she lost several friends and classmates to suicide, mental health and substance use. This was a major catalyst for her career and solidified her desire to study psychology. During graduate school, she focused on the impact family and caregiver relationships have on children’s mental health and social relationships. As a result, Donahue became increasingly interested in social determinants of health and healthcare access.
Donahue’s clinical care, research and teaching have centered on improving quality of life and healthcare experiences for youth and young adults with special dedication to trans and gender diverse young people and individuals born with differences of sex development.
Focusing on Indiana's future: Suicide awareness and prevention tips
Question: What signs should parents, caregivers, friends, etc. be on the lookout for regarding suicidal ideation?
Kelly Donahue: When it comes to short-term risks and warning signs, it is important to focus on both what a young person is saying and how they are acting.
That includes making statements talking about wanting to kill themselves or making statements like, “I wish I wasn't here,” “Everyone would just be better off without me,” or “I wish I didn't have to deal with XYZ anymore.” All these statements are things that should be taken seriously, no matter what the age of the person is. Another sign is talking about feeling hopeless, feeling trapped or feeling like a burden to others. Additional warning signs include directly looking for ways to harm themselves: searching for pills, stockpiling medications, researching or looking for access to other potentially lethal means of harming themselves.
Also think about things that are out of character for a person. This could include expression or levels of anger, hostility, irritability or agitation that are uncharacteristic, or withdrawing from friends and family or activities that they enjoy. This could also include noticeable changes in hygiene or self-care, sleeping way too much or too little, not wanting to get out of bed, changes in appetite, neglecting their appearance or increased alcohol or other drug use. Giving away belongings or saying goodbye to other people could also be a clear and important warning behavior to look out for.
Q: What are the warning signs that adults are most likely to overlook?
Donahue: Emotions outside of sadness or depressed mood are often overlooked. People tend to associate suicide risk only with those types of emotional expressions. Emotions like anger, anxiety, heightened stress and irritability can be big warning signs that we do not always connect to risk of suicide in our minds. There are also things that adults might not overlook but might not take seriously, like expressions of desire to not be around or feel like a burden. It is easy for adults to often chalk things up to young people being overdramatic, for example, or just wanting attention. And it is important that those types of statements or behaviors really be acknowledged and taken seriously.
Q: How can parents tell the difference between typical teenage emotional difficulties and symptoms that warrant professional help?
Donahue: It is not always easy. Mood swings, emotional difficulties, low mood, being irritable and heightened stress are all things that are common for teenagers. What we often think about as professionals trying to differentiate this is duration, severity and functional impairment. How long does something last? How much is it getting in the way of someone being able to do their day-to-day activities? Professional help is warranted when symptoms are severe, when they are getting in the way of getting to school, getting schoolwork done, interacting with family or other social relationships.
Q: What role do anxiety, depression, trauma, bullying or substance use play in suicide risk among youth?
Donahue: We know that most youth who die by suicide have some sort of pre-existing mental health disorder. Every mental health disorder is a risk factor in some form. For youth, the mental health symptoms and disorders that have particularly strong risks are persistent depression, PTSD, panic disorder and more generalized anxiety. History of self-harm or suicide attempts are also a long-term risk factor.
Particularly for adolescents, interpersonal stressors can be a precipitating factor. That includes experiences like bullying and cyber bullying, for both the victim and the perpetrator. Peer conflicts or breakups, major academic stressors or perceived failures and exposure to suicide of peers are other interpersonal risk factors.
LGBTQ identity for young people can be a risk, especially when it coincides with bullying or mistreatment by peers or family. Across the country, the social and political climate is making it hard for young LGBTQ people, particularly trans and gender diverse young people, to really live safe and authentic lives. We see the effects of that regularly in our adolescent medicine clinic. In general, major identity-based stressors, experiences that are rooted in discrimination or mistreatment, or marginalization related to race or ethnicity or socioeconomic status, among others, also increase a young person’s vulnerability to suicide. It’s the cumulative impact of experiencing marginalization.
Q: Indiana continues to face significant youth suicide concerns. From your perspective, what is driving this problem?
Donahue: In Indiana, we have a particularly big problem with access to mental health care and a shortage of mental health providers. There is some alarming data from HRSA that looks at the supply of all types of healthcare providers, including psychologists, versus the demand across the country. Indiana is sitting at 54% adequacy in terms of the supply over the demand for psychology services. Those numbers are even worse when we look at access to child and adolescent psychiatrists in Indiana. HRSA also makes workforce projections, and those numbers are expected to get even worse over the next decade, unfortunately.
Q: Are there misconceptions about youth suicide that you wish parents and educators understood better?
Donahue: One misconception is that asking or talking about suicide plants the idea. We have robust evidence that screening for suicidal thoughts or behaviors and talking or asking about these things does not induce suicidal thoughts for people, including children. We cannot prevent it if we do not ask or talk about it.
Another misconception would be that suicide is just a teen issue. Younger kids and preteens think about, plan and die by suicide. Restricting access to lethal means like firearms, medications or other substances, knives, ropes and other ligatures can be helpful for keeping kids safe. This means limiting or eliminating an at-risk person's access to the methods that might be most likely to be used or to be fatal in a suicidal crisis.
Q: If a caregiver reading this is worried about their child, what would you want them to do first?
Donahue: Talk to their kids. Ask directly and take any statement seriously — asking does not increase risk. When they share their thoughts and their feelings with you, as a parent, it's important to respond in a way that will encourage them to continue to share these thoughts and feelings with you in the future, even if they change.
It can be a stressful and difficult experience to have a conversation like this with your child, but you really want to thank them for sharing with you and being open. I often hear from kids and teenagers that they are afraid to talk to their parents about these things because they do not want to stress their parents out. They do not want to make them angry.
Try to be the parent whose kid knows they can come to you and that they will be met with openness and curiosity and not judgment or shame.
Q: Are there things families can do at home to reduce a young person's risk?
Donahue: Having supportive and connected relationships with parents and families is an important protective factor, which can include allowing for open communication. It can also be very impactful to help them find ways to build stable friendships and positive role models who may be peers or adults. Also pay attention to their routine and help them develop good, healthy sleep habits.
Parents: — and I am saying this as a parent who lives this every day — we often have this urge to protect our kid from distress. We do not want them to be upset. But we must help them learn that they can do hard things and get through challenging times. They need to develop strategies for handling those situations, and they do that with practice.
Parents can also model prioritizing mental health by making sure that they are getting the support they need themselves. For example, there is good evidence that treating depression in parents can reduce their children's depression symptoms and risk of suicidality.
Q: How should adults respond when a child or teenager says something like, "I don't want to be here anymore"?
Donahue: Take it seriously and respond calmly and directly. Ask about what is going on, and what they mean when they say that. They might tell you that they just had a difficult day at school and they did not want to be at school anymore that day. They might tell you that they have had more serious thoughts about not wanting to be alive anymore. Be curious about what is going on, what brought up those thoughts and what that statement means to your kid. In order to find the right way to help your kid, you need to be curious about what they are experiencing, without making assumptions or rushing to judgment about what is going on.
Q: What gives you hope when you look at the issue of youth suicide in Indiana?
Donahue: For one, a focus on increasing access to mental health services. That includes continued support for maintaining this expanded access we’ve had to telehealth over the past few years. I think that has helped close some care gaps, particularly in more rural locations in Indiana with major access barriers. There are also pediatric mental health access programs that help close those care gaps. For example, through the Department of Psychiatry, there is the Be Happy program. That is meant to provide consultation to community providers about mental health medications, connecting people to mental health and therapeutic interventions.
I also appreciate that we are seeing more non-mental health providers getting comfortable talking about these topics and incorporating it into medical training and continuing education. One example is that the Indiana American Academy of Pediatrics chapter and the Ohio American Academy of Pediatrics chapter have an ongoing quality improvement project called Store It Safe. It’s a training for primary care providers to learn how to support families on safe storage practices for lethal means like firearms or medications.
There are so many passionate people who are working to reduce stigma and advocate for the changes that we need to help prevent losing more young people from death by suicide. That gives me a lot of optimism and hope. Although the mental health crisis has increased, conversations and efforts have also increased compared to what was happening two decades ago.
Donahue’s hope for the next generation
“I think we are collectively better at talking about these things now, but we still have a lot of work to do,” Donahue said. “When kids keep things from their parents, it might be because their parents had a big or bad reaction last time the child shared something with them. Being open and curious to hear about your child's experience, without judgment, is important for parents to work toward.”
With all the emphasis on what parents can do to prevent suicide, Donahue does not want a parent or caregiver to think they failed if they have a child experiencing suicidal ideation or who has died by suicide.
“A lot of wonderful and loving parents have kids who struggle with these things,” said Donahue. “Parents and caregivers play a vital role in their child’s health and well-being. We need to recognize that no one person is responsible when someone experiences suicidal thoughts or behaviors. When a young person is lost to suicide, I think what it really reflects is that society has failed that person and their family in some way.”
