Saturday, March 21, 2015

The Tragedy of Palo Alto

Sorry for the long absence. I'm going to try to shake off the winter doldrums and resume blogging semi-regularly.

Palo Alto, CA (est. 2013 population: 66,642) is one of the wealthiest cities in America, with nationally-ranked public high schools, quiet tree-lined streets, and exceedingly low crime rates. Since 2000, the city has averaged about 1 murder per year. Sadly, that number has been dwarfed by the number of Palo Alto teens committing suicide every year.

In 2009, Palo Alto gained national notoriety when a cluster of suicides occurred amongst students at Henry Gunn High School. The attention-grabbing nature of the suicides (most occurred by jumping in front of an oncoming train) and the relative ease of access to the suicide method likely contributed to subsequent suicides. The national youth suicide rate is about 10 per 100,000 per year, so any suicide in a district that has several thousand high school students is a cause for concern. Multiple suicides in such a short span of time understandably led to alarm.

At the 2011 AACAP meeting in Toronto, I attended the session Teaching the Community in Times of Crisis: Responding to Teen Suicide. The main speaker (Madeline Gould, MPH, PhD) was very informative and presented a wealth of research-based data emphasizing how suicides can cluster and spread, while media reports on the suicides can either help or hurt the situation. Dr. Shashank Joshi, a psychiatrist at Stanford, discussed the school-based suicide prevention program that Stanford helped the Palo Alto school district put in place after the suicides. The program has similarities to public health approaches designed to combat disease outbreaks: There are efforts to decrease stigma, provide education about depression how it can lead to suicide with emphasis on the effectiveness of available treatments, train teachers and parents to recognize signs of depression, teach coping skills, and identify vulnerable teens through screening and then making appropriate referrals. From what I gather, this program is still in place, and Dr. Joshi just published an article titled School-Based Suicide Prevention: Content, Process, and the Role of Trusted Adults and Peers, with one of the key points being: "Prevention efforts must focus on school-based mental health education and promotion."

What was not addressed at the AACAP session was what may have been happening at the community level that was triggering the suicides in the first place. Given the relative rarity of suicides, it is hard to prove what causes each suicide or how effective current school-based prevention methods are. Unfortunately, what we do know is that suicides amongst Palo Alto students are still occurring, with another one earlier this month, bringing the total to 3 for the year.

In this past week, Palo Alto Weekly has published two opinion pieces, one by Palo Alto psychiatrist and parent Dr. Adam Strassberg, the other by pediatricians from the Palo Alto Medical Foundation. Both are worth reading in full, because in my opinion they make a valiant attempt to get to the root of the problem. Neither one mentioned anything about screening for depression or increasing access to mental health care. Dr. Strassberg emphasized the pressure that parents place upon their children to succeed:
We are so many of us wealthy and secure beyond imagining, and yet we have such enormous anxiety. We fear the future harm that we will lose our wealth and privilege and be unable to pass it on to our future generations. Maintaining and advancing insidiously high educational standards in our children is a way to soothe this anxiety.

But it harms our children.
The pediatricians make a similar point:
While we are not education specialists, as pediatricians we do recognize dangerously unhealthy lifestyle patterns and habits that are known to exacerbate stress, anxiety, depression and physical illness. These include chronic sleep deprivation, lack of unscheduled time for thought and relaxation, unhealthy eating habits, lack of exercise and unrealistic pressures (real or perceived) to achieve. Those unrealistic pressures include excessive homework, overly ambitious course loads and a seeming demand for perfection in grades, sports and extracurricular activities.

We see these problems day after day in our teen patients. We believe there are specific factors that could be targeted for change.

Sleep: Surveys have shown that Palo Alto teens sleep an average of 6.5 hours per night. Studies have shown that teens need 9 hours of sleep to function at their best. […]
Six-and-a-half hours of sleep, average. So for every teen sleeping 8 hours a night, there's one who's only getting 5. I know that I feel grumpy and foggy even with 7 hours, so it's hard for me to imagine what these teens are going through. I'm not saying that the school-based mental health programs are useless, but it's clear as day to me that they do not go far enough up the chain of causality to address the most important factors leading to all of these adolescent suicides. And it's not just Palo Alto, but achievement-driven communities everywhere, that have this problem. Hopefully, more professionals will start engaging families in a discussion of these root causes, rather than only trying to treat surface symptoms.