According to the Centers for Disease Control and Prevention, suicide is the second leading cause of death for adolescents in the U.S. Furthermore, between 2009 and 2019, the number of psychiatric hospitalizations for attempted suicide, suicidal ideation, or self-injury increased from 30.7% in 2009 to 64.2% in 2019.
As a pediatric psychiatrist at NewYork-Presbyterian and Columbia, Samantha Salem, M.D., is acutely aware of the mental health crisis impacting youth. With a particular interest in the study of suicide in children and youth and the effect on their families, Dr. Salem’s research focuses on improvements in treatment for this at-risk population.
There is a stark contrast between general pediatric hospitalizations and psychiatric pediatric admissions, which often involve prolonged separation from family. Studies on the experiences of children and their caregivers during inpatient psychiatric hospitalization are few and far between. These concerns compelled Dr. Salem to undertake a study to better understand what adolescents and their families go through when the hospitalization is for suicidal ideation or behavior.
Below, Dr. Salem discusses her recent study in detail and how the findings can improve psychiatric care for youth in the future.
Exploring the Helpfulness-Harmfulness Paradox
Our motivation for this study was to explore and understand through family stories how we are helping or not helping patients hospitalized with suicidal presentation and their families. Based on their observations, we hoped to identify alternate approaches to ameliorate the potential for poor experiences that can occur during emergency department waiting periods and inpatient hospitalization. At the time I began this work, I was a fellow at Duke University Medical Center and together with a group at University of North Carolina, we analyzed caregiver and patient narratives to better understand their experience.
In our paper, we chose to focus on the helpfulness-harmfulness paradox to explore whether, as clinicians, we are helping our patients or inadvertently worsening the situation. We posed this paradox to patients and caregivers to gain a clearer understanding of what they perceive as beneficial or detrimental.
Study Methods
We identified adolescents 13 to 18 years of age who were hospitalized for suicide-related risk. Nineteen adolescents, 14 of whom were female, were eligible to participate. The mean age of participants was 15.7 years, and the mean length of hospitalization was 13.2 days. Their caregivers had a mean age of 45.7 years. Interviews were held between one and six months following hospital discharge.
Findings and Implications for Care
We compiled the hospital experiences described by adolescents and caregivers into three categories: the admissions process, including their initial experiences in the ED; overall hospitalization experiences; and the similarities between caregiver and adolescent descriptions of emotional valence.
Emergency Department Observations
The emergency room waiting period before admission was an especially traumatic and uncertain time for patients and families. Adolescents largely expressed fear of being separated from their parents, while parents shared that they felt lack of control and apprehension.
One issue raised by both groups involved the wait in an emergency room pending transfer to the inpatient psychiatric unit. Our data indicated that this was a circumstance with which both the adolescents and caregivers struggled the most due to uncertainty about what would ensue.
It is very important to be as open as possible with patients experiencing or disclosing suicidal thoughts and behaviors and to reassure them that they've done the right thing by coming to the hospital. While pediatric and psychiatry teams strive to make the waiting period as manageable as possible, it’s often difficult in the ED environment due to limited space and activity level.
Reflections on Hospitalization
Although some participants felt a sense of relief being away from their day-to-day stressors, inpatient admissions are often accompanied by feelings of isolation; generate concerns over stigma; and pose a disruption in social and family connections. A major concern expressed by the patients was the lack of social interaction. Adolescents wanted to relate to other teens by sharing similar experiences but were told to refrain from doing that during the hospitalization. They described how difficult those restrictions were, and several adolescents described difficult interactions with other patients that may have negatively influenced them. Additionally, parents said they were advised not to share information with other parents because of privacy considerations.
Our recommendations include considering how to facilitate social connections and a sense of belonging during hospitalization without being detrimental to adolescents and their families. Inpatient care presents an opportunity to include parents or caregivers in the treatment process with the goal of rebuilding connectedness during and after hospitalization.
Also, we need to do more on the outpatient side, either through intensive treatments or by providing more support for the families, who can feel very isolated. Once the crisis has passed, they can remain fearful when their child returns home. Their concerns include what happens during and after hospitalization; what happens when their child goes back to school; and what to do if a crisis occurs. We need to provide resources for caregivers to create a stable environment following hospitalization.
Focusing on Staff Well-Being
It is vital to emphasize the importance of staff well-being. We can't do our jobs if we are not well, and we can't support families if we're not feeling supported ourselves. This is particularly apparent in the inpatient unit, where staff can face many challenging and even violent situations. There is a quote by Dr. Rachel Naomi Remen, one of the earliest pioneers of integrative medicine and relationship-centered care, that I share with my trainees to underscore the importance of staff well-being: “The expectation that we can be immersed in suffering and loss daily and not be touched by it, is as unrealistic as expecting to be able to walk through water without getting wet.”
Improving Patient Experiences
The implications of our exploratory study may guide future strategies that help families navigate the challenges of ongoing care for a child with suicidal ideation and behavior beyond crisis stabilization. Our study supports the need for more comprehensive, trauma-informed care that prioritizes the social and family needs of patients, as well as increased resources and support for patients, families, and the healthcare workforce.
