About Our Guest
Dr. Ananda Pandurangi is Director of the Schizophrenia Program and Brain Stimulation Therapy Program, Chairman and Medical Director, Division of Inpatient Psychiatry, and Vice Chair at the Department of Psychiatry at VCU. He received the MBBS degree from JIPMER, Pondicherry, India (1975) and an MD degree in Psychological Medicine (Bangalore University, India, 1978). He completed two residencies in Psychiatry, one at NIMHANS, Bangalore, India, and the second at Upstate Medical Center, Syracuse, New York. He completed a 2-year fellowship in schizophrenia research in the Department of Psychiatry at Columbia University in New York (1984) and is board certified in Psychiatry. His interests and work are in understanding the relation between brain and behavior in serious mental illness, medications for psychiatric disorders, and brain stimulation therapies. His work is also concerned with developing collaborations between public mental health and academic psychiatry. He is a Distinguished Fellow of the American Psychiatric Association, and member of a number of other professional psychiatric societies, community organizations and mental health boards and advocacy groups. He currently serves as chair of the State Board of Behavior Health and Developmental Services, and is on the Governor’s Task Force on Improving Mental Health Services and Crisis Response.
Jan Paynter: Hello. I’m Jan Paynter and I want to welcome you once again to our program Politics Matters. We are honored to welcome back to the program Dr. Ananda Pandurangi, Professor of Psychiatry at Virginia Commonwealth University in Richmond. Welcome again, doctor.
Dr. Ananda Pandurangi: Thank you, Jan. I appreciate the invitation to come back and the chance to have a dialogue with you on this topic.
Jan Paynter: Dr. Ananda Pandurangi is Director of the Schizophrenia Program and Brain Stimulation Therapy Program, Chairman and Medical Director, Division of Inpatient Psychiatry and Vice Chair of the Department of Psychiatry at VCU. Dr. Pandurangi received an MBBS degree from JIPMER, Pondicherry, India in 1975 and an MD degree in Psychological Medicine at Bangalore University, India, in 1978.
Among other things his work is concerned with developing collaborations between public, mental health and academic psychiatry. He currently serves as Chair of the State Board of Behavior Health and Developmental Services and is on the Governor’s Task Force on Improving Mental Health Services and Crisis Response. Thank you again, doctor.
Dr. Ananda Pandurangi: Sure, my pleasure.
Jan Paynter: I wanted to take the opportunity today to talk specifically about the issue of youth suicide, something we did not have time to explore last time, although we of course referenced the tragic circumstances surrounding the death of State Senator Creigh Deed’s son Gus and the state mental health legislation which was recently signed into law as a result, activating extended custodial waiting periods and mandating a bed of last resort. To begin with, doctor, according to an assessment done by the State of Virginia in 2010, Virginia had 11.6 suicides per 100,000 people. In 2012 for example, 1,056 individuals committed suicide. What percentage, doctor, approximately, of that number relates to suicide in youth, that is young people between the ages of 10 and 24?
Dr. Ananda Pandurangi: Okay, good question. The death of Senator Creigh Deed’s son is tragic and unfortunate. As they say, that there is a silver lining. What it is in this case is that it’s gotten us all to talk, to dialogue, to become a lot more aware of the scope and extent of this problem. So certainly we all hope that something good will come out of this tragedy and some of it has already started to come as in the changes in the law that you referenced. The medical examiner most recently put out the 2012 statistics for suicides. They collect statistics on an ongoing basis and annually put out a report and the rate you quoted is in fact what is in the medical examiner’s report for the entire population in Virginia. So teenagers, especially those between 16 and 19 years of age, and what may be called as the young adults, the youth population, which is approximately 19 to 23 or 24 years of age, these two groups are especially vulnerable to higher rates of suicide and compared to the average rate of about 12, 11 and a half to 12, the rates in this population tend to be more in the range of 18 to 25 per 100,000. That is one and a half to two times higher than the average rate. So they are a very vulnerable population.
Jan Paynter: Walk us through, doctor, if you would, for those of us unfamiliar with this, some of the suicide warning signs.
Dr. Ananda Pandurangi: Yes. So suicide is the culmination of a process that probably has begun long time before that and therefore there are behaviors and signs that give us cues or warnings that things are not going well and that there is a risk of suicide. Some of them are factors such as alienation. One is disconnecting oneself from one’s immediate family, maybe from their peer group, maybe from their activities. So these begin to indicate that the person is withdrawing or disconnecting and is not engaged anymore with these groups and that is a very strong sign that maybe there is significant depression, maybe there are other psychological issues, maybe there is some type of psychological trauma and that suicide could be the end of this process. So that’s a warning sign and it’s something that we really need to capture and we need to screen people for these types of behaviors or when we see them we need to screen them, screen the person for depression or for other psychological disorders, we need to screen for substance abuse, and we need to screen for family and related stressors, stresses that maybe going on in the person’s life so that we can prevent the ultimate tragic outcome.
Jan Paynter: I know screening can be a complex issue because there is a stigma in a lot of people’s minds about this and sensitively screening youth I would think would be of paramount importance. What are some of the ways that that can be achieved?
Dr. Ananda Pandurangi: So you bring a good point about screening and what is the most appropriate way and the most successful ways of screening and specific methods of screening. This is a subject that has some stigma. There is shame attached to it. It is a difficult topic to talk about and so it’s not something you can simply approach someone and broach the subject. The first step probably is widespread education. If we take school as an example, educating school teachers, school counselors, parents and of course the teenagers with brochures, with handouts, with classes, with announcements, with discussions, with discussion groups. So the more awareness and more education there is, the greater—the easier is the access for the counselor to access the child or the kid, the teenager and to ask more specific questions. The questions would also have to be broad based in the beginning and look at more like depression and anxiety, psychological stress, psychological trauma before one moves from there to ideas of self-injury and suicide. There are screening instruments, there are screening approaches, there are methods but the bottom line is enormous education.
Jan Paynter: It’s very important. We were talking before we started filming, doctor, that Virginia Department of Health announced that young people average between 100 and 200 attempts per completed suicide and I was thinking, although this is of course very grim relative to adults, there are greater chances to intervene with children and I wondered how is intervention, when there are repeated attempts, typically approached by professionals?
Dr. Ananda Pandurangi: Again, this is a very good point for all of us to be aware, that is completed suicide rates which we all talk about versus attempts. Turns out that people make attempts at self-injury or suicide as many as 10 times or higher than the suicide rates. So the suicide rate is 12, then the attempt rate is 120 or 150, something like that. It’s 12 times as much. And it’s not something people like to talk about. The attempts can vary in the beginning from minor self-injurious behavior, a small lower dose of pills, a cutting of oneself in an area that no one else can see. From there it can advance to more serious overdose, more serious cutting, more serious methods of hurting oneself to completed suicide. And yes, once there is any suspicion that there is those factors or any of the factors that I mentioned, alienation, disconnected, disengagement or actual self-injury behavior, such a kid should get immediate help. If they aren’t already talking with a counselor, they should be. If they aren’t already referred to a physician or a clinician, they should be and depending on the seriousness and the repetitiveness of the behavior as well as the context in which it is happening, what are the factors that are driving this including other psychiatric disorders, which often that is the case, would have to be treated. Treated as an outpatient or sometimes maybe as an inpatient in a hospital.
Jan Paynter: Doctor, in 2008 it had been reported by the Virginia Department of Health that the suicide rate for young males is 4.6 times higher than that of females and yet in 2007 it was noted that suicide rates with girls ages 10 to 19 had spiked. Seven years later, is that still the case and if so, what factors in your judgment were contributing to this?
Dr. Ananda Pandurangi: There are two points that I would make regarding this. First, historically there are more completed suicides in men, in males, than in women but the reverse is true when it comes to attempts. So suicide attempts are three to four times more common in women than in men and there are various social, family, psychological and other factors for why that is the case, why there is the difference. One reason for a spike in the actual rate of suicide amongst teenage girls is some of these differences between the two are diminishing. So girls are coming out as often or as much as men or boys are coming out into whatever field, whether it is force, whether it is social activities, whether it is educational activities, whether it is competitive activities and unfortunately for these substance abuse or alcohol or parties.
Jan Paynter: And stress levels I guess are going up.
Dr. Ananda Pandurangi: Right. So there is some equalizing. There are some good parts to the equalizing but that comes with a price and there is also a bad part to how things get equalized. Bad things get equalized as well so the spike in the suicide rate is probably best in a broader social phenomenon where men and women are doing similar things.
Jan Paynter: Oh, I see. I see.
Dr. Ananda Pandurangi: Now than ever before in the past so there’s all the good side to that but there is also a down side to it.
Jan Paynter: That’s interesting that it correlates with adults. Women are having more—higher rates of heart attacks now as a result of the stress just speaks to what you’re talking about. Let’s talk about streeting for a minute. In your view, is as NAMI suggests, an argument—is there an argument to be made for keeping even high risk youth for suicide in the community and at home if possible? What sort of organizations exist that are helpful and handle this delicate issue? And again, this brings up a key question that I wanted to talk to you about which is levels and appropriateness of care for children and youth. Can we find a balance between community-based care and traditional, residential facilities?
Dr. Ananda Pandurangi: This particular topic as you mentioned has gained a lot of awareness and in recent weeks the whole issue of streeting—the term streeting refers to letting a person who has been TD or temporary detention order out to the street, to the community because of a lack of ready availability of the bed and apparently when the previous Inspector General looked at it, there were 92 such cases in one period of time and some of it is still happening but the goal is to have zero streeting. When a person has been assessed by a clinician to be either a danger to oneself or others or simply not have the ability to care for oneself, such a person should not be “streeted”. Not even one person. So it should be zero. The rate should be zero. A colleague of mine at the task force brought up the issue of myocardial infarction and heart attacks. He said, ‘Can you ever imagine that because of a lack of bed that a person who’s come in with chest pain for heart attack would be told, ‘Oh, we don’t have a bed. We’re going to let you go back home”.’ Never. We would never even think of such a possibility so why is that allowed or why can that be allowed to happen with mental disorder. So it should not happen. Some of those I think are being fixed with the extension of the emergency custody order or the ECO into a plus four type of duration which allows a few more hours to find a bed, the safety net role of the state hospital that the state hospital bed is always available. So hopefully we will—streeting will be a past phenomenon and we will not see it. We certainly hope that will be the case. You raise a bigger and more interesting question I think and which is what is a better environment for a person who is under stress, who is feeling suicidal, who is going through the symptoms and behaviors of a mental disorder. Is it a hospital? Is it communities at one’s own home? There is no simple answer to this. The first and foremost issue is safety. The best environment or the best place is the one that offers the maximum safety. We are talking about a crisis, we are talking about life and death and therefore there is really not much of a room for chance here. So I would have to say that unless we can show that we can create a safe environment for this kid, it is better for the person to be in a hospital, although I would say a community hospital, a hospital within one’s own community, as close to one’s family as possible is better than a hospital 60 miles away. Now having said that, that is a practical solution to today’s situation. I would actually be supportive of endorsing and would like to see strong community programs established where safety is not just at the hospital, where a person can be in what are called as day programs, partial hospital programs, intensive day programs. So these are four, six or eight hours at a time type of programs, there is individual counseling, therapy, there is group therapy, there is activity therapy, there are other peers similar to you that you’re spending time with, you are with clinicians. You may be taking medication, you are under supervision and then you are connected to all of this. Then maybe it’s okay, it is safe to be with family, to be within the community and not necessarily in the hospital.
Jan Paynter: Oh, I see.
Dr. Ananda Pandurangi: So it’s not either/or. It is, can we progress towards that.
Jan Paynter: We have seen certainly and since 2008 when we just speak to what you’re describing, since the recession began, an incredibly high rate of suicide in areas that are depressed economically such as in our state, Southside Virginia versus where the job situation was more acute whereas in Northern Virginia where people are perhaps a bit more economically fortunate, the rate was considerably lower.
Dr. Ananda Pandurangi: Yes, unfortunately in Virginia what I call as the tail of Virginia or the southwest extension part, the counties there unfortunately have much higher psycho-pathology, much higher suicide rates, much higher drug abuse and so on and some of it has to do with poverty and lack of opportunities or limited opportunities and some of it has to do with access to care type of issues. But broadly speaking, yes, we saw and we heard and we treated and we intervened a lot more when the recession was at its peak, when families were suffering. There were more people who were distressed and came in for help. More got hospitalized, more attempted suicide and that clearly what was happening at the parental level was also trickling down to the level of the child and that was also noted in these age groups that we’re talking about.
Jan Paynter: The National Alliance on Mental Illness has a wonderful manual on CITs, Crisis Intervention Teams for kids and young adults. How does a CIT function in attempts to prevent youth suicide?
Dr. Ananda Pandurangi: The CIT idea is an excellent one and I’m very glad that the Governor and the Department of Behavior Health and the Community Service boards in Virginia have taken this up as a big initiative everywhere and the number of CIT teams and the number of officers who are trained is increasing quite a bit. So CIT stands for Crisis Intervention Team and the main focus is to educate police officers, law enforcement officers on signs and symptoms and behaviors of mental illness including and especially depression and psychosis like schizophrenia and crises like suicidality so that when a crisis breaks out, a domestic crisis or a crisis at school or on the street or in a shopping mall or wherever and law enforcement has to intervene, the officer is prepared, he has the necessary knowledge base as to what to look for, how to approach the person, not use excessive force and be able to create—contain—provide a safe environment, contain the damage, contain the chaos, contain the crisis. So that is all the focus of CITs and so community service boards usually put these programs together, they train officers in the signs and symptoms of mental disorders, in the types of crises that mental disorders lead to, how to intervene in these crises and how to sort of not have collateral damage, not have unintended consequences while you are trying to contain a crisis. You end up either shooting or arresting or chaining a person with a mental illness and it only makes things worse for everybody and so are there other ways of intervening and I believe it is working.
Jan Paynter: Do you anticipate that the Affordable Care Act can help make some inroads in protecting kids at risk for suicide?
Dr. Ananda Pandurangi: Yes. Clearly if 350,000 to 400,000 Virginians become eligible and obtain health insurance, they are more likely to seek help, they are more likely to seek help earlier, they are more likely to be compliant with treatments, tests, medications, therapies. They are more likely to come back. So these are all preventive steps. If you know that you have some resource to pay for and especially when we are talking about say suicidality, risks for suicide, all the factors that I mentioned about alienation, disengagement and so on, these we could intervene much, much earlier in this…
Jan Paynter: Which is the key, right?
Dr. Ananda Pandurangi: There is one concept in training and suicide prevention programs, we talk about training the gatekeepers. So the general practitioner, the primary care physician, the family physician is a gatekeeper. The school teacher and the school counselor is a gatekeeper. The law enforcement officer, the first responder, is a gatekeeper and they have what is called as a multiplying effect. So sometimes they’re also called multipliers. So if you teach one person, one school counselor, the effect is widespread and benefits 10 people.
Jan Paynter: Oh, sure. It ramifies throughout the culture.
Dr. Ananda Pandurangi: Right. So there are these gatekeepers who can become multipliers, home health visitors and so on and so by having more health insurance for a larger number of people who then feel sort of reassured that they can go seek this care, we are obviously able to intervene at a much earlier stage, capture the early suicide behaviors, capture the early signals and early warning signs and intervene more effectively than wait for a crisis to erupt.
Jan Paynter: Thank you, doctor, very much for doing this today. It’s so important for people to think about this seriously.
Dr. Ananda Pandurangi: Yes and thank you for doing this program. I think it is a big major public service. I appreciate being asked to participate and contribute my two cents to this. It is a major public health problem, no question about that, and we have to really be very aggressive in addressing this issue.
Jan Paynter: We do, we really do, and not be afraid to discuss it. As I listened to Dr. Pandurangi today, throughout our discussion, what clearly emerges is the importance of integrating, collaborating and coordinating services so as to involve the entire community in solutions for children at risk for suicide. The education of our communities as the doctor discussed is critical to reducing the number of deaths. Looking around and communicating with other communities, other states, seeing what they’re doing, is essential. Committing to this as a societal project must be the goal for the sake of everyone’s future. For our children, as we are all aware, are truly our most cherished resource and each vulnerable life is a gift we dare not waste. To do so is at our peril. Thank you again, doctor, for joining us today. Thank you at home for joining our conversation. If you would like more information concerning this topic that we have been discussing today, we invite you to take a look at our website at politicsmatters.org. We will be posting a number of books, articles and relevant links on many of the issues under discussion today there for you. You will also find an archive of prior Politics Matters broadcasts which you may watch at any time. We are in the process of revamping in the website, as we’re often saying, but we’re getting there, and we’ll be posting extended versions of the interviews online on the new site as well and we’ll shortly be adding much more content. As always, we are very interested in hearing from you with any ideas, questions and concerns for future programs. We encourage you to email us at email@example.com. We are on PBS WVPT on the second and last Sunday of every month at 11:30 am. Thank you again and until next time I’m Jan Paynter and this is Politics Matters.