Kristen L. Eckstrand, MD, PhD, Medical Director of UPMC LGBTQ+ Health, discusses why LGBTQ+ adolescences and teens are more likely to attempt suicide than their straight peers. She also provides information on the warning signs of suicide and ways you can help an adolescent or teen in need.

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– This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgments when advising their patients. Patients in need of medical care should consult their personal care provider.

– Suicide is the third-leading cause of death among young people, 15- to 24-year-olds, and LGBTQ+ youth are four times more likely to attempt suicide than their straight peers. Hi, I’m Tonia Caruso. Welcome to this UPMC HealthBeat Podcast. We are so pleased to have with us today Dr. Kristen Eckstrand. She is a child and adolescent psychiatrist and the medical director of LGBTQ+ Health at UPMC. Thank you so much for joining us.

– My pleasure.

– Such an important topic, and you’re really an MD, and you have a PhD in neuroscience. How does that play into your work with LGBTQ health?

– It’s a great question. I think first and foremost, you know, when it comes to being a psychiatrist, our No. 1 goal is to try and help people when they’re experiencing a mental health crisis. Our other goal is to try and, you know, help people work on their mental health over time and try and prevent, you know, mental distress from happening. In child and adolescent psychiatry, you know, we have a major focus on suicide. As you mentioned, it’s the third-leading cause of death, and I think the second-leading cause of death in adolescents. So it’s a really important issue, and so there’s certainly, how do we treat it when it happens, but from a neuroscience standpoint, we want to understand, you know, why is it happening? What are the things that are changing the brain that allow people, or, you know, can support people’s resilience from suicidal behaviors? And also, what are the risk factors that can lead into people actually making a suicide attempt? So it’s a multifold approach to trying to kind of understand mental well-being and resilience.

– Right, and so when we look at young people in general, is it where they are in the development of their brain, or is it just the stages of life that they’re going through? You know, there’s always challenges of adolescence that make young people more likely to attempt suicide.

– Yeah, it’s both. I mean, when you think about what teenagers go through, it is a time of rapid development, and it’s rapid development at every level. You know, teenagers start going through puberty. That can have major impacts on their brain development. They’re also spending more time outside of the home — you know, making friends, thinking about their future, becoming their own person. And each one of those things, and the importance it has on a person — who am I going to be, who likes me, what is my, you know, what college am I going to get into, and how am I going to get out of my parents’ house? — you know, all of those things are major issues that have a lot of meaning for teenagers. And each of those things, when they can be problematic, teenagers don’t have the support that they need. You know, they experience adversity in ways that perhaps other people don’t. That can put them on a path toward thinking about suicide and maybe acting on those thoughts.

– So you think about all those challenges young people in general, teenagers, adolescents have, add on top to that the layer of being someone who is LGBTQ+. And what does that do in terms of magnifying all of these things?

– Right, yeah. And that’s a really complex issue, too, again, that hits at every single one of those levels. You know, when we’re thinking about, “What does it mean to be LGBTQ?” a lot of individuals have a sense that they may be part of the community, and adolescence is really a period when they start to talk about it and they start to come out. And that can be a really difficult period in two different ways. One is, it can open people up to a lot of vulnerability because they’re not being accepted or in particular being rejected in terms of experiencing bullying or not experiencing support from their parents or their guardians in terms of affirming their identity, saying, “I accept you and I love you for who you are.” And that can be really difficult, particularly for trans and gender-diverse youth, who may also be seeking out health care. The idea of, you know, going along a developmental path where your body is changing in a way that you don’t want it to change can be extremely distressing. And so, you know, trans and gender-diverse youth have this additional burden of not only having to identify who they are, but trying to figure out how can health care help me change that in the way that feels right for me? So that comes into play, too. And then we have a lot of rules at school around what people can wear, what name they can use, what pronouns they can use, what bathrooms they can use, whether or not they can have a Gay-Straight Alliance. All of those are different factors that can either create an affirming environment where someone grows up feeling like they are meant to be the person that they are and people like them for it, or a rejecting environment, where people feel like they are not worth anything, or they’re not worth anything to other people, particularly people that matter. And that can create a space where people feel like taking their own life.

– So when we talk about risk factors: more mind and body, or more environmental? Like, what would you say to people are some of the greatest risk factors?

– Sure. It’s tough, right? I think one of the things that we’re appreciating more and more in mental health is the role of the environment and the ways in which the environment can change the brain. So if you take the environment away or fix the environment, the pattern in the brain might fix. But sometimes you can’t fix the environment, and we have to focus on the brain.

– Give me an example of fixing the environment and how that changes the brain.

– Yeah, so one of the, you know, some of the more interesting research that has been looked at is in stress and the ways in which we carry stress in our body. And so some studies, you know, and I think we can all identify with what stress does, right? Our heart rate increases, we feel tense, cortisol in our body shifts. And some research has shown that for LGBTQ folks, when they’re in an affirming environment, you know, some of those physiological patterns look like they are less stressed. And stress has an impact on how we think. And I think we can all identify with this as well. When we’re stressed out, we’re more likely to think negatively about ourselves, feel angry towards other people, and over time, it can have a cumulative impact where we might feel depressed or we might feel anxious. And in those moments, we might do things that we wouldn’t otherwise do. And so that’s an example of, you know, for example, if a teenager has to go to school every day and they can’t use the bathroom that they want to use, that aligns with their sense of self, and multiple times a day, they have to do this thing that causes them to feel rejected by society, forces them to be in an uncomfortable space with their peers, you can imagine over the course of doing that for months, that they might feel like this is not worth it, like, this is too much stress on a day-to-day basis. But if you just changed the bathroom sign, or called someone the name they wanted to use, you take that stress away in a way that can actually help people just go through the normal path of development, which as I talked about, is already difficult already for teenagers.

– So if you can’t change that environment, what sort of work can be done on the mind and body?

– Depression is multifactorial. Anxiety is multifactorial. A lot of things go into it, and it can be really tough, ’cause I think for a lot of people, the environment is unfair, and we wish we could change it. But there is a sense, as I mentioned before of, you know, teenagers often ask this question, am I worth it? Do, you know, can I accept myself? So, you know, in the absence of acceptance from other people, we can still work to accept ourselves and love ourselves in ways, and affirm ourselves in our identities. And so some of the work that can be done in the mental health space focuses in, you know, in sort of uncovering, like, you know, where is the barrier internally in terms of, you know, accepting yourself for who you are, and also self-efficacy in terms of solving some of these problems. You know, parents are always different for each person. It’s easy to look at another person’s parents and say, “Well, that person’s parents lets them eat ice cream or does this thing.” But sometimes, your parents aren’t going to do what you want to do. But being able to communicate your feelings and what you want and have conversations, that’s something that’s called self-efficacy, kind of taking your problem-solving into your own hand. And so, sometimes mental health can focus on that, you know, giving people the tools they need to have the conversations to try and help them solve the stressors that are in their environment. And that might be different for every person, but it can certainly help with LGBTQ youth, sort of addressing some of those situations with peers or with parents as well.

– So let’s talk specifically about what are some of the warning signs that parents, that friends, that teachers should be looking out for?

– A lot of teenagers try to seek help before it gets bad. You know, they feel it getting bad, so they say, “Can I go see a counselor? Can I go do this?” You know, listening to teenagers when they want help, getting them, you know, helping them get to see health care providers that can listen to them and support them, that, you know, is a really good preventive sign. Outside of that preventive piece of helping teenagers get support before they become suicidal, some of the risk factors include, you know, isolation, withdrawing from peers, feeling more depressed, and in certain ways of, you know, sleeping more, not being interested in activities, you know, eating less, again, disengagement, those types of things can be, again, that isolation can be a warning sign. Other teenagers may start to engage in self-injurious behaviors, you know, like cutting. That doesn’t always lead to suicide, but it certainly characterizes this person is distressed. And so, again, trying to get people help if they’re having those signs can be really important as well. And I think the third piece, too, is always trying to do a solid assessment of, you know, what’s going on in schools? If people are experiencing, you know, bullying from peers, or if someone is saying, you know, “My parent doesn’t love me,” or, you know, “My parent has said that they don’t believe me that I’m gay,” those types of symptoms, parental rejection, and peer victimization, are two other environmental factors that will always increase risk for suicide.

– I want to talk about all the resources available, but before that, so, you know, if you’re seeing these signs, do you not talk about suicide because you don’t want to plant an idea in someone’s head, or is that the time to go and talk with someone and say, “Hey, I think that you need some help, and we should probably look for some resources”?

– Right. Yeah, I think it’s important to realize that when someone brings up the topic of suicide or you’re concerned about the topic of suicide, talking about it isn’t planting an idea of doing it. It’s actually starting to talk about, how do you manage it so you don’t get to doing it? Talking about it is always important, especially if a teenager brings it up. Not addressing it if it is brought up is sort of pushing away this idea of saying your feelings aren’t important, your experiences aren’t important. That in and of itself is a great example of a rejecting behavior. So when a teenager brings it up, it’s really important to talk about it and address it head-on. Because for a lot of teenagers, again, it’s a time of having different thoughts and new thoughts, and sometimes there may be a thought in a time of stress of, “Things would be better if I weren’t around, things would be better if I were dead.” And to go from one’s entire life with never having that thought, it would surprise me if someone at some point, you know, never, or if someone were to say, “I’ve never had that thought.” And the goal is not to not have the thought. The goal is to know how to handle the thought and to let the thought go and not be distressed about the thought to the point where you’re actually acting on it. And so talking about it is a great way of social engagement, it’s a great way of handling a feeling, it’s a great way of accepting a feeling when it comes up, and so just the act of talking about it and problem-solving around it is a great way to demonstrate how to handle a really difficult thought, and that’s important for teenagers.

– What happens to teenagers’ best friends? They tell each other everything, and one confides in the other, and then what do you want to say to that other young person? Is that a betrayal of their best friend, if they think their friend’s going to hurt themselves and they go tell someone? What should a teen do in that situation?

– It’s a really tough situation for teenagers to be in, where they have to make a decision between, you know, am I going to risk my friendship, or am I going to risk losing my friend? And most teenagers will say, “Well, I’d rather risk the friendship but have this person in the world.” And so, you know, talking to teenagers about what to do in that situation is actually really important, helping them understand that in that moment, that’s kind of the question that they’re approaching. Am I risking a friendship, or am I risking losing a friend? Because a friendship can be repaired. The loss of a friend cannot be repaired. And so helping educate teenagers around if a friend discloses suicidal thoughts, bringing it to the attention of an adult that can act on it, and support it, and address it in the way that’s appropriate is the right thing for a teenager to do. And so that’s a good conversation to have with your teenager, you know, even when they’re in a healthy state of mind. Because they might have a friend that needs that support, too.

– Let’s talk about resources. Locally, we’re rich with them, but also nationally, what do you want to say about, there’s a place for everyone to go and find some help?

– I think locally at UPMC, we have two really important clinical programs. So, we have the Gender and Sexual Development program at UPMC Children’s Hospital, which works with LGBTQ youth, you know, in a variety of different ways to support their healthy development. That center also includes mental health, and so mental health can be included in that healthy development picture. At the Western Psychiatric Hospital of UPMC, we have an LGBTQ intensive outpatient program for individuals who are 18 and older, and that is a really great program for LGBTQ people who are experiencing distress, including suicidality, if their mood is persistently bad, or these thoughts won’t go away, or these thoughts are scaring them. That’s a really great resource and a safe, affirming environment with which to receive mental health care about some of those suicidal thoughts. And I think the third resource we have internally, you know, for anyone who is seeking care at UPMC, we can always be contacted at lgbtqhhealth@upmc.edu if you need connections to a provider, you know, for anything. Or, if you’re working at UPMC and you’re interested in doing a training for your staff but you need some resources, like, what can you give people, so that’s a great resource for us at UPMC. Nationally, particularly around suicide, one of the more — two really, really important hotlines, one is The Trevor Project, which is a suicide hotline for LGBTQ youth. They have ways to communicate via phone or via chat bot, lots of different ways for teens to get support from sort of affirming providers. And there’s also Trans Lifeline, which is a suicide hotline for trans individuals. And the last resource, and always a resource for anyone who is experiencing suicidal thoughts or behaviors is resolve Crisis Services in Allegheny County. And so that’s always a hotline to call if someone needs immediate help in the area.

– So what does the scale of intervention look like when someone does make a call? What’s probably the least intensive to the most intensive intervention?

– Sure. You know, and like I said earlier, you know, sometimes these thoughts are fleeting, right? They come up in moments of stress, and sometimes you just need to get what you’re stressed about, or you just need to take a few seconds to talk to someone to, you know, help that moment pass. So sometimes intervention may just be the talking on the phone, right, or talking to a crisis worker at resolve, and that intervention may be sufficient for the moment. That intervention may involve a connection to care that you didn’t have previously as a resource to follow up on. You know, and the range really runs the gamut. So, you know, if people need a higher level of care but they aren’t going to act on their suicidal thoughts, but they do feel like they need more support, that’s where something like the intensive outpatient program can come in. And then, at a certain point, there may be times where people feel like they are just not safe to be in the environment that they’re in, and if that is the case, that’s when hospitalization at a place like Western Psych or another facility, you know, may be what’s right for the person at that time. And we do a great deal of work on our child and adolescent unit right now working with LGBTQ youth. We have protocols in place to use people’s pronouns, use people’s names. Everyone on the unit is well-equipped to work with parents and address the needs of LGBTQ youth. And so, I think it is important to know that whichever avenue you choose, there are options available to you that can be affirmative.

– Do you feel as there is more awareness and acceptance of LGBTQ+ youth, are you hopeful we will move in a direction where the suicide numbers or attempted suicide numbers aren’t as high?

– You know, I really am hopeful of that. I think it’s going to take a lot of work, because, you know, not only do we need to, you know, we have a lot of people in the world who are affirmative and accepting, and so, you know, even though we have a lot of supportive resources right now, there are a lot of things happening in the world that convey that people are not accepted for who they are, and as long as we have those things, teenagers are really going to feel it.

– As we close, what do you want to say if there is a young person listening to this, about seeking help?

– You know, across the course of your life, you know, seeking help is a normal thing to do, and advocating for your mental health is a really important thing to do. And there are people who are going to listen, and there are people who care. And so not seeking help may feel like the right thing in the moment, and that’s understandable because it’s a scary thing to do, and embarking on that journey is the first step, I think, towards, you know, becoming a person who is able to say, you know, “I’m happy for who I am,” and we really want to be part of that journey if that’s a journey that people want to go on.

– Well, Dr. Kristen Eckstrand, thank you so much for coming in and spending time with us today. Some really good information.

– Thank you so much for having me.

– You’re welcome. I’m Tonia Caruso. Thank you for joining us. This is UPMC HealthBeat.

About UPMC Western Behavioral Health

UPMC Western Psychiatric Hospital is a nationally recognized leader in mental health clinical care, research, and education. It is one of the nation’s foremost university-based psychiatric care facilities through its integration with the Department of Psychiatry of the University of Pittsburgh School of Medicine. UPMC Western Psychiatric is the hub of UPMC Western Behavioral Health, a network of nearly 60 community-based programs providing specialized mental health and addiction care for children, adolescents, adults, and seniors throughout western Pennsylvania.