This episode of Breaking the Silence examines the youth suicide crisis with a focus on Hispanic communities. Dr. Ruby Castilla-Puentes and Dr. Tatiana Falcone discuss cultural stigma, barriers to care, and how depression is often misunderstood or dismissed. They explore the role of social media, trauma, and chronic illness in suicidality, along with Dr. Falcone’s research on biological markers like serotonin and inflammatory proteins. The conversation highlights evidence-based treatments such as CAMS and emphasizes the importance of early intervention, family engagement, and fostering hope for recovery.
Transcript
Dr. Tatiana Falcone (00:01) So will say the whole message is, it's very important, even in your patients who are doing good, to always ask the question. If you don't ask the question about suicide, people are not going to volunteer the answer. And we know that asking the question doesn't impact the risk at all. It's kind of just opening the conversation and giving the people permission to really disclose their issue.
Fatima Reynolds (00:34) Welcome to the APA More Equity series, Breaking the Silence, Addressing Youth Suicide. In this episode, we hear from Dr. Ruby Castilla-Puentes and her guest, Dr. Tatiana Falcone. Dr. Castilla-Puentes is a Colombian psychiatrist now residing in the United States. She is the current president of the American Psychiatric Association's Caucus of Hispanic Psychiatrists and author of several books, including Mental Health for Hispanic Communities, A Guide for Practitioners, and the recently released Saving Olito, Empowering Communities and Building Resilience to Prevent Youth Suicide. She has devoted her career to mentoring pre and post-graduate students and on improving access to and delivery of psychiatric care to bilingual and bicultural communities. She is also the founder of Warmy, a network dedicated to promoting women's mental health. So now, Let's break the silence with Dr. Castilla-Puentes and Dr. Tatiana Falcone.
Dr. Ruby Castilla-Puentes (01:35) This is a real pleasure to be here and to introduce my friend and colleague, Dr. Tatiana Falcone. She's a child psychiatrist at the Cleveland Clinic and she's the vice chair ⁓ of research for the pediatric neuroscience department at Cleveland Clinic Learning College of Medicine of Case Western Recept University. She has been passionate about the topic of prevention and suicidality ⁓ in children and adolescents. And really is something that is not only a topic for the ⁓ Hispanic community, but in general. So it's really my pleasure to be here with her. Welcome, Dr. Falcone.
Dr. Tatiana Falcone (02:21) Thank you so much for the invitation. Yes. I think this is such an important topic. And as we know, in the last five years, it has always been, you know, a major problem, during the COVID pandemic really impacted a lot of our minority communities, especially Hispanics.
Dr. Ruby Castilla-Puentes (02:43) Thank you. To begin, I would like to introduce to the people that they are listening to us. ⁓ To begin, can you share what inspired you to focus your career on child psychiatry and especially in suicide prevention among youth?
Dr. Tatiana Falcone (03:04) Yeah, in child psychiatry, well, as many ⁓ psychiatrists who are international medical graduates, when I came here, I did my residency before in Colombia. And in Colombia, our first year, we do it like in the state hospital, where we see a lot of patients who have been struggling with illnesses for many, many years. And sometimes even with the best of medications, our ability to impact the progress of the illness is so limited. So when I did my first rotation in child psychiatry here, and I, you know, start working with the families and I saw that making an impact at this stage can really change the lives of the people forever, was a don't deal for me. was like, this making an impact early in the stage, you can really have an impact longer term in life. So that's why I decided to focus on child psychiatry. The suicidality, I will say, you know, as a child psychiatrist, right, like is probably one of the most frequent reasons that we see someone and it's very sad, right, that instead of us being able to see the patients when they are just starting to have symptoms of depression or anxiety or OCD, ⁓ the story tends to be more frequent that we end up meeting the parents either on the emergency room or when they're admitted to a hospital. So it can take like six to nine months from the time that someone start having symptoms of depression called attempt to ask for help from their pediatrician, from their primary care provider, go to the emergency room multiple times up to three times for like headaches, stomach aches, and many times they're not even asked about suicidal thoughts. And so that's what it comes that we end up meeting the patient and the family after they have their first suicide attempt. So I felt strongly that that shouldn't be the case, that we have to really improve access and do everything that we can to make sure that we're improving the mental health of our kids early on so they don't end up attempting suicide.
Dr. Ruby Castilla-Puentes (05:44) Very interesting point, Dr. Falcone. And I think that one of the facts that we have is that suicide is the second leading cause of death for youth 10 to 24. What factors do you think that have contributed to this increase, a raise of 52 % in suicide rates over the past two decades? particularly in youth, Hispanic youth, what do you think are those factors, contributed factors?
Dr. Tatiana Falcone (06:16) think ⁓ many issues, like you can start with access to services, right? Like ⁓ even with insurance, when someone is having symptoms of depression and they ask for help, right? Sometimes they're not referred. And even when they're referred, I can tell you, you know, I'll give you an example, like, and actually I can give you ⁓ not just our example, but the general literature example too. someone can, and it's of course different by state, but someone asked for help, the pediatrician decide to refer them. It can take around three months, right? From the time that they asked to really get help. And if you think about like our best evidence-based method is the combination of both medication and therapy, right? And there are really effective therapists therapy for suicide prevention, right? Like DBT, like CAMHS. And for some people, can take up to one year from the time that you refer them to one of these ⁓ evidence-based treatments until they can really get help. And the other issue is under insurance. So even when you have insurance and you refer and they say, ⁓ yeah, let me put you on the waiting list, but you can go private, right? So, but a lot of our communities are working really hard, but it's really hard to be able to afford probably like $800 a month extra because even though you have insurance, most of the, so a lot of the practice like the private practices don't cover insurance, right? So under insurance, a stigma, I think in our community is a big, big reason. It takes a lot. And even when the kid goes to a parent and say, I'm having depression, I'm feeling sad, I don't want to go to school. ⁓ I don't want to do the things that I really used to enjoy before. Then the parent sometimes is like, It's okay, things are gonna get better. Don't worry, right? And ⁓ sometimes they are scared, right? That why is my kid having this? Like, as we know, this is an illness like any other illness, right? So if your kid break their arm, then we'll take them to the orthopedic to get a cast. So if you have depression, you take them to a psychiatrist so we can do something about it, right? ⁓ But I think in our community, stigma is very important. And I have to say that we, Dr. Castilla and I did a study on perception of Hispanics and the role of the learned hopelessness. And why don't you tell us a little bit about that?
Dr. Ruby Castilla-Puentes (09:29) Yes. Do you want that I talk a
Dr. Tatiana Falcone (09:33) Yes, digital conversations.
Dr. Ruby Castilla-Puentes (09:36) Yes, definitely. It's a very good point. You set up the stage for the following questions, but definitely it's a time to talk a little bit about our project. We had an amazing project analyzing digital conversations of Hispanics and non-Hispanics in ⁓ open conversations. And as Dr. Falcone mentioned, are ⁓ differences between the the racial and ethnic groups. And one thing that we identified as Hispanic is that we Hispanic, first of all, we don't believe in depression as a disease and is a major issue ⁓ because we, ⁓ people that we have been dealing with these issue of major depressive disorder, we ⁓ believe and we have been ⁓ studying many years and investigated the biological factors for depression and we truly believe and there are plenty of studies supporting that this is a disease, major depressive disorder. And if we don't educate our community around that, that there is a disease and that there are treatments available, of course there are not ⁓ the possibility to treat these conditions is minimal. So I think that the education is critical for the families and members of the community.
So thank you for calling the research our project here because I think it's important to educate the community about the major depressive disorder and the risk factors that we really know already that to have a major depressive disorder is a risk factor for suicide, to attempt suicide. So it's important to cover that.
Dr. Tatiana Falcone (11:27) And so one of the things that I think was really interesting in that study was that we learned that in Hispanics, there's increased learned hopelessness that sometimes for they feel that there's no treatment that is gonna be effective. So why bother, right? And this was even comparing to why it's...⁓ African Americans and other races. So I thought that was really interesting. And also just going back a little to your earlier question. stigma, hopelessness, social media, I think plays a big factor. Like 10 years ago, someone had an issue at school and then their three, four friends knew it. Today, something happened and the whole school have a text about what happened and how it happened and pictures and video of what happened. So I will say from 10 admissions for suicide ideation or attempts that we have every week, you can hear a story that something happened social media related in at least half of them. So I think as parents, right, and as providers is so important. to educate our patients about the use of social media for the kids, monitoring the social media, blocking some of the sites that we feel are not good, right? And making sure that sometimes when things start using social media and they ⁓ start using Instagram and Facebook and they start like... thinking about like the more friends and follows that I have, the people are gonna like me more. And they start, you know, adding a lot of friends that they don't know. So when people are asking for help or they're posting something that is not positive or they're like, I'm sad, I'm not having a good day. And you have a lot of people who are not really close to you. They might make comments that are bad, like, yes. ⁓ We don't care. Yes, that looks really bad for a teen. That's kind of like a narcissistic injury, right? They feel really bad and those things can also trigger suicidal thoughts. Bullying, right? I will say in teenage, adolescence, Hispanics is very frequent. And we see that, you know, with the acculturation and ⁓ the changes on how they perceive themselves in their new culture. They don't have some of the supports that they used to have before and they feel lonely and that can also impact suicidal thoughts. So hopelessness, stigma, lack of access to services, the history of past trauma and trauma can be emotional, physical, sexual. There's really interesting studies showing that for teenage adolescents, the emotional trauma can be as bad. as the sexual trauma. Actually, in one of our earlier studies, we were able to demonstrate using a blood biomarker that the emotional trauma in youth or suicidal can have the same impact of the brain that the physical trauma. We were looking at a protein, the name of the protein is S100B. That protein is normally inside the brain. And like in some countries like Spain, if you have a head trauma, you go to emergency room and they take a blood sample. If your S100B is elevated, you go to a full ⁓ head trauma protocol, you stay, they do MRI, everything. If your S100B is low, then they observe you for three hours and they send you home. So in our study, we look at kids, at teenagers who ⁓ were suicidal and teenagers who were not suicidal with a lot of different diagnosis like depression, anxiety, psychosis. And we found that if you were suicidal, the levels of these proteins S100B were really elevated. So indicating that the impact of this was as severe as the impact of having like head trauma, right? And we also like, ⁓ having emotional trauma was one of the covariates. And we saw that when someone had emotional trauma, the levels were as high as if you were having physical trauma. sometimes people are like, ⁓ it's just like words, don't worry, things are gonna be okay. Kids who are being bullied need help and support and these have long-term impact on their mental health. So it's very important that we do something about that.
Dr. Ruby Castilla-Puentes (16:38) Very good point, Dr. Falconian. And I have to recognize that you have been one of the pioneers in the study of inflammatory markers for ⁓ Jules, which is a behavior. I really ⁓ admire all of the studies that you have done. Can you please talk a little bit about what we learned about these biological factors? that they can play a role in the suicidality, in the suicidal thoughts and behaviors.
Dr. Tatiana Falcone (17:13) Yeah, so we did several studies, but our last study was an NIMH-funded study looking at inflammatory markers in kids who just attempted suicide. And then we followed these kids for one year. So we had longitudinal data on the kids for one year. One of the things that we know is that in children in tertiary care centers like our hospital, the rate of readmission after a suicide attempt can be around 33%. So it's a very high rate. So 33 % of our sample came back with either reporting suicide ideation or having another suicide attempt. So if the patient came back, we repeated the inflammatory markers. So we look at a lot of different cytokines, interleukin 6, 8, TNF-alpha, S100B, CRP.
We also look at all the different ⁓ scales on like trauma, depression, anxiety, mood. And as I said, so we did a biomarker the day that the patient was admitted to a hospital. Then we repeated the biomarker the day that the patient was discharged from the hospital. And then we follow the patient for one year, like. at one month, three months, six months, nine months, and 12 months. And if the patient was readmitted to a hospital, we repeated the biomarkers. So what we found was, and this is something that we probably heard in a study 20 years ago, right? I think it was from Dr. Kokaruk, that people who were suicidal had low levels of serotonin. So from all the biomarkers, the most significant one, that predicted the risk of readmission for suicide was low levels of serotonin. So that was our most significant one. Like we saw TNF-alpha, interleukin-6 were elevated in people with depression. We saw S100B was elevated in people with like emotional trauma, depression and suicide. But when we did multiple comparisons correction, the most significant biomarker was the low levels of serotonin. And if you think about that, totally kind of like really help us understand the picture of treatment, right? Why is important to treat these patients and why is it important to do a combination of like medication and therapy, right? So the medication, you know, like the selective serotonin inhibitors can help with the mood. but we know that takes some time. So that is the time that we use to send the patient for therapy. I, you know, there's several areas based therapists like CBTSI, DBT and CAMHS. I will say that I'm a little partial to CAMHS because we have been doing CAMHS for the last 10 years and we made it our job. to train a lot of the residents and the fellows on how to use CAMHS. And CAMHS is called the Collaborative Assessment for the Management of Societalty, focus on giving patients reasons to live and also understanding what are the drivers for the suicidal thoughts. So I think as a psychiatrist, I wanted to say, I probably learned CAMHS 10 years ago, probably learned about it. one of the APA meetings and then went after and really dive head on trying to understand CAMHS. And I can say is one of the tools that as a psychiatrist make you feel empowered to be able to help your patients because now not only you're treating their depression, but also you are understanding why they became suicidal and what are the drivers for that suicidality and how to make it better. And you are Ew, you are kind of like using tools from all different therapists, therapy kinds to help the patient make the best of a really hard situation like having the suicidal thoughts.
Dr. Ruby Castilla-Puentes (21:41) Very interesting and you have ⁓ an amazing experience also with patients with chronic conditions like epilepsy and other conditions. you mind to tell a little bit how does intersect with psychiatric risk, including suicide risks?
Dr. Tatiana Falcone (22:02) Yes. So for those with ⁓ chronic illness like epilepsy, the risk of suicide is 20 times higher than the general population. And some of the studies can show in youth with epilepsy, it can take three to six years. So I told you that for someone in the general population can take one year. For kids with epilepsy, the studies show that from the time that they report the symptoms, can take three to six years to be referred to psychiatry. So of course, the longer that the symptoms persist, right, the more likely that the depression gets worse and that people are going to become suicidal. The same happened with things with diabetes. Diabetes, the risk of suicide can be as high as 15 times higher. And there's a correlation with like, the management of the diabetes, like how poor control the patient has. So people who are having a lot of DKAs or their hemoglobin A1c is really high. They'll have definitely more suicide attempts, right? And they have access to really hurt themselves really easily with the insulin. So diabetes is very high, epilepsy is really high, kids with chronic pain is really high. chronic headaches, migraines, right? People who were on accidents and have like residual chronic pain is also really high. So I think one of the things that is very important and we make sure we do this in our CLT, every time that we evaluate anyone with chronic illness, we always ask questions about suicide because we know the risk is very high. we know there's treatment and the treatment can be really helpful.
Dr. Ruby Castilla-Puentes (24:28) youth population, what advice did you have for them?
Dr. Tatiana Falcone (24:33) Yeah, I think it's very important to understand the family and the kid where they are in the moment. Sometimes when we see them, ⁓ I'll tell you experience on like the CL service. When you see them, it's a shock to them, what whatever the news they're getting in the moment. So they might be reluctant to medication, they might be reluctant to the new treatment for whatever illness they're having. And sometimes everybody, they call psychiatry, like, should we call DCFS because ⁓ the children of family services, because these parents are not understanding, right? But, know, I will say, minority families sometimes struggle understanding like the severity of, so I think Hope and compassion is very important. know, giving the same news three times, you know, in different ways and asking questions to make sure that they're understanding so you can, they can really make an informed decision, right? I feel like breaking the stigma is the key using psychoeducation. So if we kind of empower them with the information they need to make the decisions, we take a family who was refusing them, want any treatment. air felt like this was not the best they could do for the kid at the moment to someone who understand the risk that not treating the illness. And, you know, when we said not treating it, it means medication and therapy because therapy has a lot of good tools. And sometimes we even start with therapy, right. And, and then we go to if the patient is better, therapy alone is fine. If not, then we do medication and therapy. But I think to our residents, our fellows, I think the main important job that we all have is teaching the role of psychoeducation because the more that the patient knows about why are they getting depressed, why are they getting suicidal, why is the kid cutting? Like we haven't talked about cutting and cutting is so frequent. I will say 50 % of the kids who are admitted to our inpatient psych unit are caught in. And probably the first time that the parent knew about the cutting is when the kid was in the emergency room and they saw them on like the gown. So it's kind of like a really open eye experience for the parents. So when we are seeing those parents first time in the hospital, they're in shock, right? When we are seeing them like those first three, four times, you know, the parent is in shock as the kid because they didn't know that this could happen and now they have to face what is going to happen after and how we're going to manage it. And I will say that is probably why you and I decided to write our book about suicide prevention, right? Because even though we tell the parents this information many times, they leave and they feel alone. They don't know what to do, right? And so I think I wrote that book for parents because
I felt that even though we do our best to try to explain all the risks, how to manage that stage after the patient leave the hospital, when the kid comes to a house after a suicide attempt, they feel alone and they feel that they don't know what to do. And they end up bringing the kid very soon back to the hospital because they're worried. So having these tools like to understand how to manage it, to make sure that you're looking and looking at all the risks and the risks are specific for every kid. So that's why you tailor the treatment to the kid. But Dr. Castilla, I wanna hear about your book.
Dr. Ruby Castilla-Puentes (28:46) Thank you, Dr. Farconi. It was a recent book, Saving Olito. This is a friendly book for ⁓ readers. Not to talk about suicidality has a big issue, something that happened, it's a big issue, but something that happened to every single family. And you know, Suicide in Jews, ⁓ in children and adolescent ⁓ is an issue that is very common and we don't talk a lot about this. So the book is to talk more in friendly manners of a difficult topic, very hard to talk about, very hard to put on the table ⁓ with families this topic, but we need to talk more about how to prevent, how to detect early risk factors, how to deal with family issues that they can save lives. So it was the motivation. Thank you for ⁓ asking. But you had an amazing book also dedicated to parents that I think that, and families, that is very important as ⁓ we talk more about that and we work more closely with families and the communities. ⁓ What gives you hope? in this work despite all the issues that we have seen about your suicide crisis. What gives you hope in this work?
Dr. Tatiana Falcone (30:25) When you see these patients coming back three years later, they're in college, they're doing great, they are having friends, right? ⁓ They are enjoying their lives. The other day I was in Target and someone stopped me and I almost didn't recognize him. And this was a kid who, an amazing, super intelligent kid who had epilepsy. went through epilepsy surgery and this kid, he was biracial and he was being bullied because being biracial. He was a great basketball player and he dropped his basketball team because the other people were bullying him because he wasn't black and he wasn't white. And so he came to one of the sessions, like we were doing an intervention that we did actually like in the schools and ⁓ he participated and we talk about it. He never reported suicidal thoughts to me in the intervention. ⁓ But I always feel that giving hope is the most important and I try to make sure that everybody leaves your office with hope. So he said to me, I went to the bridge and three in the morning.
And I walk and I stand there and I remember what you said that day. And, and I opened, so there's a great app. It's called the virtual home box from SAMHSA that has a lot of free tools for kids. So he opened and called for help and someone came and pick him up and he was admitted to a hospital, right? He was fine.
And as I said, three years later, I saw him in Target and he was going to college and doing great. And he stopped to remind me of the story. So it gives me hope to see people getting better, to see people continue with their lives, right? Some of them might be able to stop their medication and just take the tools that they learned from therapy forward. Some of them might have to take the medication longer. But I think the fact that we're giving them tools and they're use of them and they're enjoying their lives, that gives me hope.
Dr. Ruby Castilla-Puentes (32:56) Dr. Farcone, it has been really a pleasure talking with you, but for our listeners, whether they are clinicians, community workers, parents, patients, what is one thing that you want them to walk away from today's conversation? What is the take home message for them?
Dr. Tatiana Falcone (33:22) So I will say the whole message is, it's very important, even in your patients who are doing good, to always ask the question. If you don't ask the question about suicide, people are not gonna volunteer the answer, even if they're in the emergency room. And we know that asking the question doesn't impact the risk at all. So asking the question is kind of just opening. the conversation and giving the people permission to really disclose their issue. So that's one. And then two, like, you know, making sure that we're looking at the person as a whole. Right. So when we're talking to them, let's ask them on, you know, how's their school life going? How's their work going? How's the relationship going? Right. When we understand the person as a whole, were able to kind of like also understand what are those drivers that are pushing those suicidal thoughts, right? And I want to hear the same from you, Dr. Castilla. Why would you want the people to take home after this conversation?
Dr. Ruby Castilla-Puentes (34:35) Yeah, think that Dr. Parkani, I think that we both have been ⁓ working together ⁓ very close and with many people around about this suicidality and suicidal risks for ⁓ children. And we know that there is hope. So what my message is for the people that they are dealing with these families that they are dealing with ⁓ background, with history, genetic background of major depressive disorders, that they have high risk for suicide, that there is hope, that there are many ⁓ more with the time we have been discovering more and more things that can help families, but there is hope. There are not alone. There are many people suffering from the same thing, but there are more tools now than before, that they have more resources now than before. And now they are really people that they are dedicating their lives into, like you, that you have been really ⁓ one of our leaders in the Hispanic caucus and the APA, one of the persons that we really, you are a, a role model for many ⁓ young people that they are coming to this country and they are doing ⁓ the ⁓ job to discover more new things to improve quality of life and life of people. So I just want to say that there is hope in the communities. They need to be close together and talk about these things and also to be closer each other because sometimes if you are alone, if you feel alone, this is something that is also a risk factor for this and that.
Dr. Tatiana Falcone (36:40) Okay, I have to end this with something very important in our field. And that is we know that suicide risk is also high in doctors. It's also high in physicians and psychiatrists have doctors like anybody else. And we have close friends, psychiatrists who have died by suicide.
And that's so important, right, to make sure that you know that all your colleagues are also resources and that you're not alone. And in the worst of times, there's something else that we can do to make it better, but asking for help is very important.
Dr. Ruby Castilla-Puentes (37:31) Thank you, Dr. Farconi. Thank you for your thoughts. Thank you for your time with us. And ⁓ please continue doing this amazing job that you are doing in the Cleveland Clinic. We need really more people like you doing what you are doing. Thank you.
Dr. Tatiana Falcone (37:48) Thank you so much for the invitation, this was great.
Fatima Reynolds (37:53) Thank you for joining us on Breaking the Silence, Addressing Youth Suicide. Please visit the Medical Minds podcast homepage at psychiatry.org for more information and a resource document related to this episode. We also invite you to visit psychiatry.org slash more equity, M-O-O-R-E-E-Q-U-I-T-Y for more information on the APA More Equity in Mental Health Initiative. Take care.
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