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In this episode, we are joined by Shivana Naidoo, a child psychiatrist, who shares a poignant reflection on her experiences with some of her most worrisome teenage patients. As she prepares to leave her job, she finds herself running on empty, knowing she won’t be able to say goodbye to the five out of seven teens currently hospitalized for suicide attempts. She reflects on the work she has done with these teens and their families, wondering if she focused on the wrong person, and the challenges of working in a system that doesn’t prioritize parent psychoeducation. Shivana also shares her thoughts on the power of handwritten notes as a token of compassion, and how she crafted goodbye letters to her patients and their parents, imparting wisdom and advice on envisioning a future worth living for. She ends with a heartfelt message for anyone struggling with suicidal thoughts or caring for a loved one who is, encouraging us to make our hearts our home and find a way back to hope.
Shivana Naidoo is a child psychiatrist.
She shares her story and discusses her KevinMD article, “A goodbye note to my suicidal teenagers.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Shivana Naidoo. She’s a child psychiatrist. Her KevinMD article is titled “A goodbye note to my suicidal teenagers.” Shivana, welcome back to the show.
Shivana Naidoo: Thank you so much for having me, Kevin.
Kevin Pho: Now, for those who didn’t listen to our first few episodes together, just briefly recap your story and journey to where you are today.
Shivana Naidoo: Sure. So I’m a board-certified child and adolescent psychiatrist. I’ve been mainly practicing outpatient medicine, outpatient psychiatry, since I finished fellowship. Very recently, kind of as a consequence of writing this blog post, I have decided to switch from outpatient psychiatry to doing partial psychiatric hospitalization, a higher level of care, because I really do want to help with the crisis that we have going on with our increase of suicidal youth.
And reflecting in this blog post, I really thought about, where am I really focusing my attention? Am I focusing my attention in the right place? Instead of placing my attention on patients, should I be placing that on parents? So that’s resulted in me designing my website and my business, Do Better MD, which is a business really focused on creating transformational programs for patients and parents that help empower them to prevent suicide.
I think there is a lot of focus on the fear of increased trends, but I think we can also focus on the resilience and the ability to be protective and preventative, because this is something that, especially with youth suicide, parents can have within their power. If they know what to do and how to do it, they can keep their children safe. So that’s really my mission with Do Better MD. I want my patients and clients that come here to know better and do better, and feel supported in the how of executing that do-better.
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Kevin Pho: So we hear or see newspaper headlines all the time about the crisis of youth suicides and the mental health issues that surround today’s youth. So tell us, what are you seeing on the ground? Tell us some stories, and just tell us what you’re seeing from your world in child psychiatry.
Shivana Naidoo: So I think it depends on the perspective. Given that I’ve worked in the outpatient world for such a long time, and now have shifted to kind of a unique modality of a PHP, which is very rare but I think would be very helpful within the system, I think what I view is what a lot of parents view, which is that our system is really broken and incomplete. And I think there’s tremendous burden beyond psychiatric providers: on primary care providers, on pediatricians, on emergency rooms. It is really an unfair burden that our emergency room clinicians and medical doctors have to deal with every day.
I mean, I’m sure you’ve seen the several New York Times articles about children waiting in the emergency room for weeks, if not a month, to get into inpatient psychiatry. And the thing is, we don’t really have evidence that an inpatient psychiatric hospital prevents suicide. We don’t really have that evidence, but that is where we are at in terms of crisis. Parents, clinicians, and doctors don’t know what to do, right? How do we really help decrease the distress that our children are facing?
We know from the CDC survey that happened, the Youth Risk Behavior Survey of 2021, the first data that came out post-COVID, that 57 percent of our adolescent girls in America are experiencing symptoms of depression. That’s more than half of our teenage girls who are really struggling. And we’re still trying to understand: How does COVID relate to that? How does social media relate to that? How does the lack of mental health care relate to that? All of that and above. But I think it’s really a symbol of the distress our entire society is going through. I think when we look at the children, they come from their parents, they come from society. They’re an example of the overarching distress we are all experiencing, and I think we have to find ways to not just manage that distress but also thrive through it.
So I do think that it is a challenge, and all hands are on deck. But even this morning, I had a conversation with a patient that I’m seeing in the inpatient psychiatric hospital and the PHP. She has made several suicide attempts. She has been cutting. She’s very depressed, with lots of problems going on in the family. She has no outpatient psychiatrist. She’s been hospitalized several times and is now stepping down to my work here. I talked to the PCP, and the PCP is like, “I’ve seen her one time. I don’t know much about her, but this is beyond my scope. Can you help me find someone?” And even our system doesn’t have someone in place to help find someone.
So I really feel we’re all feeling it, from the parent to the child to the primary care doctor to the psychiatrist. In this blog post, most of my high-risk kids were hospitalized. That’s what prompted the writing, because it reflected on my feeling of inability to help these children, right? If I’m doing all this work, and still the kids are being hospitalized. So it is a challenge that we’re all trying our best to work on, and my attempt with Do Better MD, the workshops I have there, are my attempt to really try a different angle outside of the system, to empower parents to know what they need to know to help keep their kids safe.
Kevin Pho: All right, you mentioned your blog post titled “A goodbye note to my suicidal teenagers.” Now tell us, how did this article come together?
Shivana Naidoo: So yeah, I was really getting burned out in outpatient community mental health care. So in my final few days of being in my office, cleaning out my office and reflecting on my last few patients, I thought about, what do I want to share with them? I kind of was in my empty office and thought about writing them a goodbye note. So I wrote notes to the patients I did not get to say goodbye to because they were admitted psychiatrically.
And in that reflection, I came to a realization that’s been on my mind for a while, which is that when I’m with a suicidal child, and I think sometimes parents may not understand this, when a kid is in crisis and they come to me in the clinic setting, or even in the pediatric setting, you’re going to focus on the child. You’re going to spend all of your time really understanding what’s going on for that kid, and the parents, you may not have the time to spend on them, because I only have 20 minutes, and then I have another kid after that that I have to get to, who also is probably in crisis.
So it made me reflect on the amount of time I’ve spent, again and again and again, working on the children and the teens. Maybe I should have spent more time with the kid, but the system makes it really hard to do that. And I’m fortunate that where I work right now, I do have that ability, because I’ve shifted where I’m working. But really the bulk of challenges are in the outpatient world, in the clinic world, and they fall to the ER because of that. But it made me think about how maybe I need to focus on educating parents and empowering parents, and that’s really why I started Do Better MD.
And I also thought about, I had a dream about one of my patients, because I was so worried about her. And the night I had a dream about her, she overdosed on medications that I prescribed, right? Medications are supposed to help her. She downed a bottle of alcohol. You know, 25 to 50 percent of kids who make a suicide attempt also are drinking. So parents, anyone listening, if you have alcohol and a kid who’s depressed, please watch your alcohol, and medical marijuana or recreational marijuana, or nicotine, all that stuff. All of your kids know exactly where that is, and they’re going to go for that. So please keep that tucked away. I think that’s something that we don’t really talk about much, because it’s so pervasive as a coping strategy for adults to use alcohol, but it can be really deadly, especially with medications and a suicide attempt.
So I had a dream about her, and she was in the hospital the next day. And I think it just also speaks to an unspoken truth, which is that we as clinicians, as doctors, we feel our patients. We care for them. So when we’re dealing with suicidal kids, or adults who are in suicidal crisis as well, we also kind of carry on that burden, and that’s why there’s so much burnout in the mental health care world. There’s only so much we can do, and that really was happening with me in the outpatient world, which is why I decided to try a different modality of partial hospitalization.
But I wrote this to really reflect and share with parents that, you know what, I had this dream about this girl saying, “Can you keep me? I have no home.” The other thing to remember, besides the increase of suicide attempts and the risk, is there are protective factors, and one of the strongest protective factors for youth suicide is parent-child connection. The strength of your connection with your child can really be protective against suicide.
So that’s why I ended by saying: Parents, remind your children that your heart can be their home. Even if they feel that they don’t have anywhere else to go, you can keep them safe by letting them know that they’re always connected to you, and that you will do whatever you can to strengthen that connection and that love.
And I think, again, society is really distressed, so when we’re all stressed out, it’s hard to really call upon that love and connection and remind our kids, because we are so mentally busy and distracted and occupied. So I think we’re really experiencing a breakdown of us all caring for each other and us caring for ourselves. And hopefully the CDC survey and the ER crisis that we have with so much suicidal youth is just a call to action, not just for children but for parents and families, to do what they need to do to take care of themselves and come back home to their heart.
Kevin Pho: You’ve mentioned the role of parents several times, so talk more about that. Tell us some of the warning signs parents should be looking out for if their children are potentially harboring thoughts of suicide.
Shivana Naidoo: Absolutely. So the number one thing: If parents hear their child say anything, anything in the realm of suicide, “I don’t want to be here anymore,” “I wish I could escape,” “Life is too hard for me,” don’t ignore it, because there are other words behind that that they may not be telling you. So please do not ignore something you hear and think, “Oh, it’s just a phase,” or, “Oh, it’s just, everyone goes through that.” I think a lot of parents and kids will normalize it. It is not normal to want to be dead. That is not normal, not a part of normal development at all. It might be normal to think about your purpose in life. That is normal, but not to wish to be dead.
So anything in that realm, parents really need to address. Bring it up to, number one, your pediatrician. And number two, if you can’t get to the pediatrician, I would bring it up to the school, because very oftentimes the school is having eyes on your child in many different ways. And schools also have challenges with resources as well, but that would be a much quicker way to get in than to come and see me, because I have a long wait list, as everyone like me has a long wait list. But I would not ignore things you hear.
The other thing I would remember is if you find that your child has made a shift in a way that is very different than them, and that sticks. So if they’ve had any change where the frequency of that change has increased, the intensity of that change has increased, like, let’s say they’re more angry, they’re more angry more often. Frequency has gone up. Intensity: On a scale of 1 to 10, they’re at 9 out of 10 in terms of their anger explosions. More often, if that goes up, if the number of times, the episodes that they have of anger, goes up. And D, if there’s any distress and dysfunction, if the anger explosions cause dysfunctionality.
So the acronym I use is FIND. You can see that on my website, Do Better MD. If that change has happened, with that acronym of FIND, and it’s caused dysfunction, you absolutely need to bring it up to your pediatrician. That dysfunction should be within a period of two weeks or more. Yes, we know adolescents and kids go through phases, but if they go through a phase that causes them to not go to school, to not talk to their friends, to not eat, to not get out of bed, to not want to play piano when they love playing piano, if these kinds of dysfunctionalities emerge, do not wait.
It doesn’t mean that flagging this means you’ll be on a medication. I talk about that a lot on my podcast, Thinking It Through with Dr. Naidoo, as well as my website. We don’t all want to drug up kids. No, we want to make sure your child is safe and is healthy, and there are many other ways to help your child than to give them a pill. But what happens is that when we wait too long, and they have already crossed the threshold to make an attempt, it is really hard to see them in such distress and be waiting for therapy, because therapy takes time. Any change takes time. But recognizing those warning signs, as I just mentioned, is the start of getting the help you need to make that change more possible.
Kevin Pho: What are some things that parents can do to maintain a more supportive environment at home? Because a lot of this, of course, is associated with whatever the environment is at home. Anything that’s not apparently obvious? Any other tips that you can recommend to parents to create that nurturing, supportive environment at home?
Shivana Naidoo: Sure. As our youth get older, they become teenagers, adolescents, which is the bulk of when this stuff happens, really 12 to 17 I’m talking about, they need us less. They seem to need us less, but they don’t. They still need us. So I think what happens is that as parents, we may shift to, “OK, they don’t need me. They’re doing their own thing. Great, let me do my own thing. Finally,” right? Finally have some freedom. Yeah, but I think what we need to do, the recommendation from infancy until forever, is to try to spend five minutes of focused time on your kid. Five minutes with no screen time, no phone, just devoted to being in the presence of your child.
And I think that we think we do that all the time. And that’s why not only is the parent-child connection protective, family dinners are protective. Why? Because that gives you the focused time. I will tell you, I’m not doing that every day with my kids, and my kids are young. It is challenging with the busy world we live in, but that is creating the atmosphere to have that dedicated five-minute space.
So that would be the one tip I would recommend for all parents, whether your kid is in a crisis or not, but definitely if there are concerns for anxiety, depression, anger flaring. Find a space to create a habit of five minutes of nurturing, where you just see your child and remind yourself of how amazing they are, and let yourself soak up all the love that you forgot was really there. Because teenagers also do things to make us really angry. They provoke us. They bring out the worst of us sometimes. So we have to remind ourselves they can also bring out the best of us, if we let ourselves let them in.
Kevin Pho: One of the things on a more macro level is the stigma that surrounds the mental health crisis facing youth, and youth suicide. What are some things as a society that we could do to reduce that stigma?
Shivana Naidoo: Well, I think that’s one of, unfortunately, the benefits of COVID. I think COVID has really opened the window into how we all struggle with anxiety, with paranoia, with stress, and with mood. And I think that the stigma, although it’s still there, I think it has shifted for a lot of youth. I think the youth culture, Gen Z, they’re much more open to talking about what medication they’re taking, what diagnosis, in some ways, I feel, over-identifying with diagnosis. But I think the parent generation, right, the millennials and above, we’re still in a phase of having that stigma.
I think that recognizing that we can all have phases of anxiety, of depression, or of focus, and that phase can come in and come out, is really important. Just because you have “depression” (I’m air-quoting depression) now doesn’t mean you’re going to have it forever. Just because you’re anxious now doesn’t mean you’re going to have it forever. So I try to educate my patients and clients to say, “I don’t have anxiety. I have symptoms of anxiety. This is a phase. We’re going to try to push this phase through.”
So I think that might be helpful, to remember that we all struggle in different ways. It doesn’t necessarily mean we need to label it as such, but that a phase can come and go, and that it can affect us all. With the right amount of stressors and pressures, we can all develop symptoms of anxiety and depression.
Kevin Pho: So as teenagers talk about themselves, about their behavioral health issues, tell us some resources that these teens can perhaps share among their peers that you would recommend.
Shivana Naidoo: So yeah, definitely, if they’re talking to another peer and they have concerns for suicide or for mental health crises, the Lifeline number, 1-800 Lifeline, has now changed to 988. 988 is the new national suicide crisis hotline that anybody can call at any point. It’s really specifically for mental health.
I would make people aware that 988 is not like 911. When you call 911, it locates where you are, no matter who is calling. 988 is based on the phone number. So I am from New York City, but I live in Arizona right now. This is my new home. So my number is my New York City number, so if I call 988 with my 718 number, I’m going to get connected to 988 in New York City, because it’s regional behavioral health. So just to let teenagers and parents be aware of that: If you have been a transplant like me, be aware that no one can really locate you. It’s based on your phone number. But that’s a great resource.
Another resource I like is 741-741. It’s a texting hotline, again, a crisis hotline. You can use this number to text somebody if you feel like you’re in crisis, because sometimes it’s hard to talk. And again, Gen Z, they’re very used to being on their phone and typing very quickly, and you don’t need to do the face-to-face, which I think sometimes can be a little bit intimidating, or using your voice, which is also intimidating. Neither of these two numbers can hospitalize you. Neither of them can just kind of call the ambulance and say, “All right, you’ve got to come here.” There are several steps between them talking to you and the ambulance and police being escalated. So I think they are safer spaces.
The other thing I’d recommend, not really for peers but more for parents, is that sometimes, based on your county, there may be a mobile crisis team, which is a behavioral health team that can come to your home. That is based on your county, so I would look that up and see.
But I would remind peers that they’re trying to support each other, and I wouldn’t want any peer, you know, actually, right now I have a patient whose significant other is psychiatrically hospitalized, and he is so stressed because he’s the main support for his significant other. And I reminded him today, “This is not all on you. Just because you talk to a friend, and they trust you and they tell you these things, there are times where you may need to have another adult help you out, and that’s OK. It doesn’t make you a bad friend.”
It makes me think of that old song “Jumper” by Third Eye Blind, where the singer asks a friend to step back from the ledge, and says he will understand if the friend doesn’t want to speak to him again. And I think that’s where we kind of have to get our peers, our youth, to be at. I think sometimes they feel it’s all on them, it’s their responsibility to hold the secret. It’s not your responsibility to hold their secret. It’s your responsibility to keep your friend safe and alive, and that may mean you have to tell your parents, or you might tell the school, and that’s OK, if your friend will live another day.
Kevin Pho: We’re talking to Shivana Naidoo. She’s a child psychiatrist. Her KevinMD article is titled “A goodbye note to my suicidal teenagers.” Shivana, tell us some of your take-home messages that you want to leave with the KevinMD audience.
Shivana Naidoo: Sure. So my take-home message would be that psychiatrists and mental health professionals are burning out. We’re trying our best, but it is really hard for us too. There’s too much demand, and we need to find a way within the system of care, of medical care and mental care, to help. Emergency staff are stressed out, and pediatricians are stressed out as well. Our primary care clinicians are also stressed with the strain of youth suicide being on the rise. And just because the system is not addressing this doesn’t mean we can’t fix it. We can fix it.
And I do believe one of the areas we need to focus on is parent empowerment. If we can empower our parents with the tools and strategies to keep their children safe, to know when to bring them to the ER versus when to call mobile crisis or 988, to reduce the flood to the ER, and when we can empower our parents to do what they need to do to mitigate suicide risk, by locking up our guns, locking up our pills, and keeping things that really could harm kids when they’re in an impulsive state safe, we can reduce this crisis. It is not all on parents. It is a team effort, but I do believe that parent empowerment for suicide prevention is key. And you can find some of these tools on my website, Do Better MD. You can sign up for some of my workshops, and you can listen to my podcast, Thinking It Through with Dr. Naidoo.
If you are a parent listening in here, I believe in you. I know that you’re scared, and it’s a frightening situation, but there are doctors like me who believe in you, and we can give you the tools that you need so you can sit through the night with your child. And if there are any youth out there, you may believe that all psychiatrists want to do is give you drugs and meds and diagnose you, but we’re not all like that. There are some of us that do want to hear you and support you, and believe that we can help you through this crisis, and get to the other end of that rainbow.
Kevin Pho: Thank you so much for sharing your time and insight. Thanks again for being on the show.
Shivana Naidoo: You’re welcome. Thank you so much, Kevin.
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