As he talked, more children were waiting at the hospital’s Psychiatric Emergency Services, six floors below. The PES (pronounced Pez) is the first stop when children and adolescents come to Western Psych’s emergency department after passing through security and handing over their phones and bags. To fill out forms, they have to use soft, bendable plastic pens, so they can’t harm themselves or others. (For the same reason, the bathrooms’ metal toilets have nondetachable seats.) TVs play cartoons, cooking shows, Hallmark movies. The only available phone is attached to the wall. Patients often spend hours in one of two pediatric waiting areas, sometimes wearing hospital gowns after having been transferred from another medical center. They sit in the blue-and-orange plastic chairs around a table with board games or in leather chairs that fold out to become single beds. Some patients stay overnight — or several nights — when Bender’s unit cannot accommodate them.
Psychiatrists at PES interview children and their parents (or other caregivers) separately, to figure out if the patients needs to be admitted or if a referral for outpatient care, which can include crisis services, will be enough. Most teenagers who experience suicidal thoughts don’t need to be hospitalized and most don’t kill themselves (about 2,800 did in 2021). Psychiatrists have to weigh the possible protective factor of admitting a child against the reality of limited beds and the fact that hospitalization can make anxiety worse, which can drive adolescents away from mental health care altogether.
Medical professionals use the word “suicidality” to refer to a range of thoughts and actions, from passive death wishes, like the desire to go to bed and not wake up, to more active thoughts and, at the most extreme, suicide attempts and death. Though we know a lot about some causes of suicidality — mood disorders, child abuse, substance use — experts don’t understand why the numbers have been rising, on the whole, over the last decade. Some blame social media, which can both deprive children of sleep — the lack of which is associated with increased suicidal thoughts — and increase loneliness and feelings of being left out (even as it offers helpful communities for children, especially those who feel marginalized). Since 2020, the pandemic has likely been another factor.
Systemic conditions can also fuel anxiety, anger, dread and, in turn, suicidal thoughts and actions among particular groups — Black children facing trauma and persistent racism, for example, or trans children forced to use the wrong bathroom for them at school and made to feel ostracized, unseen and alone. Rates of suicidality in both populations have increased in recent years. “Ignore the social and family context at your peril,” says Brent, who has tracked the rise in adolescent suicide for years.
“It’s hard to be in this field,” he says, “and watch things getting worse.”
Salena Binnig spends most of her working hours trying to help teenagers feel understood and well enough that they don’t try to hurt or kill themselves. She is one of 10 therapists at U.P.M.C.’s STAR Center, which was co-founded by Brent 37 years ago. Patients arrive there via various routes, including a referral from a therapist, a psychiatrist or Western Psych. Parents, too, call STAR (which stands for Services for Teens at Risk) to make intake appointments for their children.
