Ketamine, a Break-through Treatment for Depression?

Over the last couple days the news has been exploding with a new ‘miracle medication’ for depression. There has been a lot of attention given to this new medication, more-so than probably any other treatment for depression in recent times. So, what it is? How is it different? And what do I need to know?

What is it?

Ketamine is a medication that has been largely used as a potent anesthetic, it has also been abused as a street drug due to potential dissociative properties. Ketamine has been used off-label for some time to acutely treat depression, particularly suicidal thoughts.

Spravato is a medication closely related to Ketamine that has been approved for treatment resistant depression in the form of a nasal spray.

Why is it different?

Traditional treatment for depression has been based on the theory that depressive symptoms are a result of an imbalance of neurotransmitters serotonin, norepinephrine, dopamine, or a combination of the three. Many people don’t respond or have limited response to traditional medications for depression. Even if a person does respond to these medications it typically takes several weeks for any effect to be noticed. Our neurotransmission (the way neurons communicate with each other) is basically like one giant game of mouse trap, this lever makes that marble drop, which lowers that ramp, which makes that basket drop and catches the mouse (p.s. if anyone has successfully set up this game please let me know, three degrees and this is still an impossible task for me). It’s similar to how the neuronal transmission in our bodies work, a medication might lead to an increase in serotonin, and a higher level of serotonin leads to further downstream effects. The theory of why ketamine and ketamine-like medications work for depression and why they work so rapidly is that they immediately target what traditional medications only effect indirectly (hence the immediate vs. delayed onset of effect). In short, theoretically this new treatment basically cuts out the “middle-man.”

What do I need to know?

  • Ketamine and Spavato certainly have demonstrable and rapid effect on depression and suicidal thoughts, however there is still more we need to learn about long-term effects. A concern with Ketamine is abuse potential because it does have dissociative properties, hence why it is used as the street drug “Special K.” It has also been theorized that there is additional effect on receptors similar to those targeted by opioids.
  • You have to be under the direct supervision of a healthcare provider to receive the medication. The nasal spray is not something you can bring home. You can physically administer the medication yourself, but it must be directly supervised by the healthcare provider.
  • Not every provider can prescribe/administer this medication. The clinic/healthcare site must get certified to use and administer this medication, each patient also has to enroll in this specified program.
  • There must be a history of not responding to traditional treatments. Because this treatment is indicated for ‘Treatment resistant depression’ this cannot be the first go-to. A person must have tried and not responded to a minimum of two previous anti-depressants.
  • It’s not used as a sole treatment. The nasal spray is intended to be used in conjunction with an oral anti-depressant.
  • The risks of this treatment include sedation, ‘feeling intoxicated,’ disassociation, abuse/dependence, sedation, vertigo, suicidal ideation, among others.

Psychiatry, like all areas of medicine is continuously evolving and treatment is becoming more sophisticated, it’s a continual learning process for patients and providers alike. This is certainly a treatment with promise, and has the potential for great benefit for individuals with severe depression, but as with any other novel treatment long-term effects/benefit still have room for assessment.

You Can’t Sit With Us. What the Mean Girl Effect has on Mass Shootings

“You Can’t Sit With Us!”

The recent tragedy in Thousand Oaks has invoked a heated and polarizing debate about gun control, even within my own family. I have people that I love and value dearly on both sides of the political spectrum, they are all good people, they’re all intelligent, they all essentially want the same thing: protection and safety for their families and themselves. The difference is in ideologies of how to get there.

I was having a conversation with my dad about the matter, and a trait he has (that I like to think I inherited to some degree) is really being able to see a disagreement from multiple vantage points. We got into the same impassioned conversation that I’m sure millions of people were having across the country: what role gun control and what role mental health treatment plays in stopping these senseless massacres. Our conclusion came to an agreement mirroring the nature vs. nurture question, and the answer being that “it’s both.”

He asked me a poignant question after we agreed on this, asking about what the root of the problem was. I came to a very simple conclusion:

We need to stop being horrible to each other.

I’ll stop a subset of people right here who will say “People need to stop being such damn snowflakes” or something of the sort. This is not one dimensional in that the “mean girls” have sole responsibility for every violent action that happens. A huge part is also being able to accept that others have differing opinions, views, and beliefs from us, and that’s okay. We also need to be able to accept criticism and accept that we are not the entity the world revolves around, and that we are all capable of fault.

I’ve talked about “internet autism” in previous posts, but it is applicable here too. On whatever platform, may it be Twitter, Instagram, SnapChat, Facebook, whatever, you will likely find a plethora of comments: You’re ugly. You’re a bitch. Go kill yourself. Slut. Drink bleach. You’re a waste of space. Everyone hates you. Your mom should have gotten an abortion. …. etc…etc…etc….

My point is not to say that people saying mean things to a person in some way excuses or justifies a person committing a horrible crime. My point is rather that we, as a culture, have fostered and fertilized an environment (in many areas/ in many people) of anger, hate, exclusion, and intolerance. My point is that yes, we need to figure out some common sense gun laws that at the same time protect the second amendment, but also ensure people who purchase/own firearms are competent to do so. Another piece is mental health treatment and eliminating the obstacles people face in seeking treatment (I’ve had patients come in for initial evaluations [especially kids/adolescents] that have been waiting weeks/months to be seen). This really is only the tip of the iceberg, in that by the time most people are sitting on the couch in my office they have been struggling with whatever issue it is for a long time…it has now just gotten to the point where it is unmanageable and they are at such a point of distress they are willing to get help.

Psychiatric treatment is no different from any other medical specialty whether it be family medicine, oncology, neurology, etc. in that preventative care, or early treatment are going to have the best outcomes.

But why is there such an influx in the need for this treatment? There is no easy answer for this, but it goes back to a few key factors: from an early age we need to be teaching and learning emotional intelligence and distress tolerance, learning how to deal with failures, adversities, and unmet expectations (the snowflake argument), while also not subjecting each other to mental torture. It’s easy to say that millennials are being overly sensitive on the surface, but this really is the first generation that has been exposed to 24/7 notifications from their classmates and peers, often receiving sentiments similar to those mentioned earlier.

There have been numerous studies showing the effect negative experiences such as insulting/negative talk have in comparison to positive talk. This has been shown on many things from plants to pitchers of water and the outcomes are pretty astounding. It makes sense if a person is told something enough, odds are they are going to believe it.

Sometimes all it takes to change someone’s life is a smile or a kind word. If you’re not able to do that, at a minimum don’t be a jerk. More often than not if someone has a need to put others down it’s likely because of some insecurities/perceived inadequacies, or unresolved emotional issues the perpetrator is experiencing.

The truth is we can have great gun control laws, we can even have great mental health care, and these things will likely make a difference, but the reality is we’re not going to get very far without kindness and compassion for each other.

Recently when the Dali Lama was speaking at UCSD he was asked how he dealt with difficult people or was abe to continue expressing compassion for them. His answer was simple but remarkable, “I think of them as my fellow human being.” He went on to describe what an amazing thing it is that out of all times we could be living, out of all the matter we could be, as humans we’re sharing this planet as the same beings, and that as humans, largely, we all have the same objective and are just trying to get through our day, rarely are we meaning intentional harm to another person. As different as our life circumstances may be, we have this in common: we’re all human beings just trying to live our lives. So he said in unpleasant situations he reminds himself to think of the other person as “my fellow human being.”

It’s something that seems so rudimentary, but it really can be profound. I found myself in a day of the grumpies driving home from work in gridlock and saw a car going around and cutting in front of dozens of other cars all patiently waiting to move down the freeway. My mom was sitting next to me in the passenger seat and watching this happen, and I let her know what a jerk i thought the guy was for purposefully using an exit lane to cut in front of dozens of people in traffic.

Later that night talking with her I reflected on how bad I felt about getting so frustrated. I thought about it and realized how I had no idea what was going on in that person’s day. Maybe his wife was giving birth to their first child unexpectedly and he was trying to get to the hospital, maybe he just got laid off from a job he loved and his family was depending on him to provide with, maybe his best friend just got served divorce papers and he needs to go talk him off the so to speak, ledge, we just don’t know.

In psychology there is something called Maslow’s Hierarchy of Needs. This model tells us that love and belonging are some of the most basic needs a person has aside from food, clothing, and shelter. Whenever a violent act occurs it comes into question if the person was mentally ill. When most people think of this it’s in terms of whether the person was psychotic or not. However that’s not the case. No one who can go into a school, bar, movie theater, etc. and murder innocent people can be mentally healthy. They may have the capacity to understand what they are doing, or be in touch with reality but there is clearly something wrong with the individual’s thought process, impulse control, and/or other executive functioning. This goes back to the importance of early intervention in mental health, to identify, assess, and treat this.

This is clearly a complicated, emotional, and political issue with no easy answers. I think the solution is a combination of common sense gun regulations, better access to mental health treatment, but also starting to just be nice to each other.

I have many patients who participated in the school walk-outs following the Thousand Oaks shooting, and I think this made a powerful statement. However, my challenge to any kiddo who participated in these walkouts, to any adult who has participated in the debate on gun control or mental health treatment to just actively engage in the simple act of being kind to each other. Think about what you say or type, insulting or berating another person accomplishes absolutely nothing, being kind on the other hand can change the whole dynamic of our culture.

Body Positivity: What it is, What it isn’t, and How to Get There

Over the last few years body positivity is something that has been getting a lot of attention. Supporters of this movement have the stance that this helps improve a person’s self esteem and overall wellbeing, and reducing judgment. However there is also the thought that this puts people in danger of ignoring larger health problems. So who’s right? Both, well, kind of.

When I explain body positivity to patients I describe it as loving and accepting yourself for where you are currently at. This doesn’t mean you get to put blinders on and ignore any health issues you are experiencing. It is rather that accepting of you where you are at. Feeling guilt, shame, or anger towards yourself certainly will not resolve these issues. Let’s take a step back and look at our body in a different way. Imagine your body as a car. Let’s say for whatever reason, you hate this car. If you have negative feelings towards it it probably won’t be a priority to take it to the car wash, you may not care that there’s trash strewn about, it might be easy to ignore that maintenance light. What happens? The car further deteriorates. Now imagine your dream car. Do you treat it the same way? Probably not. You probably will ensure maintenance is kept up, take it through a car wash, maybe even put premium fuel in it.

We cannot take care of something we don’t value, and our bodies are no exception to this.

Valuing ourselves means valuing our bodies and this is something we need to start prioritizing in childhood. I got started thinking about this earlier this month when I was getting a massage. Ok, so the best way I can describe this message was an hour of being pinched, tickled, and poked. It was awful. I hate to admit this, but it took me a lot longer than it should have to speak up. While laying on the table I remembered having the thought “Why am I not saying something? This is in no way enjoyable. You are paying for this come on.” I realized how ridiculous it was for me to be valuing the feelings of a person (who I was paying to perform a specific service) over being uncomfortable with something that was happening to my body. We need to start instilling this from a very young age; if your child does not want to hug a friend/relative/whoever he/she does not have to! When we force or pressure our kids into things like this it starts a thought process that your body is not as valuable as someone else’s feelings/wants/needs.

Traveling is one of my big passions, and I like to think it is something that helps me think on a more global level and fuels the fires of curiosity. So when thinking about all of this I began to wonder about different things that affect the perception of our body’s value. Thailand is one of the most (if not the most) infamous areas for sex tourism/sex trafficking/sex work, etc. I began to question how having this be such a prominent part of a culture affected people’s sense of self worth. How do people involved in these industries perceive and feel about themselves, how do others view the individuals working in this industry? I’m so excited to say this is something I will be fortunate enough to explore at the end of September, so check back to see what the experience is all about!

Tips for Adopting a Body Positive Mindset

1. Place a sign, post-it note, whatever on your mirror with a positive message for yourself. I love having people put something like “Hello, gorgeous” up. This is helpful for a few reasons. One being that it starts your day with a positive thought about yourself. It begins to make you feel comfortable with thinking/feeling/accepting nice things about yourself. The more that we practice this, and replace negative self talk with these thoughts the more second nature it becomes.
2. Focus on health and wellness not numbers. We can get so tied up in wanting to hit that magic number on the scale that sometimes we neglect what is more important, overall health. If you start treating your body like that brand new car I talked about earlier, guess what happens? We start putting higher quality fuel in, we’re more attentive to regular maintenance (exercise, time to de-stress, etc.) and we overall perform at a higher level.
3. Adopt an attitude of gratitude. An exercise I commonly have patients struggling with this do is body mapping. So either draw or list it out, head to toe write something that you like about each body part. If you cannot think of something you like about a particular body part write something that you can appreciate about it (eg. you may not like your stomach but you can appreciate that it houses organs that digest food to nourish you).

Just remember, you deserve the same love, kindness, and compassion you give to others, so be kind to yourself!

Mental Health in Mexico

It seems that the topics of deportation and the matter of separating parents from their children has been everywhere lately. This made me want to explore (setting aside any arguments about the legal/political issues associated with this on either side) what is this really doing to these kids, these families, and what kind of mental health treatment is available in Mexico for these people? How is mental health treatment approached in Mexico?

So what really happens when a child experiences a trauma like being separated from a parent? Childhood is when a lot our core beliefs, patterns of thought, and coping skills develop. This is a time that really sets the stage for how we relate to others and the world around us. A trauma like this certainly could lead to depressive, anxiety or trauma related disorders as well as problems with attachment. When a trauma like this happens it may lead the child to view the world as an unsafe place, have difficulty trusting others, develop feelings of inferiority, or have difficulty establishing their own self-identity. It would not be unusual for the parents in these situations to  develop extreme feelings of guilt, hopelessness and subsequent depressive, anxiety, or trauma related disorders. Personality disorders, especially Borderline Personality Disorder are also very strongly related to unhealthy attachment and fear of abandonment. The cultural importance of family puts these individuals at even higher risk.

I wondered if providers had been seeing an increase in people seeking mental health treatment specifically related to these issues. So I went down to Tijuana’s only psychiatric hospital, Hospital de Salud Mental de Tijuana and met with some of the providers to learn about the treatment and perspective of mental health in Mexico. While the providers I spoke with said they may have seen a very modest increase in hospitalizations/treatment specifically related to these issues it didn’t seem to have the major impact I suspected it would.

There is still a fair stigma about mental health issues in the U.S. and the providers I spoke with felt there was a similar if not harsher stigma about mental health treatment in Mexico. This stigma often discourages people from getting mental health treatment, frequently a person may be afraid to tell his or her family there is a need to seek treatment, or may be actively discouraged to do so if it is discussed. Mental health conditions are frequently seen as something that should can be managed by religious or family support. This puts individuals experiencing a mental health condition in a very difficult spot and seemed to be the primary barrier to seeking treatment.

I toured the facility for about two hours while the doctors I met with patiently answered my 1,001 questions. About five minutes into the tour it hit me like a Mac truck, these people have it right. There were some stark differences in how treatment is approached and I started to take note of what we need to bring to the states.

1. Length of stay. The average length of stay for inpatients is about 2 weeks. That is the average, frequently stays are 3-4 weeks. I compared this to the inpatient units I’ve worked on where the average length of stay is probably 2-3 days. If someone’s length of stay is approaching a week administration usually starts to sweat. Why is this? The most basic answer is insurance coverage. Generally speaking an insurance company will only provide coverage for a psychiatric hospitalization if a person meets one of three criteria: they are an imminent danger to themselves, others, or are gravely disabled (cannot provide for basic needs like clothing, shelter, food, or water, due to a psychiatric illness). This means that people are generally not hospitalized until their symptoms are so severe it becomes a liability if not treated. What’s more, the minute a patient no longer meets this criteria insurance coverage stops (some really good plans may authorize a few additional days, but this is pretty rare). This basically means we are using inpatient treatment as basically a means to stabilize someone to the bare minimum level, or until they are no longer assessed to be a liability.

2.  Holistic treatment. This kind of goes along with the idea of what really is the purpose of treatment, to simply stabilize someone, or actually provide treatment of the symptoms. Most inpatient units in the states will offer things like group therapy, AA meetings, and maybe art therapy, these activities are fairly minimal and not the largest part of treatment. I was amazed to see at Hospital de Salud Mental de Tijuana they had displays of expansive works of art therapy done by patients, there were volley ball courts, a gym, yoga classes, even a garden that patients tend to and what is grown is used in the meals served that are specially planned by a nutritionist. We know that good nutrition, exercise, a sense of community and purpose are vital for our mental health and yet we put such a minimal focus on it.

3. Community outreach. As mentioned above the stigma about mental health treatment is prevalent across borders, these providers are rolling up their sleeves to fight it. They host meetings, and also visit schools and other community facilities to provide education about mental health to the community. Starting in elementary school these providers are actively working to change how the next generation perceives mental health.

I left the facility dumbstruck and with one thought. As providers, as a community and society we need to be better. I believe that the vast majority of providers do want to give the best care possible and heal their patients but become limited by administrative and financial barriers. like any other kind of medical issue, doing primary prevention is without a doubt the best thing we can do, we first need to start educating our kids about mental health treatment and  and we need to be better about community outreach. We also need to fight for the ability to actually be able to treat our patients instead of giving them the bare minimum level of stabilization. It’s up to us to talk to our legislators, and to push for expanded coverage of treatment. Let’s be better.

13 Reasons Why our Kids are Depressed, Anxious, and Suicidal (Side B)

midsection of man
Photo by Hichem Deghmoum on Pexels.com

Depression and anxiety in kids and adolescents certainly isn’t something that’s new, but is it getting worse? We’re definitely seeing a rise in mental health conditions across the board, but it’s difficult to determine if this is because we’re simply getting better at recognizing it and more willing to treat it. Even though we are making great strides in identifying these issues in kids, we’re still learning, and new factors and issues effecting our mental health continue to emerge. So this is a continuation of my last post exploring a few more of the issues contributing to mood disorders.

7. Pressure: You know the way you might feel that your boss keeps wanting you to do more and more with fewer resources? Our kids frequently feel the same way about school. I regularly have kids who are not even in high school come into my office in tears because they didn’t do well on an assignment/test and are now convinced they will never get into a good college, will never get a good job, and will be a miserable loser for the rest of their lives feeding feelings of self-doubt and hopelessness. This kind of distorted thinking is common even for adults with anxiety, it’s called catastrophizing (going to the absolute worst case scenario) which is particularly problematic with kids because the parts of our brain that allow us to think more abstractly, control impulsivity, and realistically weigh consequences of events or actions are still under development. The pressure is not only academic, in many senses our kids are truly becoming mini-adults at younger and younger ages. I look at so many of the young girls that come into my office with perfectly coordinated outfits, contoured makeup, acrylic nails, and listen to them sadly talk about how they think they’re not pretty enough, thin enough, good enough. They need to hear they are good enough, and they need to hear it until they believe it.

8. Our brains are getting wired to be depressed and anxious. Dopamine is a neurotransmitter that plays a huge role in our mood, it’s also a key player in things like addiction and reward processing. There’s a reason we get so sucked in to wanting to get more and more ‘likes’ or followers. Dopamine. Every time we get a ‘like’ we get a little boost of dopamine. This basically makes our brain tell us “Hey this is awesome, we gotta get some more of that!” We subconsciously train ourselves to self-medicate with these dopamine boosts. This means that when we’re not getting that insta-dopamine we notice we don’t feel as happy, we get more depressed and may even get cravings for that dopamine boost.

9. Substance use: This really can be a chicken or the egg situation. Many people start self-medicating with substances as a way to try to escape from negative emotions. Momentarily it may work, however when the effects wear off we’re more likely in a worse place than we were before we used. This is physiologically for a number of reasons, a big part is activation of that reward cycle in Reason 8. This basically turns into a horrible self-perpetuating loop where we continue using to mask and escape from negative emotions, our brains continue to tell us “Yes this is helping, sweet!” then we crash, and repeat.

10. Everyone is stressed and we feed off each other. I think it’s a pretty fair assertion that right now pretty much everyone has some major stress right now, whether it’s worrying about making rent, the health of a loved one, the political climate, meeting a work deadline, etc. we live in a stressful time. We also tend to be pretty awful at self care, meaning we frequently don’t really manage our stresses effectively. We pick up on each other’s stress and oftentimes internalize it. I don’t think I’ll ever forget a kiddo of mine coming into my office absolutely distraught because the family was going through a lot of financial and marital stressors. She thought if she gave her dog away it would solve the family’s problems. Or the kid who thought she was causing the stress and problems leading to a parent’s substance abuse. Parents are often so wrapped up in the well-being of their children, work, school, or whatever it is they often ignore or de-prioritize their own mental health. One thing that I find myself frequently reminding parents is that it is not selfish to take care of yourself, the happier and healthier you are, the happier and healthier your kids will be.

11. We’re more and more reliant on external validation to determine our self worth. The feelings of love and belonging are some of the most basic human needs. Humans by nature are social creatures, and even from an evolutionary standpoint we have a need to be accepted by others and be part of a group. This becomes problematic when our self esteem becomes reliant on the approval of others. How many people liked our post? How many parties did we get invited to? How many texts do we have? When we let these external sources of validation dictate our self worth we aren’t really able to see ourselves through a clear lens. Another distorted way of thinking we can get into the habit of is polarized or black and white thinking, or minimizing the positives while magnifying negatives “I didn’t get invited to that party so that means no one likes me, and I’m a loser who doesn’t have any friends.” This can make it difficult to accurately evaluate ourselves or the situations we’re in and crush our self esteem. Relying on this form of validation can also lead us to behave in ways that we might not feel comfortable with in order to fit in, or avoid conflict, however when this happens we often develop huge feelings of guilt afterwards, feeding into the cycle all over again.

12. We’re disconnected. While technology is an amazing tool that gives us access to people and information, this can lead us to have less quality face to face time with each other. Think about it, look at almost any group of people, at anytime how many people are on their cell phones, or at least have them out? When our attention is split like this we limit the quality of the experience we’re having in real time. When we feel disconnected, we likely end up feeling lonely which goes back to Reason 11. The primary reason that group therapy is effective is the sense we are not the only one experiencing what we are, or that other people understand, and maybe the most important factor in psychiatric treatment is the therapeutic relationship, these things all give us that sense of love and belonging and lets us know that we are not alone.

13. It’s everywhere. Every time one of my kiddos come to me and describe these things or tell me they’ve attempted or have considered suicide it breaks my heart, and I try to think back to how old I would have been when I would have even been aware of what the concept of suicide was. It really does seem that it’s been everywhere TV, movies, news, music, you name it. Now coverage and discussion of these issues is something that is necessary and important. Risk comes when it is sensationalized or glamorized. Parents ask me all the time if they should let their child watch a show like “Thirteen Reasons Why” and my answer is usually that it depends on the purpose. I believe it can be a helpful tool in facilitating a conversation, but this should be done with guidance. Like I mentioned earlier there is still so much fine tuning and brain development that is going on during this time that kids are not able to process and analyze information like this in the same way as adults do. Kids just do not have the executive functioning to fully understand what suicide really means. Many times it may be viewed as a way to show someone how much pain they are experiencing or to prove a point. The finality of these actions is not something that they are able to process which is where the danger comes in. A good example of this is in the most recent season of Thirteen Reasons Why the protagonist who committed suicide in the first season is featured throughout the entirety of the program, seeming to still interact and communicate with at least one of the characters, continuing to tell her story and help guide others through the season. This is where the major disconnect comes in (for the purposes of this discussion let’s put aside religious beliefs about the afterlife, which would add a whole other layer to this). The finality of suicide is what is a difficult concept for kids/adolescents to understand, and the protagonist’s continued presence even though she is dead is often how kids conceptualize it.

So what do we do with all of this? The number one thing I can say is talk. Have the uncomfortable conversations. It may be the immediate reaction (and reasonably so) to hit the roof when you find an empty bottle of vodka in your kid’s room, or find inappropriate pictures on her phone, but I would ask for you to look at what else is going on. Is there something she is trying to escape? Is there some kind of validation or need that isn’t being met? I’m not saying this is an excuse, but rather may be an explanation of certain behaviors (which still need to be addressed and corrected). Encourage them not solely to succeed in school, athletics, or extracurriculars, but teach them how to handle disappointments and shortcomings and not let failures negate successes. One of the most beneficial things to do to improve overall mood is to foster an environment of gratitude. At some point in the day share things that you are grateful for and encourage your kids to do the same. When we’re able to express gratitude it helps counteract that negative all or nothing/black and white thinking and helps us bring the positive into focus. The last thing I advise would be to take care of yourself. Don’t feel selfish for taking time to go to a yoga class, have a date night with your significant other or go to a therapy session (whatever your self care is) we can’t help others effectively if we don’t help ourselves. Just remember, if you have any doubt or concern bring your kiddo in for an evaluation! Worst case scenario is you spend an hour of your time with your child discussing your concerns. Remember it is not our job as providers to make judgements on you, your child, your parenting, etc. while sometimes people may be hesitant because of past negative experiences or beliefs about psychiatry/therapy I truly believe that 99% of providers sincerely want to help and only want what is best for you and your child.

If you or someone you know is struggling with suicidal thoughts there is always someone there to help.

Call the National Suicide Prevention Lifeline available 24 hours every day 1-800-273-8255

“No matter how many reasons why, there are always more reasons why not.” –13 Reasons Why