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Preventive Interventions and Treatments for Suicidal Youth 

Preventive Interventions and Treatments for Suicidal Youth
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Preventive Interventions and Treatments for Suicidal Youth
DOI:
10.1093/9780195173642.003.0025
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date: 14 December 2018

The third and last category of youth suicide prevention efforts includes indicated interventions and treatments that target those who have already shown signs of suicidality. Such efforts seek essentially to reduce and prevent subsequent suicidal ideation and suicide attempts and prevent suicide completion. The interventions and treatments described in this chapter differ widely in the groups they target, the methods they use, and the settings in which they have been implemented.

SCHOOL-BASED PROGRAMS FOR SUICIDAL STUDENTS

Assumptions

The central underlying assumption of school-based programs for suicidal students is that subsequent suicidal thoughts and behavior can be reduced by enhancing protective factors, in particular, students' personal and social support resources.

Program Examples

The most comprehensive school-based programs are those developed and tested by Eggert, Thompson, and their colleagues (Eggert, Karovsky, & Pike, 1999; Eggert, Thompson, Herting, & Nichols, 1994, 1995; Thompson, Eggert, & Herting, 2000; Thompson, Eggert, Randell, & Pike, 2001), as part of the Reconnecting Youth (RY) Prevention Research Program. The interventions are directed at students who are deemed to be at risk of dropping out of high school, based primarily on school attendance data and observations of teachers, counselors, and other gatekeepers. Such students have been reported to have multiple co-occurring problems that, in addition to school performance difficulties, include depression, suicidality, drug involvement, and tendencies toward aggressive and violent behaviors (Eggert et al., 1994; Lewinsohn, Rohde, & Seeley, 1993).

The interventions are based on a theoretical model that rests essentially on improving students' personal resources, leading to an enhanced sense of personal control and self-esteem, improved decision making, increased use of social support resources, and reduced suicidal behavior. The early research involved systematic evaluation of a semester-long, school-based, small-group intervention called the Personal Growth Class (PGC). The intervention included life skills training using strategies of group process, teacher and peer support, goal setting, and weekly monitoring of mood management, school performance, and drug involvement.

Evaluation studies by Thompson, Eggert, and colleagues (Eggert et al., 1994, 1995; Thompson et al., 2000) involved approximately 100 high school students at risk for dropping out of high school, as determined by a set of defined criteria, who screened positive for suicidal behavior (as discussed in Chapter 22). The students were randomly assigned to one of three conditions: assessment protocol plus one semester of PGC, assessment protocol plus two semesters of PGC, and assessment protocol only. Participants were assessed at baseline and at 5 and 10 months postintervention. Participants in all three groups showed significant declines in suicidal behavior. Unlike the students who received the assessment protocol only, PGC participants showed significant improvement in self-perceived ability to manage problem circumstances. Also reported was a significant positive impact of both teacher and peer support in decreasing suicide risk behaviors and depression.

Thompson, Eggert, and colleagues (2001) subsequently tested two additional school-based prevention programs based on the PGC: a brief one-on-one intervention known as Counselors Care (C-CARE), and a small-group skills-building intervention program, Coping and Support Training (CAST), derived directly from the PGC program. Both interventions, compared to a usual care control group, were found to reduce suicide risk behaviors and depression, even at the 9-month follow-up assessment; CAST was most effective in enhancing and sustaining protective factors such as problem-solving coping.

Currently, the CARE intervention, expanded to include a parent intervention component, P-CARE (Randell, 1999), is being studied to determine the added benefit of this component to fur ther reduce depression, anger, and suicide risk behaviors. Preliminary results suggest that C-CARE, coupled with the parent intervention, is associated with more rapid rates of decline in suicidal ideation, direct suicide threats, depression, hopelessness, and anxiety when compared to usual care (Thompson, 2003b).

Critique

These programs for suicidal students at risk of dropping out of high school have demonstrated efficacy in reducing suicidal behavior and depression. There is some indication that prolonged intervention results in the most positive outcomes related to suicide, although it is not clear whether these effects are due to repeated contact with the treatment or to the nature of the treatment itself. As is often the case with programs involving multiple components, identifying which component is most responsible for the outcomes reported by these programs is difficult. Preliminary reports suggest that the inclusion of parents in the intervention is particularly effective.

The target groups addressed by the studies of Eggert and Thompson may limit the generalizability of the findings to other populations of suicidal youth. From the outset, the focus of these programs has been on students at risk of dropping out of high school as principally defined through attendance records. There is some evidence that high school dropouts may come from more deviant and neglecting families and thus may not be representative of suicidal adolescents overall. In addition, the inclusion criteria for these programs are somewhat idiosyncratic in their use of gatekeeper identification of problematic students, which may limit the exportability and testing of the model.

In addition, it should be noted that these interventions were designed and implemented by highly skilled, university-based professionals, who devoted considerable attention to ensur-ing program fidelity, evaluating program results, and making improvements based on empirical findings. Although results appear promising, replication of the program in schools that do not have such resources may be difficult. A community-based dissemination of the CAST intervention is currently being implemented and evaluated in three sites (Randell, 2003), which will begin to address this concern.

EMERGENCY DEPARTMENT INTERVENTIONS FOR YOUNG SUICIDE ATTEMPTERS

Assumptions

A considerable number of youth who make suicide attempts obtain some form of medical intervention (Grunbaum et al., 2002), typically beginning in a hospital emergency department (ED). This suggests that the ED may be a prime location for initiating treatment programs aimed at suicidal youth.

Numerous studies have documented, however, that young suicide attempters' adherence to outpatient treatment recommendations made in the ED is poor, with over 15% never attending any recommended outpatient sessions, and fewer than half attending more than a few sessions (Spirito et al., 1992; Stewart, Manion, Davidson, & Cloutier, 2001; Trautman, Stewart, & Morishima, 1993). Poor adherence has been attributed to ED factors, such as long waits, repetitive evaluations, and poor communication by ED staff, and also to cultural factors including the perception that mental health treatment is shameful (Spirito, 2003).

Table 24.1 lists the key ED interventions that have been developed to date for young suicide attempters. The primary assumption underlying these interventions is that improved treatment adherence will result in decreased suicidal behavior. Thus, their goal is to develop mechanisms for engaging suicide attempters in the treatment process.

Table 24.1 Emergency Department Programs

Reference

Intervention

Study Design

Study Length

Sample Size

Comments

Rotheram-Borus et al., 1996

Specialized emergency room program including:

1. Staff training

2. Videotape for adolescent and parent addressing treatment expectations

3. On-call family therapist

Quasi-experimental design with nonrandom assignment and treatment-as-usual comparison group

Presentation during ED visit and referral to 6-month therapy program

N = 140 Latina adolescent suicide attempters and their mothers

Ages 12–18 years

N = 65 specialized care

N = 75 no specialized care

Specialized care group reported less depression and mothers reported more positive attitudes towards treatment than those with no specialized care after intervention

Specialized care group more likely to attend at least one follow-up treatment session (95.4% vs. 82.7%)

Trend toward those in specialized care attending more treatment than those without specialized care (5.7 vs. 4.7 sessions)

Mothers of adolescent attempters in specialized care were less likely to complete treatment

Rotheram-Borus et al., 2000

See above

See above

See above

18-month follow-up

(92% participation follow-up rate)

See above

Rates of suicide re-attempts and reideation attempts were lower than expected and not different between groups

Impact of specialized care was greatest for most symptomatic suicide attempters when maternal distress and family cohesion were improved

Spirito et al., 2002

Compliance-enhancement, problem-solving intervention in ED

1. Review treatment expectations

2. Address treatment misconceptions

3. Review factors that impede treatment attendance

4. Verbal contract to attend at least 4 outpatient sessions

Random assignment to enhanced or standard disposition planning in ED

1-hr ED intervention with 3-month follow-up

N = 63 suicide attempters receiving medical care in ED

Ages 12–18 years (mean 15 years)

N = 29 in enhanced care

(25 female)

N = 34 in standard care

(32 female)

73% white

SES: 47% middle class

49% below middle class

Over 50% were hospitalized after ED visit as part of disposition

Adherence to treatment was not different between groups unless controlled for barriers to treatment

Greenfield et al., 2002

Rapid-response (RR) outpatient model:

Psychiatrist and psychiatric nurse were available to assist in making outpatient appointment, prescribe medication, and discuss misconceptions, maladaptive behaviors, and communications contributing to stress

Nonrandom assignment to RR or control group

Assignment yoked to ED psychiatrist's access to RR team

N = 286 adolescents with “suicidal risk” seen in 2 pediatric EDs and assessed to not need medical hospitalization

Ages 12–17 (mean 14 years)

70% female

+70% white

N = 158 RR

N = 128 control

RR group was less likely to be hospitalized (11% vs. 41%)

RR group had first outpatient contact and first outpatient appointment sooner

At 6-month follow-up:

RR had 59% fewer hospitalizations

No difference between RR and control for number of ED visits or subsequent suicide attempts

ED, emergency department; SES, Socioeconomic status.

Program Examples

Rotheram-Borus and colleagues (1996, 2000) designed an intervention that targeted both the ED staff and families of Latino adolescent females who attempted suicide and followed participants over 18 months. Using videotapes and thera pists, this program involved ED staff and families with a focus on encouraging participation in outpatient treatment. In comparison with patients who received family therapy alone, participants who received both family therapy and the emergency room intervention were found to adhere more frequently to the recommendation to attend a first treatment session. Families receiving the combined intervention also had more favorable outcomes in terms of maternal depression and general psychopathology, patient ideation, and parent-reported family interaction.

Spirito, Boergers, Donaldson, Bishop, and Lewander (2002) also developed an adherence enhancement intervention to improve engagement in therapy. Treatment expectations, misperceptions, and reasons for treatment dropout were separately presented to adolescents and parents, along with a brief intervention to facilitate problem solving around factors that might impede treatment attendance. After this ED intervention, telephone contacts were made at 1, 2, and 6 weeks with adolescents and parents. Many service barriers were reported such as delays in getting an appointment, being placed on a waiting list, and insurance and out-of-pocket expenses. Family barriers to treatment included parental emotional problems, transportation difficulties, language difficulties, and scheduling problems. The adherence enhancement program increased the number of sessions attended, although premature termination of treatment continued to be a problem. The program developers emphasized the importance of reducing service barriers for adolescents who have attempted suicide.

Hospitalization for suicidal behavior, though often securing the safety of the suicidal individual, is quite costly and not always beneficial. In an effort to decrease hospitalization rates and suicidality and improve functioning, Greenfield, Larson, Hechtman, Rousseau, and Platt (2002) implemented the Rapid Response (RR) ED intervention for suicidal adolescents who were not considered to require immediate medical or psychiatric hospitalization. The intervention included family therapy, medication, and community intervention, as indicated. Hospitalization rates were decreased and outpatient therapy was initiated more rapidly as a result of the RR intervention when compared with standard care. In addition, adolescents receiving the intervention were less likely to be rehospitalized during the 6 months after their visit to the ED. Neither hospitalization nor RR was found to prevent subsequent suicidal behavior or ED visits.

Critique

The results of programs implemented to date suggest that some improvement in outpatient treatment adherence by young suicide attempters, as well as reduced hospitalizations, can be achieved by concerted efforts in the ED. Such efforts, however, require education of ED staff on suicide risks and treatment needs of young suicide attempters. Barriers to outpatient treatment appear to remain significant and difficult to surmount, even for the most cohesive and well-functioning families. It seems essential that ED interventions provide some continuity of contact with the youth beyond the initial ED visit, which will require additional staffing. While this may seem costly, the cost reductions associated with decreasing immediate and future hospitalization are significant.

PSYCHOTHERAPEUTIC TREATMENTS FOR SUICIDAL YOUTH

Effectiveness of Psychotherapeutic and Psychosocial Treatments for Adults

As noted in Chapter 21, previous suicidal behavior is the most important factor associated with suicide risk among both adults and youth. Recognizing that repetition of a suicide attempt vastly increases the risk of a fatal outcome (Sakinofsky, 2000), considerable effort has been directed towards developing psychotherapeutic and other psychosocial treatment modalities to prevent subsequent suicidal behavior among identified individuals. Although suicide attempts and other forms of deliberate self-harm occur with greater frequency among young people than among adults, virtually all such treat ments have been systematically studied only among adults, primarily because of restrictions against including suicidal youth in randomized trials and other research.

In a comprehensive review of psychological and pharmacological treatments for preventing repetition of suicide attempts (primarily among adults), undertaken in conjunction with the Cochrane Collaboration's Database of Systematic Reviews, Hawton and colleagues synthesized findings from 20 randomized controlled trials (RCTs), involving 2,641 patients in which repetition of deliberate self-harm was reported as an outcome variable (Hawton et al., 1998, 2000; Townsend et al., 2001). Most of these trials studied psychotherapeutic or other psychosocial treatments.

Reports on these RCTs were independently rated by two reviewers, blind to authorship, using the recommended Cochrane criteria for quality assessment. These include determination of the study's overall validity, the quality of the randomization procedures used to assign subjects into groups, the potential biases regarding sample selection and attrition, and intervention delivery (Alderson, Green, & Higgins, 2003). Overall, Hawton and colleagues concluded that there is currently insufficient evidence on which to make firm recommendations about the most effective forms of treatment for patients who have engaged in suicidal behavior, primarily because most treatment studies to date involving identified suicide attempters have included far too few subjects to have the statistical power to detect meaningful differences in rates of repetition of suicide attempts between experimental and control treatments, if such differences existed (Hawton et al., 1998). Nevertheless, promising results were found for several psychotherapeutic modalities.

In one promising approach, dialectical behavior therapy (DBT), a number of cognitive and behavioral strategies are used to target suicidal and other dysfunctional behaviors. In DBT relatively long-term individual treatment is combined with group behavioral skills training. This therapeutic technique was developed by Linehan (1993a, 1993b) for adult suicide attempters, specifically to address the problems of poor emotional regulation that are commonly found in this population. Because individuals with borderline personality disorder (BPD) are particularly prone to affective dysregulation and maladaptive problem-solving behaviors including self-harm, DBT has been described as especially effective for this subgroup of suicide attempters (Linehan 1993a, 1993b).

Dialectical behavior therapy is designed to be given in several sessions a week for approximately a year. Its components include (1) training the patient in self-acceptance through the technique of mindfulness; (2) increasing assertiveness to reduce interpersonal conflicts; (3) training the patient to avoid situations that trigger negative moods; and (4) increasing tolerance of distress. In DBT, the suicidal behavior itself is regarded as the primary focal point of treatment; although efficacious treatment for underlying problems such as depression is important, it does not necessarily reduce suicidality (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991). An adaptation of DBT (DBT-A) has been developed for adolescents (Miller, Rathus, Linehan, Wetzler, & Leigh, 1997). Given for 6 months rather than for a year, DBT-A has not yet been tested in a controlled study.

During a 1-year course of treatment with DBT, Linehan and colleagues (1991) found that a sample of adult female patients with BPD had significantly fewer suicide attempts, less medically significant attempts, and fewer inpatient psychiatric days. They were also more likely to stay in individual therapy than were comparable patients who received treatment as usual. Between-group differences in depression, hopelessness, suicidal ideation, and reasons for living were not significant, although the DBT group showed decreases in all four measures throughout the treatment year. In a 1-year posttreatment follow-up, the DBT patients were found to have significantly higher global functioning, better social adjustment, less anger, less suicidal behavior, and fewer psychiatric inpatient days compared to control patients (Linehan, Heard, & Armstrong, 1993).

Although the efficacy of DBT was strongly supported in studies of female suicide attempters with BPD, Hawton and colleagues (1998) noted that the intensive nature of the treatment could limit its application within general psychiatric services, and that its efficacy among male patients had not been determined.

Short-term problem-solving therapy based on a cognitive behavioral model (Gibbons, Butler, Irwin, & Gibbons, 1978; McLeavey, Daly, Ludgate, & Murray, 1994) was also found in Hawton's review to result in reductions in subsequent suicidal behaviors by adult patients who had engaged in self-poisoning, although comparisons with patients who received treatment as usual were not statistically significant, likely because of the small numbers of patients studied in these trials. A subsequent meta-analysis of data reported by six trials in which brief problem-solving therapy was compared with control treatment showed that patients who were offered problem-solving therapy had significantly greater improvement in depression as hopelessness, as well as perceived improvement in the problems these patients faced (Townsend et al., 2001). These findings suggest that short-term therapy might be as efficacious as long-term treatment in preventing repetition of suicidal behavior, although Hawton and colleagues noted the need for confirmation of these findings in a large trial.

Also noted as promising in this review were studies in which experimental group patients were given, in addition to standard aftercare, 24-hour emergency access to a psychiatrist or hospital. Two such studies (Cotgrove, Zirinski, Black, & Weston, 1995; Morgan, Jones, & Owen, 1993) reported a tendency towards less repetition of self-harm among patients who were encouraged to make emergency contact with services if needed. In the only RCT reviewed by Hawton that involved adolescent patients, Cotgrove and colleagues (1995) gave tokens allowing readmission upon demand to a random sample of adolescents who had been hospitalized following a suicide attempt, in addition to standard management. Although only 11% of the sample used the tokens, the group overall showed a somewhat (but not significantly) lower rate of repeat attempts, compared to comparable adolescents who were given standard management but no tokens.

Because of small sample sizes, Hawton's review noted that meaningful conclusions could not be reached about the efficacy of hospital admission following a suicide attempt vs. outpatient treatment, or about the relative impact of inpatient behavior therapy compared to inpatient insight-oriented therapy.

Psychotherapeutic interventions that encourage compliance with treatment and attempt to decrease depression and other negative affects in the context of a supportive interpersonal relationship should theoretically reduce suicide risk. There is some evidence, however, that reexamination of painful problems may have adverse effects on some vulnerable individuals (Nemeroff, Compton, & Berger, 2001). Although no systematic attention has been given to documenting adverse outcomes of psychotherapy for suicidal individuals, one study has reported negative outcomes of “life history” interviews with elderly suicidal women who had abusive histories (Haight & Hendrix, 1998).

Assumptions Underlying Psychotherapeutic Treatments for Suicidal Youth

Psychotherapeutic approaches for treating suicidal youth are summarized in Table 24.2. Most such interventions have employed variations of cognitive behavioral therapy. The underlying assumption is that the primary focus of treatment should be the suicidal behavior itself, rather than the underlying psychopathology (Brent et al., 1997; Harrington et al., 1998). As was earlier noted, restrictions regarding the inclusion of suicidal youth in RCTs have limited systematic evaluation of some of these approaches.

Table 24.2 Psychotherapeutic Interventions

Reference

Intervention

Study Design

Program Length

Sample Size

Comments

Rudd et al., 1996

Outpatient, intensive, structured, time-limited group treatment using problem-solving and social competence approach to improve social functioning and adaptive coping

Pretest to posttest

Follow-up (24 months)

Random assignment to treatment vs. TAU comparison group

9 hr/day for 2-week period with minimum of 8 individuals

N = 264 members of military medical center in southwest U.S.

Reflects 21% dropout rate

N = 143 treatment

N = 121 TAU (inpatient and outpatient care)

Mean age = 22 years

70% completed high school

82% male

61% White

26% African American

11% Hispanic

39% married

42% never married

30% had previous hospitalization

110 suicidal ideation

107 single attempters

47 multiple attempter

Both groups improved and there were no between-group differences at posttest or follow-up

Treatment was more effective at retaining poor problem solvers over 24-month period relative to TAU controls

Harrington et al., 1998

Home-based family intervention

Random assignment to home-based intervention or TAU with 6-month follow-up

5 sessions in family home

N = 162 of 435 referred cases

Adolescents ages 10–16 seen in the hospital for self-poisoning

n = 85 home-based

Mean age, 14.4 years

89% female

63% not living with both parents

66% with DSM-III-R MDD

n = 77 TAU

Mean age, 14.6 years

90% female

70% not living with both parents

60% with DSM-III-R MDD

The groups did not differ with respect to suicidal behavior after treatment

Parents from home-based treatment were more satisfied at 2-month follow-up than TAU parents

While the MDD group did not evidence group differences, the home-based intervention was more effective than TAU for nondepressed adolescents with respect to suicidal ideation

Wood et al., 2001

Developmental group psychotherapy (DGP)

Random assignment to DGP or TAU

Follow-up at 7 months

6 “acute” group sessions followed by weekly “long-term group” until patient ready to leave

N = 63 adolescents aged 12–16 years (mean age 14 years) who were referred to mental health service of South Manchester, England, and had reported at least one other act of deliberate self-harm in the previous year (mean, 4 attempts)

Primarily from disadvantaged families

Approximately 50% had history of abuse

Majority not living with both parents

n = 32 DGP

78% female

n = 31 TAU

77% female

Those in DGP attended more sessions than those in TAU

Those in TAU were more likely to make repeat attempts and to make them sooner than those in DGP who made repeat attempts

The groups did not differ with respect to suicidal ideation or depression at follow-up

The DGP group demonstrated a reduction in behavioral disorder at 7 months relative to TAU

Adolescents with more DGP were less likely to make repeat attempts

Rathus & Miller, 2002

Dialectical behavior therapy (DBT)

Pretest to posttest

Nonrandom assignment to DBT or TAU

12 weeks of twice-weekly DBT including individual and multifamily skills therapy

N = 111

67% Hispanic

17% African American

8% white

n = 29 adolescents receiving DBT

Mean age, 16.1 years

93% female

suicide attempt within the last 16 weeks and minimum of 3 borderline personality features

n = 82 adolescents receiving TAU

Mean age, 15 years

73% female

either suicide attempt in last 16 weeks or evidenced 3 borderline personality features but not both

DBT vs. TAU

Despite greater psychopathology, the DBT group had no psychiatric hospitalizations vs. 13% of the TAU group hospitalized

DBT group had 3.4% attempts vs. 8.6% of TAU group

62% of DBT vs. 40% of TAU group completed 12 weeks of treatment

Within DBT Group

Suicidal ideation, depression, overall symptom level, and specific borderline personality features were reduced at the end of treatment

DBT, dialectical behavior therapy; DGP, developmental group therapy; MDD, major depressive disorder; TAU, treatment as usual.

Program Examples

Rudd and colleagues provided the first description of a cognitive behavioral skills group intervention designed to treat young adults with suicidal ideation or suicidal behavior (Rudd et al., 1996). The intervention, an intensive 2-week program that participants attended for 9 hr/day, included an experiential affective group, psychoeducational classes with homework, and a problem-solving and social competence group. A variety of strategies such as behavioral rehearsal, role-playing, and modeling were used to im prove basic social skills and effective coping. Participants (N = 264) were randomly assigned to either the experimental intervention or a treatment-as-usual condition involving long-term outpatient treatment. In a 2-year follow-up, Rudd et al. found that participants in both groups showed significant reductions in suicidal ideation and behavior and experienced stress, and improvements in self-appraised problem-solving ability. The intensive time-limited intervention was found to be more effective than long-term treatment in retaining the highest-risk participants. Subsequent analyses showed that patients with psychiatric symptomatology experienced the most improvement in response to this intervention (Joiner, Voelz, & Rudd, 2001). The rate of suicide attempts at follow-up was not reported for either the experimental or control group, however, and conclusions were limited by high attrition rates in both the experimental and control group.

Harrington and colleagues in Great Britain (Byford et al., 1999; Harrington et al., 1998, 2000) developed a home-based family intervention for adolescents with a history of deliberate self-poisoning. This intervention used a cognitive behavioral approach to address family dysfunction assumed to be related to the suicide attempt (Kerfoot, 1988; Keerfoot, Dyer, Harrington, Woodham, & Harrington, 1996), and to improve adherence to treatment by bringing it into the home. The intervention consisted of five highly structured sessions focusing of goal setting, reviewing the self-poisoning episode, communication, problem solving, and discussing issues related to the family. The program included a treatment manual and videotape for training.

This brief intervention was found to be effective primarily among those adolescents who were not seriously depressed and had less severe suicidal ideation, who made up about one third of the 85 participants (Harrington et al., 1998, 2000). Adherence and parental satisfaction with treatment were better for participants in this treatment relative to treatment as usual. The intervention was found to be no more costly than routine care alone (Byford et al., 1999).

Wood and colleagues have developed an additional psychotherapeutic variant, using developmental group therapy as an alternative to usual care for adolescents who have repeatedly attempted to harm themselves (Wood, Harrington, & Moore, 1996; Wood, Trainor, Rothwell, Moore, & Harrington, 2001). The group-therapy format was hypothesized to be useful in providing an arena for working on social problem-solving and relationship skills that are often considered core to suicidal behavior. Using a developmental approach to address issues unique to adolescents, the intervention combines problem-solving and cognitive behavioral interventions (Harrington, et al., 1998), DBT (Linehan et al., 1991), and psychodynamic approaches. An acute phase focusing on core themes (family and peer relationships, school problems, anger management, depression, self-harm, and hopelessness) is followed by a longer phase that concentrates on group processes. In interviews conducted about 7 months after treatment began, participants in the developmental group therapy reported engaging in less self-harm than did adolescents who received routine care, although depression did not appear to improve. Episodes of self-harm became less frequent as participants attended more sessions of the group therapy, whereas among those in usual care, self-harm behaviors were found to increase compared to baseline. Participants in the developmental group therapy, particularly youth who had made multiple suicide attempts, also showed reductions in conduct problems.

Considering suicidal behavior as the primary problem rather than the symptom, Henriques, Beck, and Brown (2003) have developed and examined a brief cognitive intervention for suicide attempters ages 18 and over. The intervention consists of 10 sessions, beginning with the identification of proximal thoughts and associated core beliefs that were activated just prior to the adolescent's suicide attempt. Cognitive and behavioral strategies are then applied to help individuals develop more adaptive ways of thinking about their situation and more functional ways of responding during periods of acute emotional distress. Specific attention is given to the role of hopelessness.

The intervention follows a structured protocol with specific therapeutic strategies developed for the early, middle, and late phases of treatment, which are designed for replication by mental health professionals working with suicidal youth. Early sessions focus on engaging the patient, setting goals, and increasing hopefulness. Middle sessions involve changing maladaptive beliefs and addressing problem-solving deficits and impulsivity while developing reasons for living, increasing adherence with health-care professionals, and increasing social support. Later sessions focus on relapse prevention, terminations, therapy extensions, and booster sessions as necessary. The efficacy and effectiveness of the intervention are currently being evaluated in a randomized controlled clinical trial. To date, the approach has not been used in the treatment of younger adolescents.

In another variation, Miller and colleagues (Miller et al., 1997; Rathus & Miller, 2002) have used a modification of DBT in their treatment of adolescent suicide attempters who demonstrated at least three features of BPD. The intervention developed by Miller et al. consists of 12 weeks of twice-weekly individual and family skills training. In one specific trial (Rathus & Miller, 2002), participants in the DBT group were found to have better adherence to treatment and fewer hospitalizations than those receiving treatment as usual, despite the fact that they had greater psychiatric comorbidity than control subjects. The DBT treatment was also found to be associated with reduced suicidal ideation, symptom severity, and distress. Although suicide attempts were less likely in the DBT group than among controls, this difference was not found to be significant.

Critique

Results reported to date suggest the effectiveness of cognitive behavioral interventions in improving social functioning and reducing suicidal ideation among suicidal adolescents, particularly those with mild to moderate depression and those with borderline features. In some cases, however, the outcomes of experimental treatments have not been substantially better than those obtained by comparison or standard care treatments. Long-term effects of psychotherapy interventions on suicidal behavior have not yet been reported. Given that maladaptive cognitions and behaviors have likely developed over a long period of time, it is not clear that short-term psychotherapies will ultimately be found to be effective in reducing suicidal behavior.

PHARMACOLOGICAL TREATMENTS FOR SUICIDAL YOUTH

Effectiveness of Pharmacological Treatments for Adults

The neurobiological underpinnings of suicidal behavior are currently the subject of considerable research, and new information that broadens our understanding of this complex area continues to emerge. Recent reviews have identified serotonergic dysfunction, noradrenergic dysfunction, dopaminergic dysfunction, and hypothalamic–pituitary–adrenal (HPA) axis hyperactivity as the key neurobiological correlates of suicidality (Mann, 2003; Nemeroff et al., 2001).

The most extensively replicated studies have focused on the role of serotonergic dysfunction. Studies have reported that depressed patients who have made suicide attempts have lower levels of 5-hydroxyindoleacetic acid (5-HIAA) in the brainstem and in cerebrospinal fluid (CSF) compared to depressed nonattempters (Nemeroff et al., 2001). Decreased CSF 5-HIAA is hypothesized to be a marker of the impulsive, aggressive, and violent nature of suicide, and appears to correlate with a high degree of suicidal planning and a high level of lethality of suicide attempts. Central nervous system (CNS) serotonergic dysfunction has also been associated with suicidal behavior.

One early small RCT study of adult chronic suicide attempters (Montgomery et al., 1979) found that depot neuroleptic medications were effective in preventing repetition of suicidal behavior, although patient reluctance and negative side effects were noted as limitations. Hawton and colleagues, in their exhaustive search using Cochrane criteria (1998), were unable to identify any other RCT conducted through the mid-1990s that found antidepressant medications to be effective in preventing subsequent suicidal behavior in patients who had made prior attempts. They noted, however, that the only antidepressants that had been systematically stud ied for suicide-related outcomes, nomifensine and mianserin, had been discontinued for general use at the time of their review.

A number of studies have reported decreased suicidality among mood-disordered adult patients receiving long-term lithium treatment (Sharma, 2003; Tondo, Jamison, & Baldessarini, 1997). Pooling results reported by several individual studies conducted between 1974 and 1996, Tondo and colleagues estimated that lithium treatment was associated with an almost 9-fold reduction in risk of suicide and suicide attempts. They noted that it is not clear whether the protection lithium provides against suicide derives from its general mood-stabilizing effect or its effects on reducing aggression and impulsivity through improved serotonergic functioning.

Long-term treatment with clozapine, an atypical antipsychotic, has been shown to produce similar effects among patients with schizophrenia, reducing suicidal behavior among this high-risk population (Sharma, 2003; Spivak, Shabash, Sheitman, Weizman, & Mester, 2003). Randomized controlled trials involving both lithium and clozapine are needed to determine the extent to which positive outcomes are related to patient characteristics that are correlated with their ability to adhere to long-term treatment.

Among patients suffering from unipolar depression, selective serotonin reuptake inhibitors (SSRIs) are currently considered superior to other antidepressants for improving both suicidal behavior and suicidal ideation (Nemeroff et al., 2001). Although no large RCTs of SSRIs have included outcomes related to suicide (due to the exclusion of suicidal patients from most pharmaceutical-sponsored trials), there is considerable evidence pointing to the positive effects of such medications on the CNS seroto-nergic dysfunction noted above to be associated with suicidality in adults (Oquendo, Malone, & Mann, 1997).

In recent years, several European studies have reported inverse correlations between use of SSRIs and suicide deaths, suggesting their potential significance for reducing suicide risk (Barbui, Campomori, D'Avanzo, Negri, & Garattini, 1999; Carlsten, Waern, Ekedahl, & Ranstam, 2001; Gunnel, Middleton, Whitley, Dorling, & Frankel, 2003; Isacsson, 2000). Although large RCTs need to be conducted to determine causative linkages, SSRIs appear to be a potent means of treating suicidality. The SSRIs have been reported to have less inherent toxicity than the previously widely used tricyclic antidepressants (TCAs), and are thus less likely to be related to death from overdoses. Although side effects such as gastrointestinal upset, insomnia, and sexual dysfunction are fairly common, most SSRIs appear to be well tolerated.

Assumptions Underlying Pharmacological Treatments for Suicidal Youth

To date there are few publicly reported studies involving the use of pharmacological interventions to treat suicidal behavior among young people. Although the effectiveness of antidepressants in treating children and adolescents has not been definitively established, use of SSRIs in treating depressed and suicidal youth has nonetheless become widespread. A recent U.S. analysis by Olfson, Shaffer, and colleagues (2003) reported an inverse relationship between regional change in use of antidepressants among youth aged 10–19 and suicide mortality. The relationship was found to be significant specifically among males, among youth aged 15–19, and in geographic regions with lower family median incomes.

Although these studies do not establish use of antidepressants to be causally linked to decreases in suicide deaths, some efforts are under way to implement and evaluate pharmacological treatments among youth with serious psychopathology, including suicidal ideation or behavior. The key assumption of these efforts is suicide risk among youth, as in adults, can be reduced through the use of antidepressant medications.

Program Examples

An intervention by Cornelius and colleagues used fluoxetine (Prozac) to treat adolescents with comorbid major depression and an alcohol use disorder, including some who demonstrated sui-cidal ideation at baseline (Cornelius, Bukstein, et al., 2001). The intervention was based on findings that reducing depression and problem drinking in adults resulted in a reduction of suicidal behavior (Dinh-Zarr, Diguiseppi, Heitman, & Roberts, 1999). Cornelius and colleagues also found fluoxetine to be effective in treating suicidal adults with an alcohol use disorder. Such treatment improved but did not completely eliminate both depressive symptoms (including suicidal ideations) and the level of drinking (Cornelius, Salhoum, Lynch, Clark, & Mann, 2001).

In their studies involving youth, all patients receiving fluoxetine improved with respect to depressive symptoms, and over half improved in symptoms of alcohol dependence. Among participants with suicidal ideation at baseline, ideation decreased and these decreases remained 1 year after treatment (Cornelius, 2003). Cornelius reported no serious adverse effects of fluoxetine among youth.

A definitive study supported by the National Institute of Mental Health, known as the Treatment of Adolescents with Depression Study (TADS), has provided the strongest evidence to date of the effectiveness of fluoxetine in treating adolescent depression and suicidality. This study randomly assigned 439 youths ages 12 to 17 diagnosed with moderate to severe depression to one of four treatment conditions for a period of 36 weeks: fluoxetine therapy alone, cognitive-behavioral therapy (CBT) alone, fluoxetine and CBT, and a placebo drug treatment. Based on the results obtained during the first 12 weeks of the study, the highest rate of clinical improvement (71%) was found among those receiving the combination treatment, followed by 61% of those who received fluoxetine alone, 43% of those who received CBT alone, and 35% of those who received the placebo drug treatment (March et al., 2004). It should be noted that the most seriously suicidal adolescents were excluded from the TADS sample, and thus only 29% of participants reported having clinically significant suicidal ideation at baseline. This percent decreased to 10% by week 12. Although no suicides occurred during the trial, the risk of a suicide attempt among study participants during the first weeks on fluoxetine was reported to be twice that for participants not receiving the medication. The study investigators concluded, however, that the benefits of the medication far outweighed its associated risk.

Critique

Since fluoxetine is presently the only antidepressant medication approved by the U.S. Food and Drug Administration (FDA) for the treatment of major depression in children and adolescents, the findings reported by Cornelius and colleagues and by the (NIMH) study have important implications for suicide prevention among depressed youth. It is encouraging that publicly supported large-scale RCTs are beginning to be undertaken. Much additional research is needed, however, to further illuminate the impact of fluoxetine, as well as that of other medications, for reducing suicidal ideation and behavior among both substance-abusing and nonabusing adolescents.

Since 2003, concerns have been raised about the safety of the newer antidepressant medications for use by children and adolescents, based initially on unpublished data from drug company studies linking use of SSRIs by children and adolescents to suicidal ideation and self-harm behaviors. In late 2003, these reports led the British drug regulatory agency to recommend against the use of all SSRIs except fluoxetine in treating depression among youth under age 18 (Goode, 2003).

In 2004, the U.S. Food and Drug Administration undertook a review of 23 clinical trials involving the use of nine different antidepressant medications by over 4,000 children and adolescents. The results of this analysis, presented in September 2004, found that the medications increased the risk of suicidal thinking and behavior (suicidality) in children and adolescents with major depressive disorder (MDD) or other psychiatric disorders (Hammad, 2004). Specifically, 4% of all youth taking medication reported an “adverse event,” i.e., thoughts of suicide and/or potentially dangerous behavior, compared to 2% of those taking a placebo drug.

On October 15, 2004, the FDA directed pharmaceutical companies to label all antidepressant medications distributed in the U.S. with a black box warning to this effect (FDA, 2004), even though their analysis had only included nine specific drugs. The warning states that the increased risk of suicidal thinking and/or behavior occurs in a small proportion of youth and is most likely to occur during the early phases of treatment. Although the FDA did not prohibit the use of antidepressants by children and adolescents, it called upon physicians and parents to closely monitor youth who are taking the medications for a worsening in symptoms of depression or unusual changes in behavior.

On February 1, 2005, the American Psychiatric Association (APA) and a coalition of other leading health, mental health, and advocacy organizations released detailed fact sheets for physicians and parents on the use of medications in treating childhood and adolescent depression (American Psychiatric Association, 2005). The fact sheets were developed because of concern that the FDA black box warning could have the unintended effect of limiting necessary, appropriate, and effective treatment of depression and other psychiatric disorders in youth.

The APA fact sheets were particularly critical of the FDA's measurement of suicidality following antidepressant use among children and adolescents, which essentially used thoughts of suicide or potentially dangerous behaviors that had been spontaneously shared by the young participants and subsequently recorded in the researchers' “adverse events reports.” Although the FDA analysis showed more such spontaneous reports among those taking an antidepressant medication as compared to placebo (4% vs. 2%), this finding was not supported by data from 17 of the 23 studies examined that had systematically asked all participants about their suicidal thoughts and behaviors, using standardized forms. The FDA's analysis of these data concluded that medication neither increased suicidality that had been present before the treatment, nor induced new suicidality in those who were not thinking about suicide at the start of the study. All studies collecting such data reported a reduction in suicidality over the course of treatment. The APA critique noted that while the FDA reported both sets of findings, it did not comment on the contradiction between them. It further questioned the reliability of the 2% and 4% spontaneous report rates, noting findings from numerous community samples that as many as half of adolescents with major depression were thinking of suicide at the time of diagnosis and 16%–35% reported making a suicide attempt.

The fact sheets included suggestions for physicians and parents in monitoring youth receiving antidepressant medication, and called for the development of a readily-accessible registry of clinical trials that could aid in resolving the controversy and conflicting information surrounding the prescribing of antidepressants to children and adolescents.

POSTHOSPITALIZATION PROGRAMS FOR SUICIDAL YOUTH

Assumptions

Research has pointed to a lack of posthospital treatment adherence among the many youth who are hospitalized in inpatient psychiatric units following serious suicidal behavior (Cohen-Sandler, Berman, & King, 1982; Spirito, Brown, Overholser, & Fritz, 1989). One result is frequent rehospitalization for repeated suicidality (Greenfield et al., 2002; Stewart et al., 2001). The key assumption of posthospitalization programs is that providing consistent support and improving adherence to aftercare recommendations will help to prevent future suicidal behavior.

Program Examples

The only full-developed program of this sort is the Youth-Nominated Support Team (YST) intervention, developed by King and colleagues (King, 2003; King, Preuss, & Kramer, 2001). This program was an outgrowth of the developers' finding that family dysfunction and parental psychopathology significantly impact treatment adherence by suicidal youth after hospitalization (King, Hovey, Brand, Wilson, & Ghaziuddin, 1997). Concentrating on the high-risk period for suicidality immediately following psychiatric hospitalization, the program specifically targets poor treatment adherence and negative perceptions of family support and helpfulness.

Before leaving the hospital, program participants nominate specific adults from their home, school, or community to support them when they are released. The YST conducts a psychoeducation session with these adults, then engages them in weekly consultations designed to improve their understanding of the suicidal youngster and how he or she can be effectively supported. A social network is encouraged among the adults, who typically come from diverse settings. The program is designed to supplement usual treatments.

Response to YST by participating youth and the nominated adults has been positive (King, 2003), with 80% of those nominated actually participating in the program. Positive effects have been reported for adolescent females, including reduced suicidal ideation and mood impairment. Similar benefits were not evidenced among male participants, although some described YST as having beneficial effects.

Critique

Since this intervention has only recently been implemented, it is too early to know whether the positive effects found among the suicidal girls will be translated into reductions of suicide attempts and rehospitalizations. It will also be important to identify the reasons underlying the lack of clear effects among male participants and to incorporate the necessary programmatic changes. The fact that the program has been manualized will likely encourage its replication, while permitting independent assessment of specific program components.

TREATMENT PROGRAMS FOR SUICIDE ATTEMPTERS ON COLLEGE CAMPUSES

Assumptions

As was noted in Chapter 22 there has been marked reluctance among college and university officials to specifically identify suicidal students or offer treatment services that specifically address this problem. One university-based treatment program has been identified, which is based on the assumption that students who engage in suicidal threats or behavior will not voluntarily submit to a clinical assessment, and thus that such assessment must be mandated as a condition of the student's continued enrollment at the university.

Program Examples

For the last 17 years, the University of Illinois has had in place a policy that requires mandatory reporting of all suicide threats and attempts by students, and mandatory clinical assessment sessions for all students identified as engaging in such behavior. Specifically, identified students are required to attend four weekly sessions with a social worker or psychologist at the University Counseling Center, during which the student receives a comprehensive clinical assessment and referral to additional treatment if needed. Students who do not attend the mandated sessions can be suspended or expelled from the university.

The program's primary developer reported high compliance among students over the past 17 years, with only one student being involuntarily dismissed from the university for refusing to attend the mandatory sessions. A significant decrease in the suicide rate at the university as a function of this policy has also been reported (Joffe, 2003).

Critique

Although the program has claimed to be uniquely successful in reducing suicidal behavior at the one campus where it has been implemented, confirmatory evidence is lacking. Comparative statistics on suicide rates over the last 17 years from universities with a similar student body to that of the University of Illinois are lacking, and it is possible the reported reductions are reflective of a general trend toward decreasing numbers of suicides among adolescents and young adults during the time period described, rather than the result of this specific program. Further, it is not clear how many suicidal students voluntarily withdrew from the university prior to identification, or how many troubled students may have decided not to enroll at all because of this particular policy.