Current Treatment Options in Psychiatry

, Volume 1, Issue 1, pp 66–83

The Treatment of Pediatric Suicidal Behavior

  • Taylor Burke
  • Jacqueline Buchanan
  • Leora Amira
  • Kseniya Yershova
  • Kelly Posner
Child and Adolescent Psychiatry (M DelBello, Section Editor)

DOI: 10.1007/s40501-014-0008-3

Cite this article as:
Burke, T., Buchanan, J., Amira, L. et al. Curr Treat Options Psych (2014) 1: 66. doi:10.1007/s40501-014-0008-3

Opinion statement

Psychotherapies have stronger empirical support of efficacy and do not have safety concerns associated with many medications; thus, at present, psychotherapy is an appropriate first-line treatment for suicidal ideation and behavior in youth. Integrated Cognitive-Behavioral Therapy (I-CBT) and Multisystemic Therapy (MST) have the strongest preliminary evidence for psychotherapeutic treatment of suicidal behavior in preadolescents and adolescents with a history of suicidal behavior. Mentalization-Based Treatment for Adolescents (MBT-A), Developmental Group Psychotherapy (DGP), and Dialectical Behavior Therapy for Adolescents (DBT-A) have received some support for youth engaging in non-suicidal and/or suicidal self-injurious behaviors. Resourceful Adolescent Parent Program (RAP-P) may be effective in reducing suicidal thoughts and/or self-injurious behaviors (Table 1). In children with a history of recurrent suicidal behavior and for whom psychotherapy alone is ineffective, psychopharmacological treatment may be necessary. Responsible pharmacological treatment of pediatric suicidal behavior requires understanding of the current dearth of efficacy evidence and the limitations of safety evidence within pediatric populations, the range of possible serious side effects, and the potential use of medications, including less toxic SSRIs (Barbey and Roose J Clin Psychiatry 59:42–8, 1998) [IV], as a suicide method. Time to effect of antidepressants may coincide with heightened suicide risk (Simon et al. Am J Psychiatr 163(1):41–7, 2006) [I], and, thus, patients should be monitored particularly closely during this time period. Psychotropic medications for pediatric patients should be part of a comprehensive and integrated treatment and monitoring strategy, including therapeutic drug monitoring and coordinated communication among providers, caregivers, and patients. Although suicide attempts in children younger than five are extremely rare, they do occur (Rosenthal and Rosenthal Am J Psychiatr 141(4):520–25, 1984) [IV]; treatment will focus on family factors and will typically employ dyadic models of psychotherapy to develop or reestablish co-regulation between the child and the caregiver.

Keywords

SuicideTreatmentSuicidal behaviorSuicidal ideationSuicide riskChildAdolescentPediatricPsychopharmacologyAntidepressantSelective serotonin reuptake inhibitor (SSRI)Serotonin-norepinephrine reuptake inhibitor (SNRI)Mood stabilizerAntiepilepticSecond generation antipsychoticPsychotherapyAttachment Based Family Therapy (ABFT)Intensive Interpersonal Psychotherapy for Depressed Adolescents with Suicide Risk (IPT-A-IN)Resourceful Adolescent Parent Program (RAP-P)Youth-Nominated Support Team (YST)Mentalization-Based Treatment for Adolescents (MBT-A)Developmental Group Psychotherapy (DGP)Dialectical Behavior Therapy for Adolescents (DBT-A)Integrated Cognitive-Behavioral Therapy (I-CBT)Multisystemic Therapy (MST)

Introduction

Historically, suicidal behavior has been characterized as a symptom of depression, bipolar disorder, and borderline personality disorder in the medical classification systems (U.S. Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD)) [4, 5] [NC, NC]. In children and adolescents, suicide is a relatively rare event. Nevertheless, in 2010, it ranked as the third leading cause of death among children ages 10 to 14; and the second leading cause of death among adolescents [6] [NC]. Clinicians often do not pay close attention to suicidal ideation and behavior in patients before adolescence, believing that children are too young to understand suicide and see it as a method of alleviating stress. Yet children five years of age to six years of age understand the idea of killing themselves even if they still believe that death is not final. By age seven or eight, children develop an accurate view of death as being irrevocable, understand the concept of killing oneself, and know lethal methods [79] [IV, IV, IV]]. Oftentimes one of the more important interventions is to convey that suicide is not inevitable or constructive for anyone.

Recognizing the risk of suicidal behavior is difficult. In young children, clinicians must be attuned to pediatric manifestations of depression such as unprompted crying, poor concentration, withdrawal, blunted emotions, or morbid themes during play. Contrary to the common belief that children and adolescents should not be asked about topics such as suicide for fear of their suggestibility, asking direct questions is a safe method for determining risk [10] [I]. Several scales exist with specific prompts to assess for suicide risk and can be used in pediatric populations (e.g., Columbia Suicide Severity Rating Scale (C-SSRS), Suicidal Behaviors Questionnaire for Children (SBQ–C), Suicidal Ideation Questionnaire-Junior (SIQ-JR). A critical objective in any suicide risk assessment is to distinguish suicidal and non-suicidal behavior or ideation on the basis of intent to die (or any non-zero intent to die as a result of the act) or wish to die, respectively.

Herein, we review treatments for high-risk children and adolescents who have a history of suicidal behavior. Few randomized controlled treatment trials examine youth suicidal behavior as a primary or even secondary outcome, and those that do must contend with low base-rates of suicidal behavior [11] [IV] and inconsistent classification and assessment of suicidal behavior (and ideation) [12] [I]. In spite of significant limitations, some support exists for the efficacy of psychotherapeutic treatment modalities and several psychopharmacological agents have shown promise and merit further research as treatment options. Other somatic treatment options targeting psychopathology (e.g., electroconvulsive therapy, transcranial magnetic stimulation, deep brain stimulation, or complementary and alternative medicine treatments such as creatine) have been tested in children and adolescents but are beyond the scope of this review.

Psychopharmacological treatment options

There is a dearth of randomized controlled trials (RCTs) to determine the safety, efficacy, and dosage of promising medications in children and adolescents engaging in suicidal behavior. Existing RCTs examine suicide-related outcomes in pediatric populations in the context of psychopathology such as major depressive disorder and many of them exclude patients with a history of suicidal behavior. Other limitations to be cognizant of in interpreting empirical findings are retrospective data collection methods, short study duration, other study design issues (e.g., open-label and uncontrolled trials, analyses that pool multiple medications), and failure to capture the substantial neurodevelopmental heterogeneity inherent in the pediatric population.

Currently, no medications demonstrate efficacy in the treatment of specifically pediatric suicidal behavior. Because of this and the unresolved safety concerns for several medications, clinicians should ensure careful monitoring of baseline and follow-up levels of anxiety, agitation, sleep disturbance, mixed states, or psychosis, all of which may increase suicide risk [13] [NC].

Evidence for psychopharmacological treatment efficacy of suicidal behavior in adults has been limited to lithium in major affective disorders [14, 15] [I, IV] and clozapine in psychotic illnesses [16] [II] and cannot be assumed to generalize to children and adolescents [17] [IV]. Drug effects and drug disposition may substantially differ between pediatric patients and adults and pharmacokinetics and pharmacodynamics may vary with age in childhood [18] [NC]. Additional limited, preliminary findings indicate efficacy of fluoxetine and venlafaxine in suicidal behavior treatment in adult and geriatric populations; in pediatric populations, fluoxetine efficacy was not found and venlafaxine efficacy was not examined [19••] [I]. However, antidepressants have demonstrated modest efficacy in the treatment of pediatric major depressive disorder [20] [I].

Three medication classes – antidepressants, mood stabilizers, and antipsychotics – are presented below on the basis of their use in pediatric major depressive disorder (MDD) and bipolar disorder (BP), which include suicidal behavior or ideation in their diagnostic criteria. Many RCT meta-analyses have suggested that antidepressants can paradoxically increase suicide risk for at least a subset of the pediatric population [2022] [I, I, IV]; however, treatment benefits for primary diagnoses may outweigh risks [20] [I]. Additional evidence is presented within these medication classes regarding their efficacy in the treatment of aggression, which is thought to derive from similar mechanisms of serotonergic dysfunction as those underlying suicidal behavior [2325] [NC, NC, IV]. Due to the lack of pharmacokinetic studies to determine dosage for the treatment of pediatric suicidal behavior, clinicians should incorporate knowledge of typical pediatric dosages, therapeutic drug monitoring, and clinical observation to formulate individualized dosage regimens.

Antidepressants

In 2004, the FDA issued a warning on possible increased risk for suicide in children and adolescents taking antidepressants. Pooled analyses of randomized controlled trials in FDA databases suggested, based on adverse event reports, that pediatric patients receiving antidepressants had twice the risk of suicidal ideation or behavior compared to those receiving placebo (4 % versus 2 %); however, no deaths by suicide occurred in any of the treatment arms [26] [I]. In 2007, after reviewing adult studies [27] [I], the FDA expanded its warning to include young adults ages 18–24. The review found a modest protective effect of antidepressants in adults ages 25–64 and a stronger protective effect in adults aged 65 and older [27] [I], findings that have been further substantiated by a subsequent FDA meta-analysis [28] [I]. Pharmaceutical industry meta-analyses in adults have also shown improvements in suicidal ideation or behavior for specific antidepressants [29, 30] [I, I], while research findings regarding antidepressant safety in children, adolescents, and adults younger than 25 years remain mixed [19••, 22] [I, IV]. Notably, the direction of the relationship between medication and suicidal events depended on the assessment method; the analysis of symptom scales in the 2006 FDA meta-analysis showed no deterioration in suicidal ideation or behavior, while the analysis of the spontaneous reports of suicide-related adverse events showed onset or worsening in suicidal ideation or behavior. The discrepancy between adverse event report data and rating scale data is illustrated in the Treatment for Adolescents with Depression Study (TADS). While fluoxetine was effective in treating depression and suicidal ideation assessed with rating scales, spontaneous reports of suicidal ideation and behavior were increased in those administered fluoxetine relative to placebo [31, 32] [I, I].

More recent RCT meta-analyses replicate findings that antidepressants are not effective in the treatment of suicidal behavior in children and adolescents in the short-term [20] [I] [19••] [I]. However, a decrease in U.S. SSRI prescription rates as a result of the FDA warning has been associated with an increase in the rate of pediatric suicides in the U.S. [33] [NC]. Conversely, a steady increase in SSRI prescriptions is associated with a decline in the pediatric suicide rate [34] [NC]. Additionally, antidepressants are effective in the treatment of pediatric major depressive disorder (MDD), obsessive-compulsive disorder (OCD), and non-OCD anxiety disorders [20] [I], all of which are risk factors for pediatric suicidal behavior [35] [NC]. Altogether, these findings suggest the possibility of long-term antidepressant efficacy for pediatric suicidal behavior [36, 37•, 38] [IV, IV, I].

Antidepressants can differentially impact subsets of the pediatric population (e.g., by age group [20] [I], severity of depression [32] [I]); thus, it is also possible that specific antidepressants may increase suicide risk for some and reduce risk for others. Some original research is consistent with this hypothesis. A recent industry-sponsored uncontrolled open-label study on duloxetine in pediatric patients with MDD found worsening of suicidal ideation and behavior in 2.8 % of all patients, along with a 90 % improvement rate in suicidal ideation among those with suicidal ideation at baseline [39] [IV]. Clinicians may need to weigh the potential treatment benefits against possible increased suicide risk for a subset of patients.

The majority of primary research suggests that antidepressants, when analyzed individually or pooled, are no more effective than psychotherapy, placebo, or other individual antidepressants in the short term in reducing suicide-related outcomes. The only existing pediatric study with suicidal behavior as a primary outcome is the Treatment of Adolescent Suicide Attempters study (TASA), with an uncontrolled, open treatment design, which used The Texas Medication Algorithm, consisting of antidepressants and mood stabilizers [40] [IV]. Medication was found to be no more effective than psychotherapy or combination treatment in reducing suicidal outcomes [41] [IV]. A randomized placebo-controlled multisite trial found that both escitalopram and placebo were associated with increased suicidal ideation during the trial and that few in either group had a worsening of suicidal behavior [42] [I]. The Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) study found no treatment differences in primary and secondary outcome measures related to depression or to suicidal ideation or behavior (all showed decreases over time) between switching to venlafaxine or to another SSRI (either paroxetine, citalopram, or fluoxetine) [43] [II].

Some side effects of venlafaxine (SNRI) may be more frequent or severe relative to those of SSRIs in adolescents [43] [II] and venlafaxine may show increases in suicidal ideation or behavior in youth in spite of its efficacy in the treatment of pediatric major depression [44] [I]. When choosing an antidepressant, clinicians may decide to prescribe SSRIs due to their low side effect profiles, but such a rationale may be premature without more extensive knowledge of long-term efficacy and mechanisms of action of specific antidepressants. Monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs), on the other hand, are not recommended due to more severe side effect profiles than the newer SSRIs, a higher potential for lethal overdose, and the finding that suicide rates have decreased since the increase in use of non-MAOI and non-TCA antidepressants in the 1980s [13, 45, 46] [NC, NC, NC].

Knowledge of time to effect of specific antidepressants may help illuminate understanding of whether there is increased short-term suicide risk in the period before onset of drug effect or whether short-term risk increases in periods corresponding to the onset of side effects such as akathisia. Drugs with shorter times to effect may be good initial candidates for research that determines antidepressant effects on suicidal behavior.

Contraindications

SSRI-induced manic episodes have been reported in children and adolescents with bipolar disorder [47] [NC]. Duloxetine should be administered with caution in children with epilepsy [48] [NC]. Venlafaxine doses should be adjusted in patients with hepatic or renal disease, as they may eliminate venlafaxine at a slower rate and experience increased serum levels [49] [NC].

Main drug interactions

SSRI interactions include MAOIs, triptans, ergotamines, tryptophan, CYP2A4-inhibiting SSRIs, tramadol, CYP2D6-inhibiting SSRIs, and tight protein-bound medications (e.g., warfarin, diazepam propandol) [50] [NC]. SNRI interactions include MAOIs, tryptophan, tramadol hyperchloride, and medications that utilize the CYP450, CYP2D6 and/or CYP1A2 pathways, including some antipsychotics, β--blockers, and antiarrhythmics.

Main side effects

Side effects of SSRIs, many of which appear within the first few weeks of treatment but resolve over time, include nausea, vomiting, mania, increased sweating, headaches, dizziness, diarrhea, fluctuations in appetite, weight changes, vivid dreams, bruxism, somnolence, tremors, and akathisia. Risk of bleeding may increase and sexual side effects may also occur [48] [NC]. Reports of SNRI side effects include headache, abdominal pain, anorexia, accidental injury, nausea, constipation, and increased blood pressure [5154] [I, I, IV, IV].

Special points

Fluoxetine is indicated for use by the FDA in children eight years and older with MDD. Escitalopram is FDA-approved for children 12 years and older with MDD [17] [NC].

Mood stabilizers

The efficacy of mood stabilizers in treating suicidal behavior in children and adolescents has not been researched. In adults with mood disorders, research suggests lithium is effective in the treatment of suicidal behavior [14, 15] [I, IV]. Lithium may be useful in treating manic episodes in some children and adolescents [5558] [IV, IV, IV, IV], as well as depressive episodes in adolescents [59] [IV], and in preventing symptomatic relapse in adolescents with bipolar disorder [60, 61] [NC, NC]. Symptom-reduction in bipolar disorder may serve to reduce suicidal ideation or behavior, a DSM-5 sub-criterion of bipolar disorder, particularly during depressive or mixed episodes, which may confer additional suicide risk [62, 63] [NC, NC]. Lithium has also been shown to effectively treat aggression in children and adolescents with conduct disorder [6466] [I, IV, I]; in adults with mood disorders, aggression is associated with suicide attempts [6769] [NC, NC, NC].

Divalproex sodium is commonly used to treat mania or mixed episodes in children and adolescents with bipolar disorder. However research is inconclusive regarding its efficacy [57, 70] [IV, I], and a recent single-blind RCT indicates that risperidone may be more effective than lithium or divalproex sodium in treating mania in children (with the disadvantage of metabolic side effects) [71] [II]. Additionally, divalproex sodium may be less safe than lithium with regard to the risk of suicide attempts or deaths by suicide among patients 14 years of age and older [72] [IV]. This is consistent with an FDA meta-analysis of spontaneous reports, which found twice the risk among patients receiving antiepileptics compared to those receiving placebo – leading to the warning (non-Black-Box) on product labels issued by the FDA in 2008 [73] [I]. Divalproex may reduce aggression, explosive temper, and mood lability - risk factors for suicidal behavior - in children and adolescents with disruptive disorders. Youth with PTSD and conduct disorder receiving high doses of divalproex showed significant improvement in aggression suppression relative to those receiving low doses [74] [II]. In children and adolescents with oppositional defiant disorder or conduct disorder ages 10–18, divalproex demonstrated efficacy in the treatment of explosive temper and mood lability [75] [I].

Contraindications

Patients with renal, cardiovascular, or thyroid disease as well as those with severe dehydration should have their serum levels monitored closely when administered lithium. Serum level and liver functions should also be carefully monitored in individuals with significant liver dysfunction [76] [NC] or deficits in ammonia metabolism [77, 78] [NC, NC]. Divalproex sodium is contraindicated for any condition in children younger than two years of age [79] [NC]. Pregnant youth should not take lithium or divalproex sodium due to an association between lithium and fetal cardiac abnormalities [80] [NC].

Main drug interactions

Interactions may occur with medications metabolized by the same cytochrome P450 enzymes as divalproex sodium. These include erythromycin, SSRIs, cimetidine, salicylates, phenobarbital, primidone, carbamazepine, phenytoin, tricyclics, and lamotrigine [48] [NC]. Antibiotics, nonsteroidal anti-inflammatory agents, angiotensin-converting enzyme inhibitors, calcium channel blockers, antipsychotic agents, propanolol, and SSRIs may increase lithium level.

Main side effects

Nausea, diarrhea, abdominal distress, sedation, tremor, polyuria, weight gain, and acne are common side effects from lithium. Due to lithium’s low therapeutic index, care should be taken not to exceed lithium’s therapeutic serum level. Tremor, headache, sedation, polycystic ovary syndrome, nausea, stomach pains, leucopenia, thrombocytopenia, elevated liver function enzymes or pancreatic enzymes, and hepatic failure (potentially fatal) may occur with divalproex sodium use [79] [NC].

Special points

Lithium is FDA-approved to treat manic episodes in patients with bipolar disorder who are 12 years of age or older.

Second generation antipsychotics

Although several studies have demonstrated efficacy of atypical antipsychotics in pediatric populations for the treatment of aggression in disruptive disorders (risperidone) [81, 82] [II, I] and mania in bipolar disorders (quetiapine and ziprasidone) [83, 84] [I, IV], no efficacy studies have been conducted specifically for suicidal behavior. In adults with bipolar disorder, augmentation of mood stabilizers with olanzapine was associated with reduced suicidal ideation [85] [I].

Contraindications

Those with myeloproliferative disorders, uncontrolled epilepsy, a history of clozapine-induced agranulocytosis or severe granulocytopenia, hepatic impairment, renal impairment, familial long QT syndrome, history of cardiac arrhythmias, or other significant cardiovascular illnesses should not take certain second generation antipsychotics [79] [NC].

Main drug interactions

Drugs that are metabolized by the same cytochrome P450 enzyme, which include CYP450 3A4, 2D6, 1A2, 2C19 and 2C9 for many atypical antipsychotics, should be avoided [86] [NC]. Only 33 % of ziprasidone undergoes CYP first-pass metabolism; hence, the probability of its drug-drug interactions is lower relative to most other antipsychotic medications.

Main side effects

Side effects can include nausea, emesis, headache, sedation, activation, akathisia and other extrapyramidal side-effects (EPSE), weight gain, agranulocystosis, neutropenia [87] [IV], seizures, glucose intolerance, orthostasis, cataracts (found in animal studies of quetiapine), prolactin elevation, QTc prolongation, and elevated heart rate [88] [NC].

Special points

Risperidone, aripiprazole, quetiapine, and olanzapine are FDA-approved to treat bipolar disorder in children ten years and older. Clozapine is FDA-approved to treat suicidal ideation and behavior in adults with schizophrenia. However, clozapine has a severe side-effect profile in children and adolescents; it induces neutropenia at a higher rate in children than in adults [87] [IV] and is associated with risk for potentially fatal agranulocytosis [88] [NC]. Clozapine may be indicated for children and adolescents with schizophrenia or schizoaffective disorder who are at high-risk for re-experiencing suicidal behavior [79] [NC].

Psychotherapeutic models of treatment

Psychotherapeutic models of treatment for youth suicidal behavior aim to reduce frequency and to treat underpinnings of the behavior. Suicidal ideation is necessarily a primary foci of psychotherapy with suicidal patients, and, as such, is typically examined in any treatment efficacy study for suicidal behavior. Some therapies directly target suicidal thoughts and behaviors while others target assumed underlying psychopathology [89, 90].

This review of empirically-tested psychotherapies for pediatric suicidal behavior limits its scope to treatments that 1) were developed or adapted specifically to reduce suicidal ideation and/or suicidal behavior in the pediatric population, 2) were examined in at least one randomized controlled trial, and 3) demonstrated significant effects in reducing suicidal ideation and/or suicidal behavior. Nine treatments were identified that meet these criteria: MST, ABFT, MBT-A, DBT-A, I-CBT, IPT-A-IN, YST, DGP, and RAP-P (Table 1).
Table 1

Psychotherapy abbreviations

ABFT

Attachment Based Family Therapy

DBT-A

Dialectical Behavior Therapy for Adolescents

DGP

Developmental Group Psychotherapy

I-CBT

Integrated Cognitive-Behavioral Therapy

IPT-A-IN

Intensive Interpersonal Psychotherapy for

Depressed Adolescents with Suicide Risk

MST

Multisystemic Therapy

MBT-A

Mentalization-Based Therapy for Adolescents

RAP-P

Resourceful Adolescent Parent Program

YST

Youth-Nominated Support Team

These psychotherapeutic treatments share common elements of providing psychoeducation, increasing crisis management skills, teaching problem-solving and coping skills, enhancing familial relationships, and improving global functioning, but their postulated mechanisms of change vary. Further, they range widely in duration (e.g., five sessions or year-long intensive treatment programs), therapy setting (e.g., outpatient, home, school, or emergency departments), and therapist time commitment (e.g., time-limited sessions or on-call 24 hours/day and 7 days/week).

Of the nine treatments reviewed, I-CBT and MST were the only treatments shown to significantly reduce suicidal behaviors, defined as self-injurious behavior with intent to die. Both emphasize caregiver involvement in the treatment process and the importance of repairing family relationships. The efficacy studies of MBT-A, DGP, DBT-A, and RAP-P claiming reduction in suicidal behaviors used a range of outcomes that combined suicidal behavior with non-suicidal self-injurious behavior and/or suicidal ideation. Attachment Based Family Therapy (ABFT), Intensive Interpersonal Psychotherapy for Depressed Adolescents with Suicide Risk (IPT-A-IN), and Youth-Nominated Support Team (YST) have only demonstrated reduction of suicidal ideation. None of the treatments have been studied with children younger than ten.

Multisystemic therapy (MST)

Description

MST is an intensive, home-based treatment rooted in the principle that maladaptive behaviors result from the interaction of individual, family, school, peer, and neighborhood factors. This treatment was originally developed for high-risk antisocial adolescents with the goal of rehabilitating them in their natural environments and has since been adapted for youth with suicidal behavior. The aim of MST is to engage members of the adolescent’s entire social network to aid in the reduction of suicidal behaviors, ideation and planning. The protocol involves administering family therapy (including behavioral parent training), teaching crisis management techniques, and training caregivers in containment and monitoring procedures, such as structuring time and supporting youth in disengaging from delinquent social networks.

Efficacy of MST has been tested in one randomized controlled trial. Participants were youth aged 10 to 17 presenting to the emergency department with a suicide attempt, suicidal ideation, suicide plans, homicidal behavior, homicidal ideation, or psychosis [91] [I]. MST-treated youth showed a reduction of self-reported suicide attempts at the one-year follow-up. No reductions in rates of depression, suicidal ideation, or hopelessness were reported [91] [I].

Treatment Duration

3–6 months

Minimum Degree to Practice

MSW

Training

Information may be accessed at http://www.mstservices.com.

Special Points

MST is a home-based treatment; therapists are on call 24 hours/day, 7 days/week to assist during crises and may engage in daily contact with family when appropriate.

Contraindications

MST is not appropriate in cases where family and/or school involvement cannot be secured.

Attachment based family therapy (ABFT)

Description

ABFT is based on the notion that adolescent suicide emerges as a result of family conflict when parents fail to help their adolescent work through difficult experiences. ABFT utilizes parent-adolescent dialogue to rebuild trust and reestablish caregivers as the “secure base,” (i.e., being caring and protective while supporting the adolescent’s autonomy and ability to withstand life stress independently). The protocol aims to increase familial support, communication, and problem-solving skills among family members. Parents are taught skills in emotion-focused parenting and in monitoring and contingency management.

One randomized controlled study has examined the efficacy of ABFT specifically for suicide risk. Participants were adolescents aged 12 to 17 presenting to primary care or emergency departments with suicidal ideation and above moderate depression [92] [I]. ABFT-treated youth showed a reduction of suicidal ideation at three and six months follow-up. ABFT did not demonstrate an effect on suicidal behavior [92] [I].

Treatment Duration

3 months

Minimum Degree to Practice

MSW

Training

Information may be accessed at http://www.research.chop.edu/programs/cfis/contactus.php.

Contraindications

ABFT is not appropriate in cases where family involvement cannot be secured.

Mentalization-based treatment for adolescents (MBT-A)

Description

MBT-A is grounded in attachment theory and is often used to treat borderline personality disorder [93•] [I]. MBT-A is a psychoanalytic treatment based on the notion that self-harming behaviors, as a form of disrupted self-regulation, are rooted in difficulties with envisioning internal states of self and others (mentalization) – a capacity that makes behavior meaningful and predictable. Enhancing one's ability to mentalize is hypothesized to decrease impulsivity, improve affect regulation, and aid in establishing a coherent concept of self, thereby enhancing interpersonal relationships and reducing self-harming behaviors.

One randomized controlled trial was conducted to determine the efficacy of MBT-A in reducing occurrences of self-harm. Participants were adolescents aged 12 to 17 presenting to community mental health services or emergency care with self-harm. MBT-A resulted in the reduction of self-harming occurrences and depression at the one-year follow-up [93•] [I]. This effect was mediated by self-reported mentalization and a decrease in avoidant attachment. The outcome measure did not distinguish between self-injurious behaviors enacted with and without suicidal intent.

Treatment Duration

12 months

Minimum Degree to Practice

MSW

Training

Information may be accessed at http://www.annafreud.org/pages/mentalization-based-treatment-training-programme.html.

Special Points

MBT-A includes weekly individual and monthly family therapy sessions.

Contraindications

None

Dialectical behavior therapy for adolescents (DBT-A)

Description

DBT is a form of cognitive-behavioral therapy, originally developed for chronically suicidal patients [94] [II]. It has since been adapted for adolescents who have attempted suicide (DBT-A) [89] [NC]. It is a multi-modal and multi-phase treatment that utilizes individual and group therapy and phone and treatment team consultations to progress patients from gaining behavioral control over immediate actions, to improving their overall emotional functioning, to reducing problems in everyday living, and, ultimately, to discovering joy. The primary target of treatment is the adolescent’s life-threatening behaviors. To that end, stabilization in the initial phase of treatment is achieved by reducing behaviors interfering with quality of life (e.g., non-suicidal self-injury) and with therapy (e.g., missing sessions), and increasing behavioral skills - most importantly, emotion regulation. Therapists teach adolescents mindfulness, interpersonal effectiveness, and stress tolerance skills.

In an ongoing RCT of a 20-week version of DBT-A with child and adolescent outpatients (ages 10–18), preliminary data suggest that participants receiving DBT-A show reductions in suicidal ideation and frequency of self-harming behaviors relative to those receiving Treatment As Usual (TAU) [95] [I]. Follow-up studies of these patients to determine maintenance of gains are currently underway.

Treatment Duration

5 months

Minimum Degree to Practice

MSW

Training

Information regarding DBT training may be accessed at www.behavioraltech.org.

Special Points

Extensive clinician training is needed and therapists are on call 24 hours/day, 7 days/week to assist during crises.

Contraindications

None

Integrated cognitive-behavioral therapy (I-CBT)

Description

I-CBT focuses on teaching individuals how to identify the relationship between their thoughts and feelings in order to alter thought patterns that lead to negative behaviors. I-CBT targets suicidal behaviors directly by modifying thoughts, behaviors, and affective response patterns that trigger suicidal ideation and behavior. Therapists working with adolescents employ motivational interviewing and teach skills in coping, problem solving, affect regulation, cognitive restructuring, and communication. The goal of parent sessions is to increase adolescent-parent communication and to teach parents skills in modeling, affect regulation and contingency management [96••].

In a RCT of I-CBT, developed for adolescents with co-occurring suicidal ideation or behavior (a suicide attempt in the past three months or elevated suicidal ideation in the past month) and alcohol or other drug use disorder (AOD), the I-CBT group showed reductions in suicide attempts, emergency department visits, arrests, inpatient psychiatric hospitalization, heavy drinking days, marijuana use, and global impairment [96••] [I].

Treatment Duration

6 months

Minimum Degree to Practice

MSW

Training

Information can be obtained from the corresponding author of Esposito-Smythers et al. (2011).

Special Points

Two therapists are assigned to each case; one administers adolescent individual therapy and another administers parent and family therapy.

Contraindications

None

Intensive interpersonal psychotherapy for depressed adolescents with suicide risk (IPT-A-IN)

Description

Interpersonal psychotherapy (IPT) was adapted for adolescents by Mufson and colleagues (2004) to treat adolescent depression (IPT-A) [97, 98] [I, I]. IPT-A-IN is a shortened and more intense form of the manualized IPT-A and is designed to address imminent suicide risk in depressed adolescents [99] [I]. IPT-A-IN is based on the premise that depression and associated self-injurious behaviors result from ineffective and conflict-ridden interpersonal relationships. The protocol involves providing adolescents with psychoeducation about interpersonal conflicts and their relationship to mood states. Therapists work with adolescents on negotiating developmental tasks (e.g., autonomy exploration).

A RCT [99] [I] compared IPT-A-IN (administered by a treating clinician in bi-weekly sessions over six weeks) with TAU in 12–18 year olds with suicidal ideation, a previous suicide attempt, or elevated symptoms of depression, anxiety, or hopelessness. The IPT-A-IN group showed significant reductions in depression, hopelessness, and suicidal ideation but not in suicidal behaviors.

Treatment Duration

6 weeks

Minimum Degree to Practice

MSW

Training

Information can be obtained from the corresponding author of Tang et al. (2009).

Special Points

Treatment typically occurs in outpatient settings, including schools.

Contraindications

None

Youth-nominated support team (YST)

Description

YST was developed as an adjunctive treatment to standard care for adolescents with recent suicidal ideation or a suicide attempt. YST is grounded in the view that social support may be a powerful protective factor against suicidal behaviors among youth. The program aims to reduce suicidal ideation and behavior through enhancing social integration and support. Adolescents nominate a guardian and three other individuals to act as support team members [100] [I] who will maintain weekly check-ins with the adolescent. Psychoeducation and crisis management are taught to the support team members in either individual or group sessions.

Two randomized controlled trials with psychiatrically hospitalized adolescents with recent (past four weeks) significant suicidal ideation or behavior have been conducted to examine the efficacy of six-month (YST-1) and three-month (YST-2) versions of the treatment. YST-1 with 12–17 year olds demonstrated reduction of suicidal ideation and functional impairment among girls at the 6-month follow-up, with no significant reductions in suicidal behaviors in either gender [100] [I]. YST-2, with 13–17 year olds did not demonstrate reduction of suicidal ideation or behavior among the general sample. In those with a history of multiple suicide attempts, it reduced suicidal ideation more rapidly than routine care measured at the six-week follow up; this effect did not hold after the six-week follow-up [101] [I].

Treatment Duration

6 months (YST-1); 3 months (YST-2)

Minimum Degree to Practice

Therapists are required to have at minimum a Master's level clinical degree.

Training

Information regarding procedures can be obtained from the principal investigator, Dr. Cheryl King [101].

Contraindications

None

Developmental group psychotherapy (DGP)

Description

DGP [102] [I] was developed specifically for adolescents with self-injurious behavior, addressing themes deemed important to them [103105] [NC, NC, NC]: relationships, school and family problems, anger management, depression and self-harm, and hopelessness. The program employs positive corrective relationships and clinical techniques derived from CBT [106] [II], DBT [107] [I], and psychodynamic group psychotherapy with the goal of reducing repeated self-harm.

In a pilot RCT [102] [I] with youth aged 12–16 with depression and repeated self-harm, routine care with DGP showed a decrease in the number of self-harm occurrences and an increased mean time to re-occurrence compared to routine care alone. There was no significant difference in reduction of suicidal ideation. Two subsequent studies [108, 109] [I, I] failed to replicate these results. Differences in treatment fidelity, treatment duration, and quality of routine care may account for the differences in the results.

Treatment Duration

6+ months

Special points

The trials involved adolescents with repeated deliberate self-harm but did not distinguish suicidal from non-suicidal intent [110] [NC]. An acute and a long-term group were run continuously to allow for immediate start of treatment at a time of crisis.

Training

The treatment manual is available from Dr. Harrington, the corresponding author [102] [II].

Contraindications

None

Resourceful adolescent parent program (RAP-P)

Description

RAP-P was originally developed to promote healthy adolescent development and to build parent skills for managing parent-adolescent conflict and negative emotional reactions. RAP-P was later modified to treat suicidal adolescents, based on the premise that family conflict and poor parent-adolescent relationships lead to suicide risk. To adapt RAP-P for suicidal adolescents [111] [I], a primary psychoeducational component was incorporated, focusing on increasing parent understanding of the occurrence of suicidal thoughts and behaviors and teaching parents skills in safety planning and crisis management.

In a RCT with adolescents (aged 12 to 17) presenting to the emergency department with a history of suicidal ideation, non-suicidal self-injury, or suicidal behavior within the past 2 months [111] [I], routine care plus RAP-P led to a significant reduction on a combined measure of suicidal ideation, suicidal plans, suicidal threats, deliberate self-injury, and suicide attempts in comparison with routine care alone [111] [I]. This effect was partially mediated by change in family functioning, as reported by adolescents. Use of a combined measure of suicidal outcomes precludes conclusion that this therapy is effective specifically in reducing suicidal ideation or suicidal behaviors.

Treatment Duration

2 weeks - 1 month

Minimum Degree to Practice

Professionals in education or mental health are eligible for training.

Training

Information can be accessed at http://www.rap.qut.edu.au/programs/rap-p.jsp.

Special Points

Treatment typically occurs in home-based settings.

Contraindications

RAP-P is not appropriate in cases where family involvement cannot be secured.

Compliance with Ethics Guidelines

Conflict of Interest

Taylor Burke, Jacqueline Buchanan, Leora Amira, and Kseniya Yershova declare that they have no conflict of interest.

Kelly Posner is the director of the Center for Suicide Risk Assessment which, as part of an effort to help execute the FDA suicidality classification mandates, has received support from Abbott, Albany Molecular Research, Alfresa, Alkermes, Amgen, AstraZeneca, Biodelivery Sciences, Biomarin, Bristol-Myers Squibb, Canam, Cato Research, Cephalon, Cetero Research, Covance, CRI Worldwide, Depomed, Douglas Pharmaceuticals, EISAI, Euthymics, Forest Laboratories, GlaxoSmithKline, GW Pharma, Human Genome Sciences, i3 Research, ICON, IntelGenx Corp., Intracellular Therapies, Johnson & Johnson, Kendle Early Stage, Lilly USA, Lundbeck A/S, Lundbeck USA, MedImmune, Medtronic, Merck, Neurosearch, Next Wave Pharmaceuticals, Novartis, Noven, NovoNordisk, Orexigen, Otsuka, Parexel, Pfizer, PGx Health, PPDI, Psyadon, QED, Quintiles, Reckitt Benckiser, Roche, Sanofi-Aventis, Schering-Plough Corporation, SCOPE International, Sepracor/Sunovion, Shire, Siena Biotech, Supernus, Synosia Therapeutics, Takeda Pharmaceutical Company, Theravance, Upsher-Smith, Valeant Pharmaceuticals, Vivus, World Wide Clinical Trials and Wyeth Research. Dr. Posner receives royalty payments from the e-CSSRS.

Human and Animal Rights and Informed Consent

This article does not contain any studies with animal subjects performed by any of the authors.

Copyright information

© Springer International Publishing AG 2014

Authors and Affiliations

  • Taylor Burke
    • 1
  • Jacqueline Buchanan
    • 2
  • Leora Amira
    • 2
  • Kseniya Yershova
    • 2
  • Kelly Posner
    • 2
  1. 1.Department of PsychologyTemple UniversityPhiladelphiaUSA
  2. 2.New York State Psychiatric Institute/Columbia University Medical CenterNew YorkUSA