Combining clinical wisdom, skill, and knowledge may allow us to shift the trend toward increasing suicide rates and provide care that helps youths build lives they want to live.
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SIGNIFICANCE FOR PRACTICING PSYCHIATRISTS
FIGURE. Care process model for youths presenting with suicide and self-harm risk
Disclaimer: Included quotes are intended to provide examples for readers. These are not quotes from individual persons and any resemblance to real persons, living or dead, is purely coincidental.
I received a message from the parent of a patient that read, “He finally did it.” Tragically, the boy was found dead in his college dorm room after hanging himself. I had treated the boy when he was 15 years old following a suicide attempt. At that time, the boy was suffering from depression and suicidal thoughts. These problems remitted with treatment, and there were no other suicide attempts during high school. He went to college, and saw a psychiatrist near the college for follow-up care.
Suicide prevention is perhaps our greatest challenge. Among youth ages 10 to 24 years, suicide is the second leading cause of death. Over 6000 individuals in the 10- to 24-year age group lost their lives to suicide in 2016.1 Although still a rare event statistically (nearly 15,000 individuals in the same age range died by unintentional injuries in 2016), many of us providing psychiatric care will lose patients to suicide.1 Despite the recognition that as much as we try it is not possible to prevent all suicides, there have been substantial advances in knowledge regarding treatment. This article reviews some of these advances, which have been selected to inform clinical care.
Adolescence offers a developmental window when early effective intervention may prevent potentially deadly patterns from becoming established. Although rare in childhood, rates of suicide deaths in the United States more than double from adolescence to young adulthood and, unlike other causes of mortality for adolescents (eg, motor vehicle accidents), suicide rates are increasing.1 The first onset of suicidal behavior often occurs during adolescence, and the rate of suicide attempts (SAs) and self harm more generally (including nonsuicidal self injury [NSSI], self harm with ambiguous intent, and SAs) also increases. For those of us who work with adolescents and/or their parents, the hope is that early recognition and intervention can prevent suicidal behavior and premature deaths.
Etiology, risk, and protective processes
Suicide has no single cause, and the causes and predictors of suicide and SAs vary across individuals. Due to this heterogeneity, most risk factors account for a small proportion of the variance in predicting suicide deaths. The variation in risk and protective factors across individuals has led to interest in machine learning and related approaches to identify individuals with heightened imminent risk for suicide, with the goal of intervening to prevent deaths. Application of machine-learning algorithms within health systems could potentially be used to identify high-risk individuals and provide monitoring and care to prevent suffering and deaths.2
A previous SA or self-harm history (hereafter referred to as SA/SH) is the most consistently replicated risk factor for suicide deaths and a strong predictor of premature death by unnatural causes (eg, drug overdose, car accidents, homicide).3 Prior SA/SH history, including NSSI particularly when associated with suicidal ideation (SI) and/or depression, is also a significant predictor of nonfatal SAs. Suicide deaths increase during the young adult years, are more common in males, and are often high among American Indians and Alaskan Native populations. SAs are more common in females. Depression, substance abuse, bipolar disorders, emerging psychosis, schizophrenia, sexual and gender minority status, bullying, exposure to suicide, and other forms of psychosocial stress are associated with increased risk for fatal and nonfatal SAs. Some medical treatments may also be associated with increased suicide risk (eg, steroids and steroid withdrawal). Sleep disturbance may be an indicator of imminent suicide risk. See reviews for more information on risk and protective factors.4
Emergency evaluation/management: when a patient expresses a desire to die, cuts, or engages in other forms of self harm
“If this is an emergency, call 911 or go to your nearest emergency room.” Referral to the emergency department (ED) is often the chosen option when there is a concern regarding patient safety. Once seen in the ED, patients are assessed and triaged to inpatient care when further evaluation and acute treatment are judged to be needed, with EDs serving as gatekeepers to care for many patients. This service pathway, however, is too frequently associated with negative experiences that can decrease the willingness of youths to come forward in the future when experiencing suicidal urges and the willingness of parents to seek care when they have concerns. The increasing number of children and adolescents presenting to EDs with mental health crises combined with a limited number of psychiatric beds places stress on ED resources, often leads to extended boarding in the ED, and, as illustrated by the following quote, can contribute to inadequate care and poor outcomes5:
“Once I told my school counselor I had taken pills to kill myself, she wouldn’t let me leave. Then the police came, put handcuffs on me and took me out of the school in front of all the other kids. They took me to the emergency room where they kept me for 12 hours. Then they sent me to the hospital. It was awful. One thing I learned was never tell anyone if you are thinking of killing yourself.”
Both enhanced mental health interventions in the ED and inpatient hospitalization from the ED are associated with higher rates of linkage to outpatient follow-up treatment compared to discharge home, a first step for adequate continuity of care.5,6 This is an important goal and listed as Objective 8.4 in the US National Strategy for Suicide Prevention due to the relatively low rates of follow-up treatment seen among patients presenting with SI and SAs.4,5 Hospitalization is necessary in some instances for further evaluation, treatment, and safety. Nevertheless, hospitalization can lead to lost opportunities to support patients in coping in their usual environments and possibly worse outcomes if patients learn that they can escape stress in their lives through hospitalizations. Hospital stays are also costly. Brief therapeutic assessment in the ED or other settings may be both more effective and lead to more cost-effective care.
For youths not requiring more intensive evaluation and protection, clinicians might consider brief emergency interventions such as the Family Intervention for Suicide Prevention/Safe Alternatives for Teens and Youths (SAFETY), therapeutic assessment, and other approaches. These brief emergency interventions generally aim to mobilize protective processes in the youth and environment, and the response of patients and parents/caregivers (hereafter referred to as “parents”) during these interventions provide opportunities to further assess youth safety and the ability of parents to keep the youth safe.5-7 More specifically, these intervention/assessment approaches focus on assessing and strengthening characteristics of the youth and environment (eg, mobilize hope and reasons for living, engage in safety planning process, problem solving as needed, increasing safety within the environment, lethal means counseling, and counseling on substance use-related disinhibition). They also focus on providing support for continuity of care (eg, rapid referral/appointment scheduled, enhancing motivation for treatment, addressing treatment barriers, caring contacts) and can be integrated within a care process and triage model when there is a potential for discharge home (Figure).5
Research also indicates advantages of intensive community-based treatment, such as multisystemic therapy (MST). A randomized controlled trial (RCT) that compared MST to hospitalization among children and adolescents presenting with acute psychiatric emergencies found better outcomes and fewer SAs/SH in youths receiving MST.8 These data combined with excessive burdens on our EDs, particularly in rural and remote regions, have contributed to interest in developing prehospital programs such as urgent care and crisis teams.5
The most promising outcomes are for intensive outpatient psychotherapies with a strong family focus such as dialectical behavior therapy (DBT), a “third wave” cognitive behavioral therapy (CBT). DBT begins with CBT strategies and adds a focus on acceptance and validation, dialectical processes such as the need to achieve a balance between acceptance and change strategies, addresses behavior that interferes with therapy, and emphasizes the therapeutic relationship as key for healing. Originally developed/tested for treating suicidal adults with borderline personality disorder, DBT for adolescents includes individual psychotherapy with some family sessions, multifamily group skills training with adolescents and parents, therapist availability for phone coaching 24 hours daily for youths and parents, and weekly therapist consultation teams to support therapists in doing the best they can to provide effective treatment and stay within the treatment model.9-11 In contrast to DBT with adults, which was developed as a 1-year treatment, DBT for adolescents is briefer (16 weeks,10 or 6 months) and includes parents.9,11 There are two RCTs demonstrating benefits of DBT relative to comparator conditions (supportive therapy, treatment as usual [TAU]) for reducing SH, with one trial indicating an advantage of DBT for reducing SAs.10,11 Replication of a DBT advantage across two independent RCTs makes DBT the first well-established treatment for SH in adolescents. Further, results from both RCTs indicate an advantage of DBT for reducing SH over a 1-year follow-up period, and one trial supports cost-effectiveness of DBT relative to TAU.10-12
Other treatments have shown efficacy in reducing SAs in single trials, although replication is needed. These include: SAFETY, a DBT-informed child- and family-centered treatment found to lead to reduced SA risk relative to TAU after an SA or recurrent SH; integrated-CBT for youths presenting with substance abuse and SAs or SI that resulted in fewer SAs compared to TAU; and mentalization-based therapy for reducing SH.13-15 Meta-analyses evaluating existing trials of therapies for SH demonstrate the importance of family interventions in reducing SH.7 DBT, SAFETY, and Integrated-CBT have strong family components and use a two-therapist model with one therapist working primarily with the teen and the other primarily with the parent(s)/caregivers. Although assignment of two therapists to a case can be challenging in practice, this model allows more intensive work with parents and family within a short time frame, which may be needed with youths at high risk for suicide and SH. Enhancing the family’s ability to keep the youth safe, and the youth’s ability to accept this protection, allows parents to function like “protective seatbelts” when a youth is experiencing intense pain and distress.13
Because at least 50% of individuals who die by suicide meet criteria for psychiatric disorders, a logical approach is to treat the associated disorder using medication appropriate for that disorder.4 Depression and antidepressant treatments are common in suicidal/self-harming youths. Other common diagnostic presentations in youths include: bipolar disorder, borderline personality disorder/features, substance abuse, emerging psychoses, anxiety, and traumatic stress. Comorbidities, co-occurring problems, potential lethality of medications, and side effects also need consideration when developing a treatment plan.
The FDA-directed black box warnings regarding a possible increase in the risk of suicidal thinking and behavior in children, adolescents, and young adults (<25 years) treated with antidepressant medications, led to decreased antidepressant prescribing.16 These warnings were based on evidence reviews indicating a small increase in rates of SI and SAs following antidepressant treatment. Analyses of risk differences for “clinical response” and for “suicidal ideation and attempts,” however, suggest that benefits of antidepressant treatment are greater than risks of SI and SAs, with 4% to 11% more depressed youths benefiting from antidepressants versus experiencing a suicidal event.16 Finally, in contrast to the clinical trials that generally excluded patients with high suicide risk, results of larger and more representative pharmacoepidemiologic studies point to a protective effect of antidepressant treatment, with several studies indicating lower suicide rates with higher antidepressant use.16
Given the collective evidence, the American Academy of Child and Adolescent Psychiatry recommends treatment for depression using medication and psychotherapy treatments supported by the evidence. As well, based on the evidence, it supports combined medication and psychotherapy treatment as the most efficacious option.17 Similarly, the Society for Adolescent Medicine (SAM) supports appropriate use of antidepressant medications in the treatment for adolescents with depression and the need to balance the risk of suicidality and clinical need.18
Results on community-based, school-based, and health system approaches to prevention are also promising. The Garret Lee Smith Memorial Youth Suicide Prevention Program (GLS) is a major US initiative that funded multiple community-based suicide prevention programs across the nation. Although programs used diverse components (eg, training, community partnerships, infrastructure for improved service linkage, crisis hotlines), gatekeeper training in which teachers/others with frequent youth contact were taught to identify and refer suicidal youths was a core feature, and served as an indicator of program exposure in the evaluations. Comparisons of data from counties with GLS programs with those for similar/control counties indicated both significantly lower rates of suicide deaths and nonfatal SAs in GLS counties.19 School-based prevention programs that offer skills and work to reduce stigma associated with help seeking have also shown promise for reducing SAs.20 The Zero Suicide initiative in the US aims to support health systems in making system-wide commitments to suicide prevention using a continuous quality improvement process to identify, treat, and provide care for at-risk patients using evidence-based tools and strategies (https://zerosuicide.sprc.org/toolkit). This approach stems from promising results from the Henry Ford Health System indicating that when the health system organized around the zero suicide goal and delivery of “perfect depression care,” a decline in suicide rates was observed.4
We now have psychotherapeutic and prevention strategies with demonstrated benefits for reducing SH and SAs, effective medication treatments for disorders associated with suicide risk, and emerging care process and triage models for improving emergency evaluation and care for youths presenting with suicide and SH risk. A combination of evidence-based psychotherapy augmented by medication as appropriate when a psychiatric disorder is present is likely to be beneficial. The variation in risk and protective processes across individual youths and the complexity of pathways to suicidal behavior present challenges and highlights the importance of personalizing approaches to care to match individuals to care strategies that will be most beneficial and to time interventions optimally. Combining clinical wisdom, skill, and knowledge gained from our science offers a way forward and may allow us to shift the trend toward increasing suicide rates, successfully prevent SAs and premature deaths in our youth, and provide care that helps youths build lives they want to live.
Dr Asarnow is Professor; Dr Fogelson is Clinical Professor; Ms Fitzpatrick is Clinical Research Coordinator; Psychiatry and Biobehavioral Sciences, University of California, Los Angeles; Dr Hughes is Assistant Professor, Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX. Dr Asarnow reports that she is a consultant/receives funding from the NIMH, the Substance Abuse and Mental Health Services Administration, the American Psychological Association, the American Foundation for Suicide Prevention, and the Klingenstein Third Generation Foundation. Drs Fogelson and Hughes and Ms Fitzpatrick report no conflicts of interest concerning the subject matter of this article.
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