EvidenceBased Practice with Suicidal Adolescents

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Evidence-Based Practice with Suicidal Adolescents

• Cheryl A. King, Ph.D., ABPP
• Departments of Psychiatry and Psychology
• University of Michigan
• Director, Youth Depression and Suicide Prevention
  Program

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U.S. Suicides by Age
Source National Center for Health Statistics,
2003
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Suicide Rates by Age, Race, and Gender United
States
Source National Center for Health Statistics,
2002 Note non-Hispanic ethnicity
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Suicide Rates by Age, Race, and Gender United
States
Source National Center for Health Statistics,
1999-2002 Note non-Hispanic ethnicity
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(No Transcript)
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Adolescent Suicide Attempts
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Mental Health Model Evidence-Based Practice

• Risk Assessment and Formulation
• Intervention and Care Management

Limited Evidence for Interventions
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Assessmentand Risk Formulation

• 1. Manage own reactions to youth and youths
  suicide risk/collaborative stance
• 2. Understand risk and protective factors
• 3. Collect accurate assessment information
• a. Risk factors
• b. Current suicidal intent/impulses
• c. Mental status
• 5. Formulate risk/Develop plan

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Risk Assessment and Formulation

• Risk Factors Current Suicidal Mental
  Status
• Ideation/Impulses
• RISK FORMULATION

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Understand Youth Suicide Risk

• History of Suicidality/Current Suicidality
• Psychopathology/Mental Disorder
• Psychological Characteristics, Behavioral
  Patterns
• Family Interpersonal Stress
• Availability of Means

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Suicidal Ideation and AttemptsContinuum of
Suicidal Behavior

• Frequent thoughts of suicide best predictor of
  suicide attempts (Kienhorst et al., 1990 9,393
  students Netherlands)
• Most adolescent suicide attempters report history
  of suicidal ideation (Oregon Adolescent
  Depression Project OADP Lewinsohn et al., 1996)
• 87.8 females
• 87.1 males

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Suicidal Ideation and AttemptsContinuum of
Suicidal Behavior

• Severity of suicidal ideation increases
  likelihood of suicide attempt during next year
  (OADP study)
• High baseline ideation 16.7 attempts
• Moderate baseline ideation 6.7
• Mild baseline ideation 2.8
• No baseline ideation 0.3

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Lifetime Suicide Attempt HistoryContinuum of
Suicidal Behavior

• In 448 psychiatrically hospitalized, suicidal
  adolescents, multiple attempts, versus single
  attempt or ideation only, assoc. with
• (King et al., 2008)
• More severe suicidal thoughts, trauma,
  alcohol/drug misuse, problematic behavior toward
  others
• In community study of 16,000 adolescents,
  multiple attempts assoc. with health risks
  (Rosenberg et al., 2005)
• Heavy alcohol use/hard drug use
• Sexual assault, Violence

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Suicidal Ideation and AttemptsContinuum of
Suicidal Behavior

• History of suicide attempts common among
  adolescents who complete suicide
• 44 (Brent et al. 1988)
• 34 (Marttunen et al., 1992)

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Suicidal Ideation and AttemptsContinuum of
Suicidal Behavior

• Outcome of adolescents hospitalized following
  suicide attempts
• MALES
• 8.7 suicide (5 years Kotila, 1992)
• 9.0 suicide (4- to 10-years Motto, 1984)
• 11.3 suicide (10-15 years Otto, 1972)
• FEMALES
• 1.2 suicide (5 yr follow-up Kotila, 1992)

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Psychiatric Disorder

• Psychiatric Disorders/Psychopathology
• Depressive /Bipolar disorder
• Alcohol/Substance abuse
• Conduct Disorder (pattern of aggressive
  impulsivity)

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Depressive Disorders in Youth and Suicidality

• 85 report significant suicidal ideation 32
  attempt suicide by late adolescence
• Past suicide attempt and current depressive
  disorder strongest predictors of future suicide
  attempt
• 1/2 adolescent male suicide victims and 2/3
  female suicide victims suffered from depressive
  disorder

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Alcohol/Substance Abuse in Youthand Suicidality

• Adolescents with alcohol abuse/dependence nearly
  7X more likely to attempt suicide than others
  (OADP Andrews Lewinsohn, 1992)
• Alcohol abuse predicts eventual suicide in 5-yr
  follow-up of hospitalized attempters (Kotila,
  1992)
• Recent alcohol ingestion common in suicide (28,
  Hoberman Garfinkel, 1988 51, Marttunen et
  al., 1991)

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Antisocial Behavior, Aggression, Impulsivity

• Psychological Autopsy Studies of Completed
  Suicide
• 43.4 adolescents displayed antisocial behavior
  during year (Marttunen et al., 1992)
• 70 adolescents had hx antisocial behavior
  (Shafii et al., 1985)

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Family and Interpersonal Stress

• Interpersonal conflict/loss is most common
  precipitant of completed suicide (Martunnen et
  al., 1993)
• Interpersonal conflict/loss and
  legal/disciplinary problems relate to suicide
  attempts
• Family loss/instability is nonspecific predictor
  of suicidality

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Gay, Lesbian, Bisexual (GLB) Youth

• General Population Surveys (Garofalo et al.,
  1998 Remafedi et al., 1998)
• 42 GLB Youth Suicidal Ideation past year
• 28 GLB Youth Suicide Attempt past year
• Unique Risk Factors
• Stigmatization, discrimination
• Double Bind Disclosure vs. Nondisclosure
• Struggles with Identity/Intimate Relationships

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Availability of Means Firearms

• Firearms used by 66.4 male suicide victims
  48.3 female suicide victims (McIntosh, 2000)
• Availability of firearms in home differentiates
  adolescent suicide victims (74.1) from
  hospitalized suicidal adolescents (33.9) (Brent
  et al., 1998)

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Ascertain Suicidal Ideation, Intent, and
Impulses

• Manage emotional reactions to suicidal youth
• Strive for collaborative, nonadversarial stance
• Communicate that resolution of problem(s) is key
• Be familiar with suicide assessment tools, and
  understand their appropriate use
• Conduct functional/behavioral analysis of
  suicidality

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Parent-Adolescent Agreement Adolescents
Suicidal Thoughts and Behaviors

• Research Aims
• Examine extent to which psychiatrically
  hospitalized adolescents and their parents agree
  about the presence of suicidal thoughts, plans
  and attempts
• Explore what predicts adolescent-only and
  parent-only reported suicidality
• Klaus, Mobilio, King, under review

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Parent-Adolescent Agreement Adolescents
Suicidal Thoughts and Behaviors

• Participants
• N 448
• 71 Female
• 84 Caucasian
• Mean Age 15.6 (SD 1.3)

• Lifetime Suicide Attempts
• None 25
• One 33
• Multiple 38

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Parent-Adolescent Agreement Adolescents
Suicidal Thoughts and Behaviors

• Inclusion Criteria
• Recent suicidal ideation that was either
  unrelenting or accompanied by specific plan
• Suicide attempt within last four weeks
• Exclusion Criteria
• Severe cognitive impairment
• Direct transfer to medical unit OR residential
  placement
• Lived too great a distance
• No legal guardian (pending court assignment)

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Parent-Adolescent Agreement Adolescents
Suicidal Thoughts and Behaviors

• Extent of Parent-Adolescent disagreement
• 37 parents unaware of reported suicidal thoughts
• 59 parents unaware of reported suicide plans
• Predictors of Parent-Only Endorsement
• Suicidal Thoughts
• Lower YSR internalizing scores

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Parent-Adolescent Agreement Adolescents
Suicidal Thoughts and Behaviors

• Predictors of Adolescent-Only Endorsement
• Suicidal Thoughts
• Parental hx mental illness
• lower internalizing symptoms
• Suicide Plans
• Lower perceived family support Less Parental
  distress
• Suicide Attempts
• Lower perceived family support

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Suicidal Ideation and Impulses Clinically Useful
Instruments (somewhat)

• Suicidal Ideation Questionnaire
• Self-report 15-item, 7-point frequency scale
  (Reynolds, 1988)
• Excellent psychometric properties
• Evidence of predictive validity
• suicide attempts in American Indian adolescents
  (Keane et al., 1996)
• post-hospitalization suicide attempts in
  adolescents (King et al., 1995)

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Suicidal Ideation Questionnaire-JR Recent
Findings from Psychometric Study

• Sample 691 psychiatrically hospitalized,
  suicidal adolescents, 12-17 years
• Method
• Exploratory factor analysis with randomly
  selected ½ sample
• Construct factor model
• Confirmatory factor analysis to examine fit with
  other ½ sample
• Examine predictive validity of full scale and
  factors for boys and girls at 6 and 12 month
  follow-up

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Suicidal Ideation Questionnaire-JR Recent
Findings from Psychometric Study

• Identified Three Factor Model
• General Ideation, Interpersonal Ideation,
  Active Ideation
• Factors very good/excellent internal consistency

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Suicidal Ideation Questionnaire-JR Recent
Findings from Psychometric Study
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Suicidal Ideation Questionnaire-JR Recent
Findings from Psychometric Study

• Total scores and factor scales ONLY had
  predictive validity for girls
• No scale differences in sensitivity/specificity
• Active Ideation scale (range 0-18) 1 point
  increase assoc. with 11.9 increase in likelihood
  of attempt over 12 months
• Findings re gender and prediction consistent
  with community-based prospective study (Lewinsohn
  et al., 2001)
• Not idiosyncratic to instrument challenge as
  male adolescents much higher suicide rate

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Suicidal Ideation and Impulses Clinically
Useful Instruments

• Beck Hopelessness Scale (BHS)
• Self-report, 20-item true/false scale
  (Beck et al., 1974 Beck Steer, 1988)
• Evidence of predictive validity
• Higher scores associated with treatment drop-out
  in adolescents (Brent et al., 1997)
• Higher scores predict suicide attempts (among
  adolescents with prior history of attempt
  Goldston et al., 2000)

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Mental StatusWarning Signs of Imminent Risk

• Threatening to hurt/kill self or talking of
  wanting to hurt/kill self
• Seeking access to firearm, pills, or other means
• Talking/writing about dying or suicide, when out
  of ordinary for youth
• Additional warning signs
• Hopelessness, rage/uncontrolled anger,
  recklessness, feeling trapped, increased
  alcohol/drug use, social withdrawal,
  anxiety/agitation, no reason for living

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Risk Assessment and Formulation

• Risk Factors Current Suicidal Mental
  Status
• Ideation/Impulses
• RISK FORMULATION

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Risk Formulation

• Integrate and prioritize information
• Warning signs of imminent risk?
• Examples of moderate/high suicide risk status
• Plans and preparation for suicide attempt
• History of multiple suicide attempts plus current
  alcohol/drug abuse or significant hopelessness

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Mental Health Model Evidence-Based Practice

• Risk Assessment and Formulation
• Intervention and Care Management

Limited Evidence for Interventions
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Intervention ResearchMultisystemic Therapy (MST)

• Intensive, time-limited, family-, home-based
• Study of 156 youths approved for psych. hosp. due
  to suicidality, psychosis, threat of harm to
  self/others
• More effective than emergency hosp. in decreasing
  youth-reported (but not parent-rep. suicide
  attempts) (Non-equivalency of groups at baseline)
• MST not effective in reducing suicidal ideation,
  hopelessness, or depression severity
• (MST Henggeler et al., 2002)

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Intervention ResearchDialectical Behavior
Therapy (DBT)

• Focus on distress tolerance, emotional
  regulation, interpersonal effectivenes
• Effective in reducing suicidal behavior in adults
  
• (Linehan et al., 1991 Linehan et al., 1993)
• Quasi-Experimental Adapted DBT adolescents
• Outpatient DBT (n 29) vs. TAU (n 82)
  Approx. 24 sessions/3 mo DBT group
  fewer psych. hospitalizations. No diff. in repeat
  suicide attempts (Rathus Miller, 2002)
• Inpatient DBT Feasibility demonstrated on units
  (Katz, Cox, Gunasekara Miller, 2004)

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Intervention ResearchCognitive-Behavioral Therapy

• Remediate maladaptive cognitions and behaviors
  related to suicidality
• One published randomized controlled pilot trial
  (Donaldson, Spirito, Esposito-Smythers, 2005)
• CBT (n 18) vs. Problem-oriented support therapy
  (n 17)
• Individual with conjoint parent-adolescent
  sessions
• 10 sessions/Seven different therapists provided
  both treatments
• Adolescents in both groups reported reductions in
  suicidal ideation no between-group differences

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Intervention ResearchDevelopmental Group Therapy

• Integration of CBT, DBT, psychodynamic
  approaches (Wood, Trainor, Rothwell, Moore
  Harrington, 2001)
• Randomized Controlled Trial
• Group Therapy vs. Routine Care Median 8
  sessions
• 63 Adolescents ( 2 self-inflicted injuries)
• Group therapy associated with less repetitive
  deliberate self-harm prior to 7-month follow-up
• No Group Therapy effects on depressive symptoms
  or suicidal ideation

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Intervention ResearchEmergency Care Family
Intervention

• Psychoeducation (suicide attempts, treatment)
  Structured Family Therapy focused on
  problem-solving (Successful Negotiation/Acting
  Positively SNAP Rotherham-Borus et al., 2000)
• Quasi-experimental trial
• 140 female adolescent suicide attempters
• Specialized emergency care intervention vs.
  standard care
• No differences in suicidal ideation or attempts
  at follow-up
• Improved treatment adherence for specialized
  intervention

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Intervention ResearchHome-Based Family
Intervention

• Four-session intervention focused on deliberate
  self-harm incident, communication,
  problem-solving, psychoeducation (Harrington et
  al., 1998)
• Randomized Controlled Trial
• 162 adolescents (10-16 yrs) Deliberate
  self-poisoning
• Routine care (M 3.6 sessions) or Routine Care
  Home-based Intervention
• No main effect for intervention (6 months
  suicidal ideation, hopelessness)
• Subgroup analyses revealed reduced suicidal
  ideation for adolescents without major
  depression.

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Intervention ResearchYouth-Nominated Support
Team Intervention

• Supplemental intervention to (1) reduce suicidal
  ideation and emotional distress and (2) improve
  treatment adherence and perceived social support
• YST-I Pilot/Feasibility Trial (King et al.,
  2006)
• YST-II Randomized Controlled Trial Underway
• Treatment as usual (TAU) versus TAU YST-II
• Two hospital sites Approx. 450
  adolescents/families
• Baseline, 6-wk, 3-mo, 6-mo, 12-mo assessments
• Stay Tuned!

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Intervention ResearchWhy so little? The
Challenges

• Liability/risk management concerns general
  worries
• Burdensome (albeit necessary) regulatory
  requirements (adverse event reports)
• Heterogeneous samples (different sets of
  co-occurring psychiatric disorders)
• High probability continued suicidal ideation or
  behavior (possible removal from trial)

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Intervention ResearchWhy so little? The
Challenges

• Ethical issues constrain research designs
  (Enhanced or high quality comparison groups)
• Poor Intervention adherence (documented for
  adolescents who have engaged in suicidal
  behavior)
• Risk Management enhances usual care and may
  reduce ability to detect group differences
• Design, retention, risk management issues can
  seriously reduce statistical power

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Treatment and Care ManagementEvidence-Based
Best Practices Model

• 1. Address safety first
• 2. Specify interventions
• Immediate Response
• Remove accessible lethal means
• Consider hospitalization Crisis Response Plan
• Acute
• Provide external support
• Treat illness/symptoms and build individuals
  resources
• Continuing treatment/Care management

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Mental Health Model Treatment and Care
Management

• 3. Consider use of Crisis Response Plan or
  Coping Cards
• 4. Involve parent/guardian in developing and
  implementing treatment plan
• 5. Use evidence-based interventions to impact
  modifiable risk and protective factors (e.g.,
  Depression, Alcohol Abuse)

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A Crisis Response PlanSample Safety Plan

• Relaxation technique______________________
• Physical Activity_________________________
• Contact family/significant other_______________
• Move to another location away from
  stressor______
• Call my therapist or emergency numbers._________
• Write in my journal if therapist unavailable or
  until emergency help arrives_____________________
  ___
• Eat chocolate__________________________________
• The one thing that is most important to me and
  worth living for is
• __________________________________________________
  ________
• Emergency Numbers Therapist
• Crisis Center Emergency Room

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Treatment and Care ManagementEvidence-Based
Best Practices Model

• 1. Address safety first
• 2. Specify interventions
• Immediate Response
• Remove accessible lethal means
• Consider hospitalization Crisis Response Plan
• Acute
• Provide external support
• Treat illness/symptoms and build individuals
  resources
• Continuing treatment/Care management

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Mental Health Model Treatment and Care
Management

• 3. Consider use of Crisis Response Plan or
  Coping Cards
• 4. Involve parent/guardian in developing and
  implementing treatment plan
• 5. Use evidence-based interventions to impact
  modifiable risk and protective factors (e.g.,
  Depression, Alcohol Abuse)

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A Crisis Response PlanSample Safety Plan

• Relaxation technique______________________
• Physical Activity_________________________
• Contact family/significant other_______________
• Move to another location away from
  stressor______
• Call my therapist or emergency numbers._________
• Write in my journal if therapist unavailable or
  until emergency help arrives_____________________
  ___
• Eat chocolate__________________________________
• The one thing that is most important to me and
  worth living for is
• __________________________________________________
  ________
• Emergency Numbers Therapist
• Crisis Center Emergency Room

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Crisis Response PlanDiffers from No Suicide
Contract

• A No Suicide Contract
• Has not been demonstrated to reduce suicide
• May reduce vigilance without reducing suicide
  risk
• Is not recommended with new patients, in ER
  settings, or with psychotic or impulsive patients
• May be useful in understanding
• available support systems
• ability to institute change

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A National Imperative

• Surgeon General Call to Action to Prevent
  Suicide (1999)
• National Strategy for Suicide Prevention Goals
  and Objectives for Action (2001)
• Institute of Medicines recent report Reducing
  Suicide A National Imperative (2002)