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Depression

Dr. Aubrey H. Fine


•For many years, children and adolescents
were thought incapable of experiencing
depression. It was considered an adult
disease.
•1975- National Institute of Mental Health
met and discussed depression among
children.
•1977- Diagnosis and existence of
depression in children and adolescents is
recognized.
Major Depression Disorder (MDD)
• Age of first onset of major depression is in adolescence
and young adulthood
• Adolescent depression is a chronic, recurrent and
serious illness.
• Children of depressed parents vs. children of non-
depressed parents have 2 to 4 fold increased risk of
depression.
• Symptoms: twice as common in females, substance
abuse, suicidal behaviors, social, occupational and
educational disability.
Diagnosis
5 or more of the following symptoms must
be present nearly every day during the same
2-week period to diagnose an adolescent
with MDD
• Depressed or irritable mood most of the day
• Markedly diminished interest or pleasure in
almost all activities, most of the day
• Significant weight loss or gain, or change in
appetite; failure to gain expected weight
• Sleep disturbance
• Psychomotor agitation or retardation
Diagnosis – con’t

• Fatigue or loss of energy


• Feelings of inappropriate guilt or
hopelessness
• Indecisiveness or diminished ability to
concentrate
• Recurrent thoughts of death or suicidal
ideation, suicide attempt.
• At least one of the following two symptoms must
be present: depressed or irritable mood, or
markedly diminished interest or pleasure in
almost all activities.

•MDD can be rated as mild, moderate, severe.

• Diagnosed s chronic when episodes last more


than 2 years.
• An undetected diagnosis in adolescents is
dysthymia- depressed or irritable mood that must
be present for a year or longer and never be
symptom free for more than 2 months.

• 2 or more symptoms must be present: change in


appetite, change in sleep, decrease in energy, low
self-esteem, difficulty making decisions or poor
concentration, feelings of hopelessness.

• Adolescents with dysthymic disorder and who


develop a major depressive episode are
considered to have a “double depression”
Comoribidity
• When depression is tied up with any number of
other childhood mental illnesses
• Anxiety disorders are the most common, with
over 60% of depressed adolescents having a
history or a concomitant anxiety disorder.
• Social phobia (pathological self-consciousness)
• Separation anxiety disorder (marked by fears about
the well-being of the family)
• Generalized anxiety disorder (a fear of the future and
constant worries about one’s performance)
• Of those who have both anxiety and depression,
research indicates that 85% experience anxiety
first.
• One study at the New York University Child
Study Center found that among children with
anxiety disorder as preadolescents, 30% went
on to have depression later on.
• Peer relationships is a predictive factor in
adolescent depression- not so much anxiety
about relating with one’s friends but about
whether they have friendships.
• Conduct disorder or juvenile delinquency is
frequently comorbid with depression in
young people but the relationship between
the two is controversial. Is the teenager
depressed because he’s been caught doing
something illegal or improper and is now
facing consequences? Or is he depressed
or demoralized about life, and this in turn
leads to outrageous, illegal or oppositional-
defiant conduct?
• Some young people simply have both
disorders at the same time.
• Posttraumatic stress disorder (PTSD) also has an
association with depression.
• Occurs when a person witnesses or experiences a
traumatic, fatal, or life-threatening event and later
relives it, either in his thoughts or dreams.
• Can bring extreme distress-intense fear, agitated
behavior, flashbacks, and even physical reactions
that might include re-experiencing smells.
• A person experiencing PTSD might be jumpy, has
trouble sleeping, and will take pains to avoid
anything associated with the trauma.
• Substance abuse in late adolescence with MDD
is common.
• Some people feel that depressed adults
“medicate” themselves with drugs and alcohol,
and that the same holds true for teenagers
• Studies have found an association between
adolescent depression and obesity, headaches,
and asthma.
Risk Factors for Depression in Adolescence
• Having a parent who has depression. Rates of
depression are 2-4 times higher in children of
depressed parents.
• Having an anxiety disorder, especially in
preadolescence, or a childhood history of
depression
• Being a female
• Having a serious negative life event or an
accumulation of damaging experiences (e.g. loss of
social support systems, loss of a parent, a
childhood history of physical or sexual abuse)
• Poverty
• Exposure to violence
Cognitive Vulnerability
• Negative beliefs about themselves, the world
and their future
• Tend to make global, stable and internal
attributions for negative events.
• When confronted with stressful life events, these
individuals will appraise the stressors and their
consequences negatively and hence are more
likely to become depressed than are individuals
who do not have such cognitive styles.
Stress
• Environmental conditions that threaten to harm
the biological or psychological well-being of the
individual
• May occur either as an acute event or as chronic
adversity, and as a major life event or as minor
events with accumulated effects.
• Events may be normative (school, transition) or
pathological (abuse)
• May be independent of, or directly related to an
thus dependent on, and individual’s actions.
• Link between stressful life events and
depression in children and adolescents.
• Depressive symptoms and disorders are
highly associated with minor and major
undesirable life events in children.
• Negative life events are more prevalent
among depressed than non-depressed
children.
• Stress that occurs as early as at
conception likely contributes to an
increased vulnerability to depression.
Examples of Stressors That are
Associated with Depression
• Childhood abuse or maltreatment
• Sexual assault
• Poverty (depression among low-income
mothers is twice as high as in the general
population)
• Events such as disappointments, loss,
separation, and interpersonal conflict
Interpersonal Relationships
• Families with a depressed member are
characterized by less support and more conflict.
• Family dysfunction increases children’s risk of
developing depression.
• Depressed individuals are themselves more
interpersonally difficult, which results in greater
problems in their social network.
• Family dysfunction, parent-child conflict, peer
difficulties, and interpersonal rejection show that
social problems precede depression and
depression contributes to interpersonal
difficulties.
• Link between interpersonal vulnerability and
depression is bidirectional
Bipolar Disorder
Mood Disorders
• Bipolar disorder belongs to the category of
mental-health experiences called mood
disorders.
• Primary feature is a significant change or
disturbance in mood.
• Mood disorders fall into four groups:
• Depressive disorders
• Bipolar disorders
• Mood disorder due to a general medical
condition
• Substance-induced mood disorder
Diagnosis
• Pediatric mania tends to be chronic and
continuous rather than episodic and acute
• Childhood-onset mania is a non-episodic,
chronic, rapid-cycling, mixed manic state
• Early-onset manics are more likely to have
comorbid behavior disorders in childhood,
and compared to adult-onset cases of
mania, to have fewer episodes of remission
over a 2 year period
• “mixed mania” affects 20-30% of adults
with mania
• High rate of suicide
• Poor response to treatment
• Early history of neuropsychological
deficits highly suggestive of ADHD
Criteria to diagnose bipolar disorder:

• A distinct period of abnormally and


persistently elevated, expansive, or
irritable mood lasting at least 1 week
• During the period of mood disturbance,
3 or more of the following symptoms
have persisted and have been present
to a significant degree:
• Inflated self-esteem or grandiosity
• Decreased need for sleep
• More talkative than usual or pressure to keep
talking
• Flight of ideas or subjective experience that
thoughts are racing
• Distractibility
• Increase in goal-directed activity
• Excessive involvement in pleasurable activities
that have a high potential for painful
consequences
Comorbidity

• Another mental-health experience


overlapping or separate from bipolar
disorder.
• May share similarities with bipolar, making
them challenging to pinpoint or diagnose.
• It is critical to focus on symptoms, not
behaviors
• The systematic overlap of childhood
mania with ADHD is one major source of
diagnostic controversy. Rates of ADHD
range from 60% to 90% in pediatric
patients with mania.
• Although ADHD has a much earlier onset
than pediatric mania, the symptomatic
syndromatic overlap between pediatric
mania and ADHD raises a fundamental
question- do children presenting with
symptoms suggestive of mania and ADHD
have ADHD, mania, or both?
With Conduct Disorder (CD)
• CD is strongly associated with pediatric
mania
• Comorbidity between CD and major
depression because pediatric depression
often presages mania
• CD includes violent behavior that may be
categorized as mild, moderate, or severe.
• Childhood-onset type (before age 10)
• Adolescent-onset type (after age 10)
• CD behaviors can start out slowly and build
over an individual’s lifetime, ranging from
lying, stealing, and physical fights to drug
use, burglary, rape, and mugging.
• 20-40% of kids with ADHD have CD
• One way to distinguish CD from bipolar
disorder is to determine if outbursts or
episodes of manic symptoms can seen with
other indicators of mania. To be diagnosed
with CD, your child must be significantly
sidetracked by the symptoms and must
have an impaired ability to function
throughout each day.
• For a diagnosis of CD, your child needs to
show a regular persisting pattern of
violating rules and the rights of others

• 3 of the following must have happened


within the past year and one must have
occurred in the past 6 months:
• Physical cruelty to people or animals
• Theft from someone in person
• Forcing someone to engage in sexual activity
• Violent use of a weapon to cause serious harm
• Instigating physical fights
• Bullying or threatening others
• Arson
• Destroying others’ property
• Breaking into someone’s house, car, or other building
• Conning or manipulating others
• Shoplifting, credit card identity theft, forging checks
• Breaking curfew
• Running away from home overnight at least twice
• Skipping school before age 13
With Anxiety Disorders
• Pediatric studies of youth with panic disorder and
youth with mania document a bidirectional
overlap.
• Subjects with panic disorder and agoraphobia had
very high rates of mania
• More panic and other anxiety disorders in children
with mania.
• Mania at any age is frequently comorbid with
severe anxiety that requires additional clinical and
scientific scrutiny.
With Substance Use Disorders (SUD)

• Bidirectional overlap between mania and


SUD in youth as well as adults
• Juvenile-onset mania may be a risk
factor for SUD
Risk Factors

• Risk factors have not been clearly


identified from community-based
studies.
• The most consistent risk factor for
bipolar disorder is family history.
• Offspring of adult bipolar patients has
an increased risk, over 3-fold, of bipolar
disorder as well as mood disorders,
compared to offspring of controls.
Gender
Gender is well known to be an
important but poorly understood factor
influencing the risk of MDD. The
prevalence of MDD, while equal
between boys and girls prior to
puberty, doubles in young women after
puberty. This increase in females has
been hypothesized to be secondary to
hormonal changes occurring during
puberty.
Treatment of Depression
and Bipolar Disorder
Psychosocial Treatments
for MDD

• Behavior therapy
• Cognitive therapy
• Interpersonal therapy
Behavior Therapy

• Primary goal is to increase the frequency


of pleasant activities in the patient’s life
• Found to be significantly better than
psychotherapy, relaxation therapy, and
medication
• An efficacious, but not uniquely effective,
acute treatment for MDD
Cognitive Therapy

• Most widely studied psychotherapy for MDD


• Treatment is based on the model that the
cognitions of depressed individuals are
negatively biased. Negative beliefs about
the self, the world, and the future.
• Typically 16-20 sessions over a period of 12-
16 weeks
• Involves both behavioral and cognitive
techniques
• Behavioral techniques serve to help patients
engage in activities that give them pleasure,
while cognitive techniques are used to
evaluate the veracity of their beliefs.
• An efficacious acute-phase treatment for
MDD
Interpersonal Therapy
• Depression is usually triggered by problems
in four interpersonal domains: role
transition, grief, interpersonal deficits, and
interpersonal disputes.
• In IPT, the interpersonal problem that
triggered the current depressive episode is
addressed and the person is helped to build
communication and interaction skills to
resolve it.
• The acute phase of IPT typically lasts for 16-
20 sessions.
Psychopharmacological Treatment for MDD

• Monotherapy
• Bupropion- blocks noradrenergic and
dopamine reuptake.
• Side effects: nausea, insomnia,
increased anxiety, restlessness,
increased incidence of seizures. No
weight gain or sexual dysfunction.
• SSRIs (Prozac, Zoloft, Luvox, Celexa, Lexapro
and Paxil)
• Make the most of the serotonin the body is
producing at this time
• The neurotransmitter (serotonin) lingers
longer on the neuron receptors, giving it more
of a chance to effectively complete the
message it needed to send.
• Rarely associated with fatalities and given its
safety profile provides an easy treatment
option for the clinician.
• Side effects: headaches, nausea, dry mouth,
insomnia, nervousness, sexual dysfunction,
diarrhea, tiredness, and agitation
• FDA issued an advisory to physicians that the use
of antidepressant may lead to suicidal thinking or
attempts in depressed youths.

• FDA requested that a warning be added to the


product label of these antidepressants
• Antidepressant medications were not originally
developed with children and adolescents in
mind (nor were they tested on this population)
• In addition to relieving symptoms of
depression, antidepressants may also be
prescribed for treating kids who grapple with
other issues.
• Phobias (often-school related)
• Anxiety
• Panic attacks
• Eating disorders
• ADHD
• Bedwetting
• OCD
• Post-traumatic stress disorder
Dosages
• Need to remember that the brains and
bodies of children and teenagers are still
growing and developing
• Because bodies are often smaller than
adults, the concentration of any medication
in their systems is much greater
• May lead to amplified side effects that are
more intense than those found in adults if
great care is not exercised
Careful Monitoring
• Monitoring and follow-up is critical
• Each medication has the potential to react
differently in each child
• May take weeks before you see any
noticeable improvement in mood
• Maintain careful communications with
doctor
Pharmacotherapy for Bipolar Disorders

• Mood Stabilizers
• Lithium
• Side effects: tremor, diarrhea, weight gain, increased
urinary frequency, and gastrointestinal distress
• Divaloproex and Carbamazepine
• Lamotrigine
• Antidepressants- should only be used with
in combination with a mood stabilizer for the
treatment of bipolar disorder
Prevention of Depression and Bipolar
Disorder
• The term prevention refers only to
interventions that occur before the initial
onset of a disorder
• Efforts to identify cases and provide care for
known disorders is called treatment
• Efforts to provide rehabilitation and reduce
relapse and reoccurrence of a disorder were
called maintenance/interventions.
• Universal mental health prevention
interventions are defined as efforts that are
beneficial to a whole population or group.
• They are targeted to the general public or a
whole population group that has not been
designated or identified as being at risk for
the disorder being prevented.
• The goal at this level of prevention is the
reduction of the occurrence of new cases of
the disorder.
• Selective mental health prevention
interventions are defined as those efforts
that target individuals or a subgroup of the
population whose risk for developing the
mental health disorder is significantly
higher than average.
• Indicated prevention interventions are
defined as those efforts that target high-risk
individuals who are identified as having
minimal but detectable signs or symptoms
that predict the mental disorder or biological
markers indicating predisposition to the
disorder.
The IOM identified three aims or desired
outcomes for mental health prevention:
• Reduction in the number of new cases of
the disorder
• Delay in the onset of illness
• Reduction in the length of time the early
symptoms continue as well as halting the
progression of severity so that individuals
ultimately do not meet diagnostic criteria.
• Goals of prevention programs:
• To extend the lives of individuals who were at risk but
did not develop the disorder by reducing both the risk of
suicide completion and the behavioral and biological
sequalae of the disorder.
• To teach resiliency to the program participants
• To develop skills and abilities to spring back from or
adapt to adversity
• To enhance and enrich the positive aspects of living so
individuals who otherwise might have a marginally
happy life may have the opportunity to develop greater
self-efficacy and live a more successful and adaptive
live
• Emotional intelligence may also be enhanced by
successful preventive programs.
Prevention programs for adolescents

• Preventative strategies are based primarily


on cognitive behavioral and family-
educational approaches that seek to reduce
risk factors and enhance protective and
resiliency factors associated with
depression in youth.
• The IOM suggested that prevention
development and evaluation proceed through 5
stages.
• First and second stages are identifying risk
factors and describing the relative contributions
of different factors to the disorder.
• The third stage is applying strategies developed
in pilot studies and completing efficacy trials to
evaluate the overall effectiveness of these
approaches.
• The fourth stage involves the examination of
such strategies in multiple sites in large-scale
investigations under non-ideal, real-world
conditions.
• The final stage consists of implementing such
strategies in large-scale public health
Penn Prevention Program
• Seligman and colleagues developed and
evaluated a school-based “indicated”
prevention program treating 10-13 year olds
in districts in the Philadelphia suburbs.
• The youth were defined as at risk for
depression.
• Participants were assigned to one of three
treatment programs:
• A cognitive training program
• A social problem-solving program
• A combined program
• Results indicated that children who
participated in any of the treatment groups
reported significantly fewer depressive
symptoms immediately following the
program and at the 6- month and 2-year
follow-ups but not at the 12- month and 3-
year follow-ups.
• Teacher reports revealed better classroom
behavior in treatment participants.
Clarke and Colleagues

• Among the first to study prevention of MDD


among adolescents.
• Study included 150 students from 9th-10th grade
• Assigned randomly to either a “prevention” or
“usual-care” group.
• The prevention program entitled “Adolescent
Coping with Stress Course” was delivered in
groups.
• The 5-week intervention was conducted within
the adolescents’ school setting and comprised
fifteen 45-minute group sessions.
• The “usual-care” youngsters were free to
continue with preexisting treatment or seek
new treatment.
• This program employed both behavioral and
cognitive coping techniques designed to
reduce vulnerability to future depressive
episodes.
• Participants were followed for 1 year and the
results were positive.
• The major strengths of this program include
random assignment of subjects, adequate
sample sizes, diagnoses of clinical mood
disorders and encouraging outcomes.
Beardslee and Associates
• Prevention program were designed to be
public health interventions and useful to all
families in which a parent is depressed.
• Programs are to be sued by a range of
health practitioners, including internists,
pediatricians, school counselors, and
nurses, as well as by mental health
practitioners such as child psychiatrists,
child psychologists, and family therapists.
• This approach includes a strong emphasis
on treatment because so much depression
is undiagnosed and untreated.
3 characteristics that described resilient
children of depressed parents.
• Support for activities and accomplishment of
developmental tasks outside of the home
• A deep involvement in human relationships
• The capacity for self-reflection and self-
understanding, in particular, in relationship to
the parent’s disorder.
Resilient youth repeatedly said that
understanding that their parent was ill, that
the disorder had a name, and that they were
not to blame for it contributed substantially
to their doing well. This, then, became a
central part of the preventive intervention.

Families believe that these programs are


helpful. Of the first 20 families enrolled,
promising effects were observed 6 months
after intervention and a further follow-up
report showed sustained effects over 3
years.
Youth Suicide
• Fifty years ago suicide among young people
aged 15-24 was a relatively infrequent event
and suicides in this age group constituted
less than 5% of all suicides in the U.S.
• Between the mid-1950s and the late 1970s,
the rate of suicide rose markedly among this
age group.
• This increase was observed most
dramatically among young males, whose
suicide rates more than tripled between
1955-1977.
• Among females ages 15-24, the suicide rate
more than doubled during this same period.
• By 1980, suicides by 15-24 year olds
constituted almost 17% of the approximately
30,000 suicides in the U.S.
• 1980-1990 suicide rates continued to rise
• 1994- reached a peak rate of 13.6 suicides
per 100,000.
• Began to decline decreasing to 9.9 per
100,000 by 2002 a drop of over 27%.
• Suicide before the age of 12 is rare, but
increases with every year past puberty.
• In 2002, 20-24 year olds had a suicide rate of
12.3 per 100,000 compared to the rate of 7.4
among 15-19 year olds.
• 4,010 suicides in 2002
• 1,513 between the ages of 15-19
• 2,497 between the ages of 20-24
• Suicide is the 3rd leading cause of death
among youth; only accidents and homicide
claim more young lives.

• Among college students specifically, suicide


is the 2nd leading cause of death, surpassed
only by accidental injury.
Increase of youth suicide due to:
• Increase in the rate of depression since the
1950s
• Increased availability of firearms
• Diminishing cohesion of the family
observed since WWII has been blamed for a
wide range of youth problems behaviors,
including both drug abuse and suicide.
• Greater freedom in sexual behavior since
the 1960s as well as changes in the
expectations that young men and women
had for themselves and for their
relationships
Decrease of youth suicide is due to:
• Efforts to restrict firearms availability among
youth. The proportion of suicides that involve
firearms has decreased somewhat in recent
years, although firearms are still used in about
60% of all suicide deaths.
• Increased use of antidepressant medication in
treating young depressed people.
• Improved economic conditions in the 1990s
have been credited for the recent decline, just
as they were blamed for the high national rates
during the depression of the 1930s.
• The most current YRBS data indicate that
8.5% of U.S. high school youth surveyed
(5.4% of males and 11.5% of females) made
one or more suicide attempts in the prior 12-
month period; 2.9 percent (2.4% of males
and 3.2% of females) required medical
attention as a result of suicide attempt
• Youth who are not currently attending
school have been found to be at higher risk
for suicide attempts and suicide deaths than
those who are in school.
• Among young people ages 15-24, males die
by suicide almost six times more frequently
than females.
• In 2002, the suicide rate among young men
ages 15-24 was 16.4% per 100,000 and the
rate among young women was 2.9%.
• Although young males die by suicide more
often than females, females report suicidal
ideation and attempts more often than
males.
In 2002, white youth had a suicidal rate
of 10.6 per 100,000 compared to rates
of 6.5 for African Americans, 6.6 for
Hispanic youth, 5.3 for Asian
Americans/Pacific Islanders, and 17.9
for American Indians and Alaskan
Natives.
Risk Factors
• Psychopathology
• Depression
• Drug and alcohol abuse
• Aggressive-impulsive behavior
• Hopelessness
• Pessimism
• Conduct Disorder (male)
• Panic Disorder (female)
• Family and Genetic
• Family history of suicidal behavior
• Parental psychopathology
• Environment
• Firearm availability
• Diminished family cohesion
• Lack of parental support
• Parent-child conflict
• Negative life events
• Child sex abuse
• Suicidal contagion
• Biology
• High 5-HT receptor expression is prefrontal
cortex and hippocampus
• Serotonergic dysfunction
• Previous suicidal behavior
• Suicide attempts

• Sexual Orientation
• Same-sex sexual orientation
• Overwhelming evidence that
psychopathology is the most significant risk
factor for both suicide deaths and suicide
attempts among adolescents.
• One recent analysis suggested that
eliminating psychopathology could prevent
78-87% of youth suicides.
• Conduct disorder is also prevalent in young
males with suicidal behavior, often
comorbid with substance disorders and
anxiety and mood disorders.
• Panic disorder has been found to be related
to suicidal behavior, particularly among
girls.
• Some studies have reported a relationship
between bipolar disorder and both suicide
deaths and suicide attempts among youth.
• Suicide ideation appears to be less directly
related to psychopathology than either
suicide attempts or suicide death, perhaps
because ideation, while occurring with
higher frequency, is less persistent and may
be fleeting.
• Aggressive-impulse behavior has an
increased association with suicidal
behavior, particularly in the context of a
mood disorder
• Hopelessness and pessimism are also
important factors associated with youth
suicidal behavior
• Previous suicide attempts is one of the
strongest predictors of both subsequent
attempts and suicide deaths. This
relationship is particularly strong among
youth with mood disorders.
• The risk for future suicidal behavior has
been estimated to increase 3-17 times when
a previous attempt has occurred.
• A number of studies report increased rates
of nonlethal suicidal behavior among youth
with same-sexual orientation.
• Stigmatization, victimization, isolation, and
parental rejection have been identified as
factors in suicidal behavior among gay,
lesbian, and bisexual youth.
Universal Approaches to
Youth Suicide
Prevention
• The ultimate goal of all suicide prevention
programs is to reduce death by suicide.
• Two broad types of universal prevention
programs
• Educational programs that aim to increase
students’ knowledge and awareness about
suicidal behavior, encourage troubled students
to seek help, and improve recognition of at-risk
students by teachers, counselors, and other
“gatekeepers” within the school or community
setting.
• Screening programs that seek to identify and
refer to treatment youth who are at risk for
suicidal behavior.
• A wide range of suicide education and
awareness programs have been developed.
• Assumptions underlying such programs are
that the conditions that contribute to suicide
risk in adolescents and young adults often
go unrecognized, undiagnosed, and
untreated, and that educating students and
gatekeepers about the warning signs for
suicide and appropriate responses will
result in better identification of at-risk youth,
and increase in help seeking and referrals
for treatment.
Program Examples
• Such programs are exemplified by those
developed by Kalafat and colleagues, which
incorporate education about the warning
signs of suicide and appropriate help-
seeking behaviors into the regular physical
education or related curricula.
• Such education has been reported by the
program developers to result in students’
increased knowledge about suicidal
behavior, more positive attitudes about
talking to friends they believe to be suicidal,
and seeking of helps from adults.
• In its most fully developed form, the
Adolescent Suicide Awareness Program
(ASAP) includes education for teachers, school
staff, and parents, as well as students.
• The Sign of Suicide (SOS) program, developed
by Jacobs and colleagues.
• Delivers the core message that suicidal
behavior is directly related to mental illness,
particularly depression, and needs to be
responded to as a mental health emergency.
• The instructional component, which occurs
over 1-2 class periods, may be augmented with
screening and parent-awareness activities.
• Schools in which the program has
been implemented have reported
substantial increases in students’ help-
seeking behavior and high satisfaction
with the program among school
officials.
• Students who had participated in the
SOS program reported lower rates of
suicide attempts and greater
knowledge and more adaptive attitudes
about depression and suicide.
• Dade County, Florida, Public School System
provide an example of universal programs
applied on a community wide level.
• Began in 1989 included related curricula
across K-12, although only 10th graders
received direct discussion of suicide and
suicide prevention.
• Also included intervention and postvention
activities by school-based crisis teams.
• The annual suicide rate decreased from 12.9
deaths per 100,000 youth prior to the
program to 4.6 per 100,000 during the 5
years of program operation.
• Many states are currently implementing
universal youth suicide prevention programs
that, in addition to student education,
frequently include parent and gatekeeper
training.
• The Suicide Options, Awareness and Relief
(SOAR) program, for example, trains school
counselors to identify students at risk of
suicide and increase the likelihood and
effectiveness of their interventions.
• This program has been reported to result in
improved knowledge and increased comfort
and confidence in dealing with at-risk students.
• Applied Suicide Intervention Skills Training
(ASIST) is the most frequently applied
gatekeeper training program
• Developed by LivingWorks Education for
application in a wider community setting.
• It is a 2 day workshop for teachers,
counselors, youth leaders, and other
community care givers that seeks to
increase their awareness and understanding
of suicide, address the associated stigma
and taboos, develop their readiness and
ability to use “first-aid” action to prevent
suicidal behavior, and network with other
gatekeepers to improve communication and
continuity of care.
• Pre- to post-evaluations of participants
suggest increased knowledge about suicidal
behavior, greater willingness to intervene,
and improved competence in dealing with
suicidal individuals.
• In one training program in Australia, more
than ¾ of ASIST workshop participants
reported using their knowledge and
intervention skills directly during the 4
months following their participation in the
program.
• Training for Trainers (T4T)
• 5 day course, offered worldwide, trains and
certifies gatekeepers to provide the ASIST
training in their local communities.
• Another approach to gatekeeper training
has involved educating general practitioners
to more effectively identify suicidal patients.
• One workshop in Australia sought to
encourage screening of young patients for
psychological distress, depression, and
suicidal behavior.
• Reported to have resulted in increased
identification of distressed, depressed, and
suicidal adolescents; no changes were reported
in physicians’ management of such patients.
• Suicide awareness and education programs
for college students are far less cohesive
and identifiable than programs addressed to
high school students.
• One of the few programs that involve more
than a single campus is Finding Hope and
Health, developed by the National Mental
Health Association in 2001.
• Facilitates partnership between a local mental
health association and a university to develop
and implement campus educational programs
on suicide and related mental health problems.
• These “campus coalitions” work with residence
hall advisers, campus counseling centers,
relevant academic departments, campus
ministries, and other student affairs personnel
to design trainings for students and staff, peer
counseling programs, and other activities to
increase knowledge and awareness of mental
health concerns.
• Another effort that targets colleges and
universities is the recently produced film
developed by the American Foundation for
Suicide Prevention (AFSP), “The Truth About
Suicide: Real Stories of Depression in
College.”
• The film is accompanied by a Facilitator’s
Guide that includes recommendations for its
use in classrooms, orientation sessions, and
dorm meetings and at other student activities,
as well as educational materials to assist
faculty and other facilitators in guiding student
discussions and answering specific questions
about suicide.
Critique
• Most suicide aware ness and suicide education
programs involve one or a limited number of
relatively brief sessions focused on suicidal
behavior, frequently as part of a larger
curricular effort aimed at reducing multiple
high-risk behaviors.
• Although pre- to post-evidence suggests that
such programs can increase students’
knowledge and awareness of suicide risk and
improve their help-seeking behaviors, little
attention has been paid to determining the
scientific accuracy of program content.
• Generalizable conclusions about the
efficacy and effectiveness of suicide
education programs for both high school
and college students are further limited by
the lack of control or comparison groups
that would make it possible to differentiate
program impact from broader co-occurring
trends.
• In the case of the comprehensive, multilevel
educational programs, insufficient attention
has been paid to documenting which
program components are responsible for
the reported outcomes.
• An additional limitation of currently
available data on the impact of universal
education programs is their short-term
focus.
• It is not clear if ongoing interventions might
serve as “booster shots” to enhance and
reinforce a program’s impact.
• Follow-up evaluations of these programs
have been rare, and thus little is currently
known about their impact on reducing
suicidal behavior among the targeted group.
• Longitudinal controlled studies that look at
youth several years after participating in
educational programs are needed to address
the question of long-term behavioral change.
• This will require addressing the fact that
neither high schools nor colleges currently
have a reliable system for reporting suicidal
behaviors among students, thus hampering
collection of reliable data to determine an
educational program’s impact.
• Also, students graduate and leave the school
environment, making follow-up difficult.
• Long-term controlled studies of gatekeeper
training programs are likewise needed to
determine the frequency or the
effectiveness of participants’ direct
interventions during the years following the
training.
• Because little is known about particular
approaches that make referral efforts safe
and effective, further evaluation is needed of
the impact of such programs on referral
processes, adequate treatment, and, in turn,
the reduction of suicide risk factors and
suicidal behavior among youth
• Some concerns have been voiced by high
school personnel and parents that overt
discussion of suicide in the school
curriculum may increase suicidal thoughts
and behavior, and adequate attention has
generally not been given by evaluators to
documenting adverse effects.
• One study found statistically significant
increases in hopelessness and maladaptive
coping resources among some male
students after exposure to a suicide
awareness curriculum.
• Studies by Shaffer and colleagues and Vieland
and colleagues found that students who had
previously made a suicide attempt were less
likely to recommend suicide awareness
programs in the schools, and were more likely
to feel that talking about suicide in the
classroom would increase suicidal behavior
among some students.
• It is essential that school personnel be made
aware of referral sources in the community and
for the school to have in place a plan of action
for identified students that includes a
debriefing component for peers and faculty
who are involved in making referrals.
• In the case of college-based programs,
concerns about effects on the institution’s
legal liability, reputation, and student
enrollment sometimes encourages campus
officials to avoid or minimize the problem of
student suicide, which appears to have
limited the development of educational
programs directed to this population.
• Providing suicide education to college
students poses unique issues.
• College students are not generally required to
take any courses in which education about
depression and suicide may be appropriately
incorporated.
• Other than a few limited number of mandatory
orientation sessions, few opportunities exist to
reach large numbers of college students with
information about mental health issues and
services.
• Involvement of parents in educational programs
on such issues is also extremely limited in most
college settings.
• Most suicide prevention programs directed
to young adults are designed specifically for
college students, who represent less that
half of all persons aged 18-24 in the United
States.
• Although few research studies have
examined suicide risk among young adults
not in college, this population may have
particular risk factors, including more
involvement with substance use, as well as
less access to mental health resources.
Screening Programs
• Universal screening programs as a youth
suicide prevention strategy are designed to
identify young people at risk for suicidal
behavior and refer them to treatment.
• Some programs focus specifically on
identifying symptoms of psychopathology
known to be related to adolescent and
young adult suicidal behavior, while others
assess specifically for signs of suicidality.
• The primary assumption underlying screening
programs is that because anxiety, depression,
substance abuse, and suicidal preoccupation
among youth often go unnoticed and
untreated, a systematic, universally applied
effort is needed to improve identification of at-
risk individuals.
• Screening programs also rest of the
assumptions that identification of youth with
psychiatric disorders will substantially
increase the number receiving treatment, the
treatment will be sufficiently effective, and
effective treatment will decrease suicides.
• Reynolds described one of the first high
school-based screening programs for youth
at risk for suicide.
• The program involved a two stage method,
in which a general population of students
was first screened using the Suicide
Ideation Questionnaire.
• Students with scores above a defended
cutoff value were subsequently evaluated
clinically with the Suicide Behavior
Interview, and those identified as being at
risk were referred treatment.
• The program devoted particular attention to
determining an appropriate cutoff score for
identifying at-risk youth, comparing two
different scores with regard to sensitivity (the
ability to identity correctly those who have
the problem, with few false negatives) and
specificity (the ability to identify correctly
those who do not have the problem, with few
false positives).
• Reynolds found that increasing the cutoff
score led to missing a disproportionate
number of at- risk youth.
• The impact of suicidal behavior and the
adherence to treatment recommendations
were not reported.
• The most widely used high school
screening program, the Columbia
TeenScreen Program (CTSP), employs a
multistage procedure.
• In one variant of the CTSP, students
complete a brief, self-report questionnaire.
• Those who screen positive on this measure
are given a computerized instrument, the
Voice DISC 2.3, which has been found to
accurately identify a comprehensive range
of psychiatric disorders in children and
adolescents. This stage of the screening is
regarded as particularly important for
• In the final stage, youth who have been
identified through Voice DISC 2.3 as meeting
specific diagnostic criteria for a psychiatric
disorder are evaluated by a clinician, who
determines whether the student needs to be
referred for treatment or further evaluation.
• The program also includes a case manager
who contacts the parents of students who
are referred and establishes links with a
clinic to facilitate treatment adherence.
• Evaluation results indicate that most of the
adolescents identified as being at high risk
for suicide through the program were not
previously recognized as such, and very few
had received prior treatment.
• About half of the students referred for
treatment attended at least one treatment
visit.
• The program’s requirements of a clinician
and a case manager may be a resource
burden for many schools.
• The screening strategy is based on a public health
prevention model that emphasizes the
identification of at-risk students on the basis of
observable behaviors.
• The first level of screening involves a review of
high school attendance registers to identify
students having high absenteeism. Teachers and
guidance counselors are asked to recommend
students they deem to be at risk.
• Identified youth are then assessed by means of
the Suicide Risk Screen (SRS).
• Those with elevated risk for suicidal behaviors are
given an appropriate intervention within the
school setting or are referred for further
evaluation and treatment.
• Screening initiatives for college students
include the Comprehensive College
Initiative (CCI) developed by Jacobs to
identify students at risk for depression and
facilitate them to get treatment.
• The program has been offered at a large
number of colleges in conjunction with
National Depression Screening Day.
• In addition to the in-person screenings
offered at this event, the program includes
an online year-round screening component.
• In campuses where it has been
implemented, the CCI has been described
by its developers as effective in identifying
at-risk students and motivating them to seek
treatment.
• Almost 20% of students taking the
screening measure scored “very likely” to
be suffering from depression and 5%
reported persistent suicidal ideation.
• Both student participants and college
officials were reported to have positive
reactions to the in-person and online
program components.
• Another recent program is the College
Screening Project developed by the American
Foundation for Suicide Prevention.
• This project uses the campus e-mail network to
target students and encourage them to
complete a Depression Screening
Questionnaire, which has been established to
be an effective tool for identifying depression
among community samples.
• The screening includes depression, items
dealing with current suicidal ideation, past
suicide attempts, anxiety and other affects,
drugs, alcohol, and eating disorders.
• Assisted by a computer program, a clinically
trained counselor evaluates the responses and
assigns the student into one of three tiers on
the basis of their suicide risk.
• The counselor then writes a personalized reply
that the student accesses on the Web site.
Students with significant problems as
determined by a well-defined set of criteria are
urged to come in for a face-to-face evaluation.
• The Web site also contains a “Dialogue”
feature that allows students to communicate
with the counselor online to discuss concerns
they may have prior to an evaluation.
• During the face-to-face meeting, treatment
options, including medication and
psychotherapy, are discussed and referrals
are made to appropriate services on and off
campus.
• In an effort to evaluate treatment effects, the
project collects data on an ongoing basis
from treatment providers on student
adherence, treatment progress, and
disposition.
• Initial reports indicate that about 80% of the
students who respond to the screening
questionnaire indicate some mental health
problems, with almost half of all
respondents falling into the highest-risk tier.
• Fewer than 15% of identified students
comply with recommendations for
evaluation, which suggests that
recommendations need to be refined to
make them more acceptable, or that
innovative strategies need to be developed
to encourage greater number of at-risk
students to seek help.
• One other Web-based screening program for
college students the ULifeLine program, has
recently been developed by the Jed
Foundation.
• This program provides computer-generated
results to students who complete the
screening instrument. Although identified
students are provided with recommendations
regarding treatment possibilities, no follow-up
is offered.
• It is not clear whether without a personal
connection, such Web-based screenings will
succeed in motivating students in need to seek
treatment.
Critique
• In their basic assumptions, screening programs
as implemented within both high school and
college settings closely conform to scientifically
validated premises regarding the causes of
suicide – i.e., that suicide risk is not randomly
distributed, but rather is conferred by certain
factors that are both identifiable and, to a
considerable extent, alterable.
•At the same time, such programs face a number
of challenges.
• Screening measures with acceptable test
characteristics (e.g., a sensitivity of 80% and
a specificity of 70%, figures similar to
screens for depression) will necessarily
miss some in the population who will go on
to make suicide attempts, while identifying
many more as at risk when they are not.
• Given that costs are involved each tome a
segment of the target is screened, most
school-based screening programs assess
students only once a year, and in some
cases, only once during a several-year
period.
• The timing of the screening may increase the
likelihood of identifying students in need of
referral (e.g., close to exams, at the beginning of
high school or college, or during the senior year)
or at other times may reduce this likelihood.
• Low adherence with treatment recommendations
among those identified through the screening
instrument to be at risk due to a range of problems
that are beyond the scope of the screening effort
(lack of parental support, perceived quality of
available treatment, and attitudes of treatment
providers) additional strategies appear to be
needed to encourage students at risk to access
and make effective use of needed treatment
services.
• In this regard, better integration of suicide
education, gatekeeper training programs, and
screening programs may be helpful.
• All school-based suicide screening programs
need to be mindful of the availability and
quality of mental health services for students
who are identified as at risk.
• It is estimated that only 38% of colleges
provide mental health services and most of
those that do limit the number of sessions or
offer only group therapy that may not be
appropriate for students at risk for suicide.
• Although many colleges require students to
have health insurance, most students are not
adequately covered for acute or long-term
mental health services.
• Even when implemented under ideal
conditions, there is no clear evidence that
screening for suicide in general populations
improves rate reduction outcomes.
• No data have been reported on the
effectiveness of high school or college-
based screening programs in reducing
suicide risk factors.
• Within high schools, there is evidence that
administrators prefer suicide education and
awareness programs over screening
programs.
• Many colleges and universities have expressed
reluctance about implementing depression and
suicide screening programs.
• This appears to reflect concerns about the liability
schools may assume in the event that students
identified as at risk for suicide not follow through
with treatment recommendations and actually
engage in suicidal behavior.
• Identification of at risk students may also put
universities into a difficult legal and ethical
position with respect to parents. Parents of
students over the age of 18 cannot be contacted
without written permission from the student.
Although confidentiality can be waived in
situations in which threat to life is concerned,
universities are reluctant to become embroiled in
such matters.
• One complication with Web-based programs
is the recent Health Insurance Portability
and Accountability Act (HIPAA) which limits
the use of electronic technology to transmit
identifiable health information, because of
the potential threats to patient
confidentiality.
• This has been interpreted as requiring that
a student’s actual identity not be revealed
online, making it impossible for the
counselor to intervene to help a student
believed to be suicidal unless he or she
presents in person for evaluation.
Preventive
Interventions and
Treatments
School-Based programs for suicidal students
• The most comprehensive school-based programs
are those developed and tested by Eggert,
Thompson, and their colleagues 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 gate keepers.
• Such students have been reported to have
multiple co-occurring problems that, in addition to
school performance difficulties, include
depression, suicidality, drug involvement, and
•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 involved 100 high school
students who screened positive for suicidal
behavior.
• The students were randomly assigned to one of
three conditions
• Assessment protocol plus one semester of PGC
• Assessment protocol plus two semesters of
PGC
• Assessment protocol only
• Participants were assessed at baseline and
at 5-10 months post-intervention.
• 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.
• Also reported was a significant positive impact of
both teacher and peer support in decreasing
suicide risk behaviors and depression.
• Thompson, Eggert, and colleagues 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)
• Both interventions were found to reduce suicide
risk behaviors and depression.
• 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
• Being studied to determine the added
benefit of this component to further 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.
Critique
• The target groups addressed by the studies
of Eggert and Thompson may limit the
generalizability of the findings to other
populations of suicidal youth.
• The focus of these programs has been on
students at risk of dropping out of school.
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.
Emergency Department Interventions For
Young Suicide Attempts
• A considerable number of youth who make
suicide attempts obtain some form of medical
intervention, typically beginning in a hospital
emergency department (ED)
• Numerous studies, however, have documented
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 that a few
sessions.
• 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.
• Rotheram-Borus and colleagues designed
and intervention that targeted both the ED
staff and families of Latino adolescent
females who attempted suicide and followed
participants over 18 months.
• Using video tapes and therapists, 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.
• 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 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.
• Hospitalization rates were decreased and
outpatient therapy was initiated more
rapidly as a result of the RR intervention
when compared with standard care.
• Adolescents receiving the intervention were
less likely to be rehospitalized during the 6
months after their visit to the ED.
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 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.
• ED interventions provide some continuity of
contact with the youth beyond the initial ED visit,
which will require additional staffing.
Psychotherapeutic Treatments for
Suicidal Youth
• Most interventions have employed
variations of cognitive behavioral therapy.
• The underlying assumptions is that the
primary focus of treatment should be the
suicidal behavior itself, rather than the
underlying psychopathology.
Program Examples
• An intense 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 improve basic social skills and
effective coping.
• Participants 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, it was 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.
• Analyses showed that patients with
psychiatric symptomatology experienced
the most improvement in response to this
intervention.
• The rate of suicide attempts at follow-up
was not reported for either experimental or
control group and conclusions were limited
by high attrition rates in both the
experimental and control group.
• Harrington and colleagues in Great Britain
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, 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.
• 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.
• Wood and colleagues have developed an
additional psychotherapeutic variant, using
developmental group therapy as a alternative
to usual care for adolescents who have
repeatedly attempted to harm themselves.
• 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, 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
process.
• In interviews conducted 7 months after
treatment began, participants in the
developmental group therapy reported
engaging in less self-harm that did adolescents
who received routine care, although
depression did not appear to improve.
• Participants in the developmental group
therapy, particularly youth who had made
multiple suicidal attempts, also showed
reductions in conduct problems.
Pharmacological Treatments for Suicidal
Youth
• 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 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.
• 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 suicidal
ideation at baseline.
• The intervention was based on findings that
reducing depression and problem drinking
in adults resulted in a reduction of suicidal
behavior
• Also found flouxetine to be effective in
treating suicidal adults with an alcohol
disorder.
• 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.
• 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.
Critique
• 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.
• These reports led the British drug regulatory
agency to recommend against the sue of all
SSRIs except fluoxetine in treating
depression among youth under age 18.
• In 2004, the U.S. Food and Drug
Administration undertook a review of 23
clinical trials involving the use of 9 different
antidepressant medications by over 4,000
children and adolescents.
• The results of this analysis found that the
medications increased the risk of suicidal
thinking and behavior in children and
adolescents with major depressive disorder
or other psychiatric disorders.
Posthospitalization Programs for Suicidal
Youth
• The only full-developed program of this sort is the
Youth-Nominated Support Team (YST)
intervention, developed by King and colleagues.
• This program was an outgrowth of the developers’
finding that family dysfunction and parental
psychopathology significantly impact treatment
adherence by suicidal youth after hospitalization.
• 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.
• They 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 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.
Research Agenda
for Youth Suicide
Prevention
What We Don’t Know About Youth Suicide
• Although the problem of youth suicide is
disproportionately due to its prevalence in
young males, explanations for this
phenomenon are currently lacking.
• The impact of race and ethnicity on suicide
vulnerability among youth and what
particular risk or protective factors are
conferred by membership in particular racial
or ethnic groups is not well understood.
• What external environments increase or
decrease youth vulnerability and
susceptibility to suicide. How can these be
improved?
• Relatively little is known about the specific
clinical pathways to youth suicide. In
particular, much more needs to be known
about the contribution of bipolar disorder,
panic attacks, and posttraumatic stress
disorder to suicide deaths among youth.
• The impact of race and ethnicity on
diagnostic profiles and clinical pathways to
suicide needs greater scrutiny.
• Much more needs to be known about the
role of neurobiological abnormalities that
contribute to youth suicidal behavior, and
the degree to which these may be inherited.
• The extent to which parental and familial
psychopathology influences suicide
ideation, attempts, and completions among
youth, over and above genetic influences,
needs to be examined. Specifically, what is
the effect of exposure to parental suicide
attempts and completion, and suicide risk
among youth? Does childhood physical
and sexual abuse confer suicide risk
independent of other effects of family
psychopathology.
• Much more needs to be understood about
the role of personal and social skills in
protecting youth from suicidal behavior. Do
strong problem-solving skills, decision-
making abilities, and support from family
and schools actually protect young people
from developing suicidal impulses, or is the
absence of such skills a manifestation of
psychopathology that is more directly
related to suicidal thoughts or behavior?
• What is the role of culture, identity, and
religious beliefs in reducing suicide risk?
What We Don’t Know About Suicide
Prevention Programs
• Most suicide education programs have not
identified the active ingredients responsible
for the outcomes they produce.
• Most suicide education programs target
outcomes whose relationship to youth
suicide has not been precisely identified.
Many, for example, have reported increased
knowledge of mental illness and suicide
among students, although the impact of this
outcome on suicidal behavior is not known.
• Although increasing the number of referrals to
treatment is a key goal of screening programs,
there is not clear evidence of a direct linkage
between increased referrals and decreased
suicidal behavior among youth.
• Screening programs have generally not
identified effective mechanisms for
encouraging larger numbers of youth identified
as at risk for suicide into treatment.
• Little data are currently available about the
cost-effectiveness of school-based screening
programs.
• Although popular in recent years, the effects
of postvention programs, both positive and
adverse, on youth exposed to a suicide
death have not been clearly documented.
• Despite limited evidence that educational
programs directed at parents, particularly
fathers, can decrease youth access to
firearms, the impact of means restriction
programs on decreasing suicide attempts
and suicide deaths among youth ahs not
been documented.
What We Don’t Know About Treatment of
Suicidality and Underlying Disorders
Among Youth
• The active ingredients of comprehensive
high school-based programs for treating
students at risk of dropping out, including
some who are depressed and suicidal, have
not been clearly identified.
• It has not been demonstrated that students
at risk of dropping out of school are
representative of suicidal youth generally,
and therefore that programs that address
this population have wide applicability.
• The replication of such programs, which
require considerable personnel and
financial resources, has not been
established.
• The impact of emergency department
programs for youth suicide attempters and
their families on decreasing suicide deaths
has not been established.
• Although some promising outcomes have
been reported, long-term of cognitive
behavior therapy with suicidal youth are not
yet known.
• Although there is increasing evidence of the
safety and efficacy of Prozac in treating
depressed and suicidal youth, the safety and
efficacy of the many other antidepressants
currently being used have not been
established.
• Much more needs to be known about the
combinations of psychotherapeutic and
pharmacological treatment that produce the
most positive short- and long-term outcomes
for depressed, suicidal youth.
• Long-term effects of post-hospitalization
programs for suicidal youth have not been
documented.
Research Needs

• In order to effectively address the


knowledge needs that have been identified,
youth suicide research must expand beyond
its present relatively narrow focus to
incorporate standards of research design
and program evaluation that are routinely
used in other prevention fields.
• Evaluation strategies that have been
employed have relied largely on pre-post
designs that do not adequately link
outcomes to program components.
Program controlled studies are needed to
determine the effectiveness, safety, and
active ingredients of universal and targeted
suicide prevention programs including
school-based education, screening, and
skills development programs; and school
and community interventions for at-risk
populations, including firearms restriction
programs and gatekeeper training
programs.
• A development that is expected to
encourage and support the use of
scientifically valid evaluation designs by
suicide prevention programs is the recent
decision of the Substance Abuse and Mental
Health Administration (SAMHSA) to expand
its National Registry of Effective Programs
and Practices (NREPP) fro its original focus
on substance abuse prevention programs to
include mental health promotion and
treatment programs including those
associated with suicide prevention.
Funding for Evaluation Studies
• Few youth suicide prevention programs
have had the necessary personnel or
financial resources to conduct independent
program evaluations.
• If the field is to move forward, mechanisms
need to be established that mandate and
support comprehensive, well-designed
outcome studies as a regular part of
prevention programming.
• Much more attention needs to be given to
evaluating the outcome of treatment programs
for suicidal youth.
• Since universal and selective suicide
prevention programs focus heavily on
encouraging help seeking and on identifying
vulnerable youth and referring them to
treatment, their impact on reducing youth
suicide depends ultimately on the
effectiveness of the treatments that are
available to such young people. Thus, the
single highest priority must be given to
determining the relative efficacy and
effectiveness of all currently employed
treatments and indicated interventions for
suicidal youth.
• Treatment evaluations need to give
particular attention to building appropriate
safeguards into treatment trials involving
high-risk youth populations.
• Maintaining troubled youth in treatment
trials over an adequate period of time to
observe both short- and long-term
outcomes is a particular challenge. Time-
limited treatments, while easier to evaluate,
leave unresolved questions about long-
term effectiveness.

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