The rate of adolescent suicide and suicidal behavior has risen dramatically in the past decade. The title of this article comes from the classic coming-of-age novel by J.D. Salinger, The Catcher in ...the Rye. Its protagonist, Holden Caulfield, is a precocious adolescent who, in the face of his inability to cope with his own self-destructives urges, imagines himself saving "little kids playing some game in this big field of rye." He is standing on the edge of a cliff trying to catch "thousands of little kids" before they fall to their demise. This vignette from The Catcher in the Rye provides a useful metaphor for the relationship between mental health professionals and youth at risk for suicide, and suggests more efficient and effective alternative interventions to prevent youth suicide compared to standing by a cliff.
These four alternative approaches are described, namely: (1) leading youth away from the cliff (ie, prevention); (2) going to where youth are (ie, improving access to care); (3) working with others to change the rules in the field (ie, changing the way care is delivered); and (4) putting a fence around the cliff (ie, restriction of access to lethal agents). The evidence to support the utility and cost-effectiveness of each of these approaches is reviewed.
There are extant, empirically supported, cost-effective approaches to the prevention and management of adolescent suicidal behavior that, if implemented widely, are likely to significantly reverse the decade-long rise in adolescent suicide.
Antidepressants and Suicidality Brent, David A
The Psychiatric clinics of North America,
09/2016, Letnik:
39, Številka:
3
Journal Article
Recenzirano
We review the evidence that antidepressants either increase or decrease the risk for suicidal ideation and behavior in adolescents. Meta-analyses of randomized clinical trials (RCTs) indicate a small ...increased risk for suicidal events in adolescents and young adults, but a protective effect in older adults. In contrast, pharmacoepidemiologic studies show a protective effect across the life span. Explanations for occurrence of suicidal events in younger patients and for the apparent contradiction between RCT and pharmacoepidemiologic studies are offered. Guidance for clinicians is provided on explaining the risk-benefit ratio of antidepressants and how to monitor and attenuate for suicidal risk.
Glenn and colleagues have examined rates of adolescent suicide across 45 countries and explored the role of sex, age, rurality and availability of guns and railways on suicide rates. Higher rates of ...adolescent suicide in New Zealand may be explained by the very high rate of adolescent suicide in young Maoris. Future work could be enhanced by reporting on national trends in suicide, reporting on rates broken down by race and ethnicity, and through the development of international psychological autopsy studies that could shed light on cross‐country differences. While this article found that income inequality was correlated with the male‐to‐female ratio of adolescent suicide across countries, the opposite trend has been reported in the United States. However, as noted by this article, the effects of poverty matter. The Move To Opportunity study found that when youth under the age of 13 were moved from a high poverty to a low poverty neighbourhood, there were enduring effects, including lower levels of depression and anxiety. While adolescent suicide is a global concern, reduction in the suicide rate may have local solutions, including those that address the pernicious effects of poverty and poor neighbourhoods on youth.
Read the full article at doi: 10.1111/jcpp.13106
Background
The COVID‐19 pandemic is the most serious global public health crisis since the 1918 influenza pandemic. This study is the first to assess its mental health impact across the lifespan in ...the United States in adolescents, adults, and health care workers.
Methods
We recruited 4909 participants through an online survey advertising on Facebook and Instagram to assess exposure to COVID‐19 and psychiatric symptoms from April 27 to July 13. We also recruited through the University of Pittsburgh, University of Pittsburgh Medical Center, and other health care systems around Pittsburgh. The primary outcomes were clinically significant depression, anxiety, and posttraumatic stress disorder (PTSD) symptoms, suicidal ideation or behavior, and grief reactions since COVID‐19.
Results
Adolescents were significantly more likely to report moderate to severe symptoms of depression (55% vs. 29%; χ2 = 122, df = 1; p < .001), anxiety (48% vs. 29%; χ2 = 73; df = 1; p < .001), PTSD (45% vs. 33%; χ2 = 12; df = 1; p < .001), suicidal ideation or behavior (38% vs. 16%; χ2 = 117; df = 1; p < .001), and sleep problems (69% vs. 57%; χ2 = 26; df = 1; p < .001) compared to adults. The rates of intense grief reactions among those who lost someone to COVID‐19 was 55%. Loneliness was the most common predictor across outcomes and higher number of hours spent on social media and exposure to media about COVID‐19 predicted depression symptoms and suicidal ideation or behavior in adolescents.
Conclusions
The COVID‐19 pandemic is associated with increased rates of clinically significant psychiatric symptoms. Loneliness could put individuals at increased risk for the onset of psychiatric disorders.
Background
Adolescent major depressive disorder (MDD) is a significant health problem, associated with substantial morbidity, cost, and mortality. Depression is a significant risk factor for suicide, ...which is now the second leading cause of death in young people. Up to twenty per cent of adolescents will experience MDD before adulthood, and while a substantial proportion will improve with standard‐of‐care treatments (psychotherapy and medication), roughly one third will not.
Methods
Here, we have reviewed the literature in order to discuss the concept of treatment‐resistant depression (TRD) in adolescence, examine risk factors, diagnostic difficulties, and challenges in evaluating symptom improvement, and providing guidance on how to define adequate medication and psychotherapy treatment trials.
Results
We propose a staging model for adolescent TRD and review the treatment literature. The evidence base for first‐ and second‐line treatments primarily derives from four large pediatric clinical trials (TADS, TORDIA, ADAPT, and IMPACT). After two medications and a trial of evidence‐based psychotherapy have failed to alleviate depressive symptoms, the evidence becomes quite thin for subsequent treatments. Here, we review the evidence for the effectiveness of medication switches, medication augmentation, psychotherapy augmentation, and interventional treatments (i.e., transcranial magnetic stimulation, electroconvulsive therapy, and ketamine) for adolescent TRD. Comparisons are drawn to the adult TRD literature, and areas for future pediatric depression research are highlighted.
Conclusions
As evidence is limited for treatments in this population, a careful consideration of the known risks and side effects of escalated treatments (e.g., mood stabilizers and atypical antipsychotics) is warranted and weighed against potential, but often untested, benefits.
Read the Commentary on this article at doi: 10.1111/jcpp.13207
Abstract The ‘default mode network’ (DMN), a collection of brain regions including the posterior cingulate cortex (PCC), shows reliable inter-regional functional connectivity at rest. It has been ...implicated in rumination and other negative affective states, but its role in suicidal ideation is not well understood. We employed seed based functional connectivity methods to analyze resting state fMRI data in 34 suicidal ideators and 40 healthy control participants. Whole-brain connectivity with dorsal PCC or ventral PCC was broadly intact between the two groups, but while the control participants showed greater coupling between the dorsal anterior cingulate cortex (dACC) and dorsal PCC, compared to the dACC and ventral PCC, this difference was reversed in the ideators. Furthermore, ongoing low frequency BOLD signal in these three regions (dorsal, ventral PCC, dACC) was reduced in the ideators. The structural integrity of the cingulum bundle, as measured using diffusion tensor imaging (DTI), also explained variation in the functional connectivity measures but did not abolish the group differences. Together, these findings provide evidence of abnormalities in the DMN underlying the tendency towards suicidal ideation.
Abstract Purpose To examine disparities between sexual minority youth (SMY) and heterosexual youth in rates of suicidality and depression symptoms. Methods Separate meta-analyses were conducted to ...examine suicidality and depression disparities. Studies were included if the average age of the participants was <18 years, and if suicidality or depression symptoms were compared across SMY and heterosexual youth. Results SMY reported significantly higher rates of suicidality (odds ratio OR = 2.92) and depression symptoms (standardized mean difference, d = .33) as compared with the heterosexual youth. Disparities increased with the increase in the severity of suicidality (ideation OR = 1.96, intent/plans OR = 2.20, suicide attempts OR = 3.18, suicide attempts requiring medical attention OR = 4.17). Effects did not vary across gender, recruitment source, and sexual orientation definition. Conclusions Disparities in suicidality and depression may be influenced by negative experiences including discrimination and victimization. Clinicians should assess sexual orientation, analyze psychosocial histories to identify associated risk factors, and promote prevention and intervention opportunities for SMY and their families.
To evaluate the clinical and prognostic significance of suicide attempts (SAs) and nonsuicidal self-injury (NSSI) in adolescents with treatment-resistant depression.
Depressed adolescents who did not ...improve with an adequate SSRI trial (N = 334) were randomized to a medication switch (SSRI or venlafaxine), with or without cognitive-behavioral therapy. NSSI and SAs were assessed at baseline and throughout the 24-week treatment period.
Of the youths, 47.4% reported a history of self-injurious behavior at baseline: 23.9% NSSI alone, 14% NSSI+SAs, and 9.5% SAs alone. The 24-week incidence rates of SAs and NSSI were 7% and 11%, respectively; these rates were highest among youths with NSSI+SAs at baseline. NSSI history predicted both incident SAs (hazard ratio HR= 5.28, 95% confidence interval CI = 1.80-15.47, z = 3.04, p = .002) and incident NSSI (HR = 7.31, z = 4.19, 95% CI = 2.88-18.54, p < .001) through week 24, and was a stronger predictor of future attempts than a history of SAs (HR = 1.92, 95% CI = 0.81-4.52, z = 2.29, p = .13). In the most parsimonious model predicting time to incident SAs, baseline NSSI history and hopelessness were significant predictors, adjusting for treatment effects. Parallel analyses predicting time to incident NSSI through week 24 identified baseline NSSI history and physical and/or sexual abuse history as significant predictors.
NSSI is a common problem among youths with treatment-resistant depression and is a significant predictor of future SAs and NSSI, underscoring the critical need for strategies that target the prevention of both NSSI and suicidal behavior.
Treatment of SSRI-Resistant Depression in Adolescents (TORDIA). URL: http://www.clinicaltrials.gov. Unique Identifier: NCT00018902.
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