Suicide is the third leading cause of death in adolescence, and medically serious suicide attempts occur in approximately 3% of adolescents. This review examines a number of risk factors that ...contribute to suicidal behavior. A prior suicide attempt is one of the best predictors of both a repeat attempt and eventual completed suicide. Depression, disruptive behavior disorders, and substance-use disorders also place adolescents at high risk for suicidal behavior, with comorbidity further increasing risk. Research on families indicates that suicidal behavior is transmitted through families. Groups at high risk for suicidal behavior include gay, lesbian, and bisexual youths, incarcerated adolescents, and homeless/runaway teens. Although abnormalities in the serotonergic system have not been consistently linked to suicidal behavior, genetic and neurobiologic studies suggest that impulsive aggression may be the mechanism through which decreased serotonergic activity is related to suicidal behavior. Findings from prevention and intervention studies are modest and indicate the need for substantially more theory-driven treatment research.
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.
Individuals in the early stages of psychosis have a markedly high risk for suicidal thoughts and behavior (STB). It is not well understood if STB among those with psychosis-risk symptoms is accounted ...for by co-occurring psychopathology (e.g., depression), unique experiences specific to psychosis-spectrum symptomatology (e.g., hallucinations, delusions), or combined effects of different factors. This cross-sectional study explored the link between psychosis-spectrum symptoms, co-occurring disorders, and STB.
This record review included 569 adolescents (mean age = 14.83) admitted to a psychiatric inpatient hospital due to exhibiting behavior indicating they were an imminent threat to themselves or others. Upon intake to the hospital, participants completed a diagnostic interview and self-report measures of suicidal ideation, suicide attempt history, and psychosis-spectrum symptoms. The primary analysis used linear regression to predict suicidal ideation from psychosis-spectrum symptom scores, controlling for known characteristics associated with STB including specific psychiatric disorders (i.e. depressive, anxiety, post-traumatic stress, and psychotic disorders), biological sex, and race.
Psychosis-spectrum symptoms predicted suicidal ideation above and beyond the significant effects of a depressive disorder diagnosis and sex, as well as the non-significant effects of anxiety, PTSD, full-threshold psychosis, and race. Item-level correlations demonstrated that several psychosis-spectrum symptoms were significantly associated with ideation and lifetime suicide attempts.
Results indicate that within this sample of psychiatrically hospitalized youth, psychosis-risk symptoms were uniquely linked to STB. These findings suggest that attention to psychosis-spectrum symptoms, including several specific psychosis-risk experiences, may be clinically important for better assessment and treatment of suicidal youth.
To identify symptom dimensions of depression that predict recovery among selective serotonin reuptake inhibitor (SSRI) treatment-resistant adolescents undergoing second-step treatment.
The Treatment ...of Resistant Depression in Adolescents (TORDIA) trial included 334 SSRI treatment-resistant youth randomized to a medication switch, or a medication switch plus CBT. This study examined five established symptom dimensions (Child Depression Rating Scale-Revised) at baseline as they predicted recovery over 24 weeks of acute and continuation treatment. The two indices of recovery that were evaluated were time to remission and number of depression-free days.
Multivariate analyses examining all five depression symptom dimensions simultaneously indicated that anhedonia was the only dimension to predict a longer time to remission, and also the only dimension to predict fewer depression-free days. In addition, when anhedonia and CDRS-total score were evaluated simultaneously, anhedonia continued to uniquely predict longer time to remission and fewer depression-free days.
Anhedonia may represent an important negative prognostic indicator among treatment-resistant depressed adolescents. Further research is needed to elucidate neurobehavioral underpinnings of anhedonia, and to test treatments that target anhedonia in the context of overall treatment of depression.
The utility of CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) in identifying current and future problematic substance use and substance use disorders (SUDs) in pediatric emergency department ...(PED) patients is unknown. We conducted a secondary analysis of a study in 16 PEDs to determine the concurrent and predictive validity of CRAFFT with respect to SUD.
At baseline, 4753 participants aged 12 to 17 years completed an assessment battery (CRAFFT and other measures of alcohol, drug use, and risk behaviors). A subsample was readministered the battery at 1-, 2-, and 3-year follow-up to investigate future SUDs.
Of 2175 participants assigned to follow-up, 1493 (68.6%) completed 1-year, 1451 (66.7%) completed 2-year, and 1265 (58.1%) completed the 3-year follow-up. A baseline CRAFFT value of ≥2 was significantly associated with problematic substance use or mild or moderate to severe SUD diagnosis on the Diagnostic Interview Schedule for Children at baseline (
< .001). The results persisted after 1, 2, and 3 years (
< .001). The best combined sensitivity and specificity was achieved with a baseline CRAFFT value of ≥1 as a cutoff for predicting problematic substance use and a
diagnosis of mild SUD at 1, 2, and 3 years. The baseline CRAFFT score that best predicted a moderate to severe SUD at 1 year was ≥2; but at 2 and 3 years, the cutoff score was ≥1.
CRAFFT has good concurrent validity for problematic substance use and SUD in PED patients and is useful in predicting SUDs at up to 3 years follow-up but with limited sensitivity.
Substance use among adolescents in the U.S. is associated with adverse physical and mental health outcomes in the long-term. Universal youth-focused substance use prevention programs have ...demonstrated effectiveness but are often not sustainable due to the significant amount of time, effort, and resources required. We describe a trial protocol for a brief, low-participant-burden intervention to improve substance use-specific parent-child communication through the promotion of family meals and increased parental engagement.
This study is a parallel-group randomized controlled trial designed to assess the efficacy of a 13-week intervention. A total of 500 dyads of parents and their 5th-7th grade children are recruited from across Massachusetts. Dyads are randomized to the intervention or attention-control condition using block urn randomization, based on child grade, gender, and school. Parents/guardians in the substance use preventive intervention arm receive a short handbook, attend two meetings with an interventionist, and receive two SMS messages per week. Parents/guardians in the control arm receive the same dose but with content focused on nutrition, physical activity, and weight stigma. Participant dyads submit videos of family meals, audio recordings of prompted conversations, and quantitative surveys over an 18-month period (baseline, 3, 6, 12, 18 months post-intervention). The primary outcomes measure the quantity and quality of parent-child substance use conversations and proximal child indicators (i.e., substance use attitudes and expectancies, affiliation with substance-using peers, and intentions and willingness to use substances). The secondary outcome is child substance use initiation.
This is a novel, brief, communication-focused intervention for parents/guardians that was designed to reduce participant burden. The intervention has the potential to improve parent-child engagement and communication and conversations about substance use specifically and decrease child substance use risk factors and substance use initiation.
ClinicalTrials.gov NCT03925220. Registered on 24 April 2019.
Suicide and suicidal behavior during adolescence have been steadily increasing over the past two decades. The preponderance of interventions focuses on crisis intervention, underlying psychiatric ...disorders, regulating negative affect, and reducing cognitive distortions. However, low positive affectivity may be a mechanism that contributes to adolescent suicidal ideation and behaviors independent of other risk factors. Skills to Enhance Positivity (STEP) is an acceptance-based intervention, designed to increase attention to, and awareness of, positive affect and positive experiences. Results from a pilot RCT demonstrated engagement of the target (positive affect) and a decrease in clinical outcomes (suicidal events; i.e., either a suicide attempt or an emergency intervention for an acute suicidal crisis), providing support to test the clinical effectiveness of STEP in a larger clinical trial with clinical staff implementing the intervention.
To test the effectiveness of STEP, compared to Enhanced Treatment as Usual (ETAU), in reducing suicidal events and ideation in adolescents admitted to inpatient psychiatric care due to suicide risk. We hypothesize that those randomized to STEP, compared to ETAU, will have lower rates of suicide events, active suicidal ideation (SI), and depressed mood over the 6-month follow-up period. We hypothesize that those randomized to STEP, compared to ETAU, will demonstrate greater improvement in the hypothesized mechanisms of attention to positive affect stimuli and gratitude and satisfaction with life.
Participants will be randomized to either STEP or ETAU. STEP consists of four in-person sessions focused on psychoeducation regarding positive and negative affect, mindfulness meditation, gratitude, and savoring. Mood monitoring prompts and skill reminders will be sent via text messaging daily for the first month post-discharge and every other day for the following two months. The ETAU condition will receive text-delivered reminders to use a safety plan provided at discharge from the hospital and healthy habits messages, matched in frequency to the STEP group. This trial was registered on 6 August 2021 (ClinicalTrials.gov NCT04994873).
The STEP protocol was approved by the National Institute of Mental Health (NIMH) Data and Safety Monitoring Board on March 4, 2022. The RCT is currently in progress.
The STEP protocol is an innovative, adjunctive treatment that has the potential to have positive effects on adolescent suicidal ideation and attempts beyond that found for standard treatment alone.
Abstract Purpose To evaluate acceptability and feasibility of a theoretically based two-part (brief in-person + 8-week automated text message) depression prevention program, “intervention for ...DepressiOn and Violence prevention in the Emergency department” (iDOVE), for high-risk adolescents. Methods English-speaking emergency department (ED) patients (age 13–17, any chief complaint) were sequentially approached for consent on a convenience sample of shifts and screened for inclusion based on current depressive symptoms and past-year violence. After consent, baseline assessments were obtained; all participants were enrolled in the two-part intervention (brief in-ED + 8-week two-way text messaging). At 8 weeks, quantitative and qualitative follow-up assessments were obtained. Measures included feasibility, acceptability, and preliminary data on efficacy. Qualitative data were transcribed verbatim, double coded, and interpreted using thematic analysis. Quantitative results were analyzed descriptively and with paired t tests. Results As planned, 16 participants (eight each gender) were recruited (75% of those who were eligible; 66% nonwhite, 63% low income, mean age 15.4). The intervention had high feasibility and acceptability: 93.8% completed 8-week follow-up; 80% of daily text messages received responses; 31% of participants requested ≥1 “on-demand” text message. In-person and text message portions were rated as good/excellent by 87%. Qualitatively, participants articulated: (1) iDOVE was welcome and helpful, if unexpected in the ED; (2) the daily text message mood assessment was “most important”; (3) content was “uplifting”; and (4) balancing intervention “relatability” and automation was challenging. Participants' mean ΔBDI-2 (Beck Depression Inventory) from baseline to 8-week follow-up was −4.9, ( p = .02). Conclusions This automated preventive text message intervention is acceptable and feasible. Qualitative data emphasize the importance of creating positive, relevant, and interactive digital health tools for adolescents.
Abstract Purpose To elucidate key elements surrounding acceptability/feasibility, language, and structure of a text message-based preventive intervention for high-risk adolescent females. Methods We ...recruited high-risk 13- to 17-year-old females screening positive for past-year peer violence and depressive symptoms, during emergency department visits for any chief complaint. Participants completed semistructured interviews exploring preferences around text message preventive interventions. Interviews were conducted by trained interviewers, audio-recorded, and transcribed verbatim. A coding structure was iteratively developed using thematic and content analysis. Each transcript was double coded. NVivo 10 was used to facilitate analysis. Results Saturation was reached after 20 interviews (mean age 15.4; 55% white; 40% Hispanic; 85% with cell phone access). (1) Acceptability/feasibility themes : A text-message intervention was felt to support and enhance existing coping strategies. Participants had a few concerns about privacy and cost. Peer endorsement may increase uptake. (2) Language themes : Messages should be simple and positive. Tone should be conversational but not slang filled. (3) Structural themes : Messages may be automated but must be individually tailored on a daily basis. Both predetermined (automatic) and as-needed messages are requested. Dose and timing of content should be varied according to participants' needs. Multimedia may be helpful but is not necessary. Conclusions High-risk adolescent females seeking emergency department care are enthusiastic about a text message-based preventive intervention. Incorporating thematic results on language and structure can inform development of future text messaging interventions for adolescent girls. Concerns about cost and privacy may be able to be addressed through the process of recruitment and introduction to the intervention.
Juvenile legal involved youth (JLIY) experience disproportionately high rates of suicidal and self-injurious thoughts and behaviors (SSITB). Many JLIY lack access to evidence-based treatment ...specifically designed to treat SSITB, thereby increasing the overall risk of suicide. The overwhelming majority of JLIY are not placed in secure facilities and almost all incarcerated youth are eventually released to the community. Consequently, SSITB are a major concern of JLIY residing in the community and it is critical that this population has access to evidence-based treatment for SSITB. Unfortunately, most community mental health providers who treat JLIY have not been trained in evidence-based interventions that are specifically designed to SSITB, which often leads to youth experiencing prolonged periods of SSITB. Training community mental health providers who serve JLIY in the detection and treatment of SSITB shows promise for decreasing the overall suicide risk for JLIY.
The current proposal aims to reduce SSITB among JLIY, and thus reduce mental health disparities in this vulnerable and underserved youth population, by increasing access to evidence-based treatment strategies specifically designed to treat SSITB behaviors. We will implement an agency-wide training among at least 9 distinct community mental health agencies that serve JLIY referred to treatment by a statewide court system in the Northeast. Agencies will be trained in an adapted version of the COping, Problem Solving, Enhancing life, Safety, and Parenting (COPES+) intervention. Training will be implemented via a cluster-randomized stepped wedge trial that proceeds through multiple phases.
This research engages multiple systems (i.e., juvenile legal and mental health systems) serving JLIY and has the potential to directly inform treatment practices in juvenile legal and mental health systems. The current protocol has significant public health implications as the primary goals are to reduce SSITB among adolescents involved in the juvenile legal system. By implementing a training protocol with community-based providers to help them learn an evidence-based intervention, this proposal aims to reduce mental health disparities in a marginalized and underserved population.
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