Assessment and treatment of the youthful suicidal patient

Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management

OBJECTIVES

To update clinical practice guidelines to assist primary care (PC) clinicians in the management of adolescent depression. This part of the updated guidelines is used to address practice preparation, identification, assessment, and initial management of adolescent depression in PC settings.

METHODS

By using a combination of evidence- and consensus-based methodologies, guidelines were developed by an expert steering committee in 2 phases as informed by (1) current scientific evidence (published and unpublished) and (2) draft revision and iteration among the steering committee, which included experts, clinicians, and youth and families with lived experience.

RESULTS

Guidelines were updated for youth aged 10 to 21 years and correspond to initial phases of adolescent depression management in PC, including the identification of at-risk youth, assessment and diagnosis, and initial management. The strength of each recommendation and its evidence base are summarized. The practice preparation, identification, assessment, and initial management section of the guidelines include recommendations for (1) the preparation of the PC practice for improved care of adolescents with depression; (2) annual universal screening of youth 12 and over at health maintenance visits; (3) the identification of depression in youth who are at high risk; (4) systematic assessment procedures by using reliable depression scales, patient and caregiver interviews, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria; (5) patient and family psychoeducation; (6) the establishment of relevant links in the community, and (7) the establishment of a safety plan.

CONCLUSIONS

This part of the guidelines is intended to assist PC clinicians in the identification and initial management of adolescents with depression in an era of great clinical need and shortage of mental health specialists, but they cannot replace clinical judgment; these guidelines are not meant to be the sole source of guidance for depression management in adolescents. Additional research that addresses the identification and initial management of youth with depression in PC is needed, including empirical testing of these guidelines.

Efficacy and acceptability of interpersonal psychotherapy for depression in adolescents: A meta-analysis of randomized controlled trials

In this study, we evaluate the efficacy and safety of interpersonal psychotherapy (IPT) for adolescents with depression. We searched our existing database and electronic databases, including PubMed, Cochrane, EMBASE, PsycINFO, Web of Science, and CINAHL databases (from inception to May 2016). We included randomized controlled trials comparing IPT with various control conditions, including waitlist, psychological placebo, treatment as usual, and no treatment, in adolescents with depression. Finally, we selected seven studies comprising 538 participants comparing IPT with three different control conditions. Pooled analyses suggested that IPT was significantly more effective than control conditions in reducing depressive symptoms at post-treatment and follow-up, and increasing the response/remission rate at post-treatment. IPT was also superior to control conditions for all-cause discontinuation and quality of life/functioning improvement outcomes. However, there was no evidence that IPT reduces the risk of suicide from these data. Meta-analysis demonstrated publication bias for primary efficacy, while the adjusted standardized mean difference using the trim-and-fill method indicated IPT was still significantly superior to the control conditions. Current evidence indicates IPT has a superior efficacy and acceptability compared with control conditions in treating adolescents with depression.

Suicidal thoughts are associated with platelet counts in adolescent inpatients

OBJECTIVE

Platelets (PLT), which serve as the primary hemostatic indicator, can be used as a peripheral model for studying monoamine turnover in the brain. Therefore, they are attractive targets as circulatory biomarkers for the detection of psychiatric disorders. However, PLT counts have not been utilized as a peripheral biomarker of psychopathology.

METHODS

This study was a retrospective analysis of PLT counts upon admission of 108drug-naïve adolescents hospitalized in an inpatient psychiatric department. PLT counts of patients with suicidal ideation (SI) were compared with those of nonsuicidal in patients (NSI) and those of 77 healthy adolescents, serving as a control group. The patients' disorders were diagnosed and classified by one of four American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM IV) diagnoses, that is, unipolar depression, bipolar depression, schizophrenia, and a pooled group of conduct and borderline personality disorders.

RESULTS

Significantly higher PLT counts were observed in SI patients, as compared with NSI patients (300,200±53.3/mL vs. 253,900±53.2/mL, respectively; p=0.0001). A significant difference in PLT counts in SI patients, relative to the control group, was also noted (300,200±53.3/mL vs. 254,000±52/mL, respectively; p=<10(-26)). Finally, a significant difference in PLT counts was observed between conduct/borderline personality disorders patient with and without suicidal ideation (292,000±55/mL vs. 246,000±64/mL, respectively; p=0.001).

CONCLUSIONS

PLT counts are higher in suicidal hospitalized adolescents than in nonsuicidal inpatients, as well as than in controls.

Perfectionism, narcissism, and depression in suicidal and nonsuicidal adolescent inpatients

OBJECTIVE

The aim of this study was to investigate the relationship between 2 psychological profiles: (a) the intrapersonal profile, involving self-critical depression, self-oriented perfectionism, and narcissism, and (b) the interpersonal profile, involving dependent depression and socially prescribed perfectionism, and the association of these 2 profiles with suicidal behavior among adolescent inpatients.

METHODS

One hundred adolescents, admitted to a university-affiliated psychiatric adolescent inpatient unit in Israel, completed the Depressive Experience Questionnaire for Adolescents, the Child and Adolescent Perfectionism Scale, and the Narcissistic Personality Inventory. The Suicidal Potential Interview was used to evaluate suicidal behavior and separate them into low-risk and high-risk groups.

RESULTS

Dependent depression correlated positively and significantly with severity of suicidal behavior. Adolescent inpatients with high levels of suicidal behavior (n = 54) were more dependent in terms of depression and were more inclined to socially prescribed perfectionism compared with adolescent inpatients with low levels of suicidal behavior (n = 45). The components of the intrapersonal profile did not correlate with severity of suicidal behavior; however, low narcissism scores characterized the psychological function that strongly predicted severe suicidal behavior.

CONCLUSIONS

The findings indicated that the conceptualization of 2 broad intrapersonal and interpersonal profiles in adolescent inpatients may have some validity in terms of the interpersonal dimension. The components of the interpersonal profile related to severe suicidal behavior and may be important in planning treatment strategy.

Behavioural activation for the treatment of low-income, African American adolescents with major depressive disorder: a case series

Behavioural activation (BA) is a psychosocial treatment that has shown promise in the treatment of adults suffering from major depressive disorder (MDD). Recent studies have shown that BA may also be effective for treating depressed adolescents. There are no studies that have reported on the BA treatment of depressed and low-income African American adolescents; thus, the current study reports on the effectiveness of a version of BA adapted for the treatment of African American adolescents who were diagnosed with MDD (n = 3). Participants were allowed to attend a maximum of 17 sessions of weekly psychotherapy. Based on results taken from structured interviews, two of the three participants no longer met criteria for MDD at the end of treatment, and the severity of clinician-rated depressive symptoms and impairment decreased for all participants at post-treatment assessment. Additionally, all participants and their caregivers reported satisfaction with treatment. Implications of these findings, study limitations and suggestions for future directions are discussed.

The interpersonal theory of suicide

Suicidal behavior is a major problem worldwide and, at the same time, has received relatively little empirical attention. This relative lack of empirical attention may be due in part to a relative absence of theory development regarding suicidal behavior. The current article presents the interpersonal theory of suicidal behavior. We propose that the most dangerous form of suicidal desire is caused by the simultaneous presence of two interpersonal constructs-thwarted belongingness and perceived burdensomeness (and hopelessness about these states)-and further that the capability to engage in suicidal behavior is separate from the desire to engage in suicidal behavior. According to the theory, the capability for suicidal behavior emerges, via habituation and opponent processes, in response to repeated exposure to physically painful and/or fear-inducing experiences. In the current article, the theory's hypotheses are more precisely delineated than in previous presentations (Joiner, 2005), with the aim of inviting scientific inquiry and potential falsification of the theory's hypotheses.

Specific depressive symptoms and disorders as associates and predictors of suicidal acts across adolescence

OBJECTIVE

To examine the role of depressive symptoms and disorders as associates and predictors of suicidal acts across adolescence.

METHOD

A representative sample of Norwegian school students (N = 2464, mean age 13.7 years) in grades 8 and 9 was reassessed after one year (T2) with the same questionnaire. All high scorers of depressive symptoms on the Mood and Feelings Questionnaire (MFQ) at T2 were defined as cases. One control from low or middle scorers, matched for age and gender, was randomly assigned to every two cases. This subset (n = 345) was diagnostically assessed by face-to-face K-SADS-PL interviews (mean age = 14.9 years). The same subset was reassessed after 5 years (T3) by using the same questionnaire (n = 252, mean age = 20.0 years) and telephone K-SADS-PL interviews (n = 242). The participation rate was 76.9% (n = 265).

RESULTS

Cognitive symptoms dominated the depressive symptom profile among suicide attempters, irrespective of age and time. Among younger adolescents, suicidal thoughts and acts of self-harm without suicidal intent were associated with suicidal acts. Recurrent thoughts about death, hopelessness, disturbed concentration and middle insomnia were associates of suicidal acts among older adolescents. Worthlessness by 15 years was a significant predictor of suicidal acts between 15 to 20 years. MDD and a depressive episode, not otherwise specified, continued to be significant associates among younger adolescents, while dysthymia by 15 years remained a predictor of suicidal acts between 15 to 20 years, even when controlled for depressive symptoms.

CONCLUSIONS

Self-harm without suicidal intent, middle insomnia, cognitive depressive symptoms and a formal psychiatric diagnosis of any depressive disorder should alert professionals in the risk assessment of suicidal adolescents.

Predicting adolescent suicidality: comparing multiple informants and assessment techniques

Adolescent suicidality is a serious problem among American youth. Common risk factors for adolescent suicidality include depression and conduct problems but there is little agreement on the best means to assess these factors. We compared multiple informants (mothers, fathers, the adolescent and a sibling) and multiple assessment techniques using a sample of more than 460 families. Assessment techniques included paper-pencil instruments, observer ratings, and diagnostic interviews. Suicidality was assessed concurrently and two years after the risk assessment. Adolescent-reported paper-pencil instruments and diagnostic interviews were strongly associated with concurrent and future suicidality. Parents' report of adolescent feelings and behaviors were also useful. Observed behaviors were not useful in assessing suicidality risk factors. Clinical recommendations include utilizing paper-pencil and diagnostic adolescent risk factor assessment and focusing on emotions.

Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management

OBJECTIVES

To develop clinical practice guidelines to assist primary care clinicians in the management of adolescent depression. This first part of the guidelines addresses identification, assessment, and initial management of adolescent depression in primary care settings.

METHODS

By using a combination of evidence- and consensus-based methodologies, guidelines were developed by an expert steering committee in 5 phases, as informed by (1) current scientific evidence (published and unpublished), (2) a series of focus groups, (3) a formal survey, (4) an expert consensus workshop, and (5) draft revision and iteration among members of the steering committee.

RESULTS

Guidelines were developed for youth aged 10 to 21 years and correspond to initial phases of adolescent depression management in primary care, including identification of at-risk youth, assessment and diagnosis, and initial management. The strength of each recommendation and its evidence base are summarized. The identification, assessment, and initial management section of the guidelines includes recommendations for (1) identification of depression in youth at high risk, (2) systematic assessment procedures using reliable depression scales, patient and caregiver interviews, and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria, (3) patient and family psychoeducation, (4) establishing relevant links in the community, and (5) the establishment of a safety plan.

CONCLUSIONS

This part of the guidelines is intended to assist primary care clinicians in the identification and initial management of depressed adolescents in an era of great clinical need and a shortage of mental health specialists but cannot replace clinical judgment; these guidelines are not meant to be the sole source of guidance for adolescent depression management. Additional research that addresses the identification and initial management of depressed youth in primary care is needed, including empirical testing of these guidelines.

Management of the depressed, suicidal child or adolescent

Two prominent risk factors for completed suicide and suicidal behavior in adolescents are previous suicide attempts and a diagnosis of a depressive episode. Adolescents with different degrees of suicidal risk and severity are referred or admitted to various clinical settings. Research has yet to identify clearly the treatment of choice for suicidal patients. Regardless, clinical interventions should be based on a thorough suicide risk assessment. Treatment strategies should be multidimensional, targeting suicidal behavior and the underlying psychiatric illness or other personality and environmental risk factors. Because adolescents are referred from one clinical setting to another, continuity of care must be one of mental health practitioners' major concerns. Lack of continuity of care places patients at an elevated risk for additional suicide attempts.

The development of impulsivity and suicidality in borderline personality disorder

Borderline personality disorder (BPD) is characterized by a broad pattern of impulsivity and suicidality. BPD usually begins in adolescence; the full clinical picture of the disorder is associated with developmental increases in impulsivity. However, BPD also has childhood precursors. The developmental pathways are similar to those found in other impulsive spectrum disorders, but children who later develop BPD probably have both externalizing and internalizing symptoms. Research in this area has made use of retrospective data from adults, prospective data from community studies, follow-up studies from children at risk, as well as research on "borderline pathology of childhood" (a condition with symptoms similar to adult BPD). Existing evidence suggests that both temperamental and environmental risk factors play a role in the development of the behavioral patterns associated with the disorder. These pathways also help account for the life course and outcome of BPD in adulthood.

Parasuizide bei Kindern und Jugendlichen

Zusammenfassung. In dieser Übersichtsarbeit werden spezifische Aspekte parasuizidalen Verhaltens bei Kindern und Jugendlichen dargestellt. Bedeutsame Risikofaktoren sind psychische Störungen der Minderjährigen sowie ein niedriges Funktionsniveau ihrer Familien, aber auch diverse andere personbezogene und psychosoziale Variablen sind überzufällig häufig mit Parasuiziden assoziiert. Eine kleine Untergruppe der Kinder und Jugendlichen zeigt wiederholt auftretendes parasuizidales Verhalten. Diagnostische und therapeutische Implikationen der dargestellten wissenschaftlichen Befunde werden erörtet.

Depression and bipolar support alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in children and adolescents

OBJECTIVE

To focus attention on the critical unmet needs of children and adolescents with mood disorders and to make recommendations for future research and allocation of healthcare resources.

METHOD

The 36-member Consensus Development Panel consisted of experts in child/adolescent or adult psychiatry and psychology, pediatrics, and mental health advocacy. Reviews of the literature concerning youth mood disorders were performed on the subjects of risk factors, prevention, diagnosis, treatment, and services delivery, and opinions and experiences of mental health advocates were obtained.

RESULTS

The Consensus Development Panel listened to presentations and participated in discussions. Independent workgroups of clinicians, scientists, and mental health advocates considered the evidence and prepared preliminary statements. Workgroup leaders presented drafts for discussion by the Consensus Development Panel. The final document was reviewed by the entire group and edited to incorporate input from all participants.

CONCLUSIONS

Evidence suggests high rates of unmet needs for children and adolescents with depression or bipolar disorder. Training is largely limited to child mental health specialists; general psychiatrists, pediatricians, and other primary care physicians receive little or no training. As a result, treatment patterns may reflect adult treatment plans that are not validated for youths. Effective treatments have been identified and some preliminary prevention models have been developed, but they are not yet widely applied. Patients experience limited exposure to clinicians adequately trained to address their problems and little information to guide care decisions, particularly concerning bipolar disorder. National efforts are required to restructure healthcare delivery and provider training and to immediately develop more advanced research on pathophysiology, prevention, and services delivery effectiveness.

Eating disorders and suicide risk factors in adolescents: an Italian community-based study

In a mixed male-female sample of 1000 adolescents age 15 to 19 years in a northeastern area of Italy, we investigated the links between eating disorders and suicidal tendencies by means of self-compiled measures, including the Eating Attitudes Test (EAT), the Bulimic Investigatory Test of Edinburgh (BITE), the Body Attitudes Test (BAT), and the SCL-90-R. More females than males reported abnormal eating patterns suggesting eating disorders: we found that 100 females (15.8%) and 8 males (2.8%) achieved scores above the suggested cutoff on EAT (cutoff = 30), 26 females (4.1%) and 1 male (.3%) achieved scores above the suggested cutoff on BITE (cutoff = 20), and 287 females (45.5%) and 24 males (8.6%) achieved scores above the suggested cutoff on BAT (cutoff = 36). More females than males also reported symptoms of hopelessness (44.3% vs. 30.5%) and suicidal ideation (30.8% vs. 25.3%). Both males and females reporting suicidal ideation achieved significantly higher scores on the eating disorders inventories, with no independent contribution by age, socioeconomic status, or body mass index. Although caution is required when drawing conclusions from self-reported measures, studies on mood disorders and suicidality in youth clearly need to include measures of eating disorders.