Remission, Recovery, Relapse, and Recurrence Rates for Suicide Attempts and Nonsuicidal Self-Injury for Suicidal Youth Treated With Dialectical Behavior Therapy or Supportive Therapy

OBJECTIVE

To evaluate rates of remission, recovery, relapse, and recurrence in suicidal youth who participated in a clinical trial comparing Dialectical Behavior Therapy (DBT) and Individual and Group Supportive Therapy (IGST).

METHOD

Participants were 173 youth, aged 12 to 18 years, with repetitive self-harm (including at least 1 prior suicide attempt [SA]) and elevated suicidal ideation (SI). Participants received 6 months of DBT or IGST and were followed for 6 months post-treatment. The sample was 95% female, 56.4% White, and 27.49% Latina. Remission was defined as absence of SA or nonsuicidal self-injury (NSSI) across one 3-month interval; recovery was defined across 2 or more consecutive intervals. Relapse and recurrence were defined as SA or NSSI following remission or recovery. Cross-tabulation with χ2 was used for between-group contrasts.

RESULTS

Over 70% of the sample reported remission of SA at each treatment and follow-up interval. There were significantly higher rates of remission and recovery and lower rates of relapse and recurrence for SA in DBT than for IGST. Across treatments and time points, SA had higher remission and recovery rates and lower relapse and recurrence rates than NSSI. There were no significant differences in NSSI remission between conditions; however, participants receiving DBT had significantly higher NSSI recovery rates than those receiving IGST for the 3- to 9-month, 3- to 12-month, and 6- to 12-month intervals.

CONCLUSION

Results showed higher percentages of SA remission and recovery for DBT as compared to IGST. NSSI was less likely to remit than SA.

DIVERSITY & INCLUSION STATEMENT

We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants.

CLINICAL TRIAL REGISTRATION INFORMATION

Collaborative Adolescent Research on Emotions and Suicide (CARES); https://www.

CLINICALTRIALS

gov/; NCT01528020.

Editorial: Suicide prevention in youth

Reducing deaths by suicide in youth is an urgent public health goal and effective treatment approaches remain limited. This editorial reviews new research published in this issue of Child and Adolescent Mental health that may inform youth suicide prevention efforts, including an open trial of a new, family-focused group intervention for youth with suicidal ideation and findings showing that life problems associated with presentation to the emergency department for self-harm vary by age and gender. The need for multi-component treatments that have the flexibility to target a range of life problems/risk factors and to include families in treatment is discussed, along with the need to find a way to make such interventions scalable. Finally, this editorial addresses this issue's debate by discussing the role of mindfulness in dialectical behavior therapy for suicidal youth and the need to carefully monitor and further examine the effectiveness and safety of mindfulness with this patient population.

Improving Care Linkage for Racial-Ethnic Minority Youths Receiving Emergency Department Treatment for Suicidality: SAFETY-A

OBJECTIVE

This study evaluated the effects of Safe Alternatives for Teens and Youths-Acute (SAFETY-A), a brief strengths-based, cognitive-behavioral family intervention, on racial-ethnic minority youths receiving emergency department (ED) treatment for suicidal episodes.

METHODS

Participants were 105 racial-ethnic minority youths enrolled in a randomized controlled trial evaluating SAFETY-A versus enhanced usual care for youths receiving ED treatment for suicidal episodes. Analyses examined group effects on care linkage after discharge and adequate treatment dose. A sample of 55 White youths was included for comparison.

RESULTS

Racial-ethnic minority youths who received SAFETY-A had higher treatment linkage rates than those receiving usual care. Adequate treatment dose rates did not differ by group.

CONCLUSIONS

Racial-ethnic minority youths receiving SAFETY-A had higher treatment linkage rates after discharge than those receiving usual care. SAFETY-A is a promising approach to enhance care continuity and mental health equity for racial-ethnic minority youths at risk for suicide.

Trajectories of Treatment Response and Nonresponse in Youth at High Risk for Suicide

OBJECTIVE

To examine trajectories of treatment response in suicidal youth who participated in a randomized controlled trial comparing dialectical behavior therapy (DBT) and individual and group supportive therapy.

METHOD

Using latent class analysis across both treatment conditions, secondary analyses were conducted of data from a multisite randomized controlled trial comprising 173 youths ages 12-18 with repetitive self-harm (SH) (including ≥1 lifetime suicide attempts) and elevated suicidal ideation (SI). The sample was 95% female, 56.4% White, and 27.49% Latina. Participants received 6 months of DBT or individual and group supportive therapy and 6 months of follow-up. Primary outcomes were SH and SI.

RESULTS

Of the sample, 63% and 74% were members of latent classes that showed improvement in SI and SH, respectively; 13% were total nonresponders, with no improvement in SI or SH. SH nonresponse emerged at the midpoint of treatment (3 months), with nonresponders showing a sharp increase in SH over the remainder of treatment and follow-up. Youth receiving DBT were significantly more likely to be an SH responder vs nonresponder than youths in individual and group supportive therapy (ꭓ21 = 6.53, p = .01). An optimal threshold cut point using multivariate predictors of total nonresponse (White, externalizing symptoms, total SH, and SI) predicted total nonresponders to DBT with 100% accuracy.

CONCLUSION

This is the first study to identify trajectories of both SI and SH response to treatment in a sample of adolescents at risk of suicide. Results may inform personalized treatment approaches.

CLINICAL TRIAL REGISTRATION INFORMATION

Collaborative Adolescent Research on Emotions and Suicide (CARES); https://www.

CLINICALTRIALS

gov/; NCT01528020.

Dialectical Behavior Therapy for Suicidal Self-Harming Youth: Emotion Regulation, Mechanisms, and Mediators

OBJECTIVE

This study evaluated mechanisms, mediation, and secondary/exploratory outcomes in our randomized controlled trial evaluating dialectical behavior therapy (DBT) compared to individual and group supportive therapy (IGST). We expand on previously reported results indicating a DBT advantage at posttreatment on planned suicide/self-harm outcomes, and greater self-harm remission (absence of self-harm, post hoc exploratory outcome) during active-treatment and follow-up periods.

METHOD

This was a multi-site randomized trial of 173 adolescents with prior suicide attempts, self-harm, and suicidal ideation. Randomization was to 6 months of DBT or IGST, with outcomes monitored through 12 months. Youth emotion regulation was the primary mechanistic outcome.

RESULTS

Compared to IGST, greater improvements in youth emotion regulation were found in DBT through the treatment-period [t(498) = 2.36, p = .019] and 12-month study period (t(498) = 2.93, p = .004). Their parents reported using more DBT skills: posttreatment t(497) = 4.12, p < .001); 12-month follow-up t(497) = 3.71, p < .001). Mediation analyses predicted to self-harm remission during the 6- to 12-month follow-up, the prespecified outcome and only suicidality/self-harm variable with a significant DBT effect at follow-up (DBT 49.3%; IGST 29.7%, p = .013). Improvements in youth emotion regulation during treatment mediated the association between DBT and self-harm remission during follow-up (months 6-12, estimate 1.71, CI 1.01-2.87, p = .045). Youths in DBT reported lower substance misuse, externalizing behavior, and total problems at posttreatment/6 months, and externalizing behavior throughout follow-up/12 months.

CONCLUSION

Results support the significance of emotion regulation as a treatment target for reducing self-harm, and indicate a DBT advantage on substance misuse, externalizing behavior, and self-harm-remission, with 49.3% of youths in DBT achieving self-harm remission during follow-up.

CLINICAL TRIAL REGISTRATION INFORMATION

Collaborative Adolescent Research on Emotions and Suicide; https://www.clinicaltrials.gov/; NCT01528020.

Sleep in youth with repeated self-harm and high suicidality: Does sleep predict self-harm risk?

OBJECTIVE

To elucidate processes contributing to continuing self-harm in youth at very high risk for suicide, focusing on sleep disturbance, a putative warning sign of imminent suicide risk.

METHOD

101 youth (ages 12-18) selected for high risk of suicide/suicide attempts based on suicidal episodes plus repeated self-harm (suicide attempts and/or nonsuicidal self-injury [NSSI]). Youth were assessed at baseline, 6-, and 12-month follow-ups on measures of self-harm, suicidality, sleep, and depression.

RESULTS

Youth showed high rates of baseline sleep disturbance: 81.2% scored in the clinical range on the Pittsburgh Sleep Quality Index (PSQI); 81.2% reported an evening (night owl) circadian preference. PSQI score was associated with elevated levels of self-harm (suicide attempts and NSSI) contemporaneously and predicted future self-harm within 30 days. Rates of self-harm were high during follow-up: 45.0% and 33.7% at 6 and 12 months, respectively.

CONCLUSIONS

Results underscore the need to move beyond an acute treatment model to prevent recurrent and potentially deadly self-harm, the importance of clarifying mechanisms contributing to elevated suicide/self-harm risk, and the potential promise of engaging sleep as a therapeutic target for optimizing treatment and elucidating mechanistic processes.

Implementation of Dialectical Behavior Therapy with Suicidal and Self-Harming Adolescents in a Community Clinic

The object of this research was to examine the feasibility and effectiveness of Dialectical Behavior Therapy (DBT) with suicidal and self-harming adolescents treated in a community clinic. A group of 24 adolescents at high risk for suicide were enrolled in 6 months of comprehensive DBT, provided by therapists and trainees at a county-run outpatient mental health clinic serving disadvantaged, ethnic minority clients. Results showed significant pre/post-treatment decreases in suicide attempts, non-suicidal self-injury behaviors (NSSI), and suicidal ideation. Results also showed significant decreases in other suicide risk factors, including emotion dysregulation, depression, impulsivity, BPD symptoms, psychopathology, PTSD symptoms, and substance use, as well as increases in family expressiveness and reasons for living. Treatment retention and satisfaction rates were high. As many youth at risk for suicide will be treated in community settings, findings showing that receiving DBT in a community clinic resulted in significant improvements across a range of suicide risk factors are an important contribution to the adolescent suicide prevention literature.

Recent advances in understanding and managing self-harm in adolescents

Adolescent suicide is a serious public health problem, and non-suicidal self-injury (NSSI) is both highly comorbid with suicidality among adolescents and a significant predictor of suicide attempts (SAs) in adolescents. We will clarify extant definitions related to suicidality and NSSI and the important similarities and differences between these constructs. We will also review several significant risk factors for suicidality, evidence-based and evidence-informed safety management strategies, and evidence-based treatment for adolescent self-harming behaviors. Currently, dialectical behavior therapy (DBT) for adolescents is the first and only treatment meeting the threshold of a well-established treatment for self-harming adolescents at high risk for suicide. Areas in need of future study include processes underlying the association between NSSI and SAs, clarification of warning signs and risk factors that are both sensitive and specific enough to accurately predict who is at imminent risk for suicide, and further efforts to sustain the effects of DBT post-treatment. DBT is a time- and labor-intensive treatment that requires extensive training for therapists and a significant time commitment for families (generally 6 months). It will therefore be helpful to assess whether other less-intensive treatment options can be established as evidence-based treatment for suicidal adolescents.

Parental Validation and Invalidation Predict Adolescent Self-Harm

This study was designed to evaluate family processes theoretically implicated in the onset and maintenance of adolescent self-harm. In the present study, we focus on understanding parental validation and invalidation in response to their adolescent in order to estimate the association between parental responses and self-harm in a high risk group of adolescents. We also sought to determine the influence of psychotherapy on parental validation and invalidation over time during participation in a randomized clinical trial of psychotherapy designed to reduce self-harm. Thirty-eight teens (M age= 14.85; 94.1% female, 55.3% Caucasian, and 17.5% Latino) and their parents participated in three assessments over a six month period corresponding to pretreatment, midtreatment and end of treatment in the trial. Results indicate a robust association between parental validation, invalidation and adolescent self-harm. There were no significant associations observed between parental validation, invalidation, and adolescent suicidal ideation. Observed levels of parental validation and invalidation were not changed during the six-month course of psychotherapy.

Efficacy of Dialectical Behavior Therapy for Adolescents at High Risk for Suicide: A Randomized Clinical Trial

Importance

Suicide is a leading cause of death among 10- to 24-year-old individuals in the United States; evidence on effective treatment for adolescents who engage in suicidal and self-harm behaviors is limited.

Objective

To evaluate the efficacy of dialectical behavior therapy (DBT) compared with individual and group supportive therapy (IGST) for reducing suicide attempts, nonsuicidal self-injury, and overall self-harm among high-risk youths.

Design, Setting, and Participants

This randomized clinical trial was conducted from January 1, 2012, through August 31, 2014, at 4 academic medical centers. A total of 173 participants (pool of 195; 22 withdrew or were excluded) 12 to 18 years of age with a prior lifetime suicide attempt (≥3 prior self-harm episodes, suicidal ideation, or emotional dysregulation) were studied. Adaptive randomization balanced participants across conditions within sites based on age, number of prior suicide attempts, and psychotropic medication use. Participants were followed up for 1 year.

Interventions

Study participants were randomly assigned to DBT or IGST. Treatment duration was 6 months. Both groups had weekly individual and group psychotherapy, therapist consultation meetings, and parent contact as needed.

Main Outcomes and Measures

A priori planned outcomes were suicide attempts, nonsuicidal self-injury, and total self-harm assessed using the Suicide Attempt Self-Injury Interview.

Results

A total of 173 adolescents (163 [94.8%] female and 97 [56.4%] white; mean [SD] age, 14.89 [1.47] years) were studied. Significant advantages were found for DBT on all primary outcomes after treatment: suicide attempts (65 [90.3%] of 72 receiving DBT vs 51 [78.9%] of 65 receiving IGST with no suicide attempts; odds ratio [OR], 0.30; 95% CI, 0.10-0.91), nonsuicidal self-injury (41 [56.9%] of 72 receiving DBT vs 26 [40.0%] of 65 receiving IGST with no self-injury; OR, 0.32; 95% CI, 0.13-0.70), and self-harm (39 [54.2%] of 72 receiving DBT vs 24 [36.9%] of 65 receiving IGST with no self-harm; OR, 0.33; 95% CI, 0.14-0.78). Rates of self-harm decreased through 1-year follow-up. The advantage of DBT decreased, with no statistically significant between-group differences from 6 to 12 months (OR, 0.65; 95% CI, 0.12-3.36; P = .61). Treatment completion rates were higher for DBT (75.6%) than for IGST (55.2%), but pattern-mixture models indicated that this difference did not informatively affect outcomes.

Conclusions and Relevance

The results of this trial support the efficacy of DBT for reducing self-harm and suicide attempts in highly suicidal self-harming adolescents. On the basis of the criteria of 2 independent trials supporting efficacy, results support DBT as the first well-established, empirically supported treatment for decreasing repeated suicide attempts and self-harm in youths.

Trial Registration

ClinicalTrials.gov Identifier: NCT01528020.

Assessment of suicidal youth in the emergency department

Accurate evaluation of suicidal adolescents in the emergency department (ED) is critical for safety and linkage to follow-up care. We examined self-reports of 181 adolescents who presented to an ED with suicidal ideation (SI) or a suicide attempt (SA). Parents also completed self-reports. Results showed fair agreement between parents and youth on the reason for the ED visit (e.g., SI vs. SA) and greater agreement between independent judges and youths than between judges and parents. In accordance with accepted definitions of suicide attempts (e.g., Crosby, Ortega, & Melanson, 2011; O'Carroll, Berman, Maris, Moscicki, Tanney, & Silverman, 1996, p. 237; Posner, Oquendo, Gould, Stanley, & Davies, 2007, p. 1035; Silverman, Berman, Sanddal, O'Carroll, & Joiner, 2007, p. 248), most youth with SA as the reason for the ED visit reported some intent to die associated with the attempt. Finally, youth presenting to the ED with SA did not differ clinically from youth presenting with SI, and almost half of youths with SI reported past suicide attempts. These results highlight the need to emphasize adolescents' reports in clinical decision making, suggest adolescents' defined suicide attempts similarly to published definitions, and show that assessment of past SAs, as well as present suicidal thoughts and behaviors, is critical in determining future risk.

Characteristics of recent suicide attempters with and without Borderline Personality Disorder

The present research compared recent suicide attempters with and without a diagnosis of Borderline Personality Disorder (BPD). One hundred and eighty recent suicide attempters, recruited in the Emergency Department, participated in extensive research interviews. Results showed that suicide attempters with BPD displayed greater severity of overall psychopathology, depression, hopelessness, suicidal ideation, past suicide attempts, and had poorer social problem solving skills than those without a BPD diagnosis. No differences were found between the groups regarding the intent to die or lethality associated with the index suicide attempt. These findings highlight the seriousness of BPD and the risk that individuals diagnosed with this disorder will attempt suicide.

Marked increases in psychopathology found in a 30-year cohort comparison of suicide attempters

BACKGROUND

Although several epidemiological studies have found increases in the percentages of people who have made a suicide attempt, few cohort comparisons have been conducted to determine changes within this population over time. The purpose of this investigation was to determine if there have been changes in the clinical profile of suicide attempters in recent decades.

METHOD

Comparisons between a sample of 258 suicide attempters evaluated between 1970 and 1973 and a second sample of 179 suicide attempters evaluated between 1999 and 2002 were made on depression, hopelessness, suicide intent, drug use, history of suicide attempts and subsequent suicide attempts.

RESULTS

Present-day suicide attempters were found to exhibit greater levels of depression (p = 0.031), hopelessness (p = 0.008), suicide intent (p < 0.001), and had much higher rates of illicit drug use (p < 0.001). Almost twice as many of the present-day suicide attempters had histories of four or more suicide attempts (p < 0.001), and the present-day suicide attempters made subsequent suicide attempts at close to four times the rate in the year following the index attempt (p < 0.001).

CONCLUSIONS

The present-day suicide attempters exhibited greater levels of psychopathology on every major variable assessed. Replication is necessary and public health implications are discussed.

History of multiple suicide attempts as a behavioral marker of severe psychopathology

OBJECTIVE

Individuals with a differing number of past suicide attempts are generally considered a homogeneous group, despite emerging evidence to the contrary. The current study aimed to test the hypothesis that multiple suicide attempters would exhibit a more severe clinical profile than single suicide attempters.

METHOD

A series of self-report batteries and clinical interviews was administered to 39 single attempters and 114 multiple attempters who came to an urban hospital emergency room after a suicide attempt. The participants were predominantly poor and nonwhite.

RESULTS

Multiple suicide attempters versus single attempters exhibited a greater degree of deleterious background characteristics (e.g., a history of childhood emotional abuse, a history of family suicide), increased psychopathology (e.g., depression, substance abuse), higher levels of suicidality (e.g., ideation), and poorer interpersonal functioning. Profile differences existed even after control for borderline personality disorder.

CONCLUSIONS

Results indicate that multiple attempters display more severe psychopathology, suicidality, and interpersonal difficulties and are more likely to have histories of deleterious background characteristics than single attempters. Moreover, these differences cannot be explained by the diagnosis of borderline personality disorder. Results suggest that the identification of attempt status is a simple, yet powerful, means of gauging levels of risk and psychopathology.

The impact of past relationships on interpersonal behavior: behavioral confirmation in the social-cognitive process of transference

This study extended research on transference in social perception (e.g., S. M. Andersen, I. Reznik, & L. M. Manzella, 1996) into the realm of social behavior by examining behavioral confirmation (e.g., M. Snyder, 1992) in transference. Each perceiver participated in a brief conversation with a naive target participant, who either did or did not appear to resemble the perceiver's own positively or negatively regarded significant other. Trained judges rated positive affect expressed in targets' behavior. As predicted, targets expressed more positive affect in their behavior when they allegedly resembled the perceiver's own positively versus negatively toned significant other, an effect not found in the control condition. This evidence demonstrates behavioral confirmation in transference, suggesting a means by which present relationships may resemble past ones.