BROOKLYN, N.Y. – Intervening effectively for children and adolescents at suicide risk involves watching for triggers such as personal loss, sleep disturbances, or interpersonal conflict, an expert said at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
Dr. Tina Goldstein
It is important to distinguish the distal risks, which are factors known to increase suicidal ideation, and proximal risk factors, which predict attempts, according to Tina R. Goldstein, PhD, associate professor of psychiatry and psychology at the University of Pittsburgh. “We know that the optimal targets for preventing suicidal behavior are proximal,” Dr. Goldstein said. Treatment of distal risks, such as depression or substance use, is a foundation for risk management, but suicidal events are driven by acute crises that appear to require individualized intervention.
Dr. Goldstein said she had just “one sad slide” to summarize drug treatments aimed at controlling suicidal behavior. That slide included citations for studies associating neuroleptics and antidepressants with a reduction in aggressive or impulsive behavior in children. The only study associating a drug with a reduction in suicide attempts was performed with lithium in adults.
However, intensive cognitive and dialectical behavior interventions involving the family have been shown to reduce suicide attempts in randomized controlled trials, said Dr. Goldstein, who also is affiliated with the university’s Child and Adolescent Bipolar Spectrum Services Research Program. Those trials underscore the messages that personalizing therapy is essential, as are addressing specific triggers and helping patients develop defenses against suicidal thoughts.
Dr. Goldstein described a recently published, National Institutes of Health–funded study that focused on suicide reduction. The study was conducted in adolescents who were being discharged from a brief hospitalization for acute suicidal ideation or a suicide attempt (J Adolesc Health. 2018 Nov. 8. doi: 10.1016/j.jadohealth.2018.09.015). “We know that there is this really high-risk period after discharge from the hospital for which we could potentially do things better,” said Dr. Goldstein, whose center was involved in the study.
Dr. Goldstein said. For risk management after discharge, the adolescents were provided with a smartphone app called BRITE that contained the safety plan as well as a summary of personalized coping skills, including reminders that the patients themselves had provided for reasons for living. The app was augmented as appropriate with favorite songs, photos of the patients’ pet, or other customized aids to provide support during the typical delay between the time of discharge and the next step in care.
In 6 months of follow-up, the rate of suicide attempts was 8.7% of those enrolled in the intensive outpatient program, compared with 27.3% (P = .08) for those who received treatment as usual. Dr. Goldstein called this trend promising, particularly in the context of other favorable results, including a significantly longer (P = .03) time to a suicide attempt in the ASAP group.
In patients at imminent risk of a suicide attempt, it is logical to assume that treatment must be personalized to the issues behind increased suicidal ideation. However, a study published by Dr. Goldstein and her associates several years ago suggested that evidence of deteriorating mental health can signal a need for intensification of suicide risk management (Arch Gen Psychiatry. 2012;69:1113-22). In one part of that study, risk factors for suicide were evaluated in the 8 weeks before a suicide attempt in 413 children with bipolar disorder. During that time, depression scores increased as did substance use, but, surprisingly, so did use of mental health services.
“The way we have come to think of these data is that the kids, their parents, and their providers were recognizing that things were getting worse and they needed more services,” Dr. Goldstein said. “The bad news is that the services we were giving them were not particularly effective.”
Those data underscore some of the challenges facing clinicians who treat pediatric patients with mental illness. “Our field has not yet developed ... gold standard treatments for preventing suicidal behavior in kids with mood disorder,” Dr. Goldstein said. However, she thinks that some progress has been made and that some of the personalized approaches are demonstrating efficacy – particularly in children and adolescents who exhibit signs of imminent risk.