Acute behavioral interventions and outpatient treatment strategies with suicidal adolescents.

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Int J Behav Consult Ther. Author manuscript; available in PMC 2015 August 12. Published in final edited form as: Int J Behav Consult Ther. 2014 ; 9(3): 19–25.

Acute behavioral interventions and outpatient treatment strategies with suicidal adolescents Kimberly H. McManama O’Brien1, Jonathan B. Singer2, Mary LeCloux3, Yovanska DuartéVélez4,5, and Anthony Spirito5 1Simmons

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2Temple

University

3Simmons 4Institute

School of Social Work, Boston Children’s Hospital, Harvard Medical School

School of Social Work

for Psychological Research, University of Puerto Rico, Rio Piedras Campus

5Department

of Psychiatry and Human Behavior, Alpert Medical School of Brown University

Abstract

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Despite the prevalence of suicidal thoughts and behaviors among adolescents, there is limited knowledge of effective interventions to use with this population. This paper reviews the findings of studies on behavioral interventions for adolescents who are at acute suicide risk, as well as outpatient treatment and risk management strategies with suicidal adolescents. The importance of addressing comorbid behaviors and enhancing protective factors are discussed. Cultural considerations in working with suicidal adolescents and strategies for conducting culturally competent treatment are explored.

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Suicide rates increase distinctly in adolescence and continue to rise until early adulthood (Bridge, Goldstein, & Brent, 2006). Suicide is the third leading cause of death for 10-to-24year-olds (National Center for Injury Prevention and Control [NCIPC], 2014) and the second for 15–24 year olds (McIntosh & Drapeau, 2014). The most recent findings from the Youth Risk Behavior Surveillance Survey estimated that of adolescents in grades 9–12, 16% reported seriously considering suicide, 13% reported creating a plan to kill themselves, and 8% reported trying to kill themselves in the 12 months preceding the survey (Kann et al., 2014). In a recent study of 6483 adolescents where face-to-face interviews were conducted, it was estimated that 12.1% of adolescents had contemplated suicide, 4.0% made a plan, and 4.1% made an attempt in their lifetime (Nock et al., 2013). Despite the prevalence of suicidal thoughts and behaviors among adolescents, there is limited knowledge of effective interventions to use with this population. Although there have been several large clinical trials conducted with suicidal adolescents over the past 20 years, we still lack the data to suggest an empirically validated treatment that prevents repeated suicidal behavior in adolescents (Brent et al., 2013). This paper reviews the

Correspondence to: Kimberly H. McManama O’Brien, Simmons School of Social Work, Boston Children’s Hospital, Harvard Medical School, 300 The Fenway, Boston, MA 02115, Phone: (617) 521-3912, Fax: (617) 521-3980.

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findings of studies on behavioral interventions for adolescents who are at acute suicide risk, as well as outpatient treatment and risk management strategies with suicidal adolescents. The importance of addressing comorbid behaviors and enhancing protective factors are discussed. Cultural considerations in working with suicidal adolescents and strategies for conducting culturally competent treatment are explored.

Behavioral interventions in the acute phase

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Because a prior suicide attempt is one of the strongest risk factors for a repeat suicide attempt and eventual death by suicide among adolescents (Bridge, Goldstein, & Brent, 2006; Goldston et al., 2003; Shaffer, Gould, Fisher, Trautman, & Moreau, 1996; Zahl & Hawton, 2004), interventions that target this high-risk group are critical. The first step of interventions in the acute phase of treatment during inpatient or outpatient care should include a chain analysis of the suicidal crisis to help the therapist and the adolescent have a better understanding of immediate triggers (proximal risk factors) for suicidal behavior in the form of events, thoughts, and emotions (Miller, Rathus, & Linehan, 2007; Stanley et al., 2009). One of the principal objectives is to better understand the function of suicidal behavior in order to guide case conceptualization and treatment planning. A family behavioral analysis, in which family members’ perspectives are taken into account, can be helpful in assessing family interaction patterns that maintain the suicidal behavior in order to better intervene with caregivers (Miller, Rathus, & Linehan, 2007).

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Inpatient psychiatric units represent one treatment setting where interventions that target high-risk adolescents should be implemented. In fact, for adolescents admitted to an inpatient psychiatric unit, the most common concern is the presence of suicidal thoughts and/or suicide attempts (Wilson, Kelly, Morgan, Harley, & O’Sullivan, 2012). Inpatient psychiatric hospitalization is deemed necessary when the adolescent presents with suicidal thoughts or behaviors that are unstable and unpredictable, signaling serious imminent risk to self (Shaffer & Pfeffer, 2001). The primary goals of these short term hospitalizations typically include safety and containment, medication evaluation, mood stabilization, and follow-up care coordination. This setting represents the most restrictive level of care for suicidal adolescents; furthermore, going from such an intensive setting to a less restrictive one puts a suicidal adolescent at increased risk for self-harm. Therefore, the post-discharge period represents a time of heightened suicide risk that warrants focused and specialized interventions (Hunt et al., 2009; Knesper, 2010).

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Part of the stabilization process for suicidal youth may involve an evaluation for psychotropic medication. Unfortunately, the research on the impact of psychotropic medications directly on suicidal ideation and behavior among youth is limited and certain studies have indicated that SSRI therapy can actually be associated with an increased risk for suicidal thoughts and behaviors among youth, hence the Black Box Warning issued by the FDA in 2004 (Varley, 2006). However, Gibbons et al. (2012) conducted a longitudinal analysis that included four randomized controlled trials of Fluoxetine for youth diagnosed with Major Depressive Disorder and found that for adult participants, suicidal thoughts and behavior actually decreased over time in response to medication, and for youth, suicidal symptoms did not show significant increases or decreases.

Int J Behav Consult Ther. Author manuscript; available in PMC 2015 August 12.

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While it is unclear from present evidence that medication treatment can directly impact suicidal thoughts and behaviors among youth, there is evidence that certain SSRIs, particularly Fluoxetine, can be effective in decreasing depressive and other comorbid symptoms among adolescents (Henry, Kisicki, & Varley, 2012; Varley, 2006). Generally, it is recommended that psychotropic medication be prescribed in conjunction with the associate disorder (Henry et al., 2012; Pelkonen & Marttunen, 2003) and it has been found that psychotropic medication is most effective in conjunction with ongoing therapy, particularly CBT (Varley, 2006). For youth who are already experiencing acute symptoms of depression and suicidal ideation and/or behavior, the benefits of psychotropic medication likely outweigh the risks as long as the youth are closely monitored and have adequate outpatient follow-up (Henry et al., 2012).

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In addition to discharge from psychiatric hospitals, discharge from general hospital Emergency Departments (EDs) represent a time of heightened risk where interventions are needed. Many suicidal adolescents are first seen in EDs, or are seen in EDs during a suicidal crisis. Because of this, and the fact that parents are typically present in ED with their adolescents, the ED represents an ideal setting for family interventions with suicidal adolescents. The Family-Based Crisis Intervention (FBCI; Wharff, Ginnis, & Ross, 2012) is one example of an empirically tested brief family intervention designed to decrease acute suicidal thoughts and behaviors in the adolescent. The goal of the FBCI is to develop a plan for the adolescent to return home safely with the family, rather than be unnecessarily hospitalized in a psychiatric unit. In the intervention’s pilot study, youth receiving FBCI were significantly less likely to be psychiatrically hospitalized, relative to a matched comparison group. At the 3 month follow-up, no adolescents in the FBCI condition reported having attempted suicide, and only two were psychiatrically hospitalized for suicidal thoughts or behaviors (Wharff et al., 2012). Limitations of the study included the inability to follow up with the matched comparison group to compare suicidal thought and behavior outcomes across groups.

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Another function of interventions designed for acutely suicidal adolescents is to improve continuity of care between the suicide risk assessment and long term community mental health services. The Family Intervention for Suicide Prevention (FISP; Asarnow, Berk, & Baraff, 2009; Hughes & Asarnow, 2013) is one such intervention for suicidal adolescents and their families seen in the ED in the context of a suicidal event. Once the adolescent has been evaluated and determined safe to return to the community, FISP is implemented to reframe the adolescent’s suicidal behaviors as maladaptive coping skills within the context of a family crisis. Through mechanisms of developing positive coping and increasing connection and adherence to follow-up care, the overarching objective of FISP is to decrease continued suicidal thoughts and behaviors in adolescents. Although FISP has been effective in its ability to connect adolescents to follow-up care in the community, it has not demonstrated efficacy in reducing suicidal thoughts and behaviors over time (Asarnow et al., 2011). A crucial element of interventions delivered during a suicidal crisis, such as at the time of discharge from EDs or inpatient psychiatric units, includes thorough and effective safety planning procedures. The intent of safety planning is to help individuals lower their


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imminent risk for suicide by developing and referring to a set of potential coping strategies and a list of individuals or agencies they can contact in the event of a future suicidal crisis (Stanley & Brown, 2011). For adolescents, safety plans should be developed in conjunction with the clinician and caregivers, involving the adolescent in the planning process as much as possible. Educating parents on limiting access to lethal means represents another critical element of the safety planning process, as there is evidence that parents do take action to limiting access to lethal means when means restriction education is provided to them (Kruesi et al., 1999).

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It is important to note that the safety plan is not a “no-suicide” contract. There is no empirical evidence in support of the effectiveness of “no-suicide” contracts in preventing suicide or self-harm behaviors (Garvey, Penn, Campbell, Esposito-Smythers, & Spirito, 2009; Wortel, Matarazzo, & Homaifar, 2013); they are ineffective because they ask for a promise to stay alive without the development of a safety plan during a time when suicidal adolescents are ambivalent about living (Wortzel, Matarazzo, & Homaifar, 2013). Further, they do not protect against liability issues (Garvey et al., 2009). Therefore, it is more effective to replace “no-suicide” contracts with safety plans which include a commitment to treatment (Rudd, Mandrusiak, & Joiner Jr, 2006).

Outpatient treatment and risk management

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In addition to providing acute care when necessary, treatment of suicidal adolescents requires outpatient treatment and ongoing risk management (Singer, 2006). Although there are promising psychosocial interventions for suicidal youth, few treatments to date have demonstrated the ability to reduce repeat suicidal behavior (Asarnow & Miranda, 2014; Brent et al., 2013). There are, however, some group, individual, and family-based treatments that have been tested with suicidal adolescents that have demonstrated decreases in suicidal thoughts and/or behaviors.

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Developmental Group Therapy (DGT; Green et al., 2011; Wood, Trainor, Rothwell, Moore, & Harrington, 2001) utilizes a group treatment modality to give self-harming youth, ages 12–16, who do not meet criteria for inpatient psychiatric care an opportunity to address peer relationships, problem solving, and other issues that are known to contribute to suicide risk in a peer-group setting. Treatment includes 6 sessions of acute outpatient group therapy that address “relationships, school problems and peer relationships, family problems, anger management, depression and self-harm, and hopelessness and feelings about the future” (Wood et al., 2001, p. 1247). After the acute phase, adolescents participate in an on-going psychodynamic group for a self-determined length of time. DGT is provided in addition to Treatment As Usual (TAU). DGT was intended to simultaneously reduce suicide risk and reduce the need for more costly and labor intensive individual therapy. Despite promising outcomes in an initial clinical trial (Wood et al., 2001), two subsequent clinical trials failed to replicate the initial findings (Green et al., 2011; Hazell et al., 2009). Donaldson et al. (2005) evaluated the effectiveness of a Skills-Based Therapy (SBT) compared to a Supportive Therapy (SRT) in reducing suicidal behavior in adolescents (N = 31) recruited from the hospital or emergency department following a suicide attempt. The


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adolescents who received the SBT condition (n = 15) “were taught steps of effective problem solving and cognitive and behavioral strategies for affect management (e.g., cognitive restructuring, relaxation) and given homework assignments to assist in skill acquisition and generalization” (Donaldson et al., 2005, p. 115). In contrast, the SRT condition (n = 16) was a youth-directed, empathic, Rogerian style supportive therapy. The same therapists provided treatment in both conditions and received weekly supervision. Adolescents in both conditions averaged nearly 10 sessions, and demonstrated a significant reduction in suicidal ideation after completing treatment, and at 3, 6, and 12-month followup assessments. Despite the methodological limitations of this study, Donaldson et al. (2005) demonstrated that suicidal thoughts and behaviors could be reduced either through the use of a manual-driven structured problem-solving therapy, or a youth-driven supportive therapy. This is an important finding, particularly for community settings where supportive therapies are common, and where there are financial and training barriers to establishing and implementing manualized treatments.

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Cognitive-Behavioral Therapy for Suicide Prevention (CBT-SP; Stanley et al., 2009) is a manualized, skill-building treatment developed for the Treatment of Adolescent Suicide Attempters (TASA) study (Brent et al., 2009). CBT-SP includes an “acute” phase (12–16 weeks) with individual therapy sessions and 6 family sessions, and a “continuation” phase of less frequent sessions for a total of six months of treatment. The treatment plan and interventions are developed collaboratively between the therapist and family. Therapists draw from standard CBT techniques such as cognitive restructuring, problem-solving, and behavioral activation. Adolescents who attempted suicide and then participated in the 6month open trial reported significantly fewer suicidal events and re-attempts than youth in comparable studies, but the lack of comparison group makes it impossible to attribute the results to the intervention itself (Brent et al., 2009).

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Perhaps the most effective psychosocial interventions for reducing youth suicide risk are those that include a family component. On a practical level, involving parents makes sense because most youth live with their parents, and rely on them for transportation, financial support, and to consent for treatment. It is well-supported that youth who report low parental support, high family conflict, and insecure attachment styles are at greater risk for suicide than those with high parental support, low family conflict, and secure attachment styles (Borowsky, Ireland, & Resnick, 2001; Donath, Graessel, Baier, Bleich, & Hillemacher, 2014; Shpigel, Diamond, & Diamond, 2012). Furthermore, it appears that there is familial transmission of suicide risk, and that the genetic contribution to suicide risk is exacerbated by stressful environments (Brent & Melhem, 2008). Multisystemic Therapy (MST; Huey, Henggeler, & Rowland, 2004) is one family-based treatment for suicidal adolescents designed to provide family members and caregivers with additional parenting, crisis management, and intervention skills to use with their adolescents. When compared to controls, Huey et al. (2004) found the MST group to have a lower likelihood for making a suicide attempt, although there were no differences in the groups in regard to suicidal ideation. Attachment-Based Family Therapy (ABFT; G. M. Diamond, 2013; G. S. Diamond et al., 2010) is a family-based psychotherapy that seeks to reduce suicidal ideation by improving


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the parent-child relationship. ABFT is grounded in attachment theory, and assumes that enhancing interpersonal relationships is a key component in reducing suicide risk. Unlike most other psychotherapies designed for suicidal adolescents, ABFT focuses on affective change, rather than behavioral change, in order to reduce suicidal ideation. ABFT uses emotion-focused techniques to amplify the adolescents’ and parents’ desire to have a warmer, more connected relationship. Adolescents and their parents identify and resolve attachment ruptures through five tasks implemented over a 16-week period.

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ABFT has an emerging evidence base with primarily low income, racial minority youth for reducing suicidal ideation and depressive symptoms (G. S. Diamond et al., 2010). A recent randomized controlled trial (RCT) with 66 suicidal youth found that twice as many youth who received ABFT compared to an enhanced usual care condition (70% vs 34%) reported clinically significant reductions in suicidal ideation at 24 weeks (G. S. Diamond et al., 2010). Notably, there were no differences in treatment outcomes among youth who reported a history of sexual or physical abuse (G.S. Diamond, Creed, Gillham, Gallop, & Hamilton, 2012). An open trial (N = 10) of ABFT modified for sexual minority youth demonstrated a reduction in suicidal ideation among LGB youth (G. M. Diamond et al., 2012).

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There are three other family-based interventions that have been developed to reduce youth suicide risk. Two of these, Successful Negotiation Acting Positively (SNAP; RotheramBorus, Piacentini, Miller, Graae, & Castro-Blanco, 1994) and Home-Based Family Therapy (HBFT; Harrington et al., 1998) taught problem-solving and addressed family conflict in 4 to 6 sessions. Neither intervention demonstrated significant reduction of suicidal ideation. The SNAP study did not have a control condition. In the HBFT study, there were no differences in suicidal ideation outcomes between the control and experimental groups. Regardless of condition, participants who did not meet criteria for major depressive disorder reported significantly greater reductions in suicidal ideation than participants with major depressive disorder.

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More recently, Pinedas and Dadds (2013) evaluated the Resourceful Adolescent Parent Program (RAP-P) as an adjunct to TAU with suicidal adolescents. RAP-P is a parentfocused intervention that provides parents with four two-hour psychoeducation and skillsbuilding sessions. Findings demonstrated that youth whose parents participated in RAP-P showed greater declines in suicidal thoughts and behaviors as well as improved functioning (Pineda & Dadds, 2013). Despite the evidence that family members contribute to and/or protect against youth suicide risk, it is unclear to what extent family involvement in treatment is necessary or effective with suicidal adolescents. Of the four family-focused interventions for suicidal adolescents described above, only two, ABFT and RAP-P, demonstrated a reduction in suicidal ideation that was greater than controls.

Addressing comorbid behaviors In order to effectively treat and manage suicidal behaviors in adolescents, comorbid behaviors that confer risk for suicide must be addressed in a coordinated manner. NonSuicidal Self-Injury (NSSI) is one behavior that has been associated with suicide attempts among adolescents (Andover, Morris, Wren & Bruzzese, 2012; Klonsky, May & Glenn,


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2013; Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006). Most of the empirical research on treatments for NSSI has focused primarily on associated outcomes, rather than the behavior itself, and has failed to delineate between suicidal versus non-suicidal self-harm in their results (Brausch & Girresch, 2012).

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Some studies have demonstrated effectiveness of CBT in decreasing NSSI when it is comorbid with suicidal thoughts and behaviors. Slee et al. (2008) conducted a RCT with 82 adolescents and adults presenting to a medical center for self-injurious behaviors to compare the effectiveness of a 12 session course of CBT specifically directed towards self-harm in addition to TAU, relative to a group receiving TAU only. Participants in the CBT + TAU condition had significantly greater decreases in self-harming behavior over time than the TAU-only group. In addition, participants receiving CBT + TAU had greater decreases over time in depressive symptoms, anxiety, and suicidal thoughts, as well as greater increases over time in self-esteem and problem-solving abilities (Slee et al., 2008).

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Problem-Solving Therapy (PST; Townsend et al., 2001), a specific type of cognitivebehavioral treatment, has mixed evidence regarding the efficacy of decreasing self-harm behaviors (Muehlenkamp, 2006). PST aims to ameliorate NSSI among adolescents indirectly by increasing other coping skills around social problem solving (Brausch et al., 2012); PST encourages individuals to define specific “problems” in their lives by the behaviors and emotions that are related to them and then encourages goal setting and stepby-step behavioral progress towards change (Townsend et al., 2001). There is some evidence that PST can be effective in decreasing comorbid symptoms that are often associated with NSSI. In a meta-analysis of 6 RCTs, four of which included adolescents as well as adults, Townsend et al. (2001) found that, on the whole, PST was effective in decreasing depression and hopelessness for individuals with a history of deliberate selfharm. Another treatment that has been studied for comorbid self-injury and suicidal behaviors is Cognitive Analytic Therapy (CAT; Chanen et al., 2008), an integrative psychotherapy that combines object relations concepts with cognitive therapy (Chanen et al., 2008). In a study (N = 78) comparing CAT to “good clinical care” (GCC), Chanen et al. (2008) found that CAT resulted in a significantly greater decrease in externalizing and internalizing psychopathology. In this study, however, participants receiving CAT did not significantly differ from those receiving GCC, in regard to Borderline Personality Disorder (BPD) symptoms or suicidal behaviors at final follow-up.

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Therapeutic Assessment (TA; Ougrin, Zundel, Kyriakopoulos, Banarsee, Stahl, & Taylor 2012) is another treatment for NSSI that specifically targets the behavior from the outset of treatment. In TA, an additional assessment session is structured in which a “target behavior” is identified, motivation to change is discussed, and strategies for change are identified in an “understanding letter” that is written with the adolescent and family members. Ougrin et al. (2012) compared TA to Assessment as Usual (AAU) in a sample of adolescents (N = 70) referred for outpatient treatment for suicidal (n = 47) or non-suicidal (n = 23) self-harm. For the adolescents referred for NSSI only, the TA group was found to have a significantly greater decrease on global psychological functioning. Another study examined the impact of


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TA on self-injury in a sample of adolescents (N = 69) presenting to EDs in London for deliberate self-harm. This study found no differences between those receiving TA and AAU in regard to frequency of self-harm or repeat presentation to EDs, though the TA group did endorse higher rates of treatment engagement (Ougrin, Boege, Stahl, Banarsee, Taylor, 2013).

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Dialectical Behavioral Therapy for Adolescents (DBT-A; Rathus & Miller, 2002) is one treatment designed for comorbid self-injury and suicidal behavior that has shown promising results in treating suicidal behavior and symptoms specifically among adolescent populations. DBT-A, which includes bi-weekly individual therapy for adolescents and multi-family skills groups, focuses on decreasing self-harm behaviors, decreasing treatment and quality of life interfering behaviors, and increasing behavioral skills. In addition, it emphasizes mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance skills (Rathus et al., 2002). Rathus et al. (2002) conducted a study of suicidal adolescents (N = 111) comparing outcomes for those receiving DBT-A relative to TAU. They found that adolescents presenting for outpatient treatment who received DBT-A were more likely to complete treatment and less likely to be psychiatrically hospitalized than those who received TAU. Additionally, participants receiving DBT-A had significant decreases in suicidal ideation, anxiety, depression, impulsivity, and emotional dysregulation scores after treatment, though comparisons with the TAU group for these outcomes was not reported. While these results are promising, it should be noted that assignment to the two treatment groups was not random; individuals with a suicide attempt within the past 4 months and a diagnosis of BPD were assigned to the DBT-A group (Rathus et al., 2002).

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In addition, two small open trials of DBT-A with adolescents with histories of severe and persistent self-harm found significant decreases in depression and hopelessness scores, as well as episodes of deliberate self-harm (James, Taylor, Winmill, & Alfoadrai, 2008; James, Winmill, Anderson, & Alfoadari, 2011). Katz et al. (2004) also found that DBT resulted in decreased levels of depression, suicidal ideation, and suicidal behaviors among adolescents on an inpatient unit at one-year follow-up, although they did not find significant betweengroup differences relative to TAU.

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Mentalization-Based Therapy for Adolescents (MBT-A; Rossouw & Fonagy, 2012) is another outpatient treatment aimed at reducing adolescent self-harm behaviors. MBT-A is designed to reduce self-harm by helping adolescents and their parents understand their own and others’ emotions and behaviors during times of stress and conflict. MBT-A focuses on helping family members “mentalize” about the adolescent’s feeling states and experiences. In a study of 80 adolescents, the odds of self-harm, as well as the presence of borderline and depressive symptoms, were decreased in the MBT-A condition relative to TAU (Rossouw & Fonagy, 2012). Substance abuse is another comorbid behavior associated with increased suicide risk among adolescents (Epstein & Spirito, 2010; Wong, Zhou, Goebert, & Hishinuman, 2013). Integrated Cognitive Behavior Treatment (I-CBT; Esposito-Smythers, Spirito, Kahler, Hunt & Monti, 2011) is an intervention that targets adolescents with co-occurring suicidal thoughts and behaviors and substance use disorders by integrating traditional CBT with


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additional components such as motivational interviewing, family treatment, cognitive restructuring, problem-solving, affect regulation, and communication skills. In a study of 36 adolescents, those who received I-CBT, compared to Enhanced Treatment As Usual (ETAU), reported fewer suicide attempts, psychiatric hospitalizations, emergency department visits, heavy drinking days, and days with marijuana use at follow-up assessments (Esposito-Smythers et al., 2011).

Enhancing protective factors


The development and enhancement of protective factors within the individual (e.g., motivation for treatment, positive affect, and self-care skills) is an important element of treatment for suicidal adolescents that warrants attention. Between 30–50% of suicidal adolescents do not adhere to treatment recommendations (Asarnow et al., 2011; Ougrin et al., 2013; Spirito, Stanton, Donaldson, & Boergers, 2002; Trautman, Stewart, & Morishima, 1993), suggesting the need for enhancing individual motivation for treatment through Motivational Interviewing (MI) techniques. While there has been minimal research on the use of MI techniques to improve treatment adherence among suicidal youth, there is some evidence that MI can be helpful in improving treatment engagement for other comorbid conditions. Stein et al. (2006) conducted a RCT with incarcerated substance abusing adolescents (N = 130) where participants received either a brief MI intervention or a relaxation training (RT) intervention prior to receiving the usual psychiatric treatment offered by the facility. Adolescents receiving MI rated the therapeutic warmth of the technique significantly higher than those receiving RT, and reported fewer negative treatment behaviors at 2-month follow up relative to RT (Stein et al., 2006). Breland-Noble (2012) investigated the effectiveness of a multi-stage MI intervention with depressed African-American adolescents who had low treatment readiness and found some evidence that MI increased follow up with treatment, though their small sample size (N = 16) limits the generalizability of the findings. While the use of MI techniques should be considered within the ethical confines of the need for safety assessment with suicidal youth (Jackman, 2012), MI may be a useful technique in increasing treatment adherence with this population and warrants further investigation.

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Preliminary evidence suggests that focusing on the development of positive affect may be helpful in the treatment of suicidal adolescents. Although this is a relatively new area of treatment focus, it is clinically intuitive, as depression, suicidal ideation and self-injury is typically associated with negative affect among adolescents. McMakin et al. (2012), for example, compared several baseline dimensions of depression (depressed mood, anhedonia, somatic symptoms, morbid thoughts, and observed depression) prior to treatment for adolescents with SSRI-resistant depression and found that anhedonia was the only significant predictor for outcome measures post-treatment. Specifically, higher anhedonia scores were associated with a longer period until remission and fewer depression free days post treatment. In addition, Chabrol, Rodgers, and Rousseau (2006) found that depressed affect significantly predicted suicidal ideation in a community sample of adolescents, and that for boys that both the presence of depressed affect (feeling blue, feeling sad) and the absence of positive affect (lack of happiness, low levels of enjoyment) were significant predictors of suicidal ideation. A recent study by Yen et al. (2013) also found positive affect


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to be associated lower suicide risk at 6 month follow up among psychiatrically hospitalized adolescents, even when controlling for depression. Finally, one study comparing selfinjuring adolescents to their non-self-injuring peers found that the self-injuring adolescents were more likely to have family environments that have less positive affect, to express less positive affect themselves, and to have lower peripheral serotonin levels (Crowell, Beauchaine, McCauley, Smith, Vasilev, & Stevens, 2008).

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Other individual protective factors that can be targeted in outpatient treatment with suicidal adolescents include self-care skills, such as sleep, diet, and exercise. Sleep deprivation, in particular, has been found to significantly increase risk of self-harm among suicidal adolescents (Wong & Brower, 2012), as well as mood lability (McGlinchey et al., 2011), impulsivity (Anderson & Platten, 2011), and negative affect (Dagys et al., 2012; Wong et al., 2012). Sleep deprivation has also been found to negatively impact the response to psychopharmacological treatments, specifically antidepressants (Emslie et al., 2012), suggesting the potential for good sleep habits to serve as a protective factor against suicidal thoughts and behaviors. Although there has been minimal investigation of the relationship between suicidal behavior and healthy diet and exercise, studies do indicate that those individuals with poor diet and exercise habits are more likely to experience major depression (Lopresti, Hood & Drummond, 2013), suggesting the pertinence of addressing these factors in the treatment of suicidal adolescents.

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In addition to protective factors within the individual, social and interpersonal protective factors also warrant attention in the treatment of suicidal adolescents. Interventions that aim to strengthen and educate social networks show promise in the treatment of suicidal adolescents. The Youth-nominated Support Team (YST; King et al., 2006) is a social network intervention that asks adolescents to identify supportive adults and then educate these adults on how to best respond to the adolescent when in crisis. King and colleagues (2006, 2009) conducted two studies comparing YST and TAU to TAU-only. One study (N = 289) found YST + TAU to be associated with a significant decrease in suicidal ideation, for girls only, relative to TAU only (King et al., 2006), and the other (N = 448) found YST + TAU to be associated with a more rapid decline in suicidal ideation at 6 month follow-up relative to TAU only, although no time by treatment condition effects were found (King et al., 2009).

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Treatments that aim to develop and increase use of interpersonal skills have also demonstrated effectiveness in decreasing suicidal thoughts and behaviors in adolescents. Tang et al. (2013) developed a school-based version of Interpersonal Therapy for Adolescents (IPT-A-IN; Tang, Jou, Huang, & Yen, 2013), in which adolescents participated in didactic sessions with teachers or peers with whom they reported interpersonal stressors or conflicts. In this study (N = 73), individuals in the IPT-A-IN group showed significant decreases in suicidal ideation, depression, hopelessness, and anxiety immediately after the intervention when compared to students receiving TAU, which included supportive individual psychotherapy and psychoeducation from counselors not trained in IPT-A-IN (Tang et al., 2013).


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Ongoing suicide risk management

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Critical to the effectiveness of outpatient treatment for suicidal adolescents is ongoing suicide risk management. Clinicians should be continually evaluating suicide risk in adolescents in outpatient treatment after a suicidal crisis (Steele & Doey, 2007). Adolescents who attempt suicide often reattempt; studies suggest that 15–30% of adolescents who attempt suicide attempt again within a one year period (Bridge et al., 2006; Hawton et al., 2012). Therefore, immediately after the suicidal crisis, thorough safety planning must be conducted with the youth, parent/guardian, and clinician. Safety planning procedures with suicidal adolescents require in-depth conversations between mental health providers, adolescents, and their parents/guardians about the recent suicidal crisis and the steps to be taken in the event of a future suicidal crisis (Wharff et al., 2012). Stanley and Brown (2012) developed a safety planning intervention which includes six steps of identification and utilization: 1) warning signs, 2) internal coping strategies, 3) people and settings that provide distraction, 4) people to ask for help, 5) professionals to contact in a crisis, and 6) making the environment safe through the removal of lethal means. This safety planning intervention has been widely disseminated across populations (Stanley & Brown, 2012), including youth (Asarnow, Berk, Hughes, & Anderson, 2014; Brent et al., 2009) to mitigate suicide risk in the aftermath of a suicidal event. Such safety planning interventions should be implemented routinely as a part of ongoing suicide risk management with suicidal youth.

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Another essential aspect of ongoing suicide risk management with youth involves coordination with school personnel (Erbacher, Singer, & Poland, 2015). Approximately half of youth who report suicidal ideation never receive mental health services (Husky et al., 2012), and only a third of youth discharged from an emergency department after a suicide assessment attend outpatient services (Grupp-Phelan, McGuire, Husky, & Olfson, 2012). However, nearly all youth return to school. Consequently, school mental health professionals become the de facto providers of suicide risk management and monitoring (Singer & Slovak, 2011). Ideally, outpatient providers would serve as the primary coordinator for services, the school personnel would provide on-going monitoring, and other professionals (e.g. probation officers, child welfare workers, etc.) would help youth access specialty services funded primarily through those service delivery systems. Coordinating between multiple systems requires thorough and contemporaneous documentation of risk, safety planning and services in order to ensure appropriate management of youth suicide risk (Wortzel et al., 2013).

Cultural considerations Author Manuscript

Culture has been defined as “the belief systems and value orientation that influence customs, norms, practices, and social institutions, including psychological process (language, care taking practices, media, educational systems) and organizations (media, educational systems)” (American Psychological Association; APA, 2003, p.9). Culture is intricately integrated into daily life but often appears invisible to those who study and treat human behavior (Smith, Domenech-Rodríguez, & Bernal, 2011; D. W. Sue, Arredondo, & McDavis, 1992; S. Sue, 2003). Multicultural approaches are a response to the culture blind point of view, and refer to an acknowledgement of cultural and worldview differences


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among minorities, but also with respect to differences in gender, sexual orientation, socioeconomic status, disability, among others (APA, 2003; D. W. Sue, Arredondo, & McDavis, 1992).

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The increasing diversity of populations in the United States (U.S. Census Bureau, 2011) and the closeness of countries due to globalization necessitates cultural competence in providing psychological interventions (Bernal & Scharró-del-Río, 2001; Cardemil, Moreno, & Sanchez, 2011). Most intervention research has been done with Caucasian adolescents; however, what is effective for one ethnic or cultural group, is not necessarily effective for another (Bernal & Scharródel-Río, 2001). Treatment with cultural adaptations, or culturally adapted treatments, i.e.,“changes made to psychotherapy processes and/or content with the intention of increasing congruence between the client’s ethnocultural worldview” and evidence based practice (Bernal & Domenech-Rodriguez, 2012, p. 11), have been found to be more beneficial than treatment without any cultural considerations (Griner & Smith, 2006; Smith, Domenech-Rodriguez, & Bernal, 2011). These two meta-analyses suggested that even among interventions with cultural adaptations those that have more adaptations and are directed to a specific cultural group increase clinical benefits (Derek & Smith, 2006; Smith, Domenech-Rodriguez, & Bernal, 2011). Also, acculturation seems to play an important role in treatment response, for example, less acculturated Latinos/as benefit more from cultural adaptations and Spanish speaking therapists than those who are more acculturated (Derek & Smith, 2006).

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Interventions found to be effective with suicidal adolescents are scant in general and even smaller for specific minority or LGB youth (Goldston et al., 2008; Leong & Leach, 2008), nevertheless some emerging studies are addressing this gap. Some studies of psychosocial interventions for suicidal adolescents have had a large number of minority adolescents (more than 65%) in their sample (e.g., DBT, ABFT, MST), suggesting their potential for cultural competence. However, having a diverse sample does not necessarily mean that cultural adaptations have been used.

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One study in progress is testing the efficacy of culturally tailored group CBT for urban, low income, African American adolescents to prevent suicidal behavior and aggression (Robinson, 5R01HD072293-02). Diamond et al. (2012), described above, recently pilot tested an AFBT protocol for LGB adolescents (half of whom identified as African American) with high levels of suicidal ideation and moderate to severe depressive symptoms. The adaptations to the protocol included helping parents manage their emotional reactions and increase their acceptance of their child’s sexual orientation. Clinically significant changes in suicidal ideation was found for all of the adolescents who completed treatment (8 of 10) and in depressive symptoms for two of them. A CBT protocol culturally adapted for Puerto Rican adolescents with depression based on a criterion of ecological validity demonstrated efficacy in reducing depressive symptoms (Rosselló & Bernal, 1999; Rosselló, Bernal, & Rivera-Medina, 2008) and was also shown to decrease suicidal ideation at post treatment evaluation (Rosselló, Duarté-Vélez, Bernal, & Zualaga, 2011). The same protocol was effectively used with a depressed gay adolescent to integrate contradictory core beliefs about his spirituality, family values, and sexuality


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(Duarté-Vélez, Bernal, & Bonilla, 2010). Duarté-Vélez and collaborators (Duarté-Vélez, Laboy-Hernández, & Torres-Dávila, in press; Duarté-Vélez, Torres-Dávila, Spirito, Polanco, & Bernal, under review) developed and piloted a socio-cognitive outpatient treatment protocol for Latino/a adolescents with suicidal behavior (SCBT-SB). Adolescents were recruited after being discharged from a psychiatric inpatient unit due to suicidal ideation or an attempt. SCBT-SB combines CBT and an ecological approach; the first therapy session is intended to hear the “story” related to the current suicidal crisis from each family member to help the adolescent, the family, and the therapist gain a better perspective on the family, the adolescent’s relationships, the neighborhood, the school, and the family’s belief systems. Of those who completed treatment (8 of 11), two had reliable clinical changes in suicidal ideation, while six maintained low levels during treatment (from pre to post) and all had reliable improvements in at least one risk factor, i.e. hopelessness, depressive symptoms (Duarté-Vélez et al., under review).


Some culturally centered treatments developed or adapted for specific groups target important risk factors for suicide, such as depression, behavioral problems, post-traumatic stress symptoms, and family functioning, but not specifically suicidal thoughts and behaviors (e.g. Kataoka, Stein, Jaycox, Escudero, et al., 2003; Szapocznik, Schwartz, Muir, & Brown, 2012). For example, Brief Strategic Family Therapy (BSFT) was originally developed to address acculturation conflicts between Cuban-American adolescents and their parents (Szapocznik, Schwartz, Muir, & Brown, 2012) and has been shown to improve treatment engagement and reduce behavioral problems and drug use in adolescents by changing family relationship patterns (Santisteban, Suarez-Morales, Robbins, & Szapocznik, 2006; Szapocznik et al., 2012). BSFT has been widely used with diverse groups of Latinos, African Americans, and Caucasian adolescents in the National Institute of Drug Abuse Clinical Trials Network (CTN) (Robbins et al., 2011).

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An ecological perspective is warranted when working with suicidal minority youth to understand their personal, familial, socio-environmental, and cultural risk and protective factors (Leong & Leach, 2008). Environmental stressors, such as the context of immigration, violence, discrimination, acculturation conflicts between adolescents and caregivers, socioeconomic difficulties, and language barriers, can be pointed out and understood as contributing factors to the crisis to help relieve guilty feelings, help the family set goals, and help the therapist with case conceptualization. Validating their stressful experiences and the family strengths that helped them “survive” prior crisis situations is important. An ecological, personal, and caring approach may increase treatment adherence in minority populations who often are suspicious of and reluctant to engage in mental health services (Lahman, Mendoza, Rodriguez, & Schwartz, 2011; Martinez Jr., McClure, Eddy, Ruth, & Hyers, 2012). Treatment alternatives for minority youths with suicidal thoughts and behaviors are limited but some promising interventions are emerging. A multicultural perspective (APA, 2003) and the Evidence Based Practice (EBP) approach (American Psychological Association, 2006) in which the best available evidence (RCT, qualitative outcomes, etc.), with the individual’s characteristics (culture, treatment preferences), and the clinician’s expertise


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(including cultural competence) combined is the best option for increasing treatment adherence and effectiveness with minority youth.

Conclusions and future directions

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Although findings from intervention studies with suicidal adolescents do not suggest one specific evidence based modality, they do indicate the importance of care coordination, access to outpatient treatment, addressing comorbid behaviors, problem-solving and coping skill development, and skills in listening and communication within the family system. In their recent review of intervention studies, Brent et al. (2013) noted that family involvement, the dose, and the timing of treatment are important factors in effective treatments for reducing suicide risk. Providing treatment when it is needed (i.e. timing) appears to significantly reduce suicidal behavior when services occur immediately following a suicidal event or discharge from an ED (While et al., 2012). However, there are significant barriers to linking youth to appropriate outpatient services following discharge from the ED (GruppPhelan et al., 2012; Sobolewski, Richey, Kowatch, & Grupp-Phelan, 2013). Some of the most frequently noted barriers are long waitlists, lack of training in outpatient treatment and management of suicidal thoughts and behaviors, provider turnover, and lack of transportation and funding. Additionally, parents and youth often believe that services are not necessary, relevant, or effective (Grupp-Phelan et al., 2012; Sobolewski et al., 2013).

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Even when adolescents are connected to long term treatment, the treatment they receive is not always effective in reducing their suicidal thoughts and behaviors. A recent study by Nock et al. (2013) found that 80% of suicidal adolescents reported receiving some form of mental health treatment. Further, the study found that in 55% of cases adolescents reported that they received treatment prior to onset of suicidal behaviors, implying that the treatment they received failed to prevent suicidal behaviors from occurring (Nock et al., 2013). Future research should focus on identifying and understanding the underlying mechanisms of suicidal thoughts and behaviors that are specific to adolescent populations. This knowledge would inform the development and testing of interventions for suicidal adolescents that specifically target these mechanisms (e.g., impulsivity, aggression, diminished positive affect, poor distress tolerance, lack of social connectedness, and family interactions), which may in turn generate treatment strategies that are more effective in reducing suicidal thoughts and behaviors in adolescents. In addition, specific attention to cultural and ethnic considerations would enhance the effectiveness of interventions and treatment with suicidal minority youth.

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Author Manuscript Author Manuscript Int J Behav Consult Ther. Author manuscript; available in PMC 2015 August 12.

An outpatient treatment alternative for suicidal youth.

Family centered brief intensive treatment: a pilot study of an outpatient treatment for acute suicidal ideation.

Effectiveness of cognitive-behavioral therapy in decreasing suicidal ideation and hopelessness of the adolescents with previous suicidal attempts.

Victimization exposure and suicidal ideation among Spaniard adolescents evaluated at outpatient mental health services.

Behavioral treatment of children and adolescents with trichotillomania.

New approaches to the assessment and treatment of suicidal adolescents.

[Outpatient treatment of patients with acute uncomplicated diverticulitis].

Follow-up treatment utilization by hospitalized suicidal adolescents.

Outpatient oral treatment for acute promyelocytic leukemia.

Examining the Course of Suicidal and Nonsuicidal Self-Injurious Thoughts and Behaviors in Outpatient and Inpatient Adolescents.

Psychosocial interventions for pregnant women in outpatient illicit drug treatment programs compared to other interventions.

Drug abstinence: exploring animal models and behavioral treatment strategies.

Do antidepressants make children and adolescents suicidal?

New strategies and findings for behavioral interventions in autism spectrum disorders.

Suicidal feelings interfere with help-seeking in bullied adolescents [corrected].

Follow-up strategies in the behavioral treatment of overweight.

The treatment of obesity in adolescents using behavioral self-control.

Cognitive behavioral therapy for adolescents with ADHD.

Voluntary medical male circumcision among adolescents: a missed opportunity for HIV behavioral interventions.

School-Based Strategies to Reduce Suicidal Ideation, Suicide Attempts, and Discrimination among Sexual Minority and Heterosexual Adolescents in Western Canada.

Relational and behavioral interventions with economically disadvantaged toddlers.

Factors underlying the success of behavioral HIV-prevention interventions for adolescents: a meta-review.

Brief Interventions for Adolescents.

Interparental Conflict Relative to Suicidal Ideation in Chinese Adolescents: The Roles of Coping Strategies and Meaning in Life.