Deidre Donaldson

Reasons for adolescent suicide attempts: associations with psychological functioning.

OBJECTIVE To determine reasons for suicide attempts in adolescents and to examine the relationship between these reasons and psychological functioning. METHOD Self-reported reasons for suicide attempts and psychological functioning were examined in 120 adolescent suicide attempters who presented to a pediatric general hospital. RESULTS Consistent with prior research, the most frequently endorsed motives for self-harm were to die, to escape, and to obtain relief. More manipulative reasons for overdose (such as making people sorry) were endorsed less frequently. Adolescents who cited death as a reason for their suicide attempt reported more hopelessness, socially prescribed perfectionism, depression, and anger expression. Discriminant function analyses indicated that high levels of depression and anger expression predicted a self-reported wish to die, and high levels of depression and socially prescribed perfectionism predicted death as the primary reason reported for the suicide attempt. CONCLUSIONS Systematic assessment of the reasons for a suicide attempt is a useful tool for clinicians in determining recommendations for follow-up treatment.

Self-Mutilative Behavior in Adolescents Who Attempt Suicide by Overdose

OBJECTIVE To examine the cognitive/affective and behavioral symptoms of adolescent suicide attempters with self-mutilative behavior (SMB). METHOD Adolescents evaluated after a suicide attempt that occurred between 1996 and 2000 were divided into two groups: suicide attempters with a history of SMB (n = 52) and suicide attempters without SMB (n = 43). The groups were then compared on psychiatric diagnosis, suicide intent, depression, hopelessness, loneliness, anger, reckless behavior, substance use, and family functioning. RESULTS Carving on the skin and picking at a wound were the most commonly reported SMBs, occurring in about one third of the sample. The SMB group was significantly more likely to be diagnosed with oppositional defiant disorder, major depression, and dysthymia and had higher scores on measures of hopelessness, loneliness, anger, risk taking, reckless behavior, and alcohol use than did the non-SMB group. Loneliness increased the odds of SMB almost 6-fold. CONCLUSIONS Adolescent suicide attempts with SMB are associated with greater cognitive/affective and behavioral symptoms. Adolescent suicide attempters should be routinely screened for SMB.

Affect Regulation and Suicide Attempts in Adolescent Inpatients

OBJECTIVE To examine the relationship between affect dysregulation and self-destructive behaviors in adolescent suicide attempters. METHOD Measures of affect dysregulation, number of risk-taking behaviors in past year, presence of self-mutilative behaviors in past year, and number of different types of self-mutilative behaviors in past year were individually administered to adolescents admitted to an inpatient unit who were either suicide ideators (n = 25) or suicide attempters (n = 35). RESULTS Suicide attempters reported significantly higher levels of affect dysregulation and a greater number of different types of self-mutilative behaviors in the past year than suicide ideators. In addition, the number of different types of self-mutilative behaviors in the past year had the strongest relationship to suicide attempts. CONCLUSION Suicidal behavior among adolescent psychiatric patients is related to poor affect regulation. A risk factor for suicidal behavior in adolescents is a broad range of self-mutilative acts in the year preceding the suicide attempt.

An intervention trial to improve adherence to community treatment by adolescents after a suicide attempt

OBJECTIVE To determine whether a problem-solving intervention would increase adherence to outpatient treatment for adolescents after a suicide attempt. METHOD Sixty-three adolescents who had attempted suicide and were evaluated in an emergency department between 1997 and 2000 were randomly assigned to undergo standard disposition planning or a compliance enhancement intervention using a problem-solving format. At 3 months after the intervention, all evaluable adolescents, guardians, and outpatient therapists were contacted to determine adherence to outpatient treatment. RESULTS At 3-month follow-up, the compliance enhancement group attended an average of 7.7 sessions compared with 6.4 sessions for the standard disposition group, but this difference was not statistically significant. However, after covarying barriers to receiving services in the community (such as being placed on a waiting list and insurance coverage difficulties), the compliance enhancement group attended significantly more treatment sessions than the standard disposition-planning group (mean = 8.4 versus 5.8 sessions). CONCLUSION Interventions designed to improve treatment attendance must address not only individual and family factors but also service barriers encountered in the community that can impede access to services.

Treatment for Adolescents Following a Suicide Attempt: Results of a Pilot Trial

OBJECTIVE To compare the efficacy of a skills-based treatment protocol to a supportive relationship therapy for adolescents after a suicide attempt. METHOD Thirty-nine adolescents (12-17 years old) and parents who presented to a general pediatric emergency department or inpatient unit of a child psychiatric hospital after a suicide attempt were randomized to either a skills-based or a supportive relationship treatment condition. Follow-up assessments were conducted at intake and 3 and 6 months post-attempt. RESULTS In contrast to the low rates of treatment received by adolescent suicide attempters in the community, approximately 60% of this sample completed the entire treatment protocol. Significant decreases in suicidal ideation and depressed mood at 3- and 6-month follow-ups were obtained, but there were no differences between treatment groups. There were six reattempts in the follow-up period. CONCLUSIONS When adolescents who attempt suicide are maintained in treatment, significant improvements in functioning can be realized for the majority of patients.

Predictors of continued suicidal behavior in adolescents following a suicide attempt

Describes adolescents who attempt suicide and their risk for ongoing suicidal behavior. Fifty-eight adolescents (53 female) who attempted suicide received a baseline evaluation that was analyzed to identify factors that were associated with continued suicidal ideation and reattempt. At a 3-month follow-up assessment, 45% reported continued suicidal ideation and 12% reported a repeat attempt. Baseline measures of family functioning, feelings of hopelessness, and abilities to regulate affect were associated with suicidal ideation at follow-up but not as strongly as depressed mood. After controlling for depressive symptoms, the association between family functioning and continued suicidal behavior was no longer significant. Depressed mood at baseline was most strongly associated with both continued suicidal ideation and reattempt.

The Role of Perfectionism and Depressive Cognitions in Understanding the Hopelessness Experienced by Adolescent Suicide Attempters

This study examined the relation of two cognitive variables, depressive cognitions and perfectionism, to the hopelessness experienced by adolescent suicide attempters. Adolescent suicide attempters (N = 68) were administered three measures assessing cognitive characteristics commonly associated with adolescent suicidal behavior: the Child and Adolescent Perfectionism Scale (CAPS), the Depressive Experiences Questionnaire for Adolescents (DEQ-A), and the Hopelessness Scale for Children (HSC). Socially prescribed perfectionism on the CAPS and self-criticism on the DEQ-A were both highly correlated with HSC. Regression analyses indicated that perfectionism was significantly related to hopelessness, but this relationship was attenuated after the effects of depressive cognitions on hopelessness were controlled. Self-criticism was the cognitive variable most strongly associated with hopelessness suggesting that it is a more important focus for cognitive interventions in adolescent suicide attempters than perfectionism.

Treatment-as-usual for adolescent suicide attempters: implications for the choice of comparison groups in psychotherapy research.

Studied Treatment-as-Usual (TAU) in a sample of 63 adolescent suicide attempters. Randomized clinical trials (RCTs) with high-risk populations, such as suicidal patients, are difficult to conduct due to clinical and ethical concerns about control groups. Therefore, TAU comparison groups have been proposed as ethically defensible alternatives to control groups. However, TAU is rarely characterized in treatment trials. Following a suicide attempt, the adolescents in our sample reported attending 0 to 22 outpatient psychotherapy sessions, with an average of 7.0 sessions. Fifty-two percent of the adolescents reported attending six or fewer sessions. Supportive psychotherapy techniques were reported by three fourths of the sample, psychodynamic and cognitive techniques by one half of the sample, and behavioral techniques by one third of the sample. Results suggest that TAU with this population of adolescents is highly variable, both in terms of the number of sessions attended and type of treatment received. This variability makes interpretation of treatment results in clinical trials with TAU comparison groups tenuous. Given the attention paid to treatment attendance and fidelity in most RCTs, even less potent control groups in such trials may be both ethically and clinically as justifiable as TAU designs for high-risk populations.

Structured disposition planning for adolescent suicide attempters in a general hospital: Preliminary findings on short-term outcome

Adolescent suicide attempters are often noncompliant with outpatient psychotherapy and drop out of treatment much more quickly than non-suicidaladolescents. In this study, 23 adolescents received medical treatment and astandard psychiatric evaluation in an Emergency Department following asuicide attempt. In addition, all subjects and their parents received apsychotherapy compliance enhancement intervention which included a verbalagreement between the adolescent and parent/guardian to attend at least fourpsychotherapy sessions. After discharge from the hospital, each subjectreceived three phone interviews over an 8 week period using a problemsolving approach around two key areas: suicidal ideation and psychotherapycompliance. Compared to a three month follow-up of 78 subjects (which didnot include an experimental intervention), conducted at the same hospital,the experimental intervention resulted in fewer outpatient psychotherapy ’noshows‘ (9% vs. 18%) and a trend toward greater number ofsessions attended (5.5 vs. 3.9). There were no re-attempts in theexperimental group as compared to 9% in the comparison group. Resultsare promising and a randomized intervention trial appears indicated.

Personality characteristics of adolescent suicide attempters

Objective: The purpose of this study was to explore both the personality characteristics and the symptoms of personality disorder of adolescent suicide attempters, as well as the relationship between personality variables and hopelessness in this population. Method: Two sample populations were used in this study. First, 102 adolescent suicide attempters between 13 and 18 years of age completed the Millon Adolescent Personality Inventory (MAPI) and the Hopelessness Scale for Children (HSC). A second group of 35 adolescent suicide attempters were administered the HSC and the revised Diagnostic Interview for Borderlines (DIB). Results: No distinctive personality characteristics or symptoms of personality disorders were found. However, affective distress seemed to be the most prominent feature in the presentation of these adolescents. Additionally, high scores on the HSC were associated with elevated scores on the Personality Style scales of the MAPI and higher (more dysfunctional) scores on Affect Regulation on the DIB. Conclusions: The results suggest that clinicians should focus most on the personality characteristic of sensitivity and on affect regulation when assessing adolescent suicide attempters. In addition, hopelessness is important to systematically assess because it appears to be related to a variety of dysfunctional personality characteristics that may affect follow-up outcome.