Suicide Prevention: Hopeful, not Futile

About eight years ago, at a meeting of the country’s leading suicide researchers, the talk at dinner eventually turned to teenagers. The scientists were discussing the most pressing needs in the field of suicide prevention.

“Depressed people who attempt suicide are different from those who do not. They need treatment for depression, but they also need therapy tailored to help with their suicidal thoughts and behaviors. We concluded that we need a specialized treatment for suicidal teens,” remembers Barbara Stanley, Ph.D., professor of clinical psychology (in psychiatry), “because at the time we knew very little about how to prevent kids from attempting suicide once they had made one attempt.”

Each year in the United States, teenagers make 2 million suicide attempts, and previous suicidal attempts are the biggest risk factor for another, with adolescents who have attempted suicide 10 to 60 times more likely to die from suicide than the average adolescent.

Researchers still don’t have all the answers, but a research consortium that grew out of that dinner conversation is starting to challenge assumptions about conducting research with suicidal teens. And their latest finding shows that a new therapy developed specifically for suicidal adolescents may succeed in preventing future attempts.

“Futile” is the word Dr. Stanley uses to describes how most of her colleagues viewed suicide treatment trials in teenagers. Ten years ago, enrolling suicidal adolescents in treatment trials was deemed impracticable because even in the best of circumstances, teenagers are hard to retain in treatment.

“Unfortunately that left the field without any empirical guidance about how to help this high-risk group,” Dr. Stanley says. “And it’s an amazingly large group.”

In 2002, the nationwide consortium formed by Dr. Stanley – and other Columbia researchers, including Laurence Greenhill, M.D., the Ruane Professor of Clinical Child and Adolescent Psychiatry, and Kelly Posner, Ph.D., associate clinical professor of medical psychology – organized a trial of a new psychotherapy, called cognitive behavior therapy for suicide prevention, specifically developed for depressed, suicidal adolescents. Researchers from the National Institute of Mental Health, Duke, Johns Hopkins, the University of Pittsburgh, and the University of Texas Southwestern Medical Center participated with Columbia. The trial also evaluated the efficacy of psychotropic medications.

The new therapy doesn’t shy away from discussing the events that led up to the suicide attempt, says Dr. Stanley, who had a big hand in developing the treatment manual used in the trial. “From the moment they come through the door, we talk about the attempt. We put that time period under a microscope to understand all the thoughts, feelings, and behaviors that led up to it,” she says. “Then we identify what skills they lack that could prevent them from attempting suicide again.” In dealing directly with the suicide attempt, the therapy takes a different tack from the way most suicidal adolescents have been treated in the past.

The events that trigger suicide attempts in teenagers often sound trivial to adults: a boyfriend doesn’t call at the promised time; an argument about grades with parents; or a conflict at school with friends. But the events often happen in the context of longstanding depression, substance abuse, or family problems and conflicts.

“Let’s say a teenager feels unbearable anger after her father, who is divorced from her mother and lives in a nearby city, cancels plans to visit for the weekend,” Dr. Stanley says. “She feels rejected and that she’s a horrible person who has done something that causes her father to reject her. She may also feel guilty for feeling so angry with her father.”

Some teens cannot handle these intense feelings and hurt themselves instead. The therapist uses the new therapy to not only help a teen understand feelings and behaviors, but also teach specific skills that can be used to enhance coping capabilities. “Our pilot study was really just step one, but it showed us that intervention research with suicidal kids is feasible, not futile.”

Because most suicidal teenagers are depressed, researchers believed that successful treatment of depression would eliminate suicidal thoughts. But recent studies, including analyses of brain chemistry by Columbia neuroscientist J. John Mann, M.D., the Paul Janssen Professor of Translational Neuroscience, suggest something different about being suicidal. “The neurochemistry of depressed people who attempt suicide is different from those that do not,” Dr. Stanley says. “Our point of view is that while they need treatment for depression, they also need therapy tailored to help with their suicidal thoughts and behaviors.”

Results from the consortium’s trial, published in the Journal of the American Academy of Child and Adolescent Psychiatry, show that the rate of suicidal events among participants who chose the new therapy was lower than rates typically found in surveys of suicidal teenagers. But because of the pilot study’s design (the participants chose their own treatment among three choices: talk therapy, antidepressants, or both), the therapy’s effectiveness is still uncertain until randomized, controlled clinical trials can be conducted.

Dr. Stanley and her colleagues are applying for grant funding to support continued research.