Suicide and Non-Suicidal Self-Injury in Adolescents

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Suicide and Non-Suicidal Self-Injury in Adolescents. Saundra Stock, MD. Suicide. CDC - 17% of adolescents think about suicide each year Thoughts of death part of MDE 3rd leading cause of death in adolescents about 2,000 deaths per year - PowerPoint PPT Presentation

Text of Suicide and Non-Suicidal Self-Injury in Adolescents

  • Suicide and Non-Suicidal Self-Injury in Adolescents

    Saundra Stock, MD

  • SuicideCDC - 17% of adolescents think about suicide each year Thoughts of death part of MDE3rd leading cause of death in adolescents about 2,000 deaths per year25% decline in suicide rate in 10-19 year range in past decadeSuicide attempts often impulsive in nature

  • FDA warningFDA reviewed 23 studies with 9 different meds - > 4,300 ptsNO SUICIDES in these studiesAdverse events reporting - SI or potentially dangerous behavior reported by 4% of pts on meds vs. 2% on placebo17 of 23 studies asked about SI - no new SI or worsening of SI, actually decreased during treatment

  • Meta Analysis of 27 RCTs with SSRIsStudies were for MDD, OCD and non-OCD anxietyFor MDD NNT = 10NNH = 112More effective and less SEs when treating OCD or non-OCD anxietyJAMA 2007

  • Suicide and SSRIsFDA black box warning for risk of suicide for all ages with ALL antidepressantsNeed to advise families about this risk and give crisis infoFDA recommended Weekly contact the first 4 weeksEvery other week through week 12As indicated after week 12

  • Suicide and SSRIsFDA changed black box warning from specific monitoring to more general oneAll patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases.

  • Treating Adol Suicide Attempters Study (TASA)Youth Most likely to re-attempt suicideHigher level of suicidal thoughtsHigher level self report of depressive sxs esp hopelessness and anxiety2 or more prior attemptsLow lethality of index attemptH/o maltreatmentLow family cohesion

    Avg time to re-attempt 6 weeks

  • MDD trialsADAPT, TADS and TORDIA have not shown great results for CBT in reducing risk of suicide attempts or NSSIFamily therapy may be helpfulGroups CBT and DBT, perhaps some reduction in risk

  • General advice for families regarding SINo firearms in homeLimit access to medication including over the counter medsRemove access to parents medicationsRemove razors from bathroom or other sharpsIncrease supervision (e.g. keep doors open, limit peer contact to with adults present)Importance of seeking help if suicidal thoughts develop or worsenCrisis numbers (234-1234), emergency room resources and 911

  • NSSI and link to suicideSuicide is the 3rd leading cause of death in adolescents90% of youth who suicide have a psychiatric disorderThe largest group (35%) have MDDPrevious self harm is present in 40% of youth who suicideSeveral large studies now with youth and MDD looking at treatment options and outcomes: TADS, TORDIA, ADAPT

  • TORDIA and SI/NSSI 354 youth with MDD23.9% NSSI baseline9.5% SA14% NSSI + SIOver 24 weeks 13% with NSSI made a suicide attempt vs 3% with prior SA11% had NSSI over the 24 weeks (more common than a SAPredictors of SA were NSSI and hopelessness

  • Tordia studyJAMA 2008

    Pts ages 12-18 failed 2month SSRI trialN= 334Switch SSRIsParoxetineFluoxetineCitalopramSwitch SSRI + add CBTSwitch to venlafaxineSwitch to venlafaxine + CBTBetter outcome 54.8%Better outcome 54.8%47% improved48.2% improved

  • Non-Suicidal Self Injury (NSSI)Intentional destruction of ones body tissue without suicidal intent & for purposes which are not socially sanctionedCommon methods: 70%-90% of people who self-injure engage in skin cutting, scraping, or carving21-44% banging, bruising, and self-hitting15-35% burning Klonsky, E. David; Muehlenkamp, Jennifer J.; Lewis, Stephen P.; Walsh, Barent (2012-06-25). Nonsuicidal Self-Injury (Advances in Psychotherapy, Evidence Based Practice)

  • NonSuicidal Self-Injury Condition for further study in DSM 5

    5 or more episodes in 1 year2 or morePreceded by negative affectPrior to engaging in the act, a period of preoccupation with the intended behavior that is difficult to resist.The urge to engage in self-injury occurs frequently, although it might not be acted upon The activity is engaged in with a purpose; maybe relief from a negative feeling/cognitive state or interpersonal difficulty or induction of a positive feeling state. The patient anticipates these will occur either during or immediately following the self-injury.Behavior and consequences cause distressNot exclusively during intoxication or psychosis

  • Epidemiology10-15% teens have self-injured at least onceMost studies find 6-8% of teens and young adults reporting current, chronic self-injuryMore common in clinical populationsSelf-injury typically begins at ages 12-15 yearsM=F lifetime rates, however females may engage in NSSI more oftenFemales tend to cut; Males hit or bangMore comon in Hispanic or Native American in US studies. UK study found more in Asian decent

  • Biology little is knownEndogenous opioids (mixed evidence)Released with physical injury and may explain positive emotions and limited painStudies with naloxone (opioid antagonist) negativeSerotonin: animal models with low serotonin engage in self injury. Also low with aggression and suicidal behavior? Dopamine: reduced in Lesch-NyhanNo differences on phsiologic measures of emotional responses compared to controls

  • Course and PrognosisOccurs with a wide range of diagnosesFew longitudinal studies of NSSI existQuestions to be answered:How many people stop NSSI and when?Is NSSI a precursor to specific mental disorders?How often does it lead to suicidal behavior?

    Some information on NSSI and sucide attempts from several large studies on depression in adolescents

  • TORDIA and SI/NSSI 354 youth with MDD23.9% NSSI baseline9.5% SA14% NSSI + SIOver 24 weeks 13% with NSSI made a suicide attempt vs 3% with prior SA11% had NSSI over the 24 weeksPredictors of SA were NSSI & hopelessness

  • ADAPT study Original trial N=208 British teens with moderate to severe depression randomized to SSRI or SSRI + 12 weeks of CBT.Outcome at 28 weeks found no difference btwn treatment groups.Subsequent analysis looked at those at risk for suicide attempt

  • ADAPT study N= 163 teens 11-17 yrsSuicide attempt in 28 week f/u period30% made a SA, lower each month Risk factors: +SI, depression severity, hopelessness, NSSI or SA in the month before baseline and impaired family functioningNNSI37% had self injury, lower each monthRisk factors: NSSI in month prior to study, depression severity, anxiety, hopelessness, female and younger age

  • ADAPT: suicide attempts & self injuryN= 163 teens 11 to17 years (mean age 14)Avg 67 weeks of depression CDI score mean 59.9One month prior to the study28 (17%) had made SA 58 (36%) had engaged in NSSI During the 28 weeks of the study50 (30%) youth made a SA60 (37%) youth engaged in NSSI

  • ADAPT study resultsSuicideNSSI a stronger predictor of suicide attempt than a prior suicide attempt10 fold greater risk of suicide attempt than those who had no self injury and good family functioningNSSI36% had NSSI the month prior to the study and 37% engaged in NSSI during the study period.Most significant predictor of subsequent self injury was prior self injury

  • ADAPT self-injuryCompared with suicidality, self-injury over the 24 week follow- up period was associated with a different pattern of predictors. Poor family functioning was not associated with self-injury (but was associated with suicide attempts)Hopelessness & anxiety disorder at baseline along with being both younger and female, were associated with self-injury but not with suicidality.

  • ADAPT suicide risk factorsA higher risk of suicide attempt during follow-up significantly associated with suicidality, depression severity, hopelessness, the presence of a suicide attempt or self- injury in the month before baseline, and impaired family functioning Multiple logistical regression revealed impaired family functioning and self injury were significantly associated with suicide attemptROC4 analysis showed self-injury to be the strongest predictor of suicide attempt

  • Assessment of NSSI: implications for interventionAge of onsetMethods used for NSSI & access to those materialsFrequency & interval from thoughts to actionLast self-injuryLocation of injury and medical severityThoughts before, during and after NSSIFunction of behavior (intra or interpersonal)

  • Assessment measuresSelf-Injurious thoughts and behavior interview (SITBI)Suicide Attempt Self Injury Interview SASII (Linehan) Suicide Behavior Questionairre (SBQ Linehan)

    Both Linehan assessment items online athttp://blogs.uw.edu/brtc/publications-assessment-instruments/ Concern for teens: all ask specifics about actions which they may not have thought of yet

  • Function of NSSIMost common are INTRApersonal reasonsTo regulate emotionsRelease emotions, calm down, stop numb feelingsReduces high arousal emotions (anger, anxiety, frustration) more than low arousal (i.e. sadness)Self punishmentSometimes INTERpersonalInterpersonal influence: letting others know how I feel getting back at someone or getting out of repsonsibiltiesPeer bonding: fitting in

  • Interventions for NSSIFew studies in adolescents looking at strictly NSSITherapy that focuses on:Emotion regulationProblem solvingImproved self esteemDBT, CBT or problem based

    Research has repeatedly documented that people who engage in NSSI have more frequent & intense negative emotions as well as poorer global emotion regulation skills

  • Level of interventionOngoing monitirong only might be appropriate if: only 1-2 episodes of NSSIOutpatient TX: consider if > episodes of NSSI, intrapersonal r