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Nessun Dorma (“None Shall Sleep”)… At Least Not Before We Digest Treatment of Adolescent Suicide Attempters (TASA)

2009; Elsevier BV; Volume: 48; Issue: 10 Linguagem: Inglês

10.1097/chi.0b013e3181b45098

1527-5418

Garry Walter,

Attention Deficit Hyperactivity Disorder

As fellow readers would glean through the Journal's array of articles over recent years, the field of child and adolescent psychiatric research is moving rapidly. Arguably, the pace is too swift for us to keep abreast, let alone become authoritative, about developments in every domain of our specialty. An article on the genetics of juvenile bipolar disorder may be followed by an article on a new diagnostic instrument, which may precede a piece on the side effects associated with a novel psychotropic. Such contributions attest the richness and contemporary state of our field and—in the ideal world—would be read, and perhaps reread. Understandably, given hectic work schedules, competing demands and a consequent need to prioritize, it is conceded by editors and authors that readers may “pick and choose,” or cursorily peruse the various Journal offerings. Notwithstanding these considerations, the three papers from the Treatment of Adolescent Suicide Attempters (TASA) trial,1Vitiello B Brent D Greenhill L et al.Depressive symptoms and clinical status during the treatment of adolescent suicide attempters.J Am Acad Child Adolesc Psychiatry. 2009; 48: 997-1004Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 2Brent D Greenhill L Compton S et al.The treatment of adolescent suicide attempters (TASA): predictors of suicidal events in an open treatment trial.J Am Acad Child Adolesc Psychiatry. 2009; 48: 987-996Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar, 3Stanley B Brown G Brent D et al.Cognitive behavior therapy for suicide prevention (CBT-SP): treatment model, feasibility and acceptability.J Am Acad Child Adolesc Psychiatry. 2009; 48: 1005-1013Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar published in this issue, warrant our careful attention. The TASA trial was a multisite pilot study to assess the feasibility of systematically treating depressed adolescents who had recently attempted suicide. After a thorough evaluation, 124 participants were treated for 6 months with antidepressant medication and/or manual-based cognitive-behavioral therapy (CBT), the latter specifically developed to address suicide risk and prevent further suicidal behavior. The clinical relevance of the three TASA articles, in turn describing the course of depression during treatment,1Vitiello B Brent D Greenhill L et al.Depressive symptoms and clinical status during the treatment of adolescent suicide attempters.J Am Acad Child Adolesc Psychiatry. 2009; 48: 997-1004Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar the predictors of suicidal events and attempts,2Brent D Greenhill L Compton S et al.The treatment of adolescent suicide attempters (TASA): predictors of suicidal events in an open treatment trial.J Am Acad Child Adolesc Psychiatry. 2009; 48: 987-996Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar and the manual-based CBT,3Stanley B Brown G Brent D et al.Cognitive behavior therapy for suicide prevention (CBT-SP): treatment model, feasibility and acceptability.J Am Acad Child Adolesc Psychiatry. 2009; 48: 1005-1013Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar is substantial. Of course, readers will be familiar with many of the sobering statistics surrounding depression and suicidal behavior in young people. For example, a study conducted in North Carolina4Costello RJ Mustillo S Erkanli A et al.Prevalence and development of psychiatric disorders in childhood and adolescents.Arch Gen Psychiatry. 2003; 60: 837-844Crossref PubMed Scopus (2732) Google Scholar found that, by the age of 16 years, 12% of girls and 7% of boys have had a depressive disorder at some period in their life. At least 40% of cases of depression in adolescence prove treatment resistant,5Birmaher B Brent DA Treatment-resistant depression.in: Rey JM Birmaher B Treating Child and Adolescent Depression. Lippincott Williams & Wilkins, Baltimore2009: 209-219Google Scholar and depression in teenagers is strongly associated with suicidal behavior6Waldrop AE Hanson RF Resnick HS Risk factors for suicidal behavior among a national sample of adolescents: Implications for prevention.J Trauma Stress. 2007; 20: 869-879Crossref PubMed Scopus (120) Google Scholar, 7Birmaher B Brent D the AACAP Work Group on Quality Issues Practice parameter for the assessment and treatment of children and adolescents with depressive disorders.J Am Acad Child Adolesc Psychiatry. 2007; 46: 1503-1526Abstract Full Text Full Text PDF PubMed Scopus (664) Google Scholar: approximately 60% of depressed adolescents report suicidal ideation, and 30% attempt suicide. A previous suicide attempt is one of the best predictors of eventual suicide in young people,8LeComte D Fornes P Suicide among youth and young adults, 15 through 24 years of age: a report of 392 cases from Paris, 1989–1996.J Forensic Sci. 1998; 43: 964-968PubMed Google Scholar and completed suicide is the third leading cause of death in the United States in the age group of 10 to 19 years.9Hamilton BE Minino AM Martin JA et al.Annual summary of vital statistics: 2005.Pediatrics. 2007; 119: 345-360Crossref PubMed Scopus (247) Google Scholar In this context, the clear formulation and evaluation of a treatment approach for adolescents with depression who have attempted suicide is most welcome. The TASA trial certainly fills a void. For example, although suicide prevention strategies, such as school-based education programs and means restrictions, have been implemented and are in the process of evaluation,10Bursztein C Apter A Adolescent suicide.Curr Opin Psychiatry. 2008; 22: 1-6Crossref Scopus (70) Google Scholar the identified adolescent suicide attempter has seldom been a specific research subject. Similarly, despite the occasional description of therapies (e.g., dialectical behavior therapy, multisystemic therapy) for adolescents who attempt suicide,11Berk MS Brown GK Wenzel A et al.A cognitive therapy intervention for adolescent suicide attempters: an empirically informed treatment.in: LeCroy CW Handbook of Evidence Based Treatment Manuals for Children and Adolescents. Oxford University Press, New York2008: 431-455Google Scholar there have been no high-quality trials focusing on adolescent suicide attempters with depression. Until now. The key findings of the TASA articles are encouraging. Vitiello et al.1Vitiello B Brent D Greenhill L et al.Depressive symptoms and clinical status during the treatment of adolescent suicide attempters.J Am Acad Child Adolesc Psychiatry. 2009; 48: 997-1004Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar suggest that, with combined medication-CBT (chosen by the majority of patients), rates of improvement and remission of depression are comparable to those in nonsuicidal depressed adolescents. Brent and colleagues2Brent D Greenhill L Compton S et al.The treatment of adolescent suicide attempters (TASA): predictors of suicidal events in an open treatment trial.J Am Acad Child Adolesc Psychiatry. 2009; 48: 987-996Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar report that allocation to CBT, medication, or the combination lowers the 6-month risks for suicidal events and reattempts. Finally, Stanley et al.3Stanley B Brown G Brent D et al.Cognitive behavior therapy for suicide prevention (CBT-SP): treatment model, feasibility and acceptability.J Am Acad Child Adolesc Psychiatry. 2009; 48: 1005-1013Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar provide a favorable assessment about the feasibility of the manual-based CBT: 12 or more sessions were completed by almost three quarters of their sample of recent suicide attempters with depression. These promising results need to be interpreted in the knowledge that the TASA trial was largely nonrandomized and uncontrolled, that patients with substance abuse (common among suicide attempters) were excluded, that the dropout rate—albeit in the range of other treatment studies and hardly surprising with this adolescent sample—was not small (31%), and that approximately 20% of the subjects displayed suicidal behavior during treatment. Furthermore, suicide research generally is beset with problems of definition (here, suicide attempt versus behavior versus event), and readers need to be vigilant regarding used terms and their intended meaning. Nevertheless, the authors, collectively, should be warmly applauded for successfully engaging a notoriously difficult population that is often excluded from clinical trials,12Pearson J Stanley B King C et al.Intervention research with persons at high risk for suicidality: safety and ethical considerations.J Clin Psychiatry. 2001; 62: 17-26PubMed Google Scholar for delineating several predictors of recurrent suicidal events (and thus demarcating treatment targets, e.g. suicidal ideation, family cohesion, sequelae of previous abuse), and for providing a solid base from which to refine and further evaluate management approaches for these patients. It is worth highlighting the finding that the majority (42%) of suicidal events during the trial occurred within the first 4 weeks; concentrating therapeutic endeavors in this high-risk period, while not ignoring any treatment phase, seems to be an important task. I implore you to “burn the midnight oil” and read the TASA articles. In the opera Turandot, the price for royal subjects sleeping (and thereby not discovering the name of Princess Turandot's suitor, Calaf) was death—hence the princess's infamous command, “Nessun Dorma!” (“None Shall Sleep”). The stakes for adolescents with depression who have attempted suicide are similar. Study the TASA articles, ponder their significance, and reflect on the teenagers they describe. After all, the plight of such patients could not be more parlous and, surely, captures the reason many of us chose our profession.