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January 2011



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First Published Saturday, 21 February 2009

Teen Suicide

Certain circumstances may predict suicidal thinking or behavior among teens with treatment-resistant major depression who are undergoing second-step treatment, according to an analysis of data from an National Institute of Mental Health (NIMH)-funded study. The study will be published in the American Journal of Psychiatry.

In the Treatment of SSRI-resistant Depression in Adolescents (TORDIA) study, 334 teens who did not get well after taking a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI) before the trial were randomly assigned to one of four treatments for 12 weeks:

  • *Switch to another SSRI
  • *Switch to venlafaxine (Effexor), a different type of antidepressant
  • *Switch to another SSRI and add cognitive behavior therapy (CBT), a type of psychotherapy
  • *Switch to venlafaxine and add CBT

Results of the trial were previously reported in February 2008. They showed that teens who received combination therapy, with either type of antidepressant, were more likely to get well than those on medication alone.

Using data from spontaneous reports by the participants and from systematic assessment by clinicians, David Brent, MD, of the Western Psychiatric Institute and Clinic, and colleagues aimed to identify characteristics or circumstances that may predict whether a teen is likely to have suicidal thoughts or behavior during treatment. Nearly 60 percent of TORDIA participants had suicidal thinking or behavior at the beginning of the trial.

Fifty-eight suicidal events-which include serious suicidal thinking or a recent suicide attempt-occurred in 48 participants during the trial, most of which happened early in the trial. The researchers found that teens who had higher levels of suicidal thinking, higher levels of parent-child conflict, and who used drugs or alcohol at the trial’s beginning were more likely to experience a suicidal event during treatment and less likely to respond to treatment. They were also less likely to have completed treatment.

These new data may contribute to developing more targeted and individualized interventions.” said NIMH co-author Benedetto Vitiello, MD “If we can know which teens may be more susceptible to suicidal thinking and behavior, we are better able to tailor safer treatments for them.

No statistically significant differences in suicidal events or non-suicidal self-injury were found among the treatment options. However, the use of venlafaxine was associated with a higher rate of self-injury in participants who had more severe suicidal thinking at the trial’s beginning. These results suggest that SSRIs are preferred over venlafaxine in the treatment of depressed teens who are at risk for suicidal thinking or behavior, according to the researchers.

Although CBT was found to have a protective effect over the long-term among teens with depression in the NIMH-funded Treatment for Adolescents with Depression Study (TADS), it did not appear to reduce the rate of suicidal events in TORDIA. The researchers theorize that because the suicidal events tended to occur soon after treatment began, the CBT did not have enough time to deliver a protective affect.

Finally, Brent and colleagues found that the use of anti-anxiety medications called benzodiazepines was associated with a higher likelihood of, and faster time to, a suicidal event-an unexpected result not found in other similar studies. The researchers theorize that participants who were taking a benzodiazepine in addition to an antidepressant may have been much more severely ill and therefore may have been more prone to suicidal thoughts or behavior. But more study is warranted on the potential role of anti-anxiety medications in suicidal thinking and actions among patients also taking an antidepressant.

Because the suicidal events tended to happen early in the treatment process, interventions that address safety, emotion regulation and family conflict should be some of the first to be implemented,” concluded Dr Brent. “With this data, we are in a better position to design future interventions that could lessen the risks of suicide even further among this vulnerable population.

Brent D, Emslie G, Clark G, et al. Predictors of spontaneous and systematically assessed suicidal adverse events in the Treatment of SSRI-resistant Depression in Adolescents (TORDIA) study. Am J Psychiatry 2009 Feb; doi:10.1176/appi.ajp.2008.08070976   [Abstract]

Childhood Anxiety, Anti-Social Behaviour May Predict Depression

Joel Schwarz


Past behavior is generally considered to be a good predictor of future behavior, but new research indicates that may not be the case in the development of depression, particularly among adolescent girls.

University of Washington social scientists tracked first- and second-graders for seven years and found that anti-social behavior among girls and anxiety among both sexes predicted depression in early adolescence. Surprisingly, early signs of depression were not predictive of adolescent depression.

Anti-social behavior has typically been viewed as a big problem among boys, so it tends to be ignored among girls. Boys with early anti-social behavior typically go on to show more anti-social behavior while girls may turn inward with symptoms, morphing into other mental health problems such as depression eating disorders, anxiety and suicidal behavior during adolescence,” said James Mazza, a UW professor of educational psychology and lead author of the new study. He is currently serving as the past president of the American Association of Suicidology.

When all the risk factors were analyzed, anti-social behavior and anxiety were the most predictive of later depression. It just may be that they are more prevalent in the early elementary school years than depression.” He noted that depression and anxiety share a number of symptoms.

Mazza said that early adolescence is when the first episode of depression typically occurs and that’s when it has been noted that gender difference occur, with more girls than boys experiencing depressive symptoms. Children can be assessed at 6 and 7 years of age, but depression is not often recognized or diagnosed until the middle school years.

Children in this study were drawn from a larger project looking at the risks for health and behavior problems. That project was conducted by the university’s Social Development Research Group, with which Mazza is affiliated. More than 800 children participated in the depression study. Eighty-one percent were white and 54 percent were boys.

Data were collected annually from the children and their parents and teachers when the children were in the first or second grade. The children filled out surveys that measured their levels of depression, anxiety and anti-social behavior, as well as other measures that were not investigated in this study. Parents and teachers filled out questionnaires about the children’s anti-social behavior and social competency, which measured such things as the youngsters’ abilities to understand other people’s feeling, to make new friends and resolve conflicts. Teachers also rated each child’s academic performance. In addition, parents filled out questionnaires concerning family and marital conflict, family stress and parental depression.

One finding from this study that is a mind-grabber is that young children can identify themselves as being anxious and depressed,” said Mazza. “When they had scores that were elevated we were a bit surprised because we thought they would say, ‘My life is fun and I play a lot.’ But they are able to understand and report feeling depressed or anxious, and tell us so. This suggests giving health surveys in early elementary school is a good idea and we should talk to kids in the first and second grades because they can give us valuable information.

The research was funded by the National Institute on Drug Abuse.

Mazza JJ, Abbott RD, Fleming CB, et al. Early Predictors of Adolescent Depression: A 7-Year Longitudinal Study. J Early Adolesc. 2009; doi:10.1177/0272431608324193   [Abstract]

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