Introduction

While there are hundreds of empirical studies in the literature focusing on risk factors and prevention strategies for adolescent suicide, there are few studies that offer insight into the preferred treatment methods for this population. Almost 30 years ago, the U.S. Secretary’s Task Force on Youth Suicide concluded that “ there are no treatment studies–psychotherapeutic, behavioral, or psychopharmacologic–which show that a clearly defined treatment approach is superior to no treatment or to some other treatment” [1]. Since that time there have been little progress in reducing the number of deaths by suicide and there has been no substantial reduction in suicide deaths over the past 60 years [2]. Today there are still few experimental and quasi-experimental studies evaluating suicide treatment models. In a systematic review of the empirical research on psychosocial treatment models of adolescent suicide several authors have concluded that Cognitive-Behavioral Therapy (CBT) is the prevailing treatment approach for suicidal and depressed adolescents [3-7]. In fact, the European Psychological Association [8] supports the use of CBT in both treatment and prevention of suicidal behavior. The aim of this essay is to provide an overview of suicidality in adolescents and examine the use of CBT as a treatment option for this population.

Adolescent Suicide

According to the results from the National Survey on Drug Use and Health suicide is the third leading cause of death of adolescents 10-14 years old and the second cause of death for adolescents and young adults 15-24 years old [9]. Among American adolescents, suicide rates tend to be higher among Caucasian males than among non-Caucasian males and higher among Caucasian females than non-Caucasian females. In general the suicide rate is remains up to four times higher for males than females and the suicide rate has continued to climb over the past 15 years without substantial information on new treatment methods. The death rate for suicide is concerning but so are the suicide attempts because adolescents who have suicidal behavior and attempt suicide are more likely to develop mental health problems and are at risk for repeat attempts to end their life [10].

Several factors are related to adolescent suicidality. Although it seems impossible to create a definitive list of causes of adolescent suicide, I can offer some trends in the literature to better understand the most common risk factors related to adolescent suicide. Gender, child maltreatment, depression, substance-abuse, low self-esteem, biological determinants and psychosocial determinants are all related to adolescent suicidality [11]. Recent studies support a correlation between suicidal behavior and the duration and quality of sleep [12]. It is suggested that suicidal behaviors are linked to a set of interrelated biological, psychological, and lifestyle factors such as depression, anxiety, and general well-being and that suicidal behavior is closely linked to sleep in some adolescents.

Of particular interest is a strong link between adolescent suicidality and depression [13]. Depression can be seen as a common correlate to adolescent suicidality or actually the causal root of some adolescent suicide attempts. There is some evidence that depression is a pre-curser to suicide attempts in adolescents who have suicidal ideation and that depression and suicidal thoughts are correlated [14]. According to a psychological autopsy study, up to 60% of adolescents who have committed suicide have a depressive disorder at the time of their death [15]. Keep in mind there is a high proportion of depression in adolescents who attempt or idealize suicide but do not actually succeed and it is evident that there is an interesting reciprocal nature between adolescent depression and suicidality. While depression has been determined a factor in adolescent suicidality, it is also the case that adolescent suicidality is a factor for depression.

Treatment of Adolescent Suicide

The empirical literature devoted to treatment for suicidal adolescents is limited even when there is an alarming growth pattern of adolescent suicidality. The few studies that do exist on the treatment of adolescent suicidality have produced limited results that support particular treatment methods. Not only is the literature on treatment outcomes for suicidal adolescents very limited; managing and treating adolescents with suicidality can be very anxiety producing for clinicians considering the lack of empirical guidelines in the area and adolescents can be particularly difficult to treat. There are no known therapy types that are empirically proven beyond a doubt to treat adolescent suicidal behavior [6]. There is some evidence that suggests that CBT may be an effective method of treatment for suicidal behaviors in adults. One of the first evidence-based studies to publish such significant findings in support of CBT was study done by Tarrier et al. [7] in which the authors concluded that CBT was highly effective in reducing suicidal behaviors in adults, but this finding could not be replicated for reducing suicidal behaviors in adolescents.

Although there is a lack of empirical evidence on the specific topic of adolescent suicide treatment, several studies suggest short and long-term cognitive-behavioral approaches may be effective in treating depression symptoms and self-injurious behaviors, which may be an indicator of suicidality among adolescents [2-8,16-18]. There have been studies that demonstrate that CBT has an impact on the reduction of suicidal behavior. In the meta-analysis done by Mewton and Andrews [19] the researchers concluded that CBT treatment was effective when focused on suicidal cognitions and behaviors. This is the most-recent evidence-based study in the literature that demonstrates CBT may be an effective treatment for suicidality, yet it does not focus on adolescents and, therefore, does not give the scientific community any more information on whether CBT is the best treatment model for adolescents who are suicidal.

Despite the limited findings specific to adolescents, I would argue that CBT is among the best options to treat adolescents who are suicidal due to the evidence provided by the adult studies that CBT has been found by several scholars to be one of the preferred treatment methods. The theory is highly adaptable to the science of suicidality and clinical psychotherapy in that it is compatible with the changing history of clinical practice and the changes in treatment of suicidal adolescents. The increased reliance on managed care companies, practice guidelines, and psychotropic medications in the treatment of adolescent suicidality has drastically changed the way that psychotherapists deliver services. Many forms of CBT have been successful in adapting to the changes in practice regarding the treatment of suicidal behaviors.

Cognitive-behavioral therapy is highly observable because it is rooted in evidence-based practice, which makes it very easy to see the results of the innovation. There are several studies that show empirical evidence to support the use of CBT with depression and suicidality. However, these studies tend to focus on adults and the quality of the studies on adolescent suicidality is limited. Therefore, there is no clear evidence that CBT is the superior method for suicide treatment for this adolescent and there is a need for more clinical trials to properly evaluate the treatment of suicidal adolescents.

In contemporary practice there are other approaches to treating suicidal adolescents that have advantages and disadvantages when compared with CBT. According to Berman et al. [3] there are many different types of suicidal adolescents and it is impossible to find a treatment that is appropriate for all types. Suicidal adolescents often need a full range of interventions– psychotherapy, medication, family therapy, engagement of peers, even spiritual or existential counseling. While CBT may have had a relative advantage over other therapy approaches of the time but it may not truly be the best therapy approach available for suicidal adolescents. There is research that points to the benefits of combining attachment theory and family therapy when treating suicidal adolescents. In a recent study on Attachment-Based Family Therapy (ABFT) researchers found that the family-based intervention for working with suicidal and depressed adolescents was an effective treatment option [20,21]. The family-based treatment model is centered on developing a strong parent-teen relationship and is an emerging treatment option for adolescents with suicide and depression. There has been 16 years of treatment development and some research to demonstrate effectiveness. However, researchers and clinicians do not have yet to test ABFT in a rigorous controlled study nor has it been tested for effectiveness against other known treatment models such as CBT.

Cognitive behavioral therapy is one of the most researched treatment models for suicidality and probably has good empirical evidence to support its effectiveness with adolescents and children. In a systematic review of the empirical literature it has been determined that CBT is an effective model for prevention of suicidal behaviors and for reduction of suicidal thoughts and behaviors [22]. However, there is a need for much more detailed empirical studies on the effectiveness of the model if clinicians hope to close the gap between clinical practice and research. Suicide among adolescents is a serious public health concern and there are a limited amount of effective treatments for this specific population.

References

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