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

Abstract

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 andVin the ideal worldVwould 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, 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, the predictors of suicidal events and attempts, and the manual-based CBT, 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 Carolina 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, and depression in teenagers is strongly associated with suicidal behavior: 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, and completed suicide is the third leading cause of death in the United States in the age group of 10 to 19 years. 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, 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, 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. 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 colleagues report that allocation to CBT, medication, or the combination lowers the 6-month risks for suicidal events and reattempts. Finally, Stanley et al. 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 Accepted June 16, 2009. Dr. Walter is with the University of Sydney and Northern Sydney Central Coast Health. Correspondence to Garry Walter, M.D., Ph.D., Coral Tree Family Service, PO Box 142, North Ryde, NSW, 1670, Australia; e-mail: GWalter@mail.usyd.edu.au. 0890-8567/09/4810-0977 2009 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/CHI.0b013e3181b45098 E D I T O R I A L