Adolescent Major Depressive Disorder, Deliberate Self-Harm, and Suicide

by Eleanor Roberts, PhD

Among the myriad of adolescent psychiatric issues, major depressive disorder (MDD) and suicide have captured the headlines. In the United States approximately 14% of 15- to 18-year-olds have at least one MDD episode, and depression is the “cardinal risk factor” for suicide in children and adolescents.(1) Deliberate self-harm (DSH) is another issue in this population, and in a recent paper, Madge et al(2) comment: “…in the UK, it [DSH] is one of the top five reasons for acute medical admissions.” To investigate the prevalence of DSH, this group carried out the Child & Adolescent Self-harm in Europe (CASE) Study, which involved a self-administered survey given to 30,476 adolescents aged 14 to 17. They found that overall, approximately one-third of girls and one-eighth of boys had either self-harmed (predominantly cutting and overdose) or had thoughts of self-harm in the previous 12 months. For boys, 32.8% of incidences were carried out under the influence of alcohol and 26.2% of incidences involved illegal drugs; however respective percentages were significantly lower for girls at only 15.6% and 8.2% (p > .001). This study illuminates the prevalence of DSH among adolescents and specifically highlights gender differences indicating that DSH warrants a great deal of attention in girls especially. Since substances of abuse are involved in many more incidences of DSH for boys than for girls, it may be that substance use should be a focus issue for this gender.

Although depression is often causally linked to DSH in adolescents, another study specifically investigated the psychiatric profile of this patient population. Jacobson et al, 2008,(3) conducted an evaluation of those admitted to an outpatient depression and suicide program. Importantly,
this study compared people who engaged in DSH to others diagnosed with a psychiatric disorder without a DSH element, as opposed to studies where the comparison is a non-psychiatric control. Participants were categorized as no DSH (n = 119), nonsuicidal self-injury only (NSSI) (n = 30), suicide attempt only (SA) (n = 38), or SA + NSSI (n = 40). They found that those in the
SA +/- NSSI groups were significantly more likely to be diagnosed with MDD (p < . 001 and .001 respectively), posttraumatic stress disorder (PTSD) (p = .001, .002), or bipolar disorder (BPD) (p < .001) than those in the no DSH group. This was also true for MDD and PTSD, but not BPD, when compared to the NSSI group. The NSSI group itself was only significantly different to the no DSH group for BPD symptoms (p = .002). This separation of BPD from MDD and PTSD with regard to DSH has indications for the possible tailoring of treatment with regard to DSH and psychiatric diagnosis.

Another very prevalent issue in adolescent psychiatry is the prescription of antidepressants (AD) following the addition of an FDA black box warning to these medications regarding incidences of increased suicidality (suicidal thinking and behavior). There is debate, however, about whether the black box warning should apply to all ADs as a few investigations (predominantly of new-generation ADs) have shown a significant link only for paroxetine and venlafaxine.(4,5) There is also the issue of whether the use of ADs leads to an increase in completed suicide or just suicidal thinking and attempts. Indeed, a study of hospitalized suicide attempters showed that although this aspect of suicide (attempts but not completion) was associated with the use of an AD, this relationship was not so for completed suicide.(6) Other studies have found a separation between rates of suicidality and age, indicating that those in the upper age range suggested by the black box warning (15 to 24 years) show less suicidality on ADs than before AD use. Despite the black box warning, a large study regarding adolescent depression—the Treatment of Adolescent Depression Study (TADS)(7)—concluded: “…treatment benefits outweigh risks when assessing a harm-related event.”

It has been postulated that the decline in use of ADs for adolescents is linked to an increase in the incidence of suicide. Indeed, of the respondents to the survey question “Do you feel the black box warning…has a negative impact on the outcomes of children and adolescents with depression,” from an earlier edition of the Clinical Compass™ (1.15.2008), 67% said Yes and only 20% said No. A recent review by Dudley et al(8) recommended the use of new-generation ADs, starting with fluoxetine, for moderate-severe depression or for unremitting mild depression, as long as they are accompanied by education on signs of suicidality, frequent treatment review, and psychological therapy. With regard to the latter, in a recent analysis Munoz-Solomando et al(9) showed that CBT for those aged 9 to 18 (n = 548) was the most advantageous form of therapy over no treatment, standard care, or any other active treatment. Thus CBT can be a useful sole treatment or adjunct for MDD.

In conclusion, suicide and DSH in adolescents is an issue that needs to be addressed when administering to this population. This may be a particular cause for concern for girls, for boys who abuse intoxicating substances, and for those who have MDD or PTSD over those with BPD. The use of an AD in adolescents, although coming with a black box warning, are proving efficacious especially in severe cases and with the addition of CBT.

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References

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