Suicide Attempts and Nonsuicidal Self-Injury in the Treatment of Resistant Depression in Adolescents: Findings from the TORDIA Study

doi:10.1016/j.jaac.2011.04.003

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 50, Issue 8, August 2011, Pages 772-781

https://doi.org/10.1016/j.jaac.2011.04.003 Get rights and content

Objective

To evaluate the clinical and prognostic significance of suicide attempts (SAs) and nonsuicidal self-injury (NSSI) in adolescents with treatment-resistant depression.

Method

Depressed adolescents who did not improve with an adequate SSRI trial (N = 334) were randomized to a medication switch (SSRI or venlafaxine), with or without cognitive-behavioral therapy. NSSI and SAs were assessed at baseline and throughout the 24-week treatment period.

Results

Of the youths, 47.4% reported a history of self-injurious behavior at baseline: 23.9% NSSI alone, 14% NSSI+SAs, and 9.5% SAs alone. The 24-week incidence rates of SAs and NSSI were 7% and 11%, respectively; these rates were highest among youths with NSSI+SAs at baseline. NSSI history predicted both incident SAs (hazard ratio [HR]= 5.28, 95% confidence interval [CI] = 1.80–15.47, z = 3.04, p = .002) and incident NSSI (HR = 7.31, z = 4.19, 95% CI = 2.88–18.54, p < .001) through week 24, and was a stronger predictor of future attempts than a history of SAs (HR = 1.92, 95% CI = 0.81–4.52, z = 2.29, p = .13). In the most parsimonious model predicting time to incident SAs, baseline NSSI history and hopelessness were significant predictors, adjusting for treatment effects. Parallel analyses predicting time to incident NSSI through week 24 identified baseline NSSI history and physical and/or sexual abuse history as significant predictors.

Conclusions

NSSI is a common problem among youths with treatment-resistant depression and is a significant predictor of future SAs and NSSI, underscoring the critical need for strategies that target the prevention of both NSSI and suicidal behavior. Clinical Trial Registration Information—Treatment of SSRI-Resistant Depression in Adolescents (TORDIA). URL: http://www.clinicaltrials.gov. Unique Identifier: NCT00018902.

Section snippets

Method

Detailed descriptions of participants, assessments, treatments and outcomes are available elsewhere.14, 16, 17 Therefore, we focus here on participant characteristics, measures, and procedures relevant to the outcomes of SAs and NSSI. The study was reviewed by each site's local institutional review board. All subjects gave informed assent/consent (as appropriate), and parents gave informed consent.

Baseline Presentation

Table 1 provides descriptive data on the baseline characteristics of the total sample and for subgroups of youths presenting at baseline with histories of no SIB, NSSI only, SAs only, and NSSI+SAs. Histories of NSSI were somewhat more common than SA histories at baseline: 78 youths (23.9%) reported a history of NSSI only, 31 (9.5%) reported a history of SAs only, and a sizeable subgroup (46 youths, 14%) reported histories of NSSI+SAs. The high likelihood of combined NSSI and suicide attempts

Discussion

The present results underscore both the prevalence and significance of NSSI among adolescents with chronic treatment-resistant depression. Consistent with results indicating relatively high rates of NSSI in the general adolescent population,2, 8 NSSI histories were relatively common in the TORDIA sample (38%) and more common than SA histories (23%). In addition, NSSI and suicide attempts tended to co-occur, with 14% of the sample presenting with baseline histories of both NSSI and SAs, and

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: Funded by National Institute of Mental Health grants MH61835 (Pittsburgh); MH61856 (Galveston); MH61864 (UCLA); MH61869 (Portland); MH61958 (Dallas); and MH62014 (Brown), and the Advanced Center for Early-Onset Mood and Anxiety Disorders (MH66371, D.A.B.).

: The authors thank the youth, families, staff, and colleagues who made this project possible. The opinions and assertions contained in this report are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of Health and Human Services, the National Institutes of Health, or the National Institute of Mental Health.

: Disclosure: Dr. Asarnow has received research grants from the National Institute of Mental Health. She has received honoraria from the California Institute of Mental Health, Hathaways-Sycamores, and the Melissa Institute. Dr. Emslie receives research support from the National Institute of Mental Health, Biobehavioral Diagnostics Inc., Eli Lilly and Co., Forest, GlaxoSmithKline, and Somerset. He has served as a consultant for Biobehavioral Diagnostics Inc., Eli Lilly and Co., Forest, GlaxoSmithKline, Pfizer, and Wyeth. He has served on the speakers' bureau for Forest. Dr. Wagner has received honoraria from Physicians Postgraduate Press, the National Institutes of Health, CMP Medica, UBM Medica, Krog and Partners, American Institute of Biological Sciences, Mexican Psychiatric Association, American Academy of Child and Adolescent Psychiatry, American Psychiatric Association, Madison Institute of Medicine, Wolters Kluwer Health, Contemporary Forums, Quantia Communications, Doctors Hospital at Renaissance, CME LLC, Springer Publishing. He serves as a deputy editor of the Journal of Clinical Psychiatry. Dr. Keller has served as a consultant to Medtronic, Sierra Neuropharmaceuticals, and CENEREX (without renumeration). He has received grant support from Pfizer. Dr. Birmaher has served as a consultant for Schering Plough. He has received research support from the National Institute of Mental Health. He has participated in forums sponsored by Dey Pharma, L.P.: Major Depressive Disorder Regional Advisory Board Meeting. He has received royalties for publications from Random House, and Lippincott Williams and Wilkins. Dr. McCracken has received research support from Eli Lilly and Co., McNeil, Bristol-Myers Squibb, and Shire; and has served as a consultant for Shire, Eli Lilly and Co., McNeil, Pfizer, Janssen, Johnson and Johnson, Novartis, and Wyeth. Dr. Brent has received research support from the National Institutes of Mental Health. He has received royalties from Guilford Press. He serves as an editor of UpToDate Psychiatry. Drs. Spirito, Berk, Clarke, and Vitiello, and Ms. Mayes and Ms. Porta, report no biomedical financial interests or potential conflicts of interest.

: This article is discussed in an editorial by Dr. Paul Wilkinson on page 741.

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New researchSuicide Attempts and Nonsuicidal Self-Injury in the Treatment of Resistant Depression in Adolescents: Findings from the TORDIA Study

Objective

Method

Results

Conclusions

Section snippets

Method

Baseline Presentation

Discussion

Psychiatry Res

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Addict Behav

Youth risk behavior surveillance—United States, 2009

MMWR Surveill Summ

Prevalence and psychological correlates of occasional and repetitive deliberate self-harm in adolescents

Arch Pediatr Adolesc Med

Distinguishing between subgroups of adolescents who self-harm

Suicide Life Threat Behav

The epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: a critical review of the literature

Arch Suicide Res

An exploratory study of correlates, onset, and offset of non-suicidal self-injury

Arch Suicide Res

Longitudinal prediction of adolescent nonsuicidal self-injury: examination of a cognitive vulnerability-stress model

J Clin Child Adolesc Psychol

Prevalence and clinical correlates of deliberate self-harm among a community sample of Italian adolescents

J Adolesc.

Risk for suicide attempts among adolescents who engage in non-suicidal self-injury

Arch Suicide Res

Deliberate self-harm in young people: characteristics and subsequent mortality in a 20-year cohort of patients presenting to hospital

J Clin Psychiatry

Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder

Arch Gen Psychiatry

Emotional dysregulation and interpersonal difficulties as risk factors for nonsuicidal self-injury in adolescent girls

J Abnorm Child Psychol

Predictors of spontaneous and systematically assessed suicidal adverse events in the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) study

Am J Psychiatry

New research
Suicide Attempts and Nonsuicidal Self-Injury in the Treatment of Resistant Depression in Adolescents: Findings from the TORDIA Study