Brief Treatment and Crisis Intervention Advance Access originally published online on July 6, 2006
Brief Treatment and Crisis Intervention 2006 6(3):234-247; doi:10.1093/brief-treatment/mhl004
| ||||||||||||||||||||||||||||||||||||||||||||||||||||
Original Article |
Making Stone Soup: Evidence-Based Practice for a Suicidal Youth With Comorbid Attention-Deficit/Hyperactivity Disorder and Major Depressive Disorder
From the School of Social Work, University of Pittsburgh.
Contact author: Jonathan B. Singer, University of Pittsburgh, School of Social Work, CL2117, Pittsburgh, PA 15260. E-mail: cooljazz{at}flash.net.
Crisis intervention for suicidal youth with comorbid attention-deficit/hyperactivity disorder (ADHD)/major depressive disorder (MDD) presents special challenges for evidence-based practitioners. This article reviews the treatment literature on suicide and comorbid ADHD/MDD. The findings are applied to a clinical case vignette. A 2-phase intervention based on expert consensus guidelines is introduced as a way of addressing both the suicidal crisis and the underlying comorbid diagnosis. Implications for practice and research are discussed.
KEY WORDS: suicidal behaviors, evidence-based practice, ADHD, major depressive disorder, comorbid, intervention, youth
The majority of youth who are seen in clinical practice meet criteria for having two or more psychiatric disorders, also referred to as having a comorbid or co-occurring disorder (Kovacs, 1996). Youth with comorbid disorders have poorer psychosocial outcomes, are at greater risk for suicide, and present greater treatment challenges than do youth with single disorders (Hendin et al., 2005; Pliszka, Carlson, & Swanson, 1999). Youth with comorbid depressive disorders (e.g., major depressive disorder—MDD) and disruptive disorders (e.g., attention-deficit/hyperactivity disorder—ADHD) are three times more likely to die by suicide than those with either a depressive disorder or a disruptive disorder alone (James, Lai, & Dahl, 2004). The presence of suicidal behaviors complicates treatment and is considered by many clinicians to be the most stressful of all clinical problems (Bongar, 2002).
Although treatment of comorbid disorders is routine, only in the last 15 years have researchers started to look at the causes of, clinical presentation of, and treatments for comorbid disorders (Angold, Costello, Farmer, Burns, & Erkanli, 1999; Mick, Spencer, Wozniak, & Biederman, 2005). Youth with comorbid disorders or those exhibiting suicidal behaviors were intentionally excluded from clinical trials. As a result, most outcome studies cannot be generalized to the treatment of comorbid disorders or of suicidal behaviors. This has produced a gap between the problems clinicians are required to treat and the problems for which there are empirically based interventions.
One approach to filling the gap between empirical evidence and the needs of the clients is evidence-based practice (EBP). EBP is a process of incorporating research, practice expertise, and client preferences into treatment (Fraser, 2003). The extent to which clinicians need to modify existing treatments to meet the needs of the client varies with the extent to which interventions have empirical support and the nature of the client's presenting problem (see Figure 1). The treatment of comorbid ADHD/MDD is challenging because the two disorders are distinct (James et al., 2004), have minimal influence on each other when they co-occur (Biederman et al., 1996), have different courses (Cohen et al., 1993), have treatments that are contraindicated for each other (Bridglal, 2003; Jensen et al., 2001), and increase the risk for suicidal behaviors (Fleischmann, Bertolote, Belfer, & Beautrais, 2005). Despite the existence of established treatments for ADHD and MDD as single disorders, there are no empirically supported psychotherapies for youth presenting with comorbid ADHD/MDD. Clinicians face additional treatment challenges when a youth with comorbid ADHD/MDD presents with suicidal behaviors. For clinical and liability reasons, clinicians should follow the best practices available for the treatment of high-risk populations. However, when there is no "off-the-shelf" treatment (as in the case of a suicidal client with comorbid ADHD/MDD), clinicians can find the ingredients for EBP in systematic reviews from various sources such as the Cochrane Library and Campbell Collaboration, practice guidelines such as treatment manuals, and expert consensus guidelines like the National Association of Social Work's Guidelines to Clinical Practice (Corcoran & Vandiver, 2004, as cited in Roberts, Yeager, & Streiner, 2004; National Association of Social Workers, 2005).
|
One way of approaching the literature is to look for answers to specific questions (Roberts et al., 2004). There are three key questions that the evidence-based clinician working with a suicidal client with comorbid ADHD/MDD can ask of the literature. (a) What treatments are most effective in reducing symptomatology associated with comorbid ADHD/MDD? (b) What is the influence of comorbid ADHD/MDD on youth suicidal behaviors? (c) Are there interventions that will reduce the likelihood that my client will attempt or complete suicide in the near future? A review of the literature found no articles that specifically examined evidence-based treatment of suicidal youth with the two most common psychiatric disorders—ADHD and MDD. In an attempt to address this gap, this article reviews the literature on treatments for comorbid ADHD/MDD and suicide, presents a clinical case vignette, discusses a two-phase approach to evidence-based treatment, and concludes with implications for policy, research, and practice.
 |
Literature Review on Comorbid ADHD/MDD |
|---|
 TOP Literature Review on Comorbid... Comorbid ADHD/MDD and Suicidal...Assessment and TreatmentCase StudyConclusionReferences |
|---|
Prevalence
In a recent review of all comorbidity studies, rates of comorbid ADHD/MDD were estimated to be between 6% and 39% (MTA Cooperative Group, 1999). Epidemiological and clinical surveys estimate that approximately 3–9% of youth meet criteria for ADHD (Erk, 2000), and 1–5% meet criteria for depression (Lewinsohn & Essau, 2002). Boys with ADHD are more likely than girls to be diagnosed as hyperactive/impulsive or combined type and are at higher risk for comorbid depression (Biederman & Faraone, 2004). In contrast, girls are twice as likely to be diagnosed with depression than boys (Lewinsohn & Essau, 2002). Both disorders are associated with long-term problems in social functioning, employment, negative self-image, academic achievement, family conflict, and suicide (Barkley, 2006; Waslick, Kandel, & Kakouros, 2002).
Clinical Presentation
Comorbid ADHD/MDD in youth is characterized by symptoms of each disorder. ADHD is characterized by symptoms such as hyperactivity, impulsivity, and/or inattention that were present prior to the age of 7. The hyperactive/impulsive child might fidget, interrupt often, or appear to be disrespectful of rules and social etiquette. In contrast, the inattentive child, often described as "a daydreamer," is likely to make careless mistakes, be forgetful, and have difficulty organizing things (Barkley, 2006). Depression in youth is characterized as much by irritability, boredom, and anhedonia as hopelessness and sadness (Brent & Birmaher, 2002). Other symptoms include significant changes in patterns of appetite, weight, sleep, activity, concentration, energy level, self-esteem, and motivation (American Psychiatric Association [APA], Diagnostic and Statistical Manual of Mental Disorders [4th ed.], DSM-IV, 1994). For both ADHD and MDD to be diagnosed, there must be considerable impairment in functioning at home, school, and work or in social relationships.
Although the diagnostic criteria for the two disorders include some symptom overlap (increased hyperactivity/motor activity, inattention/diminished concentration, and irritability), ADHD and MDD are distinct disorders, even when they co-occur. Depressive symptoms do not appear to be different in youth with a comorbid ADHD diagnosis than youth with a stand-alone MDD disorder (Pliszka et al., 1999); however, comorbidity is known to increase the risk of persistent ADHD symptomatology and increase the risk for recurrence of a depressive episode (Biederman et al., 1996; Biederman, Mick, & Faraone, 1998). Consistent with the idea that ADHD and MDD are distinct disorders, James et al. (2004) found that remission of symptoms in one disorder did not reduce symptomatology in the other disorder. Because ADHD and MDD symptomatology are not responsive to changes in each other, treatment of comorbid ADHD/MDD must address both disorders.
Treatments
The treatment of any disorder with a biological component (such as MDD or ADHD) requires consideration of pharmacotherapies, as well as psychosocial interventions. Pharmacotherapy of comorbid ADHD/MDD has typically included treatment with both stimulants and selective serotonin reuptake inhibitors (SSRIs) (Pliszka et al., 1999, 2000). However, a recent study suggested that atomoxetine in conjunction with SSRI or alone resulted in reduction of both ADHD and MDD symptomatology without reports of suicidal behaviors (Kratochvil et al., 2005). A cocktail of medications or promising single medications are important in treating comorbid ADHD/MDD because stimulants have been shown to be ineffective in treating the core depressive symptoms (Pliszka et al., 1999) and SSRIs have been found to be ineffective in reducing core ADHD symptomatology (Apter, Kronenberg, & Brent, 2005; Evans et al., 2005). Behavior management training and cognitive-behavioral therapies (CBTs) are the psychotherapies with the most empirical support for ADHD and MDD, respectively, yet they have not demonstrated efficacy in reducing core symptoms in the other disorder (Bridglal, 2003; Compton et al., 2004; Jensen et al., 2001; Pliszka et al., 1999).
In sum, current research suggests that there is little shared effectiveness between the pharmacotherapy and psychotherapy treatments in reducing the severity of the core symptoms of ADHD (inattention, hyperactivity, and impulsivity) and MDD (irritability and hopelessness). The answer to the first question is that a combination of psychotherapies with empirical support in the treatment of a single disorder is the most effective treatment in reducing comorbid ADHD/MDD. Next we turn our attention to the question of how comorbid ADHD/MDD influences youth suicidal behaviors.
|
Comorbid ADHD/MDD and Suicidal Behaviors |
|---|
|
TOPLiterature Review on Comorbid...Comorbid ADHD/MDD and Suicidal...Assessment and TreatmentCase StudyConclusionReferences |
|---|
Prevalence
There are no statistics about the prevalence of suicide among youth with comorbid ADHD/MDD. Youth with psychiatric diagnoses, particularly mood, substance-related, and disruptive disorders are at increased risk for suicide (Fleischmann et al., 2005). Brent and Birmaher (2002) reported that aggressive and impulsive behavior in combination with a mood disorder increased risk for suicide. Youth 12 and under with disruptive disorders (e.g., ADHD) and children of all ages with depressive disorders are at increased risk for suicidal ideation, attempts, and completions.
Clinical Presentation
Suicidal youth with comorbid ADHD/MDD report suicidal thoughts, plans, and possibly recent attempts and are characterized by impulsivity and aggression or irritability. Some research has suggested that impulsivity is both a constant (trait like) and temporary (state like) feature of depression in suicidal youth (Corruble, Damy, & Guelfi, 1999). Conner, Meldrum, Wieczorek, Duberstein, and Welte (2004) found that impulsivity and irritability were associated with suicidal ideation after accounting for alcohol dependence and other aggression-related constructs. Pessimism and hopelessness are two cognitive markers that characterize suicide, although only pessimism is found independently of depression (Lewinsohn, Rohde, & Seeley, 1996). Recent research suggests that hopelessness is predictive of suicide risk only in girls, suggesting a difference in cognitive response styles between boys and girls (Barbe et al., 2005).
Psychotherapy
Psychosocial treatments for suicidal youth with some empirical support include CBT (Birmaher et al., 2000; Bridglal, 2003; Compton et al., 2004), interpersonal therapy (IPT-A; Mellin & Beamish, 2002), dialectical behavioral therapy (DBT; Katz, Cox, Gunasekara, & Miller, 2004; Rathus & Miller, 2002), multisystemic therapy (MST; Huey et al., 2004), and family therapy (Birmaher et al., 2000). DBT, however, is the only treatment that was developed specifically to address suicidal behaviors (Katz et al., 2004). Nondirective, supportive therapy, a model commonly used in routine mental health treatment, is not recommended for depressed suicidal adolescents (Barbe, Bridge, Birhamer, Kolko, & Brent, 2004). In a systematic review of psychosocial interventions for youth suicide, Macgowan (2004) found that problem-solving family therapy and developmental group psychotherapy were probably efficacious for reducing suicide attempts. All treatments that demonstrated success in reducing suicidal ideation or threats were time limited, and the majority used some variant of CBT. However, in a recent meta-analysis (Weisz, McCarty, & Valeri, 2006) and a review of psychosocial treatments for adolescents and young adults (Hendin et al., 2005), effect sizes for CBT were reported to be no greater than for noncognitive approaches and that although increased social functioning and decreased suicidal ideation has been demonstrated in cognitive-behavioral interventions in youth with mild to moderate depression, treatment as usual and other experimental controls evidenced similar results.
Although there are some promising practices for working with suicidal youth (e.g., CBT, IPT, MST), there is no support for treatments developed exclusively for the treatment of suicide and related behaviors (Hendin et al., 2005). Best practices treatment of suicidal youth addresses specific suicidal behaviors rather than the symptomatology of underlying disorders (Berman, Jobes, & Silverman, 2006). Berman et al. (2006) recommend a multimodal approach that can include emergency services, hospitalization, outpatient treatment, psychosocial intervention, pharmacotherapy, and family and individual treatment. Although there is no evidence that hospitalization is an effective intervention for reducing the risk for suicide (Huey et al., 2004), most restrictive environments such as hospitals are commonly used for clients whom the clinician believes cannot be maintained in an outpatient setting (Shea, 2002).
Pharmacotherapy
There are no medications that have been designed specifically to reduce suicidal behaviors. Recommendations on pharmacotherapy for suicidal youth are derived from studies investigating the effects of medications with specific diagnoses, such as depression, rather than suicidal behaviors. Most studies are designed to exclude acutely suicidal youth (Apter et al., 2005). The two largest and most comprehensive studies of depression (Treatment for Adolescents with Depression Study [TADS] Team; Apter et al., 2005) and ADHD (Multimodal Treatment Study of ADHD [MTA]; MTA Cooperative Group, 1999) found that combined medication and psychotherapy reduced core symptomatology faster and more effectively than monotherapy of medication, psychotherapy, or placebo. Because of their effectiveness in treating adolescent depression, SSRIs have been recommended in the treatment of suicidal behaviors (Hendin et al., 2005), although the unresolved controversy around the risk for increased suicidal behaviors prompted the Food and Drug Administration to add a "black box" warning (Brent, 2005).
|
Assessment and Treatment |
|---|
|
TOPLiterature Review on Comorbid...Comorbid ADHD/MDD and Suicidal...Assessment and TreatmentCase StudyConclusionReferences |
|---|
As noted in the beginning of this article, evidence-based treatments incorporate empirical evidence, practitioner experience, and knowledge of the population and client preferences. The review of the literature makes it clear that there is very little empirical evidence about efficacious treatment for suicidal youth and none when combined with comorbid ADHD/MDD. Berman et al. (2006) comment on the challenge faced by crisis workers: "Without definitive research-based guidelines for effective treatment models, clinicians must decide for themselves on a logical treatment plan based on a theory of intervention and a thorough understanding of the suicidal adolescent, both generic and specific to the presenting case" (p. 228). They further recommend developing a plan that provides both short- and long-term solutions. The short- and long-term solutions can be thought of as the result of a two-phase approach. This two-phase approach is particularly germane to treatment of suicidal youth with comorbid disorders. The goal of Phase 1 (short-term solution) is the resolution of the suicidal crisis. Expert consensus recommends focusing on suicidal behaviors rather than disorder-related symptomatology (Berman et al., 2006; Shaffer & Pfeffer, 2001). The goal of Phase 2 (long-term solution) is the reduction in the number and severity of symptoms associated with the underlying disorders, with the associated goal of preventing future suicidal behavior. Although the disorders are not explicitly addressed in Phase 1, awareness of the relationship between the symptoms and the suicidal behaviors will increase the specificity of the treatment plan and improve the overall treatment outcome.
Assessment
Although there is no consensus on all of the information that needs to be gathered during a suicide assessment, there is expert consensus on the basic information that is needed for clinicians to determine risk for imminent harm to self. (Berman et al., 2006; Gould, Greenberg, Velting, & Shaffer, 2003; Shaffer & Pfeffer, 2001). The key areas and recommended questions for the assessment and intervention of youth in an acute suicidal crisis will be discussed below (see Table 1 for a summary). Because these areas are not specific to youth with comorbid disorders, the discussion of the following case study will pay particular attention to its application with comorbid ADHD/MDD.
|
|
|
Case Study |
|---|
|
TOPLiterature Review on Comorbid...Comorbid ADHD/MDD and Suicidal...Assessment and TreatmentCase StudyConclusionReferences |
|---|
Joshua B. is a 13-year-old White male with an existing diagnosis of 314.01 ADHD, combined type. He has been on stimulant medications since he was diagnosed at age 7. Although he has received medication through his family physician, neither he nor his family has ever participated in psychotherapy. My first contact with Joshua's mom was on a Thursday afternoon. Mrs. B. called the outpatient clinic where the author was working. She reported that an hour ago Joshua ran into traffic in an apparent suicide attempt.
Mrs. B. reported that the day before, Joshua was suspended for 3 days for fighting with a peer, causing him to miss the upcoming dance. She reported arguing in the supermarket parking lot about the suspension when "he suddenly ran out of the lot and into traffic." She reported that he had no injuries "because the cars stopped in time." Joshua ran back to the car, was visibly upset, and was crying "I'm sorry, I'm sorry." Mrs. B. reported that her husband was working but that she could bring Joshua in. The author canceled his next appointment and agreed to see them immediately.
The initial phone call provided important information about relevant risk factors. Joshua is a 13-year-old White male with a recent disciplinary action, a history of impulsivity, aggression, a possible comorbid disorder, and an apparent violent suicide attempt. If we knew nothing else about him, these risk factors would place Joshua at high risk for a suicide attempt in the near future. However, more information is needed to know whether population-based risk factors translate into risk for this specific client (Rudd, Joiner, & Rajab, 2001). Hence, the goal of the assessment is to establish level of risk for suicide as well as to gather information about underlying diagnoses.
Assessment with youth includes information gathered from interviews, play and behavioral observation, and reliable and valid instruments (Gutierrez, 2006; Shaffer & Pfeffer, 2001). The use of individual and family interviews is particularly valuable in youth treatment. Individual interviews provide a safe space for youth to discuss potentially embarrassing thoughts, feelings, or actions, without concern for parental judgment or retribution. Likewise, parents can freely share concerns about the youth and discuss "adult" issues such as marital conflict or personal history of psychiatric disorder, substance-use disorder, or prior/current suicidal behavior. The individual interview is an excellent opportunity for rapport building, one of the key stages in crisis intervention (Roberts, 2005). Gutierrez (2006) recommends using a battery of four developmentally appropriate, reliable, and valid instruments to assess risk and protective factors; risk factors: the Reynolds Adolescent Depression Scale—2 and the Suicide Ideation Questionnaire and protective factors: the Reasons For Living—Adolescent version and the Self-Harm Behavior Questionnaire.
Assessment of the Attempt
Research into suicidal symptoms suggests two overarching organizing factors: resolved plan and preparations and suicidal desire (Wingate, Joiner, Walker, Rudd, Jobes, 2004). Of the two, planning and preparation is more significant in predicting future risk than suicidal desire. The presence of impulsivity is both a blessing and a curse in predicting future risk based on planning and preparation (Berman et al., 2006). Because impulsive youth are present oriented, the suicidal crisis presents a unique opportunity to address risk in a tangible way, rather than as a future possibility. At the same time, because of the associated difficulty with planning and following plans, treatment planning must include a level of supervision and check-ins that might not be necessary with less impulsive youth. When asked about running into traffic, Joshua reported that he had had intermittent suicidal ideation over the last few months; however, the ideas were transient and rarely upset him. This could be an artifact of his attention problems. In a way, Joshua's ADHD works to our favor; although he experiences persistent irritability and hopelessness, he has trouble sustaining mental activities, which has the effect of reducing the duration of suicidal ideation. In Phase 2, this will be important to monitor as we work to improve attention-deficit issues.
Assessment of the Ideator
During the assessment of Joshua, two questions recommended by Jacobson (1994, as cited in Shaffer & Pfeffer, 2001, p. 37S) were posed to address both ADHD/MDD symptomatology and suicidal behavior. We explored his symptoms of irritability and sadness/hopelessness by first asking "Have you ever felt so upset that you wished you were not alive or wanted to die?" We then explored his impulsive and risk-taking behaviors by asking the question, "Did you ever do something that you knew was so dangerous that you could get hurt or killed by doing it?" Joshua's responses suggested that he has a high tolerance for upset and only in the last 6 months has the thought of death by suicide become an option. Research suggests that depression often appears around puberty. Joshua's history of risk-taking behavior is consistent with his ADHD diagnosis. We discussed the lethal consequences of behaviors such as running into traffic and identified alternatives such as jumping up and down or running in place. Joshua reported no current thoughts of suicide and specific plan, although he reported that he probably would not try running into traffic again "because it really upset my mom." Furthermore, he reported that he intends to kill himself "if nothing gets better."
Risk Factors for Repeated Suicide Attempts
In an actual suicide assessment, clinicians should document information pertaining to each risk and protective factor. Table 2 presents a summary of factors that increase or decrease risk for suicide in youth (Berman et al., 2006; Evans et al., 2005; Gould et al., 2003 ; Hacher et al., 2006; Shaffer & Pfeffer, 2001). For our purposes, it is sufficient to note the factors that were identified during the assessment including: "poor interpersonal problem-solving," a cognitive factor that has been found to differentiate suicidal from nonsuicidal youth (Rothman-Burns et al., 1990, as cited in Gould et al., 2003), feelings of humiliation associated with the suspension, history of impulsivity, and recent suicide attempt. Protective factors included future plans (he still hopes to attend the dance tomorrow, despite his suspension), connections with family members (he stated that he would feel guilty about "leaving" his younger brother), prior success at treating impulsivity through medications, and parents able to provide a safe and nurturing environment.
Intervention
Although the use of "no-harm" contracts (aka "stay alive" or "anti-suicide" contracts) are central to the recommendations of Brent et al. (1997) for working with suicidal youth in outpatient settings, their use has been controversial (Bongar, 2002). A common misperception is that they are legally binding, a basis for malpractice if seen by a jury as a substitute for thorough clinical care (Bongar, 2002; Shea, 2002). Furthermore, it is questionable to what extent an impulsive child can follow through with a contract. The recommended clinical usage is to affirm the value of the therapeutic relationship and document specific steps to be taken in the event of increased suicidal ideation and/or suicidal intent. For youth who have problems with irritability, inattention, or impulsivity, the no-harm contract can serve multiple functions. At a most basic level, it provides phone numbers for 24-hr crisis services and details about when and how the clinician can be reached. It can serve as a type of behavioral contract, reminding the youth of what to do when he or she has thoughts of suicide. By including details of the youth's reasons for living and what the parents value about their child, the contract protects against feelings of hopelessness. Finally, the inclusion of the clinician's commitment to the youth acts as a reminder of the youth's role in a significant relationship.
Other Considerations
Appropriate use of consultation and supervision, as well as thorough documentation of the crisis assessment can improve the quality of clinical care and reduce the likelihood of a malpractice suit. This important topic is discussed in more detail elsewhere (cf. Bongar, 2002; Simpson & Stacy, 2004).
Ultimately, the assessment should answer the following question: Is Joshua safe to return to the community (i.e., his parent's house), or does he need to be placed in a more restrictive environment (e.g., inpatient psychiatric hospital)? The assessment indicated that the client is at moderate risk for future suicide. Although he reported no current ideation, he was vague about his plan and intent. Furthermore, his impulsivity limits confidence that his current presentation is reflective of future behavior. Because he is neither at risk for immediate suicide nor actively psychotic and his parents can provide a safe home environment, it is reasonable to assume he can be maintained in the community. Phase 1 will continue until Joshua presents no risk or mild risk for suicide (Rudd et al., 2001).
Phase 2: Reducing Comorbid Symptomatology
The goal of Phase 2 is to reduce the number and severity of symptoms associated with comorbid ADHD/MDD and by extension reduce the risk for future suicidal behavior. As discussed in the literature, although there are no psychosocial treatments specifically designed for comorbid ADHD/MDD, there is empirical support for treatments for each individual disorder. As per the process of EBP, deciding which treatments to provide depends on the training and preference of the clinician as well as the preference of the clients. Based on the data gathered in Phase 1, symptoms to address include irritability, impulsivity, anger management, and conflictual relations with peers and adults. Empirical support exists for a number of treatments that can address those symptoms, including CBT and IPT for depression (Evans et al., 2005) and behavior training and Parent Management Training for ADHD. Although academic performance is commonly a target of ADHD treatment (Barkley, 2006), neither Joshua nor his mom identified academics as a focus of clinical attention. After discussing the various treatment options with the family, we decided on the following treatment plan for Phase 2: individual therapy using IPT-A (L. Mufson & Fairbanks, 1996; L. H. Mufson, Dorta, Olfson, Weissman, & Hoagwood, 2004) and problem-solving family therapy to improve client's relationship with parents and peers; individual anger management training to reduce number of aggressive incidents; continued use of stimulant and SSRIs to address core comorbid symptomatology; and continued coordination with school to establish "safe" teachers and schedule changes to minimize conflicts with negative peers.
|
Conclusion |
|---|
|
TOPLiterature Review on Comorbid...Comorbid ADHD/MDD and Suicidal...Assessment and TreatmentCase StudyConclusionReferences |
|---|
Although there are no empirically based treatments for suicidal youth with comorbid ADHD/MDD, there is enough research on the treatment of ADHD, MDD, and suicide as individual clinical issues so that clinicians do not have to rely entirely on their own practice experience or client preferences in providing crisis intervention and/or brief treatment. However, because the interventions are not well established, pulling together the ingredients of an evidence-based approach can be likened to the process of making "stone soup." The Story of Stone Soup (http://stonesoup.esd.ornl.gov/stonesoup.html) goes something like this:
A soldier arrives in an impoverished town carrying a large pot and a "magic stone." Although the soldier has no food, and has been advised that there is none to be found in the town, he invites the town to feast upon his stone soup. With the aid of pre-Ericksonian suggestive language (Haley, 1993) the soldier inspires the townspeople to add their erstwhile hidden ingredients to the pot. After a short time, the pot that once contained nothing more than water and a stone, magically has all the ingredients needed for a delicious feast.
There is nothing magical about making stone soup or providing quality clinical care. In the story, the soup was made by drawing on the resources of the town. EBP draws on empirical evidence, practitioner experience, and client preference. An evidence-based approach to crisis intervention with a suicidal youth with comorbid ADHD/MDD draws on the following ingredients: The treatments that are most effective in reducing symptomatology associated with comorbid ADHD/MDD are those treatments that are most effective in treating each disorder individually. Combined pharmacotherapy and psychotherapy are recommended as the most efficient and effective treatments for reducing core symptomatology. Comorbid symptomatology for ADHD/MDD includes irritability, hyperactivity, and impulsivity. The influence of these symptoms on suicidal behavior appears to be significant, including increased risk for suicide attempt, increase in risk-taking behavior, poor peer and adult interactions, and increased aggression. Although there are no interventions that will eliminate the possibility that clients will attempt or die by suicide, treatments with empirical support such as DBT-A (Katz et al., 2004) have shown to reduce suicidal behavior in youth. These "ingredients" answer the questions posed at the beginning of the article. When combined with clinician experience and client preference, these ingredients can increase the likelihood of successful crisis resolution. Researchers can help clinicians to be better consumers of the literature by including information on the how and why (e.g., therapist variables as well as client characteristics) of treatments in addition to comparative information such as "treatment ‘a’ resulted in greater symptom reduction than treatment ‘b’" (Fraser, 2003; Jensen, Weersing, Hoagwood, & Goldman, 2005).
|
Acknowledgments |
|---|
Conflict of Interest: None declared.
|
References |
|---|
|
TOPLiterature Review on Comorbid...Comorbid ADHD/MDD and Suicidal...Assessment and TreatmentCase StudyConclusionReferences |
|---|
-
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
Angold, A., Costello, E., Farmer, E. M., Burns, B. J., & Erkanli, A. (1999). Impaired but undiagnosed. Journal of the American Academy of Child & Adolescent Psychiatry, 38, 129–137.
Apter, A., Kronenberg, S., & Brent, B. (2005). Turning darkness into light: A new landmark study on the treatment of adolescent depression. Comments on the TADS study. European Child & Adolescent Psychiatry, 14, 113–116.[Medline]
Barbe, R. P., Bridge, J., Birhamer, B., Kolko, D., & Brent, D. A. (2004). Suicidality and its relationship to treatment outcome in depressed adolescents. Suicide and Life-Threatening Behavior, 34, 44–55.[CrossRef][ISI][Medline]
Barbe, R. P., Williamson, D. E., Bridge, J. A., Birmaher, B., Dahl, R. E., Axelson, D. A., et al. (2005). Clinical differences between suicidal and nonsuicidal depressed children and adolescents. Journal of Clinical Psychiatry, 66, 492–498.
Barkley, R. A. (2006). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (3rd ed.). New York: Guilford Press.
Berman, A. L., Jobes, D. A., & Silverman, M. M. (2006). Adolescent suicide: Assessment and intervention (2nd ed., Vol. ix). Washington, DC: American Psychological Association.
Biederman, J., & Faraone, S. V. (2004). The Massachusetts general hospital studies of gender influences on attention-deficit/hyperactivity disorder in youth and relatives. Psychiatric Clinics of North America, 27, 225–232.[Medline]
Biederman, J., Faraone, S., Mick, E., Moore, P., & Lelon, E. (1996). Child behavior checklist findings further support comorbidity between ADHD and major depression in a referred sample. Journal of the American Academy of Child & Adolescent Psychiatry, 35, 734–742.
Biederman, J., Mick, E., & Faraone, S. V. (1998). Depression in attention deficit hyperactivity disorder (ADHD) children: "True" depression or demoralization? Journal of Affective Disorders, 47, 113–122.[CrossRef][ISI][Medline]
Birmaher, B., Brent, D. A., Kolko, D., Baugher, M., Bridge, J., Holder, D., et al. (2000). Clinical outcome after short-term psychotherapy for adolescents with major depressive disorder. Archives of General Psychiatry, 57, 29–36.
Bongar, B. (2002). The suicidal patient: Clinical and legal standards of care (2nd ed.). Washington, DC: American Psychological Association.
Brent, D. A. (2005). Editorial: Is the medication bottle for pediatric and adolescent depression half-full or half-empty? Journal of Adolescent Health, 37, 431–433.[CrossRef][ISI][Medline]
Brent, D. A., & Birmaher, B. (2002). Adolescent depression. New England Journal of Medicine, 347, 667–671.
Brent, D. A., Holder, D., Kolko, D., Birmaher, B., Baugher, M., Roth, C., et al. (1997). A clinical psychotherapy trial for adolescent depression comparing cognitive, family, and supportive therapy. Archives of General Psychiatry, 54, 877–885.[Abstract]
Bridglal, S. A. (2003). Cognitive-behavioral therapy with children and adolescents: Methods, strategies, and studies based on tests of efficacy. Psichiatria e Psicoterapia, 22, 160–171.
Cohen, P., Cohen, J., Kasen, S., Velez, C. N., et al. (1993). An epidemiological study of disorders in late childhood and adolescence: I. Age- and gender-specific prevalence. Journal of Child Psychology and Psychiatry, 34, 851–867.[ISI][Medline]
Compton, S. N., March, J. S., Brent, D., Albano, A. M., Weersing, V., & Curry, J. (2004). Cognitive-behavioral psychotherapy for anxiety and depressive disorders in children and adolescents: An evidence-based medicine review. Journal of the American Academy of Child & Adolescent Psychiatry, 43, 930–959.
Conner, K. R., Meldrum, S., Wieczorek, W. F., Duberstein, P. R., & Welte, J. W. (2004). The association of irritability and impulsivity with suicidal ideation among 15- to 20-year-old males. Suicide and Life-Threatening Behavior, 34, 363–373.[Medline]
Corruble, E., Damy, C., & Guelfi, J. D. (1999). Impulsivity: A relevant dimension in depression regarding suicide attempts? Journal of Affective Disorders, 53, 211–215.[CrossRef][ISI][Medline]
Erk, R. R. (2000). Five frameworks for increasing understanding and effective treatment of attention-deficit/hyperactivity disorder: Predominately inattentive type. Journal of Counseling & Development, 78, 389–399.
Evans, D. L., Foa, E. B., Gur, R. E., Hendin, H., O'Brien, C. P., Seligman, M. E., et al. (2005). Treating and preventing adolescent mental health disorders: What we know and what we don't know: A research agenda for improving the mental health of our youth. New York: Oxford University Press.
Fleischmann, A., Bertolote, J. M., Belfer, M., & Beautrais, A. (2005). Completed suicide and psychiatric diagnoses in young people: A critical examination of the evidence. American Journal of Orthopsychiatry, 75, 676–683.[Medline]
Fraser, M. W. (2003). Intervention research in social work: A basis for evidence-based practice and practice guidelines. In A. Rosen & E. K. Proctor (Eds.), Developing practice guidelines for social work intervention: Issues, methods, and research (pp. 17–36). New York: Columbia University Press.
Gould, M. S., Greenberg, T., Velting, D. M., & Shaffer, D. (2003). Youth suicide risk and preventive interventions: A review of the past 10 years. Journal of the American Academy of Child & Adolescent Psychiatry, 42, 386–405.
Gutierrez, P. M. (2006). Integratively assessing risk and protective factors for adolescent suicide. Suicide and Life-Threatening Behavior, 36, 129–135.[Medline]
Hacker, K. A., Suglia, S. F., Fried, L. E., Rappaport, N., & Howard Cabral, P. (2006). Developmental differences in risk factors for suicide attempts between ninth and eleventh graders. Suicide and Life-Threatening Behavior, 36, 154–166.[Medline]
Haley, J. (1993). Uncommon therapy: The psychiatric techniques of Milton H. Erickson, M.D. New York: W. W. Norton & Company.
Hendin, H., Brent, D. B., Cornelious, J. R., Coyne-Beasly, T., Greenberg, T., Gould, M., et al. (2005). Defining youth suicide. In D. L. Evans, E. B. Foa, R. E. Gur, H. Hendin, C. P. O'Brien, M. E. P. Seligman, & B. T. Walsh (Eds.), Treating and preventing adolescent mental health disorders: What we know and what we don't know (pp. 433–443). New York: Oxford University Press.
Huey, S. J., Jr., Henggeler, S. W., Rowland, M. D., Halliday-Boykins, C. A., Cunningham, P. B., Pickrel, S. G., et al. (2004). Multisystemic therapy effects on attempted suicide by youths presenting psychiatric emergencies. Journal of the American Academy of Child & Adolescent Psychiatry, 43, 183–190.
James, A., Lai, F., & Dahl, C. (2004). Attention deficit hyperactivity disorder and suicide: A review of possible associations. Acta Psychiatrica Scandinavica, 110, 408–415.[CrossRef][ISI][Medline]
Jensen, P. S., Hinshaw, S. P., Swanson, J. M., Greenhill, L. L., Conners, C., Arnold, L., et al. (2001). Findings from the NIMH multimodal treatment study of ADHD (MTA): Implications and applications for primary care providers. Journal of Developmental & Behavioral Pediatrics, 22, 60–73.[ISI][Medline]
Jensen, P. S., Weersing, R., Hoagwood, K. E., & Goldman, E. (2005). What is the evidence for evidence-based treatments? A hard look at our soft underbelly. Mental Health Services Research, 7, 53–74.[CrossRef][Medline]
Katz, L. Y., Cox, B. J., Gunasekara, S., & Miller, A. L. (2004). Feasibility of dialectical behavior therapy for suicidal adolescent inpatients. Journal of the American Academy of Child & Adolescent Psychiatry, 43, 276–282.[CrossRef]
Kovacs, M. (1996). Presentation and course of major depressive disorder during childhood and later years of the life span. Journal of the American Academy of Child & Adolescent Psychiatry, 35, 705–715.
Kratochvil, C. J., Newcorn, J. H., Arnold, L., Duesenberg, D., Emslie, G. J., Quintana, H., et al. (2005). Atomoxetine alone or combined with fluoxetine for treating ADHD with comorbid depressive or anxiety symptoms. Journal of the American Academy of Child & Adolescent Psychiatry, 44, 915–924.
Lewinsohn, P. M., & Essau, C. A. (2002). Depression in adolescents. In I. H. Gotlib & C. L. Hammen (Eds.), Handbook of depression (pp. 541–559). New York: Guilford Press.
Lewinsohn, P. M., Rohde, P., & Seeley, J. R. (1996). Adolescent suicidal ideation and attempts: Prevalence, risk factors, and clinical implications. Clinical Psychology: Science and Practice, 3, 25–46.[ISI]
Macgowan, M. J. (2004). Psychosocial treatment of youth suicide: A systematic review of the research. Research on Social Work Practice, 14, 147–162.[Abstract]
Mellin, E. A., & Beamish, P. M. (2002). Interpersonal theory and adolescents with depression: Clinical update. Journal of Mental Health Counseling, 24(2), 110–125.
Mick, E., Spencer, T., Wozniak, J., & Biederman, J. (2005). Heterogeneity of irritability in attention-deficit/hyperactivity disorder subjects with and without mood disorders. Biological Psychiatry, 58, 576–582.[CrossRef][ISI][Medline]
MTA Cooperative Group. (1999). A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Archives of General Psychiatry, 56, 1073–1086.
Mufson, L., & Fairbanks, J. (1996). Interpersonal psychotherapy for depressed adolescents: A one-year naturalistic follow-up study. Journal of the American Academy of Child & Adolescent Psychiatry, 35, 1145–1155.
Mufson, L. H., Dorta, K. P., Olfson, M., Weissman, M. M., & Hoagwood, K. (2004). Effectiveness research: Transporting interpersonal psychotherapy for depressed adolescents (IPT-A) from the lab to school-based health clinics. Clinical Child and Family Psychology Review, 7, 251–261.[CrossRef][ISI][Medline]
National Association of Social Workers. (2005). NASW standards for clinical social work in social work practice. Washington, DC: Author.
Pliszka, S. R., Carlson, C. L., & Swanson, J. M. (1999). ADHD with comorbid disorders: Clinical assessment and management. New York: Guilford Press.
Pliszka, S. R., Greenhill, L. L., Crimson, M., Sedillo, A., Carlson, C., Conners, K., et al. (2000). The Texas children's medication algorithm project: Report of the Texas consensus conference panel on medication treatment of childhood attention-deficit/hyperactivity disorder. Part II: Tactics. Journal of the American Academy of Child & Adolescent Psychiatry, 39, 920–927.
Rathus, J. H., & Miller, A. L. (2002). Dialectical behavior therapy adapted for suicidal adolescents. Suicide and Life-Threatening Behavior, 32, 146–157.[CrossRef][ISI][Medline]
Roberts, A. R. (2005). Crisis intervention handbook: Assessment, treatment, and research (3rd ed.). New York: Oxford University Press.
Roberts, A. R., Yeager, K., & Streiner, D. L. (2004). Evidence-based practice with comorbid substance abuse, mental illness, and suicidality: Can the evidence be found? Brief Treatment and Crisis Intervention, 4, 123–136.[Abstract]
Rudd, M., Joiner, T. E., Jr., Jobes, D. A., & King, C. A. (1999). The outpatient treatment of suicidality: An integration of science and recognition of its limitations. Professional Psychology: Research and Practice, 30, 437–446.[CrossRef]
Rudd, M. D., Joiner, T. E., & Rajab, M. H. (2001). Treating suicidal behavior: An effective, time-limited approach. New York: Guilford Press.
Shaffer, D., & Pfeffer, C. R. (2001). Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. Journal of the American Academy of Child & Adolescent Psychiatry, 40(Suppl. l7), 24S–51S.
Shea, S. C. (2002). The practical art of suicide assessment: A guide for mental health professionals and substance abuse counselors. New York: John Wiley & Sons.
Simpson, S., & Stacy, M. (2004). Avoiding the malpractice snare: Documenting suicidal risk assessment. Journal of Psychiatric Practice, 10, 185–189.[CrossRef][Medline]
Waslick, B. D., Kandel, R., & Kakouros, A. (2002). Depression in children and adolescents: An overview. In D. Shaffer & B. D. Waslick (Eds.), The many faces of depression in children and adolescents (Vol. xiii, pp. 1–36). Washington, DC: American Psychiatric Publishing.
Weisz, J. R., McCarty, C. A., & Valeri, S. M. (2006). Effects of psychotherapy for depression in children and adolescents: A meta-analysis. Psychological Bulletin, 132, 132–149.[CrossRef][ISI][Medline]
Wingate, L. R., Joiner, T. E., Jr., Walker, R. L., Rudd, M., & Jobes, D. A. (2004). Empirically informed approaches to topics in suicide risk assessment. Behavioral Sciences & the Law, 22, 651–665.[Medline]
| ||||||||||||||||||||||||||||||||||||||||||||||||||||
