ClinicalTrials.gov Identifier: NCT01528020.

Objective Suicide is the third leading cause of death among adolescents. Many suicidal youths treated in Emergency Departments (EDs) do not receive follow-up treatment, as advocated by our National Strategy for Suicide Prevention. We compared two strategies for improving rates of follow-up treatment. Methods Randomized controlled trial in which suicidal youths at two EDs (N=181; aged 10–18) were individually randomized between April 2003 and August 2005 to one of two conditions: an enhanced mental health intervention involving a family-based cognitive-behavior therapy session in the ED designed to increase motivation for follow-up treatment and safety, supplemented by care linkage telephone contacts after discharge; or Usual ED-Care enhanced by provider education. Assessments were conducted at baseline and at about 2-months after ED/hospital discharge. The primary outcome measure was rates of outpatient mental health treatment after discharge. Results Intervention patients were significantly more likely to attend outpatient treatment, as compared to usual ED-Care patients (92% vs 76%, p=.004). The intervention group also had a significantly higher rate of psychotherapy (76% vs 49%; p=.001); combined psychotherapy and medication (58% vs 37%; p=.003); and significantly more psychotherapy visits (mean 5.3 vs 3.1; p=.003). Neither the ED intervention nor community outpatient treatment (in exploratory analyses) was significantly associated with improved clinical/functioning outcomes. Conclusions Results support efficacy of the enhanced ED intervention for improving linkage to outpatient mental health treatment, but underscore the need for improved community outpatient treatment to prevent suicide/suicide attempts and poor clinical/functioning outcomes in the high-risk youths treated in EDs for suicidality.

Objective To evaluate the clinical and prognostic significance of suicide attempts (SAs) and non-suicidal 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-behavior therapy. NSSI and SAs were assessed at baseline and throughout the 24-week treatment period. Results 47.4% of youths reported a history of self-injurious behavior at baseline: 23.8% NSS-alone, 14% NSSI+SAs, 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 (HR= 5.28, 95% 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: z = 2.29, p=.13). In the most parsimonious model predicting to 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 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.