Cognitive Behavioral Treatment for Suicidal Alcohol Abusing Adolescents: Development and Pilot Testing

Abstract

The purpose of this study was to pilot a cognitive behavioral treatment protocol for adolescents with co-occurring alcohol use disorder and suicidality, examine its association with symptomatic improvement, and determine its feasibility and acceptability. Treatment consisted of a 6 month acute treatment phase, 3 month maintenance phase, and a 3 month booster phase, as well as case management services. Participants were also permitted to receive concurrent pharmacotherapy. Five of six families completed the protocol. Measures of alcohol use and suicidality were collected at intake, end of acute treatment, and post-treatment. Decreases in alcohol use and suicidal ideation were reported for all participants. Two of the five participants, both with a prior history of suicide attempts, re-attempted during the course of the protocol. Both were maintained in the study and improved over the subsequent portion of the treatment. A high retention rate, strong therapeutic alliance ratings, and low perceived treatment obstacles provide support for the feasibility and acceptability of this intervention. Preliminary results suggest that integrated outpatient cognitive behavioral treatment for alcohol abusing suicidal adolescents is feasible, acceptable, and associated with symptomatic improvement.The odds of experiencing suicidal ideation and/or suicide attempts are approximately 3 times greater among adolescents with alcohol dependence in comparison to those without. 1,2 The odds of completed suicide are 5 to 13 times greater among adolescents diagnosed with an alcohol/illicit substance use disorder. 3 Given the association between alcohol use disorders and suicidality, interventions geared at treating these co-occurring conditions in youth are needed.Randomized studies have not been published to date to examine the efficacy of an integrated intervention for adolescents with co-occurring alcohol use disorder and suicidality. Cognitive behavioral therapy may be particularly effective for this population as it can be used to target cognitive distortions and common skill deficits that underlie adolescent alcohol abuse and suicidality. Only six randomized clinical trials have been published to examine behavioral/ cognitive-behavioral treatment for adolescent substance abuse in general 4-9 and two to examine the efficacy of cognitive behavioral treatment of adolescent suicidality. 10,11

Evidence-Based Psychosocial Treatments for Self-Injurious Thoughts and Behaviors in Youth

“…The initial individual CBT intervention developed by this group (Donaldson et al, 2005) was not more effective than supportive therapy for reducing SITBs. When family sessions were added to the intervention, significant reductions in SI, but not SAs, were found (although this could be due to the small sample size in this pilot study: Esposito-Smythers et al, 2006). It was not until parent training was added to the treatment package in I-CBT that significant reductions in SAs were observed (Esposito-Smythers et al, 2011).…”

“…Given that substance use increases risk for suicidal behavior among adolescents (Esposito-Smythers & Spirito, 2004), reductions in alcohol and drug use in the I-CBT group may have been important for treatment efficacy. Second, this version of the treatment package, which included parent training, led to significant reductions in suicidal behavior, whereas previous versions of the intervention (Donaldson et al, 2005; Esposito-Smythers et al, 2006) did not. We will return to these points later when we discuss common elements of efficacious interventions.…”

“…Moreover, reductions in risk factors at both the individual and family level were identified as treatment targets. In an initial pilot study, Esposito-Smythers and colleagues (2006) modified their individual CBT treatment package (examined by Donaldson et al, 2005) to include family therapy and motivational enhancement. The combined individual and family CBT intervention was examined in a small sample of adolescents ( n = 6) with recent SI or SAs and comorbid substance use disorders.…”

“…Building on earlier versions of their CBT packages (Donaldson et al, 2005; Esposito-Smythers et al, 2006), Esposito-Smythers et al (2011) added a parent training component to create integrated CBT (I-CBT), which includes a variety of individual CBT (e.g., problem-solving), family CBT (e.g., behavioral contracting), and parent training (e.g., monitoring) sessions delivered over 12 months (six months active-weekly sessions, 3 months continuation-biweekly sessions, and 3 months maintenance-monthly sessions). In a small RCT of adolescents with SAs or significant SI and comorbid substance use disorders ( n = 40), the authors compared I-CBT to enhanced treatment as usual (E-TAU: community-based TAU enhanced with a diagnostic evaluation report and case monitoring).…”

Substance Use/Abuse and Suicidal Behavior in Young Adult Women: A Population-Based Study

“…Social connectedness, confidence in problemsolving, and an internal locus of control constitute protective factors 1 for serious suicide attempts in young adults (Donald, Dower, Correa-Velez, & Jones, 2006). Examples of promising treatments include dialectic behavioral therapy (Linehan et al, 1999), cognitive behavioral treatment (Esposito-Smythers, Spirito, Uth, & Lachance, 2006), and motivational interviewing, which can be applied both for substance use (Miller & Rollnick, 1991) and suicidal behavior (Britton, Williams, & Conner, 2008). The latter treatment approach is well suited to the primary care setting.…”