Youth suicide — are you doing enough?
Published in Health News and Evidence
Date published: About this date
- Suicide is the leading cause of death among young Australians aged 15–24 years.
- More than half of people who commit suicide seek medical help in the 6 months before their death.
- Health professionals are well placed to identify adolescents at risk of suicide, including those with a history of mental health disorders, significant physical illness, or problems with alcohol or drug abuse, and to implement effective suicide prevention strategies.
- Establish a rapport with adolescents by adopting a caring, understanding and non-judgemental manner.
- Explain confidentiality parameters early to both adolescent and parent, ensuring that all parties understand the limitations.
- Ask all young people presenting with depressive symptoms directly about suicidal thinking or planning, any past suicide attempts, and any recent stressful events or confounding factors.
Know available options
- Be aware of Medicare GP mental health care arrangements, and health professionals and organisations who can provide subsidised psychology-based therapies.
Offer non-drug therapies
- Offer non-drug therapies such as cognitive behavioural therapy, interpersonal psychotherapy or problem-solving therapy as first-line treatment for adolescents with mild to moderate depression.
- Starting — if an antidepressant is indicated, consider the SSRI fluoxetine first.
- Monitoring — monitor weekly for an increase in suicidal thinking during the first 4 weeks of antidepressant therapy.
- Stopping — do not stop treatment abruptly unless there is an increase in suicidal thinking in the first 7–10 days after starting treatment or after increasing the dose.
When to refer
- Refer adolescents with more severe symptoms, or who are suicidal, for specialist psychological or psychiatric assessment and support.
- See Useful links for some mental health-related initiatives available for GPs.
- For comprehensive information on the assessment and management of depression in adolescence, refer to the NHMRC-approved Beyond Blue Clinical Practice Guidelines: Depression in Adolescents and Young Adults.
GP behaviour can strongly influence whether depressive symptoms are revealed. Establishing a rapport can build trust and foster a safe and accepting environment where adolescents feel comfortable to talk freely about particular challenges or difficulties they may be facing. Here are some simple ways you can establish rapport:
- establish early an acceptable level of confidentiality for both parent and adolescent
- actively listen, e.g. ask open-ended questions, paying attention to verbal and non-verbal cues
- be informed about treatment options available for adolescents
- talk directly to the adolescent and involve them in the decision-making process
- adopt a sympathetic, caring and non-judgemental approach in your dealings with adolescents
- avoid an authoritarian approach by balancing the treatment strategies you think may benefit the adolescent with what they may want
- maintain a continuing therapeutic relationship with the adolescent, ensuring an appropriate amount of time is allocated at each consultation so they avoid feeling rushed.
Using time-tiered rebates
Time constraints can present a major barrier to the diagnosis and management of mental illness in general practice.1 However, under the 'Better access to mental health care' initiative,2 time-tiered rebates are now available.
As a result, GPs who have undergone General Practice Mental Health Standards Collaboration mental health skills training are now able to access higher schedule fee items for delivery of mental health care assessments, treatment plans and reviews.2
Using the Mental Health Care Treatment Plan
Preparation of a GP Mental Health Care Treatment Plan allows access to additional Medicare rebates for consultation or group therapy with a psychologist, psychiatrist or other mental health professional (up to 10 individual consultations and up to 10 group therapy sessions) per calendar year for depression or other mental illnesses.3
What’s available and when to use them
Focussed psychological strategies including cognitive behavioural therapy and interpersonal therapy are recommended first-line treatment of mild to major depression in adolescents, unless symptoms are severe.4
Refer adolescents with more severe symptoms, or who are suicidal, for specialist psychological or psychiatric assessment.
Several other therapies such as problem-solving therapy5 and exercise6 have been studied for their effectiveness in adult depression; however, evidence for their effectiveness in adolescent depression is limited.7
Cognitive behavioural therapy
What is it?
CBT is a highly effective and well-established method of treating adult depression.8 It focusses on correcting false beliefs and related behaviours that lead to negative moods and behaviours.
Streamlined CBT interventions are being developed (e.g. brief CBT and internet-based CBT) that will be more easily accessed by patients and easier for GPs without extensive CBT training or experience to implement.9
How effective is CBT?
Several studies have additionally reported the effectiveness of CBT in reducing rates of adolescent depression and depressive symptoms compared with standard GP care.10
Preliminary findings suggest that internet-based CBT may reduce depression symptoms11 and provide increased access to psychological interventions for GPs.
What is it?
IPT is an effective, evidence-based first-line therapy for depression that links recent interpersonal events to depressive symptoms.12 Originally developed for adults, IPT was modified for adolescents with major depression (IPT-A) to include parental involvement.
How effective is it?
IPT has shown promise in open trials;13 however, further controlled studies are required.
Studies comparing the efficacy of IPT with that of CBT in adult depression suggest that both treatments are equally effective.12
The unique focus of IPT on interpersonal relationships has been proposed as being more adequately suited to teenagers;15 however, larger studies are needed to determine its efficacy compared with that of CBT in adolescent depression.
What is it?
PST aims to address dysfunctional coping strategies using rational problem-solving skills. Using this approach, problems are viewed as challenges or opportunities rather than insurmountable tasks.16
How effective is it?
Most PST studies to date have focussed on adult depression. Evidence for using PST in adolescents is less well established; however, the small number of randomised studies conducted report benefits.7,17 PST requires less training than CBT or IPT and can be provided during a 15–30-minute consultation, making it well suited to primary care.
The case for exercise as a therapy
The symptoms of mild to moderate depression in adults have been shown to be effectively relieved with exercise.18 However, there are limited data on the efficacy of exercise in preventing or treating adolescent depression.
A 2006 Cochrane review reported limited evidence to support exercise as a preventive treatment because of the small number of randomised studies available; these all had low methodological quality.19
More robust studies are required to determine whether the benefits of exercise therapy can be extended to adolescents. Based on the currently available literature, no conclusions can yet be drawn on the efficacy of exercise in adolescent depression.
Antidepressants are not approved by the Australian Therapeutic Goods Administration for the treatment of major depression in adolescents < 18 years of age.20 However, SSRIs have been widely used outside of their indication to treat adolescent depression.21
What the FDA says
In 2004 the U.S. Food and Drug Administration re-analysed all available suicide-related data because of concerns over suicidal ideation and attempts; it found an increased risk of suicidal ideation and behaviour and issued a black-box warning on SSRIs.22 In 2006 the FDA warning was extended to include adults up to 24 years of age.23
A 2012 Cochrane meta-analysis of newer generation antidepressants in adolescent depression reported higher rates of response and reductions in depressive symptoms compared with placebo, although these improvements were modest and an increase in adverse events and suicide-related outcomes for these antidepressants was also found.
However, given the risk of untreated depression, the authors concluded that fluoxetine should be used if a decision to use antidepressants is reached.24
If SSRIs are being considered they should only be prescribed in cases of moderate to severe depression and only if symptoms are severe or psychological therapy is ineffective, not available or has been refused.4
Monitor weekly for any emergence or worsening of suicidal thinking or behaviour during the first month of treatment.4
Treatment should only be stopped immediately if there is an increase in suicidal thinking in the first 7–10 days after starting treatment or after increasing the dose.4
Otherwise, once started do not stop treatment abruptly, instead taper slowly over 2–12 weeks to avoid a ‘discontinuation syndrome’.4
In adolescents with severe symptoms, consider tapering more slowly.
- Better Outcomes in Mental Health Care Program
- Better Access to Psychiatrists, Psychologists and General Practitioners through the MBS (Fact Sheet for General Practice, Australian Government Department of Health and Ageing).
- Suicide Prevention Service
- Mental Health Nurse Incentive Program
- Depression — challenges in primary care (NPS News, April 2012).
- Depression — challenges in primary care (NPS program).
- Australian Government Department of Health and Ageing. Consultations with general practitioners. Sect.17: People living with psychotic illnesses. 2010. http://health.gov.au/internet/publications/publishing.nsf/Content/mental-pubs-p-psych10-toc (accessed 28 March 2013).
- Australian Government Department of Health and Ageing. Fact Sheet: New medicare items for GP mental health treatment plans: 2011-2012 budget measure. 2011. http://www.health.gov.au/internet/main/publishing.nsf/content/mental-ba-fact-gp (accessed 28 March 2013).
- Australian Government Department of Health and Ageing. Better Access to Mental Health Care. Fact sheet: New transition arrangements for the allied mental health services available under the Better Access initiative. http://www.health.gov.au/internet/main/publishing.nsf/Content/85903561599397C8CA257996007F4587/$File/transfac.pdf (accessed 2 April 2012).
- Beyond Blue. Clinical Practice Guidelines: depression in adolescents and young adults. 2010. http://www.beyondblue.org.au/index.aspx?link_id=6.1247&tmp=FileDownload&fid=1625 (accessed 2 April 2013).
- Bell AC, D'Zurilla TJ. Problem-solving therapy for depression: a meta-analysis. Clin Psychol Rev 2009;29:348–53. [PubMed]
- Dunn AL, Trivedi MH, Kampert JB, et al. Exercise treatment for depression: efficacy and dose response. Am J Prev Med 2005;28:1–8. [PubMed]
- Eskin M EK, Demir H. Efficacy of a problem-solving therapy for depression and suicide potential in adolescents and young adults. Cogn Ther Res 2008;32:227–45. http://biology.unm.edu/biology/pwatson/public_html/Eskin%20et%20al%202008.pdf
- Butler AC, Chapman JE, Forman EM, et al. The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clin Psychol Rev 2006;26:17–31. [PubMed]
- Christensen H, Griffiths KM, Jorm AF. Delivering interventions for depression by using the internet: randomised controlled trial. BMJ 2004;328:265. [PubMed]
- Reinecke MA, Ryan NE, DuBois DL. Cognitive-behavioral therapy of depression and depressive symptoms during adolescence: a review and meta-analysis. J Am Acad Child Adolesc Psychiatry 1998;37:26–34. [PubMed]
- Calear AL, Christensen H. Review of internet-based prevention and treatment programs for anxiety and depression in children and adolescents. Med J Aust 2010;192:S12–4. [PubMed]
- de Mello MF, de Jesus Mari J, Bacaltchuk J, et al. A systematic review of research findings on the efficacy of interpersonal therapy for depressive disorders. Eur Arch Psychiatry Clin Neurosci 2005;255:75–82. [PubMed]
- Santor DA, Kusumakar V. Open trial of interpersonal therapy in adolescents with moderate to severe major depression: effectiveness of novice IPT therapists. J Am Acad Child Adolesc Psychiatry 2001;40:236–40. [PubMed]
- Mufson L, Weissman MM, Moreau D, et al. Efficacy of interpersonal psychotherapy for depressed adolescents. Arch Gen Psychiatry 1999;56:573–9. [PubMed]
- Morris J. Interpersonal psychotherapy in child and adolescent mental health services. Clin Psychol Psychother 2012;19:141–9. [PubMed]
- Pierce D. Problem solving therapy – use and effectiveness in general practice. Aust Fam Physician 2012;41:676–9. [PubMed]
- Lerner MS CG. Treatment of suicide ideators: a problem-solving approach. Behav Ther 1990;21:403–11. http://www.sciencedirect.com/science/article/pii/S0005789405803545
- Josefsson T, Lindwall M, Archer T. Physical exercise intervention in depressive disorders: Meta-analysis and systematic review. Scand J Med Sci Sports 2013;Jan 30.doi:10.1111/sms.12050. [Epub ahead of print] [PubMed]
- Larun L, Nordheim LV, Ekeland E, et al. Exercise in prevention and treatment of anxiety and depression among children and young people. Cochrane Database Syst Rev 2006:CD004691. [PubMed]
- Australian Government Department of Health and Ageing Therapeutic Goods Administration. Use of SSRI antidepressants in children and adolescents. 2004. http://www.tga.gov.au/safety/committees-adrac-ssri-041015.htm (accessed 28 March 2013).
- Rey JA. Children, serotonin and suicide. Aust Prescr 2005;28:111–3. http://www.australianprescriber.com/magazine/28/5/111/3.
- U.S. Food and Drug Administration. Antidepressant use in children, adolescents, and adults. Revisions to product labelling. 2007. http://www.fda.gov/downloads/Drugs/DrugSafety/InformationbyDrugClass/UCM173233.pdf (accessed 2 April 2013).
- U.S. Food and Drug Administration. FDA proposes new warnings about suicidal thinking, behavior in young adults who take antidepressant medications. 2007. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2007/ucm108905.htm (accessed 10 April 2013).
- Hetrick SE, McKenzie JE, Cox GR, et al. Newer generation antidepressants for depressive disorders in children and adolescents. Cochrane Database Syst Rev 2012;11:CD004851. [PubMed]