48 HOW TO TREAT : SUICIDALITY IN CHILDREN AND ADOLESCENTS
48 HOW TO TREAT : SUICIDALITY IN CHILDREN AND ADOLESCENTS
14 JULY 2023 ausdoc . com . au
Figure 6 . It is important to work collaboratively with the family and any other significant people in the young person ’ s life .
depressive disorders in children and adolescents .
Various psychological and social interventions demonstrably work for suicidal youth . A selection of these is briefly described .
Notably , all these programs typically involve families and extend over at least several months . However , with the possible exception of dialectical behaviour therapy , where some state health departments have initiated public outreach , such as Project Air , none is widely available .
Dialectical behaviour therapy This is well-known and has strong supporting empirical evidence . Dialectical behaviour therapy adapts CBT , augmenting its reason-based , change-directed approaches with acceptance and emotion management skills . It teaches mindfulness , distress tolerance , emotion regulation and interpersonal effectiveness ( in individual and group formats ). Multi-study evidence shows it works with borderline personality disorder , youth suicidal behaviours and self-harm ( and other indications ). 61
Attachment-based family therapy This interpersonal psychotherapy aims to mend damaged attachments , restore trust and security in the parent – child relationship and promote adolescent autonomy and reduce suicidal ideation . 62
Mentalisation-based therapy Mentalisation-based therapy focuses on improving the adolescent and family ’ s ability to infer thoughts and feelings from actions , which is believed to then enhance affect regulation and self-control and empirically reduces self-harm , depression and borderline behaviours . 63
Integrated-CBT Integrated-CBT augments standard CBT with motivational interviewing
Table 2 . Principles of safety planning Activities
Safety planning with the patient
Safety planning with the patient ’ s family and friends
Details
Box 3 . Themes identified by GPs in their management of suicidal behaviours
• Training needs .
• Communication challenges ( especially between primary care and mental health teams , EDs and child and adolescent mental health services ).
• Service provision , for example , the need for single-point contact for key workers sharing information across services .
• Nurse , counselling or psychology key workers attached to services and / or dedicated primary care self-harm services .
• Shortage of alternative self-harm and support services , patient liaison and community services , in-practice self-harm services and counsellors who speak minority languages .
• The need for co-produced clinical guidelines . Source : Mughal F et al 2020 74
• Identify warning signs and triggers of a worsening mental state ( eg , social withdrawal )
• Restrict access to means ; suicide methods can always be found by those determined to use them , but faced by ambivalence about suicide and youth impulsivity and substance-affected mental states , restriction of collaborative methods buys time
• Avoid recreational substances as they facilitate impulsivity and / or suicidal behaviours
• Consider self-care ; coping strategies and healthy activities such as making positive behavioural choices ; acceptance of anxiety ( self and family )
• Key places and people with whom to connect ( family , friends , professionals ; school , community , emergency professional contacts ), including connecting to aftercare programs where possible ( eg , the Way Back Support Service of Beyond Blue ); peer support workers , brief therapies
• Consider reasons for living , values
• Attend mental health follow-up early and ensure treatment adherence ( medications , appointments )
• Ensure that medications are taken , appointments are made / kept , remove sources of harm , undertake pleasant events , keep routines going , avoid conflict , recognise that a level of anxiety is normal , get help for oneself
• Identify effective modes of communication
• List emergency professional contacts
to address substance use and family involvement over parent – child communication , monitoring , crisis management and problem-solving . It demonstrably reduces suicide attempts , substance abuse , arrests and re-hospitalisations . 64 In the Youth-Nominated Support
Team-Version II study , youth post-suicide attempt with suicidal thoughts or behaviour nominate adults who then receive psychoeducation , listen , help problem-solve , collaboratively encourage healthy behaviours and are supported themselves . This reduces patients ’ suicidal ideation and may reduce all-cause mortality over protracted periods . 65
The resourceful adolescent parent program The Resourceful Adolescent Parent Program , a strengths-based parent program , educates parents about adolescent suicidal and self-injurious behaviour , prevention strategies and accessing services ; discusses parent strengths and stress management ; reviews normal adolescent development , self-esteem promotion and balancing individuation and attachment ; and examines strategies to promote family cohesion and manage conflict . There is evidence that it improves suicidal ideation , self-harm and suicidal behaviour and also functioning . 66
PSYCHOPHARMACOLOGY There are no specific psychopharmacological treatments for suicidal youth . However , antidepressants , particularly SSRIs , SNRIs , or other new generation antidepressants are widely used to treat underlying psychiatric conditions : for example , clinical depression , anxiety and obsessive compulsive disorder in young people .
SPECIFIC POPULATIONS
INDIGENOUS SUICIDE PREVENTION INDIGENOUS youth suicide rates are treble those of the non-Indigenous population . 67 Addressing this involves GPs having awareness of Indigenous cultural , settlement and family histories and of Indigenous suicide prevention resources and tools ( such as the iBobbly app 68 ); listening carefully , training and screening for suicidal ideation and identifying referral pathways .
RURAL AND REMOTE Rural areas have higher suicide rates , fewer mental health services and GPs , challenges regarding confidentiality , traditionally more self-reliance and more firearms . 69 Telehealth , initiatives like the Rural Adversity Mental Health Program of the Centre for Rural and Remote Mental Health and government initiatives to lure doctors and nurses to rural , regional / remote areas by slashing university debt may help bridge these gaps .
CULTURALLY AND LINGUISTICALLY DIVERSE POPULATIONS Suicide may be over-represented among some culturally and linguistically diverse groups , for example refugee and conflict-affected populations , in which stigma may affect reporting . 70 It is important for GPs to consider the interpretation of mental health problems in non-Western cultures and responses to suicidal behaviour especially among some older people , as well as intergenerational differences in cultural experience and orientation ( with the younger generation being bicultural ). 50 Working with interpreters can be complex and requires training . 71