Teen suicide study highlights need for better training

Suicidal thoughts are common among U.S. adolescents, many of whom receive mental health treatment before the onset of suicidal plans or attempts, the first large-scale study on the subject finds.

A team led by Harvard University clinical psychologist Matthew K. Nock, Ph.D., found 12.1 percent of teens in a national sample reported thinking about suicide while 4.0 percent made plans and 4.1 percent made attempts. More than 80 percent had received mental health treatment and 55 percent had started treatment before the onset of suicidal behaviors. Data analyzed came from 6,483 adolescents aged 13 to 18 interviewed as part of the National Comorbidity Survey Replication Adolescent Supplement.

The findings published in January online in JAMA Psychiatry highlight the need for more research on the third leading cause of death among those aged 15-24 and more training for mental health professionals. In an email interview, Nock cited three factors behind a lack of evidence-based treatments:

“First, there is not a lot of research being done on the treatment or prevention of suicidal behaviors. We need more research to help identify what works,” Nock states.

“Second, treatments that have been tested have not proven effective, so new research moving forward needs to test new ideas about how to decrease suicidal thoughts and behaviors. Finally, there is a lot being done in practice, some of which may be effective, but we won’t know unless that is tested and reported to the scientific and clinical community as well.”

Most teens surveyed met criteria for at least one of the DSM-IV mental disorders. Major depressive disorder/dysthmia was most common followed by specific phobia, oppositional defiant disorder, intermittent explosive disorder, substance abuse and conduct disorder.

Little is known about the precursors of suicide. Studies have shown the risk increases after exposure to a suicide and in the 30 days following discharge from inpatient treatment. Clinicians rely on patients’ verbal self-reports when screening for suicide risk. That’s problematic if the patient wants to avoid hospitalization or has another motive to deny or conceal having suicidal thoughts.

“Most young people tell us they don’t want to tell an adult because the adults will overreact. That’s right. We often do,” says psychologist Larry Berkowitz, Ed.D., co-founder of the Needham, Mass.-based Riverside Trauma Center, which provides trauma response services and intervention for schools, workplaces and communities in eastern and central Massachusetts.

Berkowitz, co-chair of the Northeast Massachusetts Coalition for Suicide Prevention, says clinicians often don’t know the right questions to ask to determine suicide risk. He adds graduate school programs for psychologists, social workers and marriage and family therapy counselors often lack courses on suicide assessment and intervention.

Washington is the only U.S. state that mandates training in suicide risk assessment and treatment for community mental health workers, psychologists, social workers, and others as part of their continuing education requirement.

An American Association of Suicidology task force issued a 2012 report calling for accrediting organizations to include suicide-specific education and skill acquisition as part of their respective post-baccalaureate degree programs.

It also urged state licensing boards to require suicide-specific continuing education as a requirement for mental health professional license renewals. Other recommendations included state and federal legislation requiring publicly funded facilities to prove their mental health staff had training in suicide risk detection, assessment, management, treatment and prevention and requiring hospital and emergency department accreditation and certification boards to verify their staff members received adequate training.

“We need to see across the board better training for clinicians,” Berkowitz says.

Riverside Trauma Center provides a six-hour continuing education workshop for mental health professionals on best practices developed by the American Association of Suicidology for assessing and managing suicide risk.

More people die by suicide than violence each year, yet Nock says funding for this research area remains a low priority.

A 2011 MacArthur Fellow, Nock is working to adapt the Implicit Association Test social psychologists use to uncover people’s hidden biases regarding race, ethnicity, gender or obesity to assess suicide risk.

“Policy makers and funding agencies must dedicate money to solve this problem and then researchers and clinicians must work together to test out new treatment approaches,” Nock states.