pists, this program involved ED staff and families with a focus on encouraging participation in outpatient treatment. In comparison with patients who received family therapy alone, participants who received both family therapy and the emergency room intervention were found to adhere more frequently to the recommendation to attend a first treatment session. Families receiving the combined intervention also had more favorable outcomes in terms of maternal depression and general psychopathology, patient ideation, and parent-reported family interaction.

Spirito, Boergers, Donaldson, Bishop, and Lewander (2002) also developed an adherence enhancement intervention to improve engagement in therapy. Treatment expectations, misperceptions, and reasons for treatment dropout were separately presented to adolescents and parents, along with a brief intervention to facilitate problem solving around factors that might impede treatment attendance. After this ED intervention, telephone contacts were made at 1, 2, and 6 weeks with adolescents and parents. Many service barriers were reported such as delays in getting an appointment, being placed on a waiting list, and insurance and out-of-pocket expenses. Family barriers to treatment included parental emotional problems, transportation difficulties, language difficulties, and scheduling problems. The adherence enhancement program increased the number of sessions attended, although premature termination of treatment continued to be a problem. The program developers emphasized the importance of reducing service barriers for adolescents who have attempted suicide.

Hospitalization for suicidal behavior, though often securing the safety of the suicidal individual, is quite costly and not always beneficial. In an effort to decrease hospitalization rates and suicidality and improve functioning, Greenfield, Larson, Hechtman, Rousseau, and Platt (2002) implemented the Rapid Response (RR) ED intervention for suicidal adolescents who were not considered to require immediate medical or psychiatric hospitalization. The intervention included family therapy, medication, and community intervention, as indicated. Hospitalization rates were decreased and outpatient therapy was initiated more rapidly as a result of the RR intervention when compared with standard care. In addition, adolescents receiving the intervention were less likely to be rehospitalized during the 6 months after their visit to the ED. Neither hospitalization nor RR was found to prevent subsequent suicidal behavior or ED visits.

The results of programs implemented to date suggest that some improvement in outpatient treatment adherence by young suicide attempters, as well as reduced hospitalizations, can be achieved by concerted efforts in the ED. Such efforts, however, require education of ED staff on suicide risks and treatment needs of young suicide attempters. Barriers to outpatient treatment appear to remain significant and difficult to surmount, even for the most cohesive and well-functioning families. It seems essential that ED interventions provide some continuity of contact with the youth beyond the initial ED visit, which will require additional staffing. While this may seem costly, the cost reductions associated with decreasing immediate and future hospitalization are significant.

As noted in Chapter 21, previous suicidal behavior is the most important factor associated with suicide risk among both adults and youth. Recognizing that repetition of a suicide attempt vastly increases the risk of a fatal outcome (Sakinofsky, 2000), considerable effort has been directed towards developing psychotherapeutic and other psychosocial treatment modalities to prevent subsequent suicidal behavior among identified individuals. Although suicide attempts and other forms of deliberate self-harm occur with greater frequency among young people than among adults, virtually all such treat

ments have been systematically studied only among adults, primarily because of restrictions against including suicidal youth in randomized trials and other research.

In a comprehensive review of psychological and pharmacological treatments for preventing repetition of suicide attempts (primarily among adults), undertaken in conjunction with the Cochrane Collaboration's Database of Systematic Reviews, Hawton and colleagues synthesized findings from 20 randomized controlled trials (RCTs), involving 2,641 patients in which repetition of deliberate self-harm was reported as an outcome variable (Hawton et al., 1998, 2000; Townsend et al., 2001). Most of these trials studied psychotherapeutic or other psychosocial treatments.

Reports on these RCTs were independently rated by two reviewers, blind to authorship, using the recommended Cochrane criteria for quality assessment. These include determination of the study's overall validity, the quality of the randomization procedures used to assign subjects into groups, the potential biases regarding sample selection and attrition, and intervention delivery (Alderson, Green, & Higgins, 2003). Overall, Hawton and colleagues concluded that there is currently insufficient evidence on which to make firm recommendations about the most effective forms of treatment for patients who have engaged in suicidal behavior, primarily because most treatment studies to date involving identified suicide attempters have included far too few subjects to have the statistical power to detect meaningful differences in rates of repetition of suicide attempts between experimental and control treatments, if such differences existed (Hawton et al., 1998). Nevertheless, promising results were found for several psychotherapeutic modalities.

In one promising approach, dialectical behavior therapy (DBT), a number of cognitive and behavioral strategies are used to target suicidal and other dysfunctional behaviors. In DBT relatively long-term individual treatment is combined with group behavioral skills training. This therapeutic technique was developed by Linehan (1993a, 1993b) for adult suicide attempters, specifically to address the problems of poor emotional regulation that are commonly found in this population. Because individuals with borderline personality disorder (BPD) are particularly prone to affective dysregulation and maladaptive problem-solving behaviors including self-harm, DBT has been described as especially effective for this subgroup of suicide attempters (Linehan 1993a, 1993b).

Dialectical behavior therapy is designed to be given in several sessions a week for approximately a year. Its components include (1) training the patient in self-acceptance through the technique of mindfulness; (2) increasing assertiveness to reduce interpersonal conflicts; (3) training the patient to avoid situations that trigger negative moods; and (4) increasing tolerance of distress. In DBT, the suicidal behavior itself is regarded as the primary focal point of treatment; although efficacious treatment for underlying problems such as depression is important, it does not necessarily reduce suicidality (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991). An adaptation of DBT (DBT-A) has been developed for adolescents (Miller, Rathus, Linehan, Wetzler, & Leigh, 1997). Given for 6 months rather than for a year, DBT-A has not yet been tested in a controlled study.

During a 1-year course of treatment with DBT, Linehan and colleagues (1991) found that a sample of adult female patients with BPD had significantly fewer suicide attempts, less medically significant attempts, and fewer inpatient psychiatric days. They were also more likely to stay in individual therapy than were comparable patients who received treatment as usual. Between-group differences in depression, hopelessness, suicidal ideation, and reasons for living were not significant, although the DBT group showed decreases in all four measures throughout the treatment year. In a 1-year posttreatment follow-up, the DBT patients were found to have significantly higher global functioning, better social adjustment, less anger, less suicidal behavior, and fewer psychiatric inpatient days compared to control patients (Linehan, Heard, & Armstrong, 1993).

Although the efficacy of DBT was strongly supported in studies of female suicide attempters with BPD, Hawton and colleagues (1998) noted that the intensive nature of the treatment could limit its application within general psychiatric

services, and that its efficacy among male patients had not been determined.

Short-term problem-solving therapy based on a cognitive behavioral model (Gibbons, Butler, Irwin, & Gibbons, 1978; McLeavey, Daly, Ludgate, & Murray, 1994) was also found in Hawton's review to result in reductions in subsequent suicidal behaviors by adult patients who had engaged in self-poisoning, although comparisons with patients who received treatment as usual were not statistically significant, likely because of the small numbers of patients studied in these trials. A subsequent meta-analysis of data reported by six trials in which brief problem-solving therapy was compared with control treatment showed that patients who were offered problem-solving therapy had significantly greater improvement in depression as hopelessness, as well as perceived improvement in the problems these patients faced (Townsend et al., 2001). These findings suggest that short-term therapy might be as efficacious as long-term treatment in preventing repetition of suicidal behavior, although Hawton and colleagues noted the need for confirmation of these findings in a large trial.

Also noted as promising in this review were studies in which experimental group patients were given, in addition to standard aftercare, 24-hour emergency access to a psychiatrist or hospital. Two such studies (Cotgrove, Zirinski, Black, & Weston, 1995; Morgan, Jones, & Owen, 1993) reported a tendency towards less repetition of self-harm among patients who were encouraged to make emergency contact with services if needed. In the only RCT reviewed by Hawton that involved adolescent patients, Cotgrove and colleagues (1995) gave tokens allowing readmission upon demand to a random sample of adolescents who had been hospitalized following a suicide attempt, in addition to standard management. Although only 11% of the sample used the tokens, the group overall showed a somewhat (but not significantly) lower rate of repeat attempts, compared to comparable adolescents who were given standard management but no tokens.

Because of small sample sizes, Hawton's review noted that meaningful conclusions could not be reached about the efficacy of hospital ad mission following a suicide attempt vs. outpatient treatment, or about the relative impact of inpatient behavior therapy compared to inpatient insight-oriented therapy.

Psychotherapeutic interventions that encourage compliance with treatment and attempt to decrease depression and other negative affects in the context of a supportive interpersonal relationship should theoretically reduce suicide risk. There is some evidence, however, that reexamination of painful problems may have adverse effects on some vulnerable individuals (Nemeroff, Compton, & Berger, 2001). Although no systematic attention has been given to documenting adverse outcomes of psychotherapy for suicidal individuals, one study has reported negative outcomes of “life history” interviews with elderly suicidal women who had abusive histories (Haight & Hendrix, 1998).

Psychotherapeutic approaches for treating suicidal youth are summarized in Table 24.2. Most such interventions have employed variations of cognitive behavioral therapy. The underlying assumption is that the primary focus of treatment should be the suicidal behavior itself, rather than the underlying psychopathology (Brent et al., 1997; Harrington et al., 1998). As was earlier noted, restrictions regarding the inclusion of suicidal youth in RCTs have limited systematic evaluation of some of these approaches.

Rudd and colleagues provided the first description of a cognitive behavioral skills group intervention designed to treat young adults with suicidal ideation or suicidal behavior (Rudd et al., 1996). The intervention, an intensive 2-week program that participants attended for 9 hr/day, included an experiential affective group, psychoeducational classes with homework, and a problem-solving and social competence group. A variety of strategies such as behavioral rehearsal, role-playing, and modeling were used to im