Family Therapy as Hospital Aftercare for Adolescent Suicide Attempters
Condition: Suicide Ideation; Depression; Family Conflict
MeSH terms: Depression; Suicide
Study type: Interventional
Phase: Phase 2

Summary: 
      Few empirically-based treatment models exist for adolescent suicide attempters post
      psychiatric hospitalization, despite the fact that managed care has limited the role of
      hospitalization to stabilization, rather than remission. This study will test the efficacy
      and initial outcomes of Attachment Based Family Therapy (ABFT) as an aftercare model to
      further gains made in inpatient treatment and reduce risk factors for future suicide
      attempts.
    

Detailed description: 
      Annually, more adolescents and young adults in the United States die from suicide than from
      cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza and chronic lung
      disease combined (U.S. Public Health Service, 1999). Each year approximately 1 in 5 teenagers
      seriously consider killing themselves, over one million teenagers attempt suicide, and
      between 1,600 and 2,000 die by suicide (U.S. Public Health Service, 1999). Clearly, the need
      for more empirically based treatment models is urgently needed.

      Typically, after a suicide attempt or reporting of suicidal ideation with an intent or plan
      to kill themselves, adolescents are treated in a psychiatric hospital. In the past, an
      inpatient stay could provide intensive individual, group, family, and or medication therapy.
      However, managed care has shifted the goal of hospitalizations from treatment to
      stabilization. Adolescents are discharged when they are deemed to be no longer a threat to
      themselves, leaving the treatment of precipitating factors to outpatient aftercare. In a
      recent review of 21 studies on compliance with aftercare, Daniel and colleagues (2004) found
      that a majority of youth do received aftercare, but that noncompliance is very high. Very
      little evidence was found to support the effectiveness of aftercare. Surprisingly there are
      no studies on preventing adolescent reattempts of suicide after hospitalization. Important
      studies by Harrington et al. (1998) and King et al. (2007) have shown some promising results
      for aftercare reducing suicidal ideation, but no published studies have looked at preventing
      reattempts. Given the dearth of treatment studies for youth attempting suicide in general, it
      is not surprising that there are even fewer studies of aftercare for this population. Yet,
      given the high cost of even a short inpatient treatment, developing and testing effective
      aftercare programs that build on the gains made in inpatient treatment for youth who attempt
      suicide seems warranted.

      One promising outpatient treatment approach for this population is Attachment-Based Family
      Therapy (ABFT; Diamond et al., 2002). ABFT is a manualized, brief (i.e., 12 to 16 week)
      family-based model designed specifically for treating depressed and suicidal adolescents. The
      model aims to reduce adolescent depression, suicidal ideation, family conflict, parental
      criticism, and adolescent isolation and hopelessness; all factors associated with adolescent
      suicide attempts (e.g., Brent et al., 1988). To accomplish these goals with the parent, ABFT
      aims to increase parental warmth, communication skills, and appropriate monitoring. For the
      adolescent, treatment aims to improve interpersonal problem solving, emotional regulation,
      and reengagement with positive prosocial activities (e.g., school, job, peers). As
      communication improves and trust is rebuilt, the parents reclaim their position as a secure
      base for adolescent development. The family becomes a context where adolescents learn to
      express their emotions and thoughts (including their suicidal ideation) in a differentiated
      and regulated manner, problem solve, and control their impulses. In many families, repairing
      the attachment rupture requires a "working through" of prior traumatic events (e.g., loss,
      divorce, abuse) often associated with the suicidal behavior. As adolescents become less
      preoccupied with suicide ideation and family conflict, treatment focuses on parents helping
      their adolescent navigate the challenges of school, peer relations and other life domains.

      ABFT has recently proven effective in reducing suicidal ideation and depressive symptoms in a
      non-hospitalized population identified in primary care (Diamond et al., 2007). This grant
      will set the foundation for a programmatic look at treating adolescents who have been
      psychiatrically hospitalized for attempting suicide. This study will have two improvements
      over current aftercare services. First, it will improve the quality of aftercare by using an
      empirically based, family-based, manualized treatment. Second, it will rely on a continuity
      of care model where aftercare treatment begins while families are still in the hospital,
      potentially enhancing treatment compliance once the adolescent leaves the hospital.

        -  Objective 1: Develop a collaborative relationship with Belmont Psychiatric hospital and
           their Therapeutic Bridge Program to foster a research infrastructure that can support
           future adolescent suicide clinical trials research. This will include integrating
           standardized assessment tools into the inpatient procedures and establishing procedures
           for making referrals to the research program.

        -  Objective 2: Evaluate the feasibility and acceptability of ABFT outpatient aftercare for
           youth with a suicide attempt, after discharge from inpatient care. This will be
           evaluated by our ability to make contact with at least 80% of eligible patients, collect
           weekly follow up data, obtain at least 90% post treatment data, meet our recruitment
           goals, retain patients in treatment for at least 10 sessions, and be rated high on
           patient report of treatment acceptability and satisfaction.

        -  Objective 3: In an exploratory fashion, examine the differential effect sizes between
           Enhanced Usual Care (EUC) and ABFT at 14 weeks post hospital discharge for a) preventing
           future suicide attempts, b) reducing associated risk factors (suicide ideation,
           depression, and family conflict) and c) increasing treatment compliance (e.g., time to
           first session, number of sessions attended).
    

Intervention name(s): Attachment Based Family Therapy; Enhanced Usual Care
Intervention type(s): Behavioral; Behavioral
Intervention description(s): ABFT has three phases. In phase one, treatment focuses on helping the adolescent identify past and present family conflicts that have strained the attachment bond and damaged trust. Adolescents and parents are taught new communication and affect regulation skills in preparation for reparative conversations in phase two. This phase of treatment involves adolescents and parents discussing these past and present conflicts using their new communication skills. The final phase of treatment focuses on promoting adolescent autonomy (i.e., improving school productivity, finding a job, etc.). For the suicidal/depressed adolescent, this can decrease isolation and increase exposure to positive experiences. To accomplish these goals, there are five ABFT treatment tasks. Each task may take one or several sessions. Youth randomized to this condition will receive approximately 14 weeks of ABFT. One orientation meeting will occur, whenever possible, on the inpatient unit prior to discharge.; Belmont offers the Therapeutic Bridge Program, funded by the Pew Charitable Trusts, which helps adolescents make the transition from the hospital back to home, school and community behavioral health services. The program serves as a "bridge" between inpatient and outpatient care during the first 90 days after discharge, linking them to supportive services. Aftercare begins at the point of intake. Several discharge planning meetings are held with the adolescent and parents during the inpatient stay. The range of services are based on the patient and families' need, and may include meeting with school personnel , conducting home visits or making referrals to other community services agencies. The main objective is to secure outpatient mental health services for the patient. These services will be enhanced by the weekly research tracking, assessment and 24-hour crisis phone line which will call into a cell phone rotated among the licensed mental health professionals on the research team.
Other intervention name(s): Attached Based Family Therapy; ABFT
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Suicide Ideation; Depression; Family Conflict