Teenaged, Depressed, and Treatment Resistant: What Predicts Self-Harm?
Authors: Myrna M. Weissman
Journal: American Journal of Psychiatry (2009)

Self-harm affects thousands of depressed teenagers each year.A careful meta-analysis of pediatric antidepressant trials by the Food and Drug Administration (FDA) showed a higher rate of spontaneously reported suicidal behaviors in adolescents randomly assigned to antidepressants versus placebo.The publicity about this relationship and the subsequent FDA black box warning was followed by a decrease in antidepressant use (1) and a possible increase in adolescent suicides.Whether the increase is real and sustained is still unclear (2-4).Data that can identify who is at risk for an increase in reported self-harm with medication are difficult to find.Standardized systematic assessment of suicidal events in adolescent trials have only recently been developed (5), and adolescents with a history of self-harm behaviors, the ones with greatest risk, have usually been excluded from clinical trials.Brent and his associates tackled these issues directly in the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) trial ( 6) and produced a report full of pearls for psychiatrists and families who must confront this problem.Treatment-resistant depressed adolescents (N=334) who had not responded to a previous 12-week trial of an SSRI antidepressant were switched to either another SSRI or venlafaxine with and without cognitive behavioral therapy (CBT).Over 60% of the adolescents had clinically significant suicidal ideation at entry into the trial.Many developed suicidal behaviors early in treatment.In the report featured in this issue (7), the authors attempt to identify the predictors of self-harm adverse events during the course of the trial.Because the tools for systematic identification improved while the trial was still in progress, the authors could capitalize on a natural experiment to find out how best to detect suicidal behavior during the course of treatment.Adverse events were assessed by spontaneous report for the first 181 adolescents and by systematic weekly assessments for the last 153, which permitted comparison of the two strategies.Second, the self-harm events they recorded not only included suicidal thoughts and behavior but also nonsuicidal self-injury events.These are defined as self-injurious behaviors such as cutting/burning/skin scratching resulting in physical damage with no explicit or implicit intent to die but rather to gain relief from negative emotion or obtain social reinforcement.As the authors note, except for one unpublished FDA report that suggested a trend toward an increased risk of nonsuicidal self-injury with antidepressants versus placebo, the occurrence of nonsuicidal self-injury has not been examined in pediatric trials (8).Nonsuicidal self-injury is alarmingly prevalent in adolescents (13%-23% lifetime prevalence) and may be increasing (9).A recent paper by Hilt et al. (10) found that only 21% of adolescents received medical treatment as a result of self-injury.Nonsuicidal self-injury prevalence was associated with poor communication with peers and an increase in rumination.