Suicide is the third leading cause of death in adolescents

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1 Article Clinicl nd Psychosocil Predictors of Suicide Attempts nd Nonsuicidl Self-Injury in the Adolescent Depression Antidepressnts nd Psychotherpy Tril (ADAPT) Pul Wilkinson, M.D., M.R.C.Psych. Rphel Kelvin, M.R.C.Psych. Chris Roberts, Ph.D. Berndk Dubick, M.D., M.R.C.Psych. In Goodyer, M.D., F.R.C.Psych. Objective: The uthors ssessed whether clinicl nd psychosocil fctors in depressed dolescents t bseline predict suicide ttempts nd nonsuicidl selfinjury over 28 weeks of follow-up. Method: Prticipnts were 164 dolescents with mjor depressive disorder tking prt in the Adolescent Depression Antidepressnts nd Psychotherpy Tril (ADAPT). Clinicl symptoms, fmily function, qulity of current personl friendships, nd suicidl nd nonsuicidl self-hrm were ssessed t bseline. Suicidl nd nonsuicidl self-hrm thoughts nd behviors were ssessed during 28 weeks of follow-up. Results: High suicidlity, nonsuicidl selfinjury, nd poor fmily function t entry were significnt independent predictors of suicide ttempts over the 28 weeks of follow-up. Nonsuicidl self-injury over the follow-up period ws independently predicted by nonsuicidl self-injury, hopelessness, nxiety disorder, nd being younger nd femle t entry. Conclusions: Both suicidl nd nonsuicidl self-hrm persisted in depressed dolescents receiving tretment in the ADAPT study. A history of nonsuicidl self-injury prior to tretment is clinicl mrker for subsequent suicide ttempts nd should be s crefully ssessed in depressed youths s current suicidl intent nd behvior. (Am J Psychitry 2011; 168: ) Suicide is the third leding cuse of deth in dolescents in the United Sttes nd the second leding cuse in the rest of the developed world (1, 2). Reducing suicide rtes, prticulrly in individuls with severe mentl illness, is key public helth trget in severl countries, including the United Kingdom nd the United Sttes (3, 4). If psychitrists re to help chieve these importnt trgets, it is crucil tht we be ble to identify those ptients who, t presenttion, re most t risk of suicide, so tht we cn focus our interventions ppropritely. Psychitric disorders re present in bout 90% of dolescents who commit suicide (5). Associtions hve been found between suicide nd most psychitric disorders (including substnce use disorders, conduct disorder, nxiety disorders, nd eting disorders [1, 5]). Mjor depressive disorder is the most common single disorder, present in 35% of suicides (5). Self-hrm (with or without suicidl intent) is n importnt predictor of future completed suicide nd is present in the recent histories of round 40% of suicides (6). Adolescents who hve ttempted suicide in the pst re up to 60 times more likely to commit suicide thn those who hve not (5). Hopelessness hs been found to be ssocited with suicide, lthough some studies found tht this fctor ws confounded by the presence of depression (5). Psychosocil fctors ssocited with completed suicide include fmily psychopthology, fmily discord, buse, nd loss of prent by deth or divorce (4, 7, 8). Peer reltionship problems, including being bullied, hve been found to be ssocited with suicide ttempts but not with completed suicide (7). While treting depression effectively is likely to reduce suicide rtes, it is lso importnt to estblish which fctors increse the risk of suicidl behviors mong currently depressed dolescents. So doing will help us identify those ptients who re prticulrly t risk for completed suicides nd my revel risks in need of tretment in their own right. Nonsuicidl self-injury, often in the form of cutting (8), is much less studied thn suicide. Individuls self-injure for multitude of resons, such s to relieve distressing ffect, to punish the self, nd to gin ttention. Most reserch on self-injurious behviors hs filed to distinguish the prognostic implictions of suicide ttempt with cler intent to die from nonsuicidl self-injury. One lrge ll-ges cohort study demonstrted tht n ct of either type of self-hrm is ssocited with gretly incresed risk of suicide over 4-yer follow-up (9). Interestingly, there ws no difference in suicide risk over time between those with suicidl nd nonsuicidl self-hrm episodes t entry (9). Two studies hve cpitlized on dt from lrge, rndomized controlled tretment trils, investigting which risk fctors re ssocited with self-hrm events mong depressed dolescents. Definitions of self-hrm events were not the sme in these studies, nd only one of the studies mesured nonsuicidl self-hrm s seprte This rticle is fetured in this month s AJP Audio, is discussed in n editoril by Dr. Brent (p. 452), nd is n rticle tht provides Clinicl Guidnce (p. 501). Am J Psychitry 168:5, My 2011 jp.psychitryonline.org 495

2 Predictors of Suicide Attempts nd Nonsuicidl Self-Injury in Adolescents entity. In the Tretment of SSRI-Resistnt Depression in Adolescents (TORDIA) study (10), 14% of prticipnts hd suicidl event (5% mde suicide ttempt) over 12 weeks of follow-up nd 9% hd n ct of nonsuicidl selfinjury. Bseline suicidl idetion nd fmily conflict were significntly nd independently ssocited with suicidl event. The only predictor of nonsuicidl self-injury ws history of nonsuicidl self-injury before tril entry (odds rtio=9.6). In the Tretment for Adolescents with Depression Study (TADS) (11), 10% of prticipnts hd suicidl events (hlf of which were suicide ttempts) over 36 weeks of follow-up. Suicidl events were predicted by bseline suicidlity nd high levels of self-rted depressive symptoms in univrite nlyses. There ws no seprte ctegory of nonsuicidl self-injury. In this rticle we report the prevlence nd predictors of suicidlity nd nonsuicidl self-injury, t entry nd over the 28-week period of ssessment, from the Adolescent Depression Antidepressnts nd Psychotherpy Tril (ADAPT), prgmtic effectiveness superiority tril of the tretment of dolescent mjor depression (12). We hypothesized tht 1) higher suicidlity nd impired fmily function t entry would both be independently ssocited with suicide ttempt during 28 weeks of follow-up, fter controlling for severity of depressive symptoms t entry; 2) nonsuicidl self-injury in the month before entry would predict nonsuicidl self-injury over the follow-up period, independently of suicidlity or depression severity t entry; nd 3) suicidlity nd nonsuicidl self-injury would be ssocited t bseline nd together exert dditive effects on the likelihood of either one persisting through the tretment period. Method Prticipnts Prticipnts were recruited from the ADAPT study. This prgmtic effectiveness tril of depressed 11- to 17-yer-olds in British Ntionl Helth Service clinics showed no dded vlue for cognitive-behviorl therpy (CBT) plus selective serotonin reuptke inhibitor (SSRI) nd specilist clinicl cre over n SSRI plus specilist clinicl cre for modertely to severely depressed dolescents (12). To fcilitte generlizbility of the results, only prticipnts with DSM-IV mjor depressive disorder (N=192) were eligible for the nlysis reported here. The study ws pproved nd monitored by the North West Multi-Centre Reserch Ethics Committee nd ll locl reserch ethics committees. After receiving complete description of the study, prticipnts nd one dult with prentl responsibility provided written informed consent. Outcome Mesures The Schedule for Affective Disorders nd Schizophreni for School-Age Children Present nd Lifetime Version (K-SADS-PL) (13) ws used to mesure whether DSM-IV dignoses nd individul depressive symptoms were present t bseline. The more detiled suicidlity nd self-hrm sections of different instrument, the Schedule for Affective Disorders nd Schizophreni for Adolescents Lifetime Version (14), were dded to the tril protocol shortly fter the strt of the study (nd so dt were not vilble for 12 prticipnts) to obtin precise detils bout self-hrm over the 28 weeks of the study. Specific informtion bout self-hrm ws not collected for ech period of the study, lthough K-SADS-PL informtion ws collected for the month prior to ll ssessment points (6 weeks, 12 weeks, 28 weeks). A suicide ttempt ws defined s t lest one ct t the level of definite suicidl intent or higher. Self-injury ws defined s t lest one nonsuicidl self-injury ct s response to the nonsuicidl self-dmging cts item. Behvior disorder ws defined s conduct disorder or oppositionl defint disorder. Anxiety disorder ws defined s gorphobi, pnic disorder, seprtion nxiety disorder, socil phobi, or simple phobi. The severity of depressive symptoms ws mesured by the Children s Depression Rting Scle Revised (15), which ws designed s peditric version of the Hmilton Depression Rting Scle. We used item 13, 7-point item bout suicidl idetion, s continuous mesure of suicidlity. The depression severity vrible ws the sum of ll items on the Children s Depression Rting Scle Revised except item 13. We used scores from the dolescent-completed McMster Fmily Assessment Device 12-Item Generl Functioning Scle (16) to rte fmily functioning. Friendship functioning ws ssessed by the dolescent-completed Cmbridge Friendships Questionnire (17). All prents with whom the dolescent lived were sked to complete the Generl Helth Questionnire 28 (18), self-rted questionnire ssessing mentl helth sttus over the pst few weeks. Sttisticl Anlysis Initilly we determined whether suicide ttempts nd nonsuicidl self-injury in the month before bseline ssessment were ssocited. Second, we investigted which bseline vribles were ssocited with t lest one ct of self-hrm (divided into suicidl nd nonsuicidl) during the 28-week follow-up period. Chi-squre tests were used for ctegoricl predictors; for continuous predictors, Student s t test nd the Mnn-Whitney test were used for normlly nd non-normlly distributed dt, respectively. Multiple logistic regressions were performed to investigte which vribles were independently ssocited with t lest one suicide ttempt, then with t lest one nonsuicidl self-hrm ct, during the follow-up period. All items tht were ssocited (p<0.1) on univrite nlysis, together with depression severity, ge, nd gender, were included. The first step of the model for suicide ttempts did not include self-injury; the second step dded self-injury. Covrites were checked for collinerity using the vrince infltion fctor; vrince infltion fctor bove 10 indictes high multicollinerity (19). Pirwise correltions were clculted between predictor vribles to indicte potentil sources of multicollinerity; for ctegoricl-ctegoricl pirs, tetrchoric clcultions were used; for continuous-ctegoricl pirs, Person point-biseril correltions were clculted. All tests were two-tiled. Dt nlysis ws performed using Stt, version 11 (SttCorp, College Sttion, Tex.), nd MPlus, version 5.2 ( Vribles found to be significntly ssocited with self-hrm were entered into ROC4 nlyses (20, 21). ROC4 is multivrite procedure tht simultneously crries out univrite tests using ech predictor vrible in dt set. It determines which vrible, t which cut point, most efficiently predicts dichotomous outcome. A kpp vlue of 0.5 (equl preference given to sensitivity nd specificity) ws used with ROC4. Results A totl of 192 prticipnts in ADAPT hd mjor depressive disorder t bseline. Vlid dt were vilble for ll but one on bseline suicide ttempts nd nonsuicidl self-injury, nd for 163 on self-injury nd 164 on suicide 496 jp.psychitryonline.org Am J Psychitry 168:5, My 2011

3 Wilkinson, Kelvin, Roberts, et l. TABLE 1. Bseline Demogrphic nd Clinicl Chrcteristics of Prticipnts in Study of Nonsuicidl Self-Hrm nd Suicide Attempts in Depressed Adolescents Bseline Dt Avilble (N=191) Follow-Up Dt Avilble (N=163) Chrcteristic Men SD Men SD Age (yers) Durtion of depression (weeks) Children s Depression Rting Scle Revised, totl score Children s Depression Rting Scle Revised, T score Number of comorbid disorders N % N % Mle Suicide ttempt in pst month Nonsuicidl self-injury in pst month Medin IQR Medin IQR Children s Depression Rting Scle Revised, suicidlity item score IQR=interqurtile rnge. Bseline Predictors of Nonsuicidl Self-Injury During Follow-Up Fifty-eight dolescents (36%) hd t lest one ct of nonsuicidl self-injury in the month before bseline. Sixty dolescents (37%) hd t lest one ct of self-injury during the 28-week follow-up period. The risk of self-injury ws lower cross ll mesured months of the study thn in the month before bseline (month preceding the 6-week ssessment, 26%; month preceding the 12-week ssessment, 19%; month preceding the 28-week ssessment, 16%). Tble S1 in the online dt supplement shows tht self-injury in the month before bseline, high suicidlity t bseline, high depression severity t bseline, bseline nxiety disorder nd hopelessness, nd femle gender were significntly ssocited with higher risk of t lest one nonsuicidl selfinjury incident during follow-up. Neither tretment group nor suicide ttempt in the month before bseline ws ssocited with self-injury during follow-up. Tble 4 shows tht self-injury in the month before the bseline ssessment ws the most significnt indepenttempts during the follow-up period. Tble 1 summrizes the bseline demogrphic nd clinicl dt for those with bseline suicidlity dt nd those with vlid follow-up dt for both suicide ttempts nd self-injury. There were no significnt differences between those with nd without follow-up dt. There ws significnt ssocition between suicidl nd nonsuicidl self-hrm in the month before bseline (self-injury present: suicide ttempt in 15/58 [26%]; self-injury bsent: suicide ttempt in 12/105 [11%]; odds rtio=2.7, c 2 =5.6, df=1, p=0.018). Bseline Predictors of Suicide Attempt During Follow-Up During the month before bseline, 28 dolescents (17%) mde t lest one suicide ttempt. Fifty dolescents (30%) mde t lest one suicide ttempt during the 28-week follow-up period. The risk of suicide ttempt ws lower cross ech mesured month of the study thn in the month before bseline (month preceding the 6-week ssessment, 8%; month preceding the 12-week ssessment, 7%; month preceding the 28-week ssessment, 7%). Suicide nd self-hrm risk over the follow-up period by predictor vrible is shown in Tble S1 in the dt supplement tht ccompnies the online edition of this rticle. A higher risk of suicide ttempt during follow-up ws significntly ssocited with suicidlity, depression severity, hopelessness, the presence of suicide ttempt or selfinjury in the month before bseline, nd impired fmily functioning, but not with tretment group, prentl mentl helth, or friendship problems. Multiple logistic regression demonstrted tht only impired fmily functioning (odds rtio=2.27, p<0.0005) nd higher suicidlity t entry (odds rtio=1.59, p=0.026) were significnt independent predictors of subsequent suicide ttempt. Self-injury ws then dded in the second step of the model, which is presented in Tble 2. Model fit significntly improved (Dc 2 =7.7, df=1, p<0.01). Self-injury nd fmily function, but not bseline suicidlity, were signifi- cntly ssocited with suicide ttempt. Similr results were obtined when presence of suicide ttempt in the month before bseline (yes/no) ws used in the model insted of suicidlity item: nonsuicidl self-hrm nd fmily function, but not prebseline suicide ttempt (odds rtio=2.4, p=0.08), were ssocited with suicide ttempt. Pirwise correltions of predictor vribles re listed in Tble 3. With the exception of suicidlity nd prebseline suicide ttempt, ll pirwise correltion coefficients were <0.5. Mximum vrince infltion fctor ws low t ROC4 nlysis demonstrted tht the optiml predictor for suicide ttempt ws prebseline nonsuicidl selfinjury (univrite reltive risk=2.95). Among the lrger subgroup with no prebseline self-injury, the optiml predictor cutoff for suicide ttempt ws fmily function, s ssessed by the McMster Fmily Assessment Device, with cutoff of 25/26; 15/45 (33%) with scores >25 nd 3/56 (5%) with scores <26 hd suicide ttempt. Am J Psychitry 168:5, My 2011 jp.psychitryonline.org 497

4 Predictors of Suicide Attempts nd Nonsuicidl Self-Injury in Adolescents TABLE 2. Multivrite Predictors of Risk of Suicide Attempt in Depressed Adolescents During 28-Week Follow-Up Risk of Suicide Attempt Vrible Odds Rtio 95% CI p Suicidlity item from the Children s Depression Rting Scle Revised Prebseline nonsuicidl self-injury Nonsuicidlity items from the Children s Depression Rting Scle Revised Hopelessness Fmily functioning Age Femle Likelihood rtio χ 2 =38, df=7, p< Pseudo R 2 =0.20. Hosmer-Lemeshow χ 2 =2, df=8, p=0.99. Mximum vrince infltion fctor=1.25. All Children s Depression Rting Scle Revised mesures nd fmily functioning re z-trnsformed scores, with one unit representing one stndrd devition. TABLE 3. Correltion Coeffi cients Between Relevnt Predictor Vrib les in Study of Nonsuicidl Self-Hrm nd Suicide Attempts in Depressed Adolescents Vrible Suicide ttempt prebseline 1 2. Suicidlity item from the Children s 0.91* 1 Depression Rting Scle Revised 3. Nonsuicidl self injury prebseline 0.38* 0.49* 1 4. Nonsuicidlity items from the Children s * 0.30* 1 Depression Rting Scle Revised 5. Fmily functioning * 0.32* Mternl Generl Helth Questionnire * score 7. Pternl Generl Helth Questionnire score 8. Hopelessness * * Anxiety disorder * * Gender Age * * Person s correltion coefficient used for continuous-continuous mesure ssocition; point-biseril correltion for dichotomous-continuous; tetrchoric correltion for dichotomous-dichotomous. * p<0.05. dent predictor of subsequent self-injury over the followup period. Other significnt independent predictors were bseline nxiety disorder nd hopelessness, femle gender, nd younger ge. Figure 1 shows the risk of suicidl nd nonsuicidl self-hrm over the follow-up period mong those with nd without bseline self-hrm. ROC4 nlysis demonstrted tht prebseline self-injury ws the most efficient predictor of self-injury (univrite reltive risk=3.59). Reltionships Between Depression Outcomes nd Self-Hrm Events During Follow-Up Tble S1 in the online dt supplement shows tht high depressive symptoms t 28 weeks were significntly (p=0.001) ssocited with self-injury but not suicide ttempts nd tht presence of one type of self-hrm during follow-up ws significntly ssocited with presence of the other type (odds rtio=2.5, p=0.007). Discussion In this rticle, we report the proportion of depressed dolescents with suicidl nd nonsuicidl self-hrm t study entry nd over 28 weeks of follow-up who prticipted in lrge, rndomized, prgmtic effectiveness tril of tretment of the cute episode. Mesuring nonsuicidl self-injury seprtely from suicidl intent, t entry nd t follow-up, is consistent with the form of reporting in the tril of SSRI-resistnt depression in dolescents (the TOR- DIA study) (10). Reltive to the TORDIA smple (10), the ADAPT smple hd much higher risks of both suicidl (30% compred with 5%) nd nonsuicidl (37% compred with 9%) self-hrm cts. The higher level of self-hrm my reflect the lower level of socil functioning (s mesured by the Children s Globl Assessment Scle [22]), nd hence greter complexity, in the depressed dolescents recruited to ADAPT, despite similr levels of depressive symptoms compred with other studies (12, 23, 24). More prticipnts hd suicide ttempts nd nonsuicidl self-injury over the 28 weeks of the study thn in the month before bseline. This difference my be methodologicl, resulting from the greter follow-up intervl, s rtes were lower for ll three mesured months of the study thn for the month before bseline. 498 jp.psychitryonline.org Am J Psychitry 168:5, My 2011

5 Wilkinson, Kelvin, Roberts, et l. TABLE 4. Multivrite Predictors of Risk of Nonsuicidl Self-Injury in Depressed Adolescents During 28 Weeks of Follow-Up Risk of Nonsuicidl Self-Injury Vrible Odds Rtio 95% CI p Suicidlity item from the Children s Depression Rting Scle Revised Prebseline Nonsuicidl self-injury < Nonsuicidlity items from the Children s Depression Rting Scle Revised Hopelessness Fmily functioning Anxiety disorder Age Femle Likelihood rtio χ 2 = 65, df=9, p< Pseudo R 2 =0.32. Hosmer-Lemeshow χ 2 =5, df=8, p=0.8. Mximum vrince infltion fctor=1.30. All Children s Depression Rting Scle Revised mesures nd fmily functioning re z-trnsformed scores, with one unit representing one stndrd devition. Our findings replicted those of TORDIA: suicide ttempts were independently predicted by both bseline suicidlity or recent suicide ttempts nd impired fmily function. In ddition, this study suggests tht nonsuicidl self-injury in the month before bseline ws stronger predictor of suicide ttempts thn prebseline suicide ttempts. Since there ws collinerity between suicide ttempts nd self-injury (r=0.38), this my be type II error. Overll, this finding emphsizes the need for more reserch on the independence nd vlidity of nonsuicidl self-injury nd suicidl events in dolescents nd their contributions to the emergence of depressive episodes. Consistent with findings from TORDIA, we did not observe ny ssocition of suicide ttempts with other nondepressive clinicl fetures. There ws no effect of prentl mentl helth on subsequent suicide ttempts. This suggests tht fmily dysfunction per se is the risk mrker rther thn surrogte for prentl psychopthology. Interestingly, problems in personl friendships (personl disppointments), which re ssocited with depression onset (25), were not ssocited with subsequent suicide ttempts. This supports findings from previous studies demonstrting tht in depressed dolescents, rguments with fmily members re by fr the most common precipitnts of ttempted suicide (26). Overll, our results demonstrte tht in our smple, dolescents with prebseline nonsuicidl self-injury (suicide ttempt risk=53%) hd 10-fold greter risk of suicide ttempt during tretment thn those with no selfinjury nd with resonbly good fmily functioning (suicide ttempt risk=5%). Compred with suicidlity, self-injury over the followup period ws ssocited with different pttern of predictors. Thus, poor fmily functioning ws not ssocited with self-injury, wheres hopelessness nd nxiety disorder t bseline, s well s being both younger nd femle, were ssocited with self-injury but not with suicidlity. As in TORDIA (10), the lrgest predictor of self-injury ws self-injury t bseline. Higher depressive symptoms t 28 weeks were ssocited with greter risk of nonsuicidl self-injury. Possible FIGURE 1. Effects of Bseline Nonsuicidl Self-Injury on Risk of Hrm Events in Adolescents With Mjor Depression Over 28 Weeks of Follow-Up Percentge With Self-Hrm Event No nonsuicidl self-injury in month prebseline (N=105) Nonsuicidl self-injury present in month prebseline (N=58) Nonsuicidl Self-Injury Suicide Attempt Type of Follow-Up Self-Hrm Event For nonsuicidl self-injury, χ 2 =39, df=1, p<0.0005; for suicide ttempt, χ 2 =22, df=1, p< explntions re tht continued depressive symptoms led to nonsuicidl self-injury, possibly to regulte ffect, nd tht there is subtype of depression chrcterized by self-injury tht leds to poor response to tretment. Nonsuicidl self-injury is often seen s less serious thn suicide ttempts. However, our results support previous findings from nonselective (ll ges nd not disorder specific) cohort study (9) indicting tht nonsuicidl self-injury is s likely s suicide ttempts to predict future suicide ttempts. Therefore, depressed dolescents with self-injury require the sme high level of urgent ssessment nd tretment s those who hve mde suicide ttempt. The mjority of depressed dolescents with suicidl idetion do not ttempt suicide. According to Joiner s interpersonl-psychologicl theory of suicidl behvior (27), people mke serious suicide ttempts only if they hve the combintion of wish to die nd the cpbility to ct on tht wish. Joiner s group hs stted (28) tht repeted nonsuicidl self-injury my result in higher pin tolernce nd reduced fer of deth, incresing the cpbility to cross Am J Psychitry 168:5, My 2011 jp.psychitryonline.org 499

6 Predictors of Suicide Attempts nd Nonsuicidl Self-Injury in Adolescents the boundry between suicidl ides nd cts. Our study is the first longitudinl study to demonstrte tht self-injury is ssocited with future suicide ttempts, independent of depressive symptoms, nd provides prtil support for this theory. It is eqully possible tht self-injury is behviorl mrker for neuropsychologicl processes tht subserve suicidlity, such s impired behviorl inhibition, leding to impulsivity nd loss of emotion regultion. Depression nd nonsuicidl self-injury my reflect co morbid disorders whose etiologies nd prognostic significnce re independent nd require different pproches to tretment. Indeed non-suicidl self-injury hs been proposed s new ctegory mong childhood disorders for DSM-5 (29). If this hypothesis is vlidted in further reserch, ctive tretments focused on self-injury should be provided longside tretment for depression, s this my dditively improve the likelihood of reduction in subsequent suicide ttempts. Trils to dte in this ge rnge hve shown limited effectiveness in reducing suicidl nd nonsuicidl self-hrm. In ADAPT, TADS, nd TORDIA, the ddition of CBT did not led to sttisticlly significnt dditionl reduction in suicide ttempts or in nonsuicidl self-injury (12, 23, 24). These trils were powered to test for tretment effects on depressive symptoms, however, not the rrer outcomes of self-hrm. A recent smll study of ttchment-bsed fmily therpy shows promise, with reductions in suicidlity in depressed nd nondepressed dolescents compred with stndrd tretment (30). Trils of group therpy using CBT nd dilecticl behvior therpy techniques hve hd contrsting results, with both lower (31) nd higher (32) rtes of suicide ttempt in the intervention compred with the comprison group. A brief home-bsed fmily intervention for children nd dolescents fter self-hrm hs been shown to reduce suicidlity in nondepressed but not in depressed subgroups (33). Dilecticl behvior therpy, while demonstrted to be effective in reducing suicidl nd nonsuicidl self-hrm in some studies in dults (34), hs not been proven to be more effective thn tretment s usul in reducing suicidl or nonsuicidl self-hrm in dolescents (35, 36). Further reserch is needed to identify effective nd deliverble interventions for suicidl nd nonsuicidl selfhrm in depressed nd nondepressed dolescents. Limittions Becuse this is secondry nlysis from rndomized controlled tril, there is risk of type I errors. However, s the min results replicte those of nother tril (TORDIA), it is more likely tht these vribles re true risk fctors for suicidl nd nonsuicidl self-hrm. Unlike in TORDIA, dt on self-hrm over the 28 weeks of the study were collected only t the 28-week follow-up ssessment, which my hve led to underestimtion of self-hrm events (10). It lso mens tht we cnnot distinguish between ptients who self-hrm only t the beginning of tretment (who my stop self-hrm once depression is successfully treted) nd those who hve persistent self-hrm throughout tretment. It is possible tht dolescents who remin depressed re more likely to remember self-hrm over the previous 28 weeks. Suicidl nd nonsuicidl self-hrm dt were collected by three reserch ssessors. Interrter relibility ws not ssessed, so there my hve been inccurcies in clssifiction. Dt were not collected on severl vribles tht my hve ffected suicidl nd nonsuicidl self-hrm, including drug nd lcohol use, self-hrming behvior prior to 1 month before bseline, fmily history of self-hrm or suicide, environmentl dversity (including buse), impulsivity, nd personlity dimensions. This study ws crried out on clinic ptients treted with SSRIs. The rnge of comorbidities nd illness severity in the smple mkes it representtive of depressed dolescents seen in U.K. Ntionl Helth Service clinics. However, the results my not be generlizble to ptients receiving tretments other thn ntidepressnts. Finlly, the results should only be generlized to depressed dolescents: nonsuicidl self-injury is common in nondepressed teengers nd my not hve the sme effects on risk of suicide ttempts in the popultion t lrge. Clinicl Implictions Suicidl nd nonsuicidl self-hrm re both significnt risks for depressed dolescents treted in the clinic. The presence of fmily dysfunction, high levels of suicidlity, nd recent self-hrm (suicidl or nonsuicidl) should lert us to high risk for future suicide ttempts. The presence of recent nonsuicidl self-injury is by fr the strongest predictor of future nonsuicidl self-injury. The lck of positive results to dte from trils tht offered specific tretments focused on self-injury indictes the need for the development nd testing of new tretments. Received My 17, 2010; revisions received Sept. 2 nd Nov. 9, 2010; ccepted Nov. 15, 2010 (doi: /ppi.jp ). From the Developmentl Psychitry Section, Deprtment of Psychitry, Cmbridge University, Cmbridge, Englnd; the Deprtment of Child nd Adolescent Psychitry, Mnchester University, Mnchester, Englnd; nd the Royl Mnchester Children s Hospitl, Pendlebury, Mnchester. Address correspondence nd reprint requests to Dr. Wilkinson, Developmentl Psychitry Section, Deprtment of Psychitry, Cmbridge University, Cmbridge CB2 2AH, UK; pow12@cm. c.uk (e-mil). The uthors report no finncil reltionships with commercil interests. Supported by grnt 97/29/01 from the U.K. Ntionl Helth Service Helth Technology Assessment Progrmme. References 1. Spirito A, Esposito-Smythers C: Attempted nd completed suicide in dolescence. Annu Rev Clin Psychol 2006; 2: Shffer D, Gutstein J: Suicide nd ttempted suicide, in Child nd Adolescent Psychitry, 4th ed. Edited by Rutter M, Tylor E. Oxford, Englnd, Blckwell Scientific, UK Deprtment of Helth: Ntionl Suicide Prevention Strtegy for Englnd. London, UK Deprtment of Helth, The Surgeon Generl s Cll to Action to Prevent Suicide. Wshington, DC, US Public Helth Service, jp.psychitryonline.org Am J Psychitry 168:5, My 2011

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JAMA 2008; 299: Goodyer IM, Herbert J, Tmplin A, Althm PM: Recent life events, cortisol, dehydroepindrosterone, nd the onset of mjor depression in high-risk dolescents. Br J Psychitry 2000; 177: Hwton K, Fgg J, Simkin S: Deliberte self-poisoning nd selfinjury in children nd dolescents under 16 yers of ge in Oxford, Br J Psychitry 1996; 169: Joiner TEJ: Why People Die by Suicide. Cmbridge, Mss, Hrvrd University Press, Ribeiro JD, Joiner TE: The interpersonl-psychologicl theory of suicidl behvior: current sttus nd future directions. J Clin Psychol 2009; 65: Americn Psychitric Assocition: DSM-5 Development: nonsuicidl self-injury. Pges/proposedrevision.spx?rid= Dimond GS, Wintersteen MB, Brown GK, Dimond GM, Gllop R, Shelef K, Levy S: Attchment-bsed fmily therpy for dolescents with suicidl idetion: rndomized controlled tril. J Am Acd Child Adolesc Psychitry 2010; 49: Wood A, Trinor G, Rothwell J, Moore A, Hrrington R: Rndomized tril of group therpy for repeted deliberte selfhrm in dolescents. J Am Acd Child Adolesc Psychitry 2001; 40: Hzell PL, Mrtin G, McGill K, Ky T, Wood A, Trinor G, Hrrington R: Group therpy for repeted deliberte self-hrm in dolescents: filure of repliction of rndomized tril. J Am Acd Child Adolesc Psychitry 2009; 48: Hrrington R, Kerfoot M, Dyer E, McNiven F, Gill F, Hrrington V, Woodhm A, Byford S: Rndomized tril of home-bsed fmily intervention for children who hve delibertely poisoned themselves. J Am Acd Child Adolesc Psychitry 1998; 37: Lynch TR, Trost W T, Slsmn N, Linehn MM: Dilecticl behvior therpy for borderline personlity disorder. Annu Rev Clin Psychol 2007; 3: Rthus JH, Miller AL: Dilecticl behvior therpy dpted for suicidl dolescents. Suicide Life Thret Behv 2002; 32: Ktz LY, Cox BJ, Gunsekr S, Miller AL: Fesibility of dilecticl behvior therpy for suicidl dolescent inptients. J Am Acd Child Adolesc Psychitry 2004; 43: Clinicl Guidnce: Nonsuicidl Self-Injury nd Adolescent Suicide Risk Nonsuicidl self-injury predicts subsequent suicide ttempts in depressed dolescents nerly s strongly s previous suicide ttempts themselves. Wilkinson et l. found tht poor fmily function is nother mjor predictor of suicidlity. Nonsuicidl self-injury is predicted by hopelessness, nxiety disorder, nd being younger nd femle, but not by poor fmily function. Improvement in depression during tretment reduces nonsuicidl self-injury more thn suicide ttempts, s pointed out by Brent (p. 452). Becuse nonsuicidl self-injury occurs more frequently in younger ptients thn suicidl behvior itself, it should be seen s sentinel, but potentilly tretble event for lter suicide risk. Am J Psychitry 168:5, My 2011 jp.psychitryonline.org 501