A transportable assessment protocol for prescribing youth psychosocial treatments in real-world settings: reducing assessment burden via self-report scales

Current evidence-based assessment methods, such as structured interviews and lengthy assessment batteries, often require hours to administer, score, and interpret and thus are infrequently used in real-world practice. As evidence-based assessment tools are developed for implementation in real-world youth mental health settings, the transportability properties of assessment procedures (including administration and interpretation burden) need to be considered and improved. In the present study, we thus conducted an initial feasibility study using a clinical sample of community-based youths (N = 306) to develop an assessment protocol based on 2 child and 2 parent self-report questionnaires (thus low on administration burden). Using decision-tree analysis, we identified a series of cutoff scores across these scales that may be used to inform treatment need related to anxiety, depression, attention-deficit/hyperactivity disorder (ADHD), and disruptive behavior problems. This algorithm-based approach to interpreting assessment information provided clear and simple guidelines (thus low on interpretation burden) that matched the best estimate treatment determinations derived by trained assessors, supervisors, and expert consultants who integrated information provided by child and parent structured interviews and self-report scales. The present study demonstrated the feasibility of developing an assessment protocol to inform various treatment allocation decisions in a way that imposes little assessment administration and interpretation burden yet maintains adequate classification accuracy. These characteristics make the proposed protocol promising with regard to its transportability and suitability for adoption and implementation in real-world mental health settings.     

Prospective predictors of suicidality: defeat and entrapment lead to changes in suicidal ideation over time

Theoretical perspectives into suicidality have suggested that heightened perceptions of defeat and entrapment lead to suicidality. However, all previous empirical work has been cross-sectional. We provide the first longitudinal test of the theoretical predictions, in a sample of 79 students who reported suicidality. Participants completed self-report measures of suicidal ideation, depression, defeat, and entrapment at two time points, approximately 12 months apart. People higher in defeat became more suicidal over time (β= .45), with baseline levels of suicidality and depressive symptoms controlled. The current results support the posited role of perceived defeat in driving suicidal ideation.     

The Relation of Self-Hatred and Suicidality in People With Schizophrenia-Spectrum Symptoms

It is well known that depressive symptoms represent a risk for suicidality in general. It is less clear, however, that general depressive symptoms comprise a definite suicide risk factor for people with schizophrenia. Based on this, as well as on the early writings of E. Bleuler (1911/1987), it was hypothesized that there may be a particular aspect of depressive symptoms that combines with schizophrenia to encourage suicidality. Specifically, schizophrenia may impart to self-concept a quality of self-hatred that encourages suicidality in schizophrenic people. If so, then an index of self-hatred should be more correlated with suicidality among people with schizophrenia-spectrum symptoms than among people with fewer such symptoms. Two studies evaluated this possibility. In Study 1 on 243 suicidal outpatients affiliated with the military, self-hate and suicidality were more correlated among people with schizotypal symptoms than among other patients. In Study 2 on 113 VA psychiatric inpatients, self-hate and suicidality were more correlated among people with a diagnosis of schizophrenia than among patients with a diagnosis of major depression. Study limitations were noted, and it was suggested that self-hatred be a focus of suicide risk assessment in schizophrenic people.     

Violent obsessions are associated with suicidality in an OCD analog sample of college students

The picture of suicide in obsessive-compulsive disorder (OCD) is unclear because previous research did not uniformly control for depressive symptoms when examining the relationship between OCD and suicidality. Specific links between OC symptom dimensions and suicidality were also not adequately studied. As such, we investigated specific associations between OC symptom dimensions and suicidality, beyond the contribution of depressive symptoms, in an OCD analog sample of college students, a group traditionally at risk for suicide. One hundred and forty-six college students (103 females; 43 males) who exceeded the clinical cut-off for OC symptoms on the Obsessive-Compulsive Inventory, Revised (OCI-R) were recruited. Participants completed an online questionnaire containing measures that assessed suicidality and OC and depressive symptom severity. Total OC symptom severity, unacceptable thoughts, and especially violent obsessions exhibited significant positive zero-order correlations with suicidality. However, analyses of part correlations indicated that only violent obsessions had a significant unique association with suicidality after controlling for depressive symptoms. Our findings support the hypothesis that violent obsessions have a specific role in suicidality beyond the influence of depressive symptoms in an OCD analog sample of college students. A strong clinical focus on suicide risk assessment and safety planning in college students reporting violent obsessions is therefore warranted. Future related research should employ longitudinal or prospective designs and control for other possible comorbid symptoms in larger and more representative samples of participants formally diagnosed with OCD in order to verify the generalizability of our findings to these groups.     

Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms

The purpose of the present study was to examine the potential efficacy, patient acceptability, and feasibility of a novel, cognitive-behavioral therapy (CBT) for adults with attention-deficit hyperactivity disorder (ADHD) who have been stabilized on medications but still show clinically significant symptoms. Thirty-one adults with ADHD and stable psychopharmacology for ADHD were randomized to CBT plus continued psychopharmacology or continued psychopharmacology alone. Assessments included ADHD severity and associated anxiety and depression rated by an independent evaluator (IE) and by self-report. At the outcome assessment, those who were randomized to CBT had lower IE-rated ADHD symptoms (p < .01) and global severity (p < .002), as well as self-reported ADHD symptoms (p < .0001) than those randomized to continued psychopharmacology alone. Those in the CBT group also had lower IE-rated and self-report anxiety (p's < .04), lower IE-rated depression (p < .01), and a trend to have lower self-reported depression (p = .06). CBT continued to show superiority over continued psychopharmacology alone when statistically controlling levels of depression in analyses of core ADHD symptoms. There were significantly more treatment responders among patients who received CBT (56%) compared to those who did not (13%) (p < .02). These data support the hypothesis that CBT for adults with ADHD with residual symptoms is a feasible, acceptable, and potentially efficacious next-step treatment approach, worthy of further testing.     

Characteristics of Suicidality Among Adolescents

The identification of high-risk adolescent suicide attempters in a population of depressed and suicidal adolescents is of crucial importance. This retrospective study examined characteristics of suicidality (recent and lifetime, active and passive) and psychopathology (depression, aggression, impulsivity, stressful life events, SCL-90 dimensions) among four groups of depressed adolescent outpatients: (1) suicide attempters who required medical treatment (n = 84), (2) suicide attempters who did not require medical treatment (n = 57), (3) suicidal ideators who had never made a suicide attempt (n = 40), and (4) nonsuicidal patients (n = 44). Results indicate that the nonsuicidal group could be differentiated from the three suicidal groups on the basis of suicidality and psychopathology, and that the three suicidal groups could be differentiated from one another on the basis of suicidality but not psychopathology. These findings are discussed in terms of the usefulness of certain self-report measures of suicidality for identifying suicidal adolescents and for differentiating among them. Furthermore, the findings suggest that psychopathological factors do not determine which suicidal adolescents make a medically dangerous suicide attempt and which do not.     

Peer victimization, depression, and suicidiality in adolescents

The association between specific types of peer victimization with depression, suicidal ideation, and suicide attempts among adolescents was examined. A self-report survey was completed by 2,342 high-school students. Regression analyses indicated that frequent exposure to all types of peer victimization was related to high risk of depression, ideation, and attempts compared to students not victimized. Infrequent victimization was also related to increased risk, particularly among females. The more types of victimization the higher the risk for depression and suicidality among both genders. Specific types of peer victimization are a potential risk factor for adolescent depression and suicidality. It is important to assess depression and suicidality among victimized students in order to develop appropriate intervention methods.     

Likelihood of suicidality at varying levels of depression severity: a re-analysis of NESARC data

Although it is clear that increasing depression severity is associated with more risk for suicidality, less is known about at what levels of depression severity the risk for different suicide symptoms increases. We used item response theory to estimate the likelihood of endorsing suicide symptoms across levels of depression severity in an epidemiological data set. Regardless of depression severity, suicide attempts were less frequently endorsed than ideation, which was less frequently endorsed than feeling like one wanted to die. All suicide symptoms were generally less likely to be endorsed than other depression symptoms. There was a low probability of suicidality at depression levels that likely would not merit a diagnosis of major depression.     

High school bullying as a risk for later depression and suicidality

This is the first study to examine whether high school students experiencing frequent bullying behaviors are at risk for later depression and suicidality. A total of 236 students who reported frequent bullying behavior without depression or suicidality during a suicide screening were interviewed 4 years later to reassess depression, suicidal ideation, attempts, substance problems, and functional impairment and were compared to at‐risk youth identified during the screen, including 96 youth who also experienced bullying behavior. Youth who only reported frequent bullying behaviors (as bullies, victims, or both) did not develop later depression or suicidality and continued to have fewer psychiatric problems than students identified as at‐risk for suicide. Students who experienced bullying behaviors and depression or suicidality were more impaired 4 years later than those who had only reported depression or suicidality. Thus, assessment of bullying behaviors in screening protocols is recommended.     

Risk Factors for Suicidality Among Clients With Schizophrenia

Among clients with schizophrenia, suicidality is associated with extreme personal distress, an increased number of inpatient hospitalizations, increased health care expenditures, and early mortality. This study attempted to identify risk factors for current suicidality in clients diagnosed with schizophrenia (N = 223). Results indicated that severity of depressive symptoms most strongly correlated with degree of suicidality. Younger age and recent traumatic stress each significantly predicted suicidality independent of depressive symptoms. Stepwise regression procedures showed that the combination of depression, younger age, and traumatic stress might provide a general prediction model for suicidality among clients diagnosed with schizophrenia. Counseling implications of these findings are outlined.     

Specificity of Depressive Symptoms and Suicidality in a Juvenile Delinquent Population

Research which has related scores on the Children's Depression Inventory (CDI) to suicidality have generally neglected to examine the possibility that specific depressive factors within the CDI may be more predictive of suicidality than the full scale score. Knowledge of such factors would help to explain the relationship between depression and suicidality and improve the prediction of suicidal behavior. The current study examined the relationship of depressive factors to suicidality in a sample of 200 incarcerated juvenile delinquents. The published factor structure for the CDI and one derived from the delinquent population were compared. Results revealed two factors from the derived solution, hopelessness and low self-esteem, to be more powerful predictors of suicidal ideation than the full-scale CDI score. These results suggest that symptoms such as low self-esteem and hopelessness may be responsible for the well-documented relationship between depression and suicidality. Furthermore, it appears that the prediction of suicidality may be improved by examining specific depressive factors in suicide research as opposed to full-scale scores from depression inventories such as the CDI.     

Social Anxiety Symptoms and Suicidal Ideation in a Clinical Sample of Early Adolescents: Examining Loneliness and Social Support as Longitudinal Mediators

Recent research has shown that social anxiety may be related to increased risk for suicidal ideation in teens, although this research largely has been cross-sectional and has not examined potential mediators of this relationship. A clinical sample of 144 early adolescents (72 % female; 12–15 years old) was assessed during psychiatric inpatient hospitalization and followed up at 9 and 18 months post-baseline. Symptoms of social anxiety, depression, suicidal ideation, loneliness, and perceived social support were assessed via structured interviews and self-report instruments. Structural equation modeling revealed a significant direct relationship between social anxiety symptoms at baseline and suicidal ideation at 18 months post-baseline, even after controlling for baseline depressive symptoms and ideation. A second multiple mediation model revealed that baseline social anxiety had a significant indirect effect on suicidal ideation at 18 months post-baseline through loneliness at 9 months post-baseline. Social anxiety did not have a significant indirect effect on suicidal ideation through perceived social support from either parents or close friends. Findings suggest that loneliness may be particularly implicated in the relationship between social anxiety and suicidality in teens. Clinicians should assess and address feelings of loneliness when treating socially anxious adolescents.     

The Impact of Negative Stimuli on Suicidality among Adulthoods: A Mediating Effect of Depression

ABSTRACT

Suicide is the leading cause of mortality in the world. The major factors of suicidal behavior are depressive symptoms. Using data from the Korean General Social Survey conducted in 2012, this study identified the causes of suicidality using general strain theory (GST). The total sample size was 1,396. The results showed that physical punishment and mental abuse experienced in childhood increased the mediating variable, level of depression, in adulthood. This study also found that suicidality was significantly associated with depression level. Furthermore, physical punishment and mental abuse had significantly direct effects on the suicidality. As a result, this study found that negative experiences before 18 years of age have an influence on later depression, which increases the likelihood of suicide. Also, this study strongly supported GST. Therefore, reducing the causes of depression during adolescent period would be a key strategy to decrease suicide risk during adulthood.     

The relationship between personality traits and psychotic like experiences in a large non-clinical adolescent sample

ObjectiveThe relationship between personality and psychosis is well established. It has been suggested that this relationship may be partly accounted for by higher levels of depression in individuals with certain personality traits. We explored whether the link between personality and psychotic symptoms is already apparent in adolescence, and if this association would still hold when depression was controlled for.Method654 secondary school students were surveyed via self-report questionnaires measuring the Five-Factor model of personality (NEO-FFI), depression (CES-D) and psychotic-like experiences (CAPE).ResultsPositive associations were found between Neuroticism and all CAPE-subscales except Magical Thinking, which was in turn associated with all other personality traits when at high levels. Agreeableness was negatively associated with all CAPE-subscales, while Openness to Experience was only positively associated with Persecutory Ideas and Magical Thinking. After controlling for depression, many of the significant associations remained.ConclusionOur findings suggest that the chance of having psychotic like experiences is more likely for adolescents with certain personality traits. These associations are not fully explained by depression, especially when psychotic experiences are at higher levels. Future research is needed to investigate if these personality traits might put a person at risk for the development of full-blown psychosis.     

Cultural identity, explanatory style, and depression in Navajo adolescents

This study investigated the interrelationships among cultural identity, explanatory style, and depression in Navajo adolescents. A total of 332 (197 female, 135 male) Navajo adolescents completed 7 self-report measures. These data were used to create, via structural equation modeling, a series of factor models and full structural models. Analyses indicated that current factor structures for explanatory style and depression are adequate for use with Navajo adolescents. Increased control and predictability and limited duration of stressful encounters were both predictive of decreased symptoms of depression. Higher levels of Navajo cultural identity had a modest effect in terms of reducing depression. Other factors, such as perceived discrimination and urban/reservation domicile, are important to study to provide an increased understanding of depression among Navajo adolescents.     

Treatment-resistant depression in late life

Treatment resistance is reported in up to 40% of older patients with major depression. Before labeling an episode of depression as treatment resistant, it is important to ensure that the diagnosis is correct and that the patient has received and adhered to an adequate dose of treatment for an appropriate length of time. It is also important to assess the patient for comorbid physical and psychiatric conditions that can contribute to treatment resistance. In patients who do not experience remission of symptoms with an adequate trial of medication, the following options can be considered: augmenting the antidepressant with a drug that is not primarily an antidepressant, adding a second antidepressant to the first, switching to a different antidepressant medication, or switching to electroconvulsive therapy. This paper reviews the concept of treatment-resistant depression and discusses its assessment and management in the elderly. The author concludes that when a systematic stepped-care approach to treatment is followed, most older patients with major depression will experience remission of symptoms.     

The Effect of PTSD Symptom Change on Suicidal Ideation in a Combined Military and Civilian Sample Engaged in Cognitive Processing Therapy

In light of the well-established relationship between posttraumatic stress disorder (PTSD) and suicidal ideation (SI), there has been a push for treatments that simultaneously improve symptoms of PTSD and decrease SI. Using data from a randomized controlled hybrid implementation-effectiveness trial, the current study investigated the effectiveness of Cognitive Processing Therapy (CPT; Resick, Monson, & Chard, 2016) on PTSD and SI. The patient sample (N = 188) was diverse in military and veteran status, gender, and comorbidity, and 73% of the sample endorsed SI at one or more points during CPT. Participants demonstrated significant improvement in SI over the course of CPT. Multilevel growth curve modeling revealed a significant association between PTSD symptom change and change in SI. Results from cross-lagged multilevel regressions indicated that PTSD symptoms predicted SI in the next session, yet SI in a given session did not predict PTSD symptoms in the next session. Potentially relevant clinical factors (i.e., military status, gender, depression diagnosis, baseline SI, study consultation condition) were not associated with the relationship between PTSD symptoms and SI. These results add to the burgeoning literature suggesting that evidence-based treatments for PTSD, like CPT, reduce suicidality in a range of individuals with PTSD, and that this reduction is predicted by improvements in PTSD symptoms.     

Influence of functional impairment and social support on depressive symptoms in persons with diabetes

Tested the buffering model of social support among 158 adults with diabetes. We predicted that, among patients with higher levels of illness-related impairment, adequate social support would act as a buffer against depression. Measures included the Beck Depression Inventory; the Sickness Impact Profile; and an assessment of the adequacy of social support to enable the patient to deal with illness-related tasks, domestic chores, financial responsibilities, and emotional needs. Depressive symptoms correlated positively with functional impairment (r = .58, p less than .001) and negatively with the adequacy of social support (r = -.31, p less than .001). In addition, social support moderated depression in the face of greater impairment such that, among patients who reported the most illness-related functional disabilities, adequate support provided a relative protection from depression. The findings suggest that individuals with inadequate support are most at risk to become depressed when disability related to illness increases.     

Evidence-based assessment of anxiety disorders in adults

This article discusses issues related to the development and dissemination of evidence-based assessment strategies for anxiety disorders and associated problems. It begins with a review of the criteria that should be considered when determining whether particular assessment procedures are evidence-based. These include such factors as reliability, validity, cost-effectiveness, consumer acceptability, utility across different populations, and ease of dissemination. The importance of considering the purpose of the assessment process when deciding whether a procedure is evidence-based is emphasized. Next, the major assessment domains that are particularly important in the area of anxiety disorders (e.g., triggers for anxiety symptoms, avoidance behaviors) are reviewed. Finally, some potential obstacles to the dissemination of evidence-based assessment procedures are discussed along with suggestions for managing these obstacles.