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An Intervention Trial to Improve Adherence to Community Treatment by Adolescents After a Suicide Attempt
An Intervention Trial to Improve Adherence to Community Treatment by Adolescents After a Suicide Attempt ANTHONY SPIRITO, PH.D., JULIE BOERGERS, PH.D., DEIDRE DONALDSON, PH.D., DUANE BISHOP, M.D., AND WILLIAM LEWANDER, M.D.
ABSTRACT Objective: To determine whether a problem-solving intervention would increase adherence to outpatient treatment for adolescents after a suicide attempt. Method: Sixty-three adolescents who had attempted suicide and were evaluated in an emergency department between 1997 and 2000 were randomly assigned to undergo standard disposition planning or a compliance enhancement intervention using a problem-solving format. At 3 months after the intervention, all evaluable adolescents, guardians, and outpatient therapists were contacted to determine adherence to outpatient treatment. Results: At 3-month follow-up, the compliance enhancement group attended an average of 7.7 sessions compared with 6.4 sessions for the standard disposition group, but this difference was not statistically significant. However, after covarying barriers to receiving services in the community (such as being placed on a waiting list and insurance coverage difficulties), the compliance enhancement group attended significantly more treatment sessions than the standard disposition-planning group (mean = 8.4 versus 5.8 sessions). Conclusion: Interventions designed to improve treatment attendance must address not only individual and family factors but also service barriers encountered in the community that can impede access to services. J. Am. Acad. Child Adolesc. Psychiatry, 2002, 41(4):435–442. Key Words: adolescent suicide attempts, treatment compliance, family barriers, service barriers.
Lack of adherence to treatment regimens for psychiatric disorders is a significant problem, diminishing the potential benefits of both psychiatric and psychosocial interventions. Few would argue with the notion that adolescents who attempt suicide should receive a full evaluation, psychotropic medications as indicated, and at least a brief course of psychotherapy after the attempt. However, several studies have demonstrated a very poor rate of treatment adherence in this group of patients regardless of treatment setting. For example, Spirito et al. (1992) followed a primarily white patient sample from a range of Accepted October 19, 2001. From Brown University School of Medicine, Providence, RI. Drs. Spirito, Boergers, Donaldson, and Bishop are with the Department of Psychiatry and Human Behavior and Dr. Lewander is with the Department of Pediatrics. This investigation was supported by NIMH grant MH52411 and by a grant from the van Ameringen Foundation. Correspondence to Dr. Spirito, Clinical Psychology Training Consortium, Brown University, Box G-BH; Providence, RI 02912; e-mail: Anthony_Spirito@ Brown.edu. 0890-8567/02/4104–0435䉷2002 by the American Academy of Child and Adolescent Psychiatry.
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socioeconomic classes who were referred from the emergency department (ED) to a variety of agencies and private practitioners in the community. Approximately one third of these patients and their families went to two or fewer sessions. In another study (Trautman et al., 1993), adolescent suicide attempters and nonsuicidal adolescents stopped treatment “against medical advice” at the same rate, about 77%. However, survival analyses revealed that the suicide attempters dropped out much more quickly than nonsuicidal adolescents (median number of sessions before dropout was 3 sessions for attempters and 11 sessions for nonsuicidal adolescents). Suicide attempters who completed a course of treatment, on the other hand, attended significantly more appointments (mean = 11.6) than the dropouts. In an attempt to improve treatment adherence in this high-risk group of adolescents, training workshops for ED staff, a videotape for families regarding typical treatment, and an on-call family therapist were used for a group of primarily female Latino adolescent suicide attempters (RotheramBorus et al., 1996). The intervention slightly improved the 435
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mean number of sessions attended (5.7 versus 4.7) compared with a standard care group. Another group (Zimmerman et al., 1995) developed a multifamily psychoeducational intervention for depressed and/or suicidal adolescents (including some suicide attempters) and their families. The psychoeducational module addressed such issues as treatment adherence and the adolescent’s suicidality. However, the intervention did not improve continued attendance in treatment beyond the first appointment. Given the modest success of prior interventions addressing adherence, the purpose of the present study was to determine whether a problem-solving intervention designed to increase adherence to outpatient treatment in adolescent suicide attempters and their parents might be more efficacious than the previously described approaches. A general hospital site was chosen to study suicide attempters because it is often the first point of contact in the medical system for serious youth suicide attempts. It was hypothesized that adolescents who participated in the experimental compliance enhancement protocol would attend more outpatient psychotherapy sessions than a comparison group of adolescents who received standard disposition planning. METHOD Participants Adolescents aged 12 to 18 years who had made a suicide attempt and were receiving medical care in either the ED or pediatrics ward of a children’s hospital in the Northeast were eligible for the project. A suicide attempt was defined as any intentional self-injury, regardless of lethality, which was reported as an attempt to harm or kill oneself. The large majority of the final sample (86%) attempted suicide by overdose. There were 82 adolescents eligible for the project, and 76 (93%) of those agreed to participate in the study. Socioeconomic status (SES) was classified by state census tract data into one of four categories (poverty, low, middle, high) for families living in-state. Seven experimental and six standard disposition participants (17%) were either lost to follow-up or dropped out of the study. The final sample with complete follow-up data (N = 63; 83%) consisted of 34 participants randomly assigned to the standard disposition-planning group (32 female, 2 male) and 29 participants randomly assigned to the experimental compliance enhancement group (25 female, 4 male). Procedure Eligible participants were approached about being in the project after they had been medically stabilized after a suicide attempt and had received a standard psychiatric evaluation. Adolescents also completed a battery of diagnostic and self-report measures. After parents (and 18-year-old patients) signed an informed consent document and adolescents younger than 18 years of age assented to participate, the families were randomly assigned to either standard disposition planning or standard disposition planning plus the compliance enhancement intervention. This procedure was approved by the hospital institutional review board.
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Standard Disposition Planning Patient disposition was based on the judgment of the psychiatric clinician who conducted the evaluation. Some attempters in both groups had a brief inpatient psychiatric stay prior to receiving outpatient care. The remainder were provided with an outpatient appointment at the local mental health center. Fidelity to Standard Disposition Planning. A total of 37 (59%) of the evaluations by psychiatry service clinicians were observed to determine whether they were adequately completed. Research assistants rated patient adherence to 16 points that were deemed important to cover in a standard clinical evaluation, such as assessment of contributing factors to the suicide attempt. Adherence to these 16 points averaged 74.2% (minimum 50%, maximum 100%, SD 12.4%). Interrater reliability for these adherence ratings on 18 cases averaged 85.6% (minimum 71%, maximum 100%, SD 7.9%). Standard Disposition Planning Plus Compliance Enhancement Intervention The 1-hour compliance enhancement intervention was conducted subsequent to standard disposition planning by one of three postdoctoral fellows in psychology. The major components of the compliance enhancement intervention conducted in the hospital were as follows: to review expectations for outpatient treatment and address treatment misconceptions; to review with adolescents and parents those factors that might impede treatment attendance; and to make a verbal contract between parents and adolescent to attend at least four outpatient therapy sessions, the modal number of sessions attended in a naturalistic follow-up study of adolescent suicide attempters (Spirito et al., 1992). The adolescents and their parents or guardians were also informed that they would be contacted separately by telephone at 1, 2, 4, and 8 weeks after discharge regarding their participation in outpatient care. Most of the adolescents (83%) completed all four telephone calls. The telephone tracking method was a structured process, not psychotherapy, designed to provide support, facilitate problem solving, and help with any obstacles in obtaining care. Each telephone contact followed a specific procedure designed to review psychotherapy attendance and suicidal ideation. Potential compliance problems were identified, and the adolescent and parents were assisted in generating solutions to the problems. Interventions were provided as needed and included information distribution, expression of feelings, task directives when necessary (e.g., “call your therapist”), problem reframing, and support for treatment-seeking behaviors. Fidelity to Compliance Enhancement Intervention. To ensure fidelity to the compliance enhancement intervention, 45% of the interventions were observed and rated on 24 points to be covered in the standardized in-hospital experimental intervention. Percent adherence ranged from 83% to 100%, with a mean of 92%. Competence of Intervention Clinicians. The compliance enhancement clinician was also rated on five competence scales, including feedback to the family, interpersonal effectiveness, maintaining a focus during the contact, direct communication, and clarifying communication among family members. Ratings were made on a 3-point scale (not effective; effective; very effective). Mean competence ratings ranged from 2.6 to 3.0 (mean = 2.9, SD = 0.1). Overlap Between Standard Disposition Planning and Experimental Intervention To establish that our compliance enhancement intervention was distinct from standard disposition planning, research assistants also rated the standard disposition-planning clinical interviews on 26 top-
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ics that were contained in the compliance enhancement condition but were not expected to be covered in these standard interviews (e.g., agreement to attend at least four sessions). Although psychiatric service clinicians were not instructed to refrain from covering these issues, overlap between standard clinical practice and the compliance enhancement intervention was low, ranging from zero to 33% (mean = 7.1%, SD = 0.1%). Baseline Assessment Measures Diagnostic Interview Schedule for Children. The Diagnostic Interview Schedule for Children (DISC) is a structured interview developed for use with children and adolescents that assesses current and past symptoms, behaviors, and emotions. The version corresponding to DSMIV diagnostic criteria was used in this study (Shaffer et al., 1998). Only the diagnostic modules corresponding to the most commonly found diagnoses in samples of adolescent suicide attempters (major depression, disruptive behavior disorders, substance abuse) were administered to the adolescents. The DISC has demonstrated good to excellent diagnostic sensitivity (Fisher et al., 1993; Shaffer et al., 1996). Suicide Intent Scale. The Suicide Intent Scale (Beck et al., 1974) is a 15-item interviewer rating scale that assesses the degree of suicidal intent of the suicide attempt. Adequate psychometric characteristics have been demonstrated with adolescents (Spirito et al., 1996). Center for Epidemiologic Studies-Depression Scale. The Center for Epidemiologic Studies-Depression Scale (Radloff, 1991) is a 20-item measure of depressive symptoms which has been validated for use with adolescents (Radloff, 1991). Hopelessness Scale for Children. The Hopelessness Scale for Children (HSC) (Kazdin et al., 1983) consists of 17 true/false statements designed to measure negative expectancies toward oneself and one’s future. The HSC has shown adequate reliability and internal consistency with a sample of adolescent suicide attempters (Spirito et al., 1988). State-Trait Anger Expression Inventory. The State-Trait Anger Expression Inventory (STAXI) (Spielberger, 1988) consists of 44 items, rated on 4-point Likert scales, designed to measure both the experience of anger and the expression of anger. The STAXI has been used with adolescents (Lehnert et al., 1994), and adequate internal consistency and construct validity have been reported for the subscales (Spielberger, 1988). McMaster Family Assessment Device. The McMaster Family Assessment Device (Epstein et al., 1983) is a screening measure of family interactions that is based on the McMaster Model of Family Functioning. Respondents rate how well each item describes their family, using a 4-point scale which ranges from “strongly agree” to “strongly disagree.” The General Functioning subscale was used in this study. Adequate reliability and validity have been demonstrated for the General Functioning Subscale in a large epidemiological study with children (Byles et al., 1988). Follow-up Interview Three months after the suicide attempt, a research assistant conducted a telephone follow-up interview with parents and adolescents in each condition. This structured interview (Spirito et al., 1992) included questions regarding the number of psychotherapy sessions attended, suicidal behavior, and an open-ended question regarding any problems the parents or adolescents had concerning therapy sessions. A separate contact was also made with treatment providers. Therapists were asked to report the number of sessions attended by the patient as well as whether the therapist terminated treatment or the family terminated prematurely. Data on the number of sessions from all three sources were available for 65% of the sample; 29% of the sample had reports of the number of sessions from two sources,
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and 6% had reports from a single source. When a range of sessions was reported by an individual (e.g., “five or six sessions”), the lowest number was recorded. In the event of a discrepancy, a mean was taken to determine the total number of sessions reported. Two research assistants reviewed 3-month follow-up interview data to code barriers to treatment reported by patients and their parents. Responses to the Barriers to Service Questionnaire, a component of the Child and Adolescent Services Assessment (Farmer et al., 1994), and comments made by the patient and parent during the telephone interview were examined for the presence of barriers. Barriers were categorized into service delivery problems and family-based problems. Complete agreement on the number and types of barriers was achieved for 78% of the sample (intraclass correlation coefficient = 0.90). A postdoctoral fellow in psychology resolved any coding discrepancies. Family Barriers. Using an approach similar to other studies (Kazdin and Wassell, 1999), the following five factors were classified as family barriers to treatment: parental report of emotional problems, transportation difficulties, language problems, parent or adolescent ambivalence about treatment, cost of treatment, and scheduling difficulties. Service Barriers. The following six problems were classified as service barriers: delays in getting an appointment, being placed on a waiting list, therapist or agency reported no further treatment was needed despite patient’s or parent’s desire for further treatment, inability to switch therapists due to agency policy, and problems with insurance coverage. Statistical Analyses All evaluable patients in each group were compared on baseline and follow-up measures using t tests for continuous variables and χ2 values for dichotomous variables. Analyses of variance (ANOVAs) covarying baseline and follow-up measures that were significantly different between the groups were the primary analyses to test the research question regarding effects of the intervention on therapy attendance/ completion. Pearson correlation coefficients were calculated to examine relationships of child, family, and service barrier variables to number of therapy sessions attended. A hierarchical regression analysis was used to test the contribution of psychological and treatment variables to the number of outpatient sessions attended.
RESULTS Preliminary Analyses
Adolescents who refused to participate in the project (n = 6) were compared on age and gender to those who were enrolled. No significant differences were found. In addition, adolescents who were lost to follow-up (n = 13) were compared to those who remained in the project. There were no significant differences noted on age, gender, race, SES, or any of the baseline psychological measures. There was no difference between the compliance enhancement group and standard disposition- planning group on age (t61 = 1.98, not significant [NS]), SES (χ2 [1, N = 57] = 3.35, NS), or race (χ2 [1, N = 63] = 2.55, NS). The mean age of the sample was 15.0 years (SD = 1.4). The SES distribution, based on state census tract data, was as follows: 437
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poverty, 28%; low SES, 21%; middle level SES, 47%; and high SES, 4%. The majority of the sample was white (n = 46; 73%), followed by Hispanic (n = 8; 13%), African American (n = 7; 11%), and mixed ancestry (n = 2; 3%). Although the two groups did not significantly differ by gender (χ2 [1, N = 63] = 1.14, NS), there were only a small number of males in each group. Upon discharge, 17 adolescents (50%) in the standard disposition group were psychiatrically hospitalized versus 17 adolescents (58%) in the compliance enhancement group. There was no difference between the two groups on disposition upon discharge from the general hospital (outpatient versus inpatient psychiatric care) (χ2 [1, N = 63] = 0.47, NS). In the compliance enhancement group, 68% had a history of mental health treatment versus 52% in the standard care group (χ2 [1, N = 58] = 1.59, NS). The rates of psychotropic medication use in the compliance enhancement group (56%) and the standard care group (36%) was also nonsignificant (χ2 [1, N = 58] = 2.22, NS). Psychiatric Diagnoses
The short length of stay precluded completing the CDISC with all adolescents. C-DISC–derived DSM-IV diagnoses were available on 46 patients; 50% of the sample did not meet criteria for a diagnosis. Twenty-eight diagnoses were recorded for the remaining 23 adolescents. Two adolescents in the compliance enhancement group and three in the standard disposition-planning group had comorbid diagnoses. The diagnoses were as follows: one dysthymia, six major depression, five oppositional defiant disorder, six conduct disorder, four alcohol abuse, four marijuana abuse, and two marijuana dependence.
Chi-square analyses were used to compare the two groups on each of the C-DISC diagnoses, and none of the differences was significant. Group Comparisons on Baseline Psychological Measures and Follow-up Data
A series of t tests was used to compare the two groups on the psychological measures administered at baseline. As shown in Table 1, the only statistically significant difference between the groups was with respect to hopelessness, with adolescents in the compliance enhancement group reporting greater levels of hopelessness at baseline. The two groups were also compared on follow-up measures of family barriers and service barriers. As noted in Table 2, the groups did not differ on mean number of family barriers. In the compliance enhancement group, 33% of the families reported experiencing a family barrier compared with 22% of the standard care group. The rates of reported family barriers did not differ across groups (χ2 [1, N = 58] = 1.03, NS). The types of family barriers reported were as follows: parental psychiatric problems (3%), transportation difficulties (3%), parental ambivalence about treatment (5%), concerns about the cost of treatment (12%), scheduling difficulties (3%), and adolescent resistance to treatment (14%). As noted in Table 2, adolescents and parents in the compliance enhancement group on average reported significantly more service barriers. In the compliance enhancement group, 43% of the families reported experiencing a service barrier compared with 15% in the standard care group. Overall, 58% of the sample reported experiencing a service barrier. The rates of reported service barriers were significantly different across groups (χ2 [1, N = 56] = 5.15
TABLE 1 Baseline Measures of Psychological Functioning by Group Compliance Enhancement
No. of prior suicide attempts Suicide Intent Scale CES-D HSC STAXI FAD-Global Functioning
Standard Disposition Planning
Mean
SD
n
Mean
SD
n
t
d
0.5 11.4 30.9 8.0 33.8
0.8 6.7 12.7 5.3 13.4
29 25 27 28 28
0.6 10.2 27.5 4.0 32.7
1.0 6.6 15.1 3.7 12.6
34 26 32 32 32
0.31 0.69 0.94 3.43*** 0.33
0.11 0.18 0.24 0.88 0.08
2.5
0.5
28
2.4
0.6
32
0.90
0.18
Note: d = effect size; CES-D = Center for Epidemiologic Studies-Depression Scale; HSC = Hopelessness Scale for Children; STAXI = total score for the State-Trait Anger Expression Inventory; FAD = Family Assessment Device. *** p < .001.
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TABLE 2 Means and Standard Deviations by Group on Follow-up Measures Compliance Enhancement
Family barriers Service barriers Outpatient therapy sessions (no.)
Standard Disposition Planning
Mean
SD
n
Mean
SD
n
t
d
0.3 0.9
0.8 1.2
29 29
0.2 0.2
0.4 0.4
34 34
1.12 2.87**
0.16 0.79
7.7
5.8
29
6.4
4.4
34
1.01
0.25
Note: d = effect size. ** p < .01.
p < .05). The types of service barriers reported by the two groups were as follows: waiting lists (30% compliance enhancement, 4% standard care), problems in scheduling additional appointments (17% compliance enhancement, 4% standard care), language barriers (0% compliance enhancement, 7% standard care), problems with insurance coverage (13% compliance enhancement; 4% standard care), and dissatisfaction with therapist (10% compliance enhancement, 4% standard care). Effects of the Intervention on Number of Sessions and Premature Termination
A direct comparison of the groups by t test did not reveal a statistically significant difference between the compliance enhancement (mean = 7.7, SD = 5.8) and standard disposition (mean = 6.4, SD = 4.4) groups on number of sessions attended (t61 = 1.01, NS). The compliance enhancement and standard disposition groups were also comparable on the number of no-shows (i.e., never attended therapy): 6.9% versus 8.8%, respectively (χ2 [1, N = 63] = 0.08, NS). Because families in the compliance enhancement group were asked to attend four sessions before considering termination, the two groups were compared on the percentage of participants who attended four or more sessions. A χ2 analysis did not reveal a significant difference between groups (χ2 [1, N = 63] = 0.52, NS); 75.9% of the compliance enhancement group attended four or more sessions compared with 67.6% of the standard disposition group. Finally, the groups were compared on rates of premature termination. Premature termination was based on either parent or therapist report. In the compliance enhancement group, 42% of the families reported stopping treatment prematurely compared with 52% in the standard core group. This difference was not statistically significant (χ2 [1, N = 58] = 0.95, NS). J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 4 , A P R I L 2 0 0 2
Effects of Intervention Accounting for Potential Confounds
Analyses were conducted to control for differences between groups that were noted at baseline (hopelessness) and follow-up (service barriers). An ANOVA covarying baseline scores on the HSC did not reveal a statistically significant difference on number of sessions of outpatient treatment between the compliance enhancement and standard disposition groups (F1,60 = 0.07, NS). A separate ANOVA covarying service barriers was statistically significant (F1,60 = 4.07, p < .05): the compliance enhancement group attended significantly more outpatient psychotherapy sessions (mean = 8.4, SE = 10.9; 95% confidence interval 6.5, 10.2) than the standard disposition group (mean = 5.8, SE = 10.9; 95% confidence interval 4.1, 7.5). Other Predictors of Treatment Attendance
Table 3 presents the correlation coefficients between the number of psychotherapy sessions attended and the child, family, and service variables. Higher levels of depression, a greater number of prior suicide attempts, and more family and service barriers to treatment were all significantly related to fewer treatment sessions attended. Three other potential predictors of treatment attendance were also examined: prior mental health treatment, inpatient psychiatric treatment immediately after the suicide attempt, and psychotropic medication use. A t test comparing those who reported mental health treatment versus no treatment prior to the suicide attempt did not reveal a significant difference in number of sessions attended (7.5 ± 5.1 versus 5.7 ± 4.4; t56 = 1.38, NS). An ANOVA comparing three groups (no treatment, prior treatment, and current treatment) was also nonsignificant (F2,57 = 1.39, NS). Adolescents who were discharged from the ED to inpatient psychiatric care did not differ on sociodemographic 439
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TABLE 3 Correlations Between Number of Therapy Sessions and Child, Family, and Service Variables No. of Therapy Sessions Attended r Child variables Suicide Intent Scale HSC CES-D STAXI No. of prior attempts Family variables FAD Global Functioning Family barriers (total no.) Service barriers Total no.
n
0.23 0.17 0.27* 0.07 0.34**
51 60 59 60 63
0.18 –0.62***
60 63
–0.33**
63
Note: HSC = Hopelessness Scale for Children; CES-D = Center for Epidemiologic Studies-Depression Scale; STAXI = State-Trait Anger Expression Inventory; FAD = Family Assessment Device. * p < .05; ** p < .01; *** p < .001.
characteristics but, as might be expected, obtained higher (worse) scores on the measures of depression, hopelessness, anger, drinking, suicide intent, and family functioning. Adolescents discharged to inpatient care attended significantly more sessions than those referred only to outpatient care (8.7 ± 5.2 versus 4.9 ± 4.1; t61 = 3.16, p < .05). A difference in therapy sessions attended also depended on whether or not adolescents were taking prescribed medications (t56 = 2.97, p < .01). The adolescents taking psychotropic medications (n = 26) attended more sessions (mean = 9.1, SD = 5.4) than those not taking medications (n = 32, mean = 5.3, SD = 4.4). However, medication visits were included in the total number of sessions, which inflated the number of sessions attended. A χ2 analysis revealed that there was a relationship between psychotropic medication use and inpatient treatment following the attempt (χ2 [1, N = 58] 12.48, p < .001). Adolescents who were admitted to a psychiatric unit after their suicide attempt were more likely to be prescribed psychotropic medications. Regression Analyses
To determine the relative contribution of psychological factors and treatment barriers to treatment attendance (i.e., number of sessions attended), a hierarchical linear regression analysis was conducted. Only variables found to correlate with the number of psychotherapy sessions in the bivariate analyses were entered into the regression. As shown in Table 4, psychological characteristics 440
TABLE 4 Hierarchical Linear Regression Analyses Predicting Number of Therapy Sessions Variables
β
Step 1. psychological characteristics Prior suicide attempts CES-D total score
.29 .12
Step 2. treatment barriers Family barriers Service barriers
R2
F
0.16
6.51**
0.14
7.27**
–.38 –.09
Note: CES-D = Center for Epidemiologic Studies-Depression Scale. ** p < .01.
and treatment barriers both significantly predicted treatment attendance and accounted for an almost equal amount of the variance, 16% versus 14%, respectively. DISCUSSION
Lack of adherence to treatment is a significant problem in psychotherapy research and has been shown to be particularly problematic with adolescent suicide attempters. The compliance enhancement intervention in this study was effective in increasing treatment adherence compared with standard disposition planning only when the barriers to service in the community were controlled. Thus, problem-solving interventions with families were not sufficient to overcome barriers to service. When barriers to service were covaried in the analyses, the intervention resulted in significantly greater treatment adherence (eight versus five sessions) compared with the standard disposition-planning group. This three-session improvement is comparable with that reported by Rotheram-Borus et al. (2000) in their ED intervention. The intervention provided here addressed a broader range of factors related to treatment adherence than previous studies. Not only were adolescent and parental expectations about treatment and understanding of suicidal behavior addressed in the present study, but also the barriers families encountered to obtaining services. The latter area was addressed most specifically during the follow-up telephone calls. Thus it is surprising that even with follow-up assistance for up to 2 months by doctoral-level clinicians, these same families could not overcome the barriers to receiving treatment in the community. A study with adult suicide attempters in Germany (Torhorst et al., 1987) also found that special motivation procedures did not improve treatment adherence when patients had to change therapists or institutions. Similarly, a recent study J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 4 , A P R I L 2 0 0 2
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in Finland reported inadequate psychopharmacological and psychotherapeutic treatment following suicide attempts in adults that could not be attributed to patient nonadherence (Suominen et al., 1998). Could other factors, such as patient characteristics, have affected the efficacy of the intervention? A prior suicide attempt was not related to better treatment attendance. Although the compliance enhancement group reported significantly higher levels of hopelessness than the standard disposition-planning group, when hopelessness was controlled in the analyses, there was no effect on treatment adherence. Family barriers to participation in treatment, such as expectations about treatment, have been shown to affect adherence in other studies (Kazdin and Wassell, 1999). These factors were addressed in the compliance enhancement intervention, but they did not affect treatment adherence. It is possible that the results could be a factor of other family variables not measured, such as adverse family living arrangements. For example, Rotheram-Borus et al. (2000) reported that family adaptability characterized the families of adolescents who attended three to six sessions versus those who attended zero to two sessions. One factor was related to treatment adherence: a brief psychiatric hospitalization after the attempt did result in greater treatment attendance at follow-up. This may have been related to the fact that adolescents who were hospitalized were also prescribed medication more frequently than those referred to outpatient care. Thus they were more likely to have contact with mental health professionals because they had therapy and medication appointments as outpatients. The hospitalized patients were also likely to be more seriously ill, which may have resulted in more attention to aftercare by their families. Alternatively, the hospitalization itself may have impressed upon families the seriousness of the suicide attempt and the need to follow through with outpatient treatment. Limitations
Several limitations should be considered in evaluating these findings. First, the groups were relatively small, limiting the power to detect differences in outcome. Similarly, the small number of subjects affects regression analyses and the stability of the β weight coefficients. Second, the experimental group may have been more sensitized to reporting barriers at follow-up because they participated in an intervention that helped them solve problems related to service access. Alternatively, respondents in the experJ . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 4 , A P R I L 2 0 0 2
imental group may have reported more barriers to service to rationalize their failure to attend therapy. Third, perceptions of the adolescent and family toward the treating clinician, another potential barrier, was not assessed in this study. Clinical Implications
A recent study in Britain (Hawton et al., 2000) of 174 cases of completed suicide in youths under 25 years of age found that almost half of the suicide victims had attempted suicide in the year before their death. This finding led Hawton et al. (2000) to emphasize the need to ensure that clinical services for adolescents who harm themselves is of high quality. Indeed, not completing an adequate course of therapy was found to be more common in adults with mood disorders who eventually completed suicide than in those who did not complete suicide (Dahlsgaard et al., 1998). A brief inpatient psychiatric stay following the suicide attempt was related to both higher use of psychotropic medication and more contact with mental health professionals in the 3 months following a suicide attempt. Because hospitalization in this study was not controlled, we cannot infer causality with regard to the relationship between inpatient care and subsequent treatment compliance. Nonetheless, adolescent suicide attempters may best be served by a brief psychiatric stay, even in the absence of acute ongoing suicide risk, immediately following a suicide attempt because many families minimize the seriousness of the attempt and do not view ongoing outpatient treatment as important. Other studies, e.g., Peterson et al. (1996), have found that hospitalization of suicidal children at the time of their initial medical visit reduced the rate of repeated suicidality in subsequent ED visits. Once stabilized, a partial hospitalization program designed specifically to treat suicide attempters might significantly improve the care of these adolescents. The fact that half of the sample did not have a DISC-derived diagnosis suggests that these treatment programs should be directed specifically at suicidal behavior rather than at a psychiatric disorder. Limited access to service stands out in this study; more than half of the families in this study reported access to services as a major problem. Other studies with adolescents have also found service process characteristics to account for adolescent participation in treatment (Tolan et al., 1998). The reduction in funds for psychosocial treatment and the low reimbursement rates for psychotherapy may result in reduced access to services beyond that provided 441
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to stabilize a patient during an immediate crisis. The community mental health services that are available are often overburdened, and maintaining patients in treatment to complete a reasonable course of therapy may no longer be a priority. Nor is there any incentive, financial or otherwise, for therapists to follow these patients once a crisis has stabilized because of the large waiting lists at most agencies and clinics. In an adequate service delivery system, further investigation of individual and family characteristics that affect treatment adherence is indicated. Unfortunately, service delivery characteristics and barriers to service in this study were the most formidable obstacles to patients obtaining treatment. It is these service barriers that need to be addressed in the future. In conclusion, the type of intervention described here, which is designed to primarily affect family and individual barriers to participation in treatment, may be useful, but only if there are enough resources devoted to ensuring adequate access to services. In the Surgeon General’s recently published Call to Action to Prevent Suicide, one key recommendation was to “eliminate barriers in public and private insurance programs for provision of quality mental and substance abuse disorder treatments” (US Public Health Service, 1999). The findings reported here underscore just how critical it is to eliminate service barriers for adolescents who have attempted suicide and are seeking treatment. REFERENCES Beck AT, Schuyler D, Herman I (1974), Development of suicidal intent scales. In: The Prediction of Suicide, Beck AT, Resnik HLP, Lettiere DJ, eds. Philadelphia: Charles Press, pp 45–56 Byles J, Byrne C, Boyle MH, Offord DR (1988), Ontario Child Health Study: reliability and validity of the General Functioning subscale of the McMaster Family Assessment Device. Fam Process 27:97–104 Dahlsgaard K, Beck AT, Brown G (1998), Inadequate response to therapy as a predictor of suicide. Suicide Life Threat Behav 28:197–204 Epstein NB, Baldwin LM, Bishop DS (1983), The McMaster Family Assessment Device. J Marital Fam Ther 9:171–180 Farmer E, Angold A, Burns B, Costello EJ (1994), Reliability of self-reported service use: test-retest consistency of children’s responses to the Child and Adolescent Services Assessment. J Child Fam Stud 3:307–325 Fisher P, Shaffer D, Piacentini J et al. (1993), Sensitivity of the Diagnostic Interview for Children, second edition (DISC-2.1) for specific diagnoses of children and adolescents. J Am Acad Child Adolesc Psychiatry 32:666–673
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Hawton K, Houston K, Shepperd R (2000), Suicide in young people: study of 174 cases, aged under 25 years, based on coroners’ and medical records. Br J Psychiatry 175:271–276 Kazdin A, Wassell G (1999), Barriers to treatment participation and therapeutic change among children referred for conduct disorder. J Clin Child Psychol 28:160–172 Kazdin AE, French N, Unis A, Esveldt-Dawson K, Sherick R (1983), Hopelessness, depression and suicidal intent among psychiatrically disturbed inpatient children. J Consult Clin Psychol 51:504–510 Lehnert KL, Overholser JC, Spirito A (1994), Internalized and externalized anger in adolescent suicide attempters. J Adolesc Res 9:105–119 Peterson BS, Zhang H, Santa-Lucia R, King RA, Lewis M (1996), Risk factors for presenting problems in child psychiatric emergencies. J Am Acad Child Adolesc Psychiatry 35:1162–1173 Radloff LS (1991), The use of the Center for Epidemiologic Studies Depression Scale in adolescents and young adults. J Youth Adolesc 20:149–166 Rotheram-Borus MJ, Piacentini J, Cantwell C, Belin T, Song J (2000), The 18-month impact of an emergency room intervention for adolescent female suicide attempters. J Consult Clin Psychol 68:1081–1093 Rotheram-Borus MJ, Piacentini J, Van Roosem R et al. (1996), Enhancing treatment adherence with a specialized emergency room program for adolescent suicide attempters. J Am Acad Child Adolesc Psychiatry 35:654–663 Shaffer D, Fisher P, Dulcan MK et al. (1996), The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3): description, acceptability, prevalence rates, and performance in the MECA study. J Am Acad Child Adolesc Psychiatry 35:865–877 Shaffer D, Fisher P, Lucas C, NIMH DISC Editorial Board (1998), NIMH DISC-IV, Youth Informant Version. New York: Columbia University ([email protected]) Spielberger CE (1988), State-Trait Anger Expression Inventory. Odessa, FL: Psychological Resources Spirito A, Plummer B, Gispert M et al. (1992), Adolescent suicide attempts: outcomes at follow-up. Am J Orthopsychiatry 62:464–468 Spirito A, Sterling C, Donaldson D, Arrigan M (1996), Factor analyses of the Suicide Intent Scale with adolescent suicide attempters. J Pers Assess 67:90–101 Spirito A, Williams CA, Stark LJ, Hart KJ (1988), The Hopelessness Scale for Children: psychometric properties with normal and emotionally disturbed adolescents. J Abnorm Child Psychol 16:445–458 Suominen K, Isometsa E, Henriksson M, Ostamo A, Lonnqvist J (1998), Inadequate treatment for major depression both before and after attempted suicide. Am J Psychiatry 155:1778–1780 Tolan P, Ryan K, Jaffe C (1998), Adolescents’ mental health service use and provider, process, and recipient characteristics. J Clin Child Psychol 17:229–236 Torhorst A, Moller HJ, Burk F, Kurz A, Wachtler C, Lauter H (1987), The psychiatric management of parasuicide patients: a controlled clinical study comparing different strategies of outpatient treatment. Crisis 8:53–61 Trautman P, Stewart M, Morishima A (1993), Are adolescent suicide attempters noncompliant with outcome care? J Am Acad Child Adolesc Psychiatry 32:89–94 US Public Health Service (1999), The Surgeon General’s Call to Action to Prevent Suicide. Washington, DC: US Department of Health and Human Services, Public Health Service Zimmerman JK, Asnis GM, Schwartz BJ (1995), Enhancing outpatient treatment compliance. In: Treatment Approaches With Suicidal Adolescents, Zimmerman JK, Asnis GM, eds. New York: Wiley, pp 106–134
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ABSTRACT Objective: To determine whether a problem-solving intervention would increase adherence to outpatient treatment for adolescents after a suicide attempt. Method: Sixty-three adolescents who had attempted suicide and were evaluated in an emergency department between 1997 and 2000 were randomly assigned to undergo standard disposition planning or a compliance enhancement intervention using a problem-solving format. At 3 months after the intervention, all evaluable adolescents, guardians, and outpatient therapists were contacted to determine adherence to outpatient treatment. Results: At 3-month follow-up, the compliance enhancement group attended an average of 7.7 sessions compared with 6.4 sessions for the standard disposition group, but this difference was not statistically significant. However, after covarying barriers to receiving services in the community (such as being placed on a waiting list and insurance coverage difficulties), the compliance enhancement group attended significantly more treatment sessions than the standard disposition-planning group (mean = 8.4 versus 5.8 sessions). Conclusion: Interventions designed to improve treatment attendance must address not only individual and family factors but also service barriers encountered in the community that can impede access to services. J. Am. Acad. Child Adolesc. Psychiatry, 2002, 41(4):435–442. Key Words: adolescent suicide attempts, treatment compliance, family barriers, service barriers.
Lack of adherence to treatment regimens for psychiatric disorders is a significant problem, diminishing the potential benefits of both psychiatric and psychosocial interventions. Few would argue with the notion that adolescents who attempt suicide should receive a full evaluation, psychotropic medications as indicated, and at least a brief course of psychotherapy after the attempt. However, several studies have demonstrated a very poor rate of treatment adherence in this group of patients regardless of treatment setting. For example, Spirito et al. (1992) followed a primarily white patient sample from a range of Accepted October 19, 2001. From Brown University School of Medicine, Providence, RI. Drs. Spirito, Boergers, Donaldson, and Bishop are with the Department of Psychiatry and Human Behavior and Dr. Lewander is with the Department of Pediatrics. This investigation was supported by NIMH grant MH52411 and by a grant from the van Ameringen Foundation. Correspondence to Dr. Spirito, Clinical Psychology Training Consortium, Brown University, Box G-BH; Providence, RI 02912; e-mail: Anthony_Spirito@ Brown.edu. 0890-8567/02/4104–0435䉷2002 by the American Academy of Child and Adolescent Psychiatry.
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socioeconomic classes who were referred from the emergency department (ED) to a variety of agencies and private practitioners in the community. Approximately one third of these patients and their families went to two or fewer sessions. In another study (Trautman et al., 1993), adolescent suicide attempters and nonsuicidal adolescents stopped treatment “against medical advice” at the same rate, about 77%. However, survival analyses revealed that the suicide attempters dropped out much more quickly than nonsuicidal adolescents (median number of sessions before dropout was 3 sessions for attempters and 11 sessions for nonsuicidal adolescents). Suicide attempters who completed a course of treatment, on the other hand, attended significantly more appointments (mean = 11.6) than the dropouts. In an attempt to improve treatment adherence in this high-risk group of adolescents, training workshops for ED staff, a videotape for families regarding typical treatment, and an on-call family therapist were used for a group of primarily female Latino adolescent suicide attempters (RotheramBorus et al., 1996). The intervention slightly improved the 435
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mean number of sessions attended (5.7 versus 4.7) compared with a standard care group. Another group (Zimmerman et al., 1995) developed a multifamily psychoeducational intervention for depressed and/or suicidal adolescents (including some suicide attempters) and their families. The psychoeducational module addressed such issues as treatment adherence and the adolescent’s suicidality. However, the intervention did not improve continued attendance in treatment beyond the first appointment. Given the modest success of prior interventions addressing adherence, the purpose of the present study was to determine whether a problem-solving intervention designed to increase adherence to outpatient treatment in adolescent suicide attempters and their parents might be more efficacious than the previously described approaches. A general hospital site was chosen to study suicide attempters because it is often the first point of contact in the medical system for serious youth suicide attempts. It was hypothesized that adolescents who participated in the experimental compliance enhancement protocol would attend more outpatient psychotherapy sessions than a comparison group of adolescents who received standard disposition planning. METHOD Participants Adolescents aged 12 to 18 years who had made a suicide attempt and were receiving medical care in either the ED or pediatrics ward of a children’s hospital in the Northeast were eligible for the project. A suicide attempt was defined as any intentional self-injury, regardless of lethality, which was reported as an attempt to harm or kill oneself. The large majority of the final sample (86%) attempted suicide by overdose. There were 82 adolescents eligible for the project, and 76 (93%) of those agreed to participate in the study. Socioeconomic status (SES) was classified by state census tract data into one of four categories (poverty, low, middle, high) for families living in-state. Seven experimental and six standard disposition participants (17%) were either lost to follow-up or dropped out of the study. The final sample with complete follow-up data (N = 63; 83%) consisted of 34 participants randomly assigned to the standard disposition-planning group (32 female, 2 male) and 29 participants randomly assigned to the experimental compliance enhancement group (25 female, 4 male). Procedure Eligible participants were approached about being in the project after they had been medically stabilized after a suicide attempt and had received a standard psychiatric evaluation. Adolescents also completed a battery of diagnostic and self-report measures. After parents (and 18-year-old patients) signed an informed consent document and adolescents younger than 18 years of age assented to participate, the families were randomly assigned to either standard disposition planning or standard disposition planning plus the compliance enhancement intervention. This procedure was approved by the hospital institutional review board.
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Standard Disposition Planning Patient disposition was based on the judgment of the psychiatric clinician who conducted the evaluation. Some attempters in both groups had a brief inpatient psychiatric stay prior to receiving outpatient care. The remainder were provided with an outpatient appointment at the local mental health center. Fidelity to Standard Disposition Planning. A total of 37 (59%) of the evaluations by psychiatry service clinicians were observed to determine whether they were adequately completed. Research assistants rated patient adherence to 16 points that were deemed important to cover in a standard clinical evaluation, such as assessment of contributing factors to the suicide attempt. Adherence to these 16 points averaged 74.2% (minimum 50%, maximum 100%, SD 12.4%). Interrater reliability for these adherence ratings on 18 cases averaged 85.6% (minimum 71%, maximum 100%, SD 7.9%). Standard Disposition Planning Plus Compliance Enhancement Intervention The 1-hour compliance enhancement intervention was conducted subsequent to standard disposition planning by one of three postdoctoral fellows in psychology. The major components of the compliance enhancement intervention conducted in the hospital were as follows: to review expectations for outpatient treatment and address treatment misconceptions; to review with adolescents and parents those factors that might impede treatment attendance; and to make a verbal contract between parents and adolescent to attend at least four outpatient therapy sessions, the modal number of sessions attended in a naturalistic follow-up study of adolescent suicide attempters (Spirito et al., 1992). The adolescents and their parents or guardians were also informed that they would be contacted separately by telephone at 1, 2, 4, and 8 weeks after discharge regarding their participation in outpatient care. Most of the adolescents (83%) completed all four telephone calls. The telephone tracking method was a structured process, not psychotherapy, designed to provide support, facilitate problem solving, and help with any obstacles in obtaining care. Each telephone contact followed a specific procedure designed to review psychotherapy attendance and suicidal ideation. Potential compliance problems were identified, and the adolescent and parents were assisted in generating solutions to the problems. Interventions were provided as needed and included information distribution, expression of feelings, task directives when necessary (e.g., “call your therapist”), problem reframing, and support for treatment-seeking behaviors. Fidelity to Compliance Enhancement Intervention. To ensure fidelity to the compliance enhancement intervention, 45% of the interventions were observed and rated on 24 points to be covered in the standardized in-hospital experimental intervention. Percent adherence ranged from 83% to 100%, with a mean of 92%. Competence of Intervention Clinicians. The compliance enhancement clinician was also rated on five competence scales, including feedback to the family, interpersonal effectiveness, maintaining a focus during the contact, direct communication, and clarifying communication among family members. Ratings were made on a 3-point scale (not effective; effective; very effective). Mean competence ratings ranged from 2.6 to 3.0 (mean = 2.9, SD = 0.1). Overlap Between Standard Disposition Planning and Experimental Intervention To establish that our compliance enhancement intervention was distinct from standard disposition planning, research assistants also rated the standard disposition-planning clinical interviews on 26 top-
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ics that were contained in the compliance enhancement condition but were not expected to be covered in these standard interviews (e.g., agreement to attend at least four sessions). Although psychiatric service clinicians were not instructed to refrain from covering these issues, overlap between standard clinical practice and the compliance enhancement intervention was low, ranging from zero to 33% (mean = 7.1%, SD = 0.1%). Baseline Assessment Measures Diagnostic Interview Schedule for Children. The Diagnostic Interview Schedule for Children (DISC) is a structured interview developed for use with children and adolescents that assesses current and past symptoms, behaviors, and emotions. The version corresponding to DSMIV diagnostic criteria was used in this study (Shaffer et al., 1998). Only the diagnostic modules corresponding to the most commonly found diagnoses in samples of adolescent suicide attempters (major depression, disruptive behavior disorders, substance abuse) were administered to the adolescents. The DISC has demonstrated good to excellent diagnostic sensitivity (Fisher et al., 1993; Shaffer et al., 1996). Suicide Intent Scale. The Suicide Intent Scale (Beck et al., 1974) is a 15-item interviewer rating scale that assesses the degree of suicidal intent of the suicide attempt. Adequate psychometric characteristics have been demonstrated with adolescents (Spirito et al., 1996). Center for Epidemiologic Studies-Depression Scale. The Center for Epidemiologic Studies-Depression Scale (Radloff, 1991) is a 20-item measure of depressive symptoms which has been validated for use with adolescents (Radloff, 1991). Hopelessness Scale for Children. The Hopelessness Scale for Children (HSC) (Kazdin et al., 1983) consists of 17 true/false statements designed to measure negative expectancies toward oneself and one’s future. The HSC has shown adequate reliability and internal consistency with a sample of adolescent suicide attempters (Spirito et al., 1988). State-Trait Anger Expression Inventory. The State-Trait Anger Expression Inventory (STAXI) (Spielberger, 1988) consists of 44 items, rated on 4-point Likert scales, designed to measure both the experience of anger and the expression of anger. The STAXI has been used with adolescents (Lehnert et al., 1994), and adequate internal consistency and construct validity have been reported for the subscales (Spielberger, 1988). McMaster Family Assessment Device. The McMaster Family Assessment Device (Epstein et al., 1983) is a screening measure of family interactions that is based on the McMaster Model of Family Functioning. Respondents rate how well each item describes their family, using a 4-point scale which ranges from “strongly agree” to “strongly disagree.” The General Functioning subscale was used in this study. Adequate reliability and validity have been demonstrated for the General Functioning Subscale in a large epidemiological study with children (Byles et al., 1988). Follow-up Interview Three months after the suicide attempt, a research assistant conducted a telephone follow-up interview with parents and adolescents in each condition. This structured interview (Spirito et al., 1992) included questions regarding the number of psychotherapy sessions attended, suicidal behavior, and an open-ended question regarding any problems the parents or adolescents had concerning therapy sessions. A separate contact was also made with treatment providers. Therapists were asked to report the number of sessions attended by the patient as well as whether the therapist terminated treatment or the family terminated prematurely. Data on the number of sessions from all three sources were available for 65% of the sample; 29% of the sample had reports of the number of sessions from two sources,
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and 6% had reports from a single source. When a range of sessions was reported by an individual (e.g., “five or six sessions”), the lowest number was recorded. In the event of a discrepancy, a mean was taken to determine the total number of sessions reported. Two research assistants reviewed 3-month follow-up interview data to code barriers to treatment reported by patients and their parents. Responses to the Barriers to Service Questionnaire, a component of the Child and Adolescent Services Assessment (Farmer et al., 1994), and comments made by the patient and parent during the telephone interview were examined for the presence of barriers. Barriers were categorized into service delivery problems and family-based problems. Complete agreement on the number and types of barriers was achieved for 78% of the sample (intraclass correlation coefficient = 0.90). A postdoctoral fellow in psychology resolved any coding discrepancies. Family Barriers. Using an approach similar to other studies (Kazdin and Wassell, 1999), the following five factors were classified as family barriers to treatment: parental report of emotional problems, transportation difficulties, language problems, parent or adolescent ambivalence about treatment, cost of treatment, and scheduling difficulties. Service Barriers. The following six problems were classified as service barriers: delays in getting an appointment, being placed on a waiting list, therapist or agency reported no further treatment was needed despite patient’s or parent’s desire for further treatment, inability to switch therapists due to agency policy, and problems with insurance coverage. Statistical Analyses All evaluable patients in each group were compared on baseline and follow-up measures using t tests for continuous variables and χ2 values for dichotomous variables. Analyses of variance (ANOVAs) covarying baseline and follow-up measures that were significantly different between the groups were the primary analyses to test the research question regarding effects of the intervention on therapy attendance/ completion. Pearson correlation coefficients were calculated to examine relationships of child, family, and service barrier variables to number of therapy sessions attended. A hierarchical regression analysis was used to test the contribution of psychological and treatment variables to the number of outpatient sessions attended.
RESULTS Preliminary Analyses
Adolescents who refused to participate in the project (n = 6) were compared on age and gender to those who were enrolled. No significant differences were found. In addition, adolescents who were lost to follow-up (n = 13) were compared to those who remained in the project. There were no significant differences noted on age, gender, race, SES, or any of the baseline psychological measures. There was no difference between the compliance enhancement group and standard disposition- planning group on age (t61 = 1.98, not significant [NS]), SES (χ2 [1, N = 57] = 3.35, NS), or race (χ2 [1, N = 63] = 2.55, NS). The mean age of the sample was 15.0 years (SD = 1.4). The SES distribution, based on state census tract data, was as follows: 437
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poverty, 28%; low SES, 21%; middle level SES, 47%; and high SES, 4%. The majority of the sample was white (n = 46; 73%), followed by Hispanic (n = 8; 13%), African American (n = 7; 11%), and mixed ancestry (n = 2; 3%). Although the two groups did not significantly differ by gender (χ2 [1, N = 63] = 1.14, NS), there were only a small number of males in each group. Upon discharge, 17 adolescents (50%) in the standard disposition group were psychiatrically hospitalized versus 17 adolescents (58%) in the compliance enhancement group. There was no difference between the two groups on disposition upon discharge from the general hospital (outpatient versus inpatient psychiatric care) (χ2 [1, N = 63] = 0.47, NS). In the compliance enhancement group, 68% had a history of mental health treatment versus 52% in the standard care group (χ2 [1, N = 58] = 1.59, NS). The rates of psychotropic medication use in the compliance enhancement group (56%) and the standard care group (36%) was also nonsignificant (χ2 [1, N = 58] = 2.22, NS). Psychiatric Diagnoses
The short length of stay precluded completing the CDISC with all adolescents. C-DISC–derived DSM-IV diagnoses were available on 46 patients; 50% of the sample did not meet criteria for a diagnosis. Twenty-eight diagnoses were recorded for the remaining 23 adolescents. Two adolescents in the compliance enhancement group and three in the standard disposition-planning group had comorbid diagnoses. The diagnoses were as follows: one dysthymia, six major depression, five oppositional defiant disorder, six conduct disorder, four alcohol abuse, four marijuana abuse, and two marijuana dependence.
Chi-square analyses were used to compare the two groups on each of the C-DISC diagnoses, and none of the differences was significant. Group Comparisons on Baseline Psychological Measures and Follow-up Data
A series of t tests was used to compare the two groups on the psychological measures administered at baseline. As shown in Table 1, the only statistically significant difference between the groups was with respect to hopelessness, with adolescents in the compliance enhancement group reporting greater levels of hopelessness at baseline. The two groups were also compared on follow-up measures of family barriers and service barriers. As noted in Table 2, the groups did not differ on mean number of family barriers. In the compliance enhancement group, 33% of the families reported experiencing a family barrier compared with 22% of the standard care group. The rates of reported family barriers did not differ across groups (χ2 [1, N = 58] = 1.03, NS). The types of family barriers reported were as follows: parental psychiatric problems (3%), transportation difficulties (3%), parental ambivalence about treatment (5%), concerns about the cost of treatment (12%), scheduling difficulties (3%), and adolescent resistance to treatment (14%). As noted in Table 2, adolescents and parents in the compliance enhancement group on average reported significantly more service barriers. In the compliance enhancement group, 43% of the families reported experiencing a service barrier compared with 15% in the standard care group. Overall, 58% of the sample reported experiencing a service barrier. The rates of reported service barriers were significantly different across groups (χ2 [1, N = 56] = 5.15
TABLE 1 Baseline Measures of Psychological Functioning by Group Compliance Enhancement
No. of prior suicide attempts Suicide Intent Scale CES-D HSC STAXI FAD-Global Functioning
Standard Disposition Planning
Mean
SD
n
Mean
SD
n
t
d
0.5 11.4 30.9 8.0 33.8
0.8 6.7 12.7 5.3 13.4
29 25 27 28 28
0.6 10.2 27.5 4.0 32.7
1.0 6.6 15.1 3.7 12.6
34 26 32 32 32
0.31 0.69 0.94 3.43*** 0.33
0.11 0.18 0.24 0.88 0.08
2.5
0.5
28
2.4
0.6
32
0.90
0.18
Note: d = effect size; CES-D = Center for Epidemiologic Studies-Depression Scale; HSC = Hopelessness Scale for Children; STAXI = total score for the State-Trait Anger Expression Inventory; FAD = Family Assessment Device. *** p < .001.
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TABLE 2 Means and Standard Deviations by Group on Follow-up Measures Compliance Enhancement
Family barriers Service barriers Outpatient therapy sessions (no.)
Standard Disposition Planning
Mean
SD
n
Mean
SD
n
t
d
0.3 0.9
0.8 1.2
29 29
0.2 0.2
0.4 0.4
34 34
1.12 2.87**
0.16 0.79
7.7
5.8
29
6.4
4.4
34
1.01
0.25
Note: d = effect size. ** p < .01.
p < .05). The types of service barriers reported by the two groups were as follows: waiting lists (30% compliance enhancement, 4% standard care), problems in scheduling additional appointments (17% compliance enhancement, 4% standard care), language barriers (0% compliance enhancement, 7% standard care), problems with insurance coverage (13% compliance enhancement; 4% standard care), and dissatisfaction with therapist (10% compliance enhancement, 4% standard care). Effects of the Intervention on Number of Sessions and Premature Termination
A direct comparison of the groups by t test did not reveal a statistically significant difference between the compliance enhancement (mean = 7.7, SD = 5.8) and standard disposition (mean = 6.4, SD = 4.4) groups on number of sessions attended (t61 = 1.01, NS). The compliance enhancement and standard disposition groups were also comparable on the number of no-shows (i.e., never attended therapy): 6.9% versus 8.8%, respectively (χ2 [1, N = 63] = 0.08, NS). Because families in the compliance enhancement group were asked to attend four sessions before considering termination, the two groups were compared on the percentage of participants who attended four or more sessions. A χ2 analysis did not reveal a significant difference between groups (χ2 [1, N = 63] = 0.52, NS); 75.9% of the compliance enhancement group attended four or more sessions compared with 67.6% of the standard disposition group. Finally, the groups were compared on rates of premature termination. Premature termination was based on either parent or therapist report. In the compliance enhancement group, 42% of the families reported stopping treatment prematurely compared with 52% in the standard core group. This difference was not statistically significant (χ2 [1, N = 58] = 0.95, NS). J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 4 , A P R I L 2 0 0 2
Effects of Intervention Accounting for Potential Confounds
Analyses were conducted to control for differences between groups that were noted at baseline (hopelessness) and follow-up (service barriers). An ANOVA covarying baseline scores on the HSC did not reveal a statistically significant difference on number of sessions of outpatient treatment between the compliance enhancement and standard disposition groups (F1,60 = 0.07, NS). A separate ANOVA covarying service barriers was statistically significant (F1,60 = 4.07, p < .05): the compliance enhancement group attended significantly more outpatient psychotherapy sessions (mean = 8.4, SE = 10.9; 95% confidence interval 6.5, 10.2) than the standard disposition group (mean = 5.8, SE = 10.9; 95% confidence interval 4.1, 7.5). Other Predictors of Treatment Attendance
Table 3 presents the correlation coefficients between the number of psychotherapy sessions attended and the child, family, and service variables. Higher levels of depression, a greater number of prior suicide attempts, and more family and service barriers to treatment were all significantly related to fewer treatment sessions attended. Three other potential predictors of treatment attendance were also examined: prior mental health treatment, inpatient psychiatric treatment immediately after the suicide attempt, and psychotropic medication use. A t test comparing those who reported mental health treatment versus no treatment prior to the suicide attempt did not reveal a significant difference in number of sessions attended (7.5 ± 5.1 versus 5.7 ± 4.4; t56 = 1.38, NS). An ANOVA comparing three groups (no treatment, prior treatment, and current treatment) was also nonsignificant (F2,57 = 1.39, NS). Adolescents who were discharged from the ED to inpatient psychiatric care did not differ on sociodemographic 439
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TABLE 3 Correlations Between Number of Therapy Sessions and Child, Family, and Service Variables No. of Therapy Sessions Attended r Child variables Suicide Intent Scale HSC CES-D STAXI No. of prior attempts Family variables FAD Global Functioning Family barriers (total no.) Service barriers Total no.
n
0.23 0.17 0.27* 0.07 0.34**
51 60 59 60 63
0.18 –0.62***
60 63
–0.33**
63
Note: HSC = Hopelessness Scale for Children; CES-D = Center for Epidemiologic Studies-Depression Scale; STAXI = State-Trait Anger Expression Inventory; FAD = Family Assessment Device. * p < .05; ** p < .01; *** p < .001.
characteristics but, as might be expected, obtained higher (worse) scores on the measures of depression, hopelessness, anger, drinking, suicide intent, and family functioning. Adolescents discharged to inpatient care attended significantly more sessions than those referred only to outpatient care (8.7 ± 5.2 versus 4.9 ± 4.1; t61 = 3.16, p < .05). A difference in therapy sessions attended also depended on whether or not adolescents were taking prescribed medications (t56 = 2.97, p < .01). The adolescents taking psychotropic medications (n = 26) attended more sessions (mean = 9.1, SD = 5.4) than those not taking medications (n = 32, mean = 5.3, SD = 4.4). However, medication visits were included in the total number of sessions, which inflated the number of sessions attended. A χ2 analysis revealed that there was a relationship between psychotropic medication use and inpatient treatment following the attempt (χ2 [1, N = 58] 12.48, p < .001). Adolescents who were admitted to a psychiatric unit after their suicide attempt were more likely to be prescribed psychotropic medications. Regression Analyses
To determine the relative contribution of psychological factors and treatment barriers to treatment attendance (i.e., number of sessions attended), a hierarchical linear regression analysis was conducted. Only variables found to correlate with the number of psychotherapy sessions in the bivariate analyses were entered into the regression. As shown in Table 4, psychological characteristics 440
TABLE 4 Hierarchical Linear Regression Analyses Predicting Number of Therapy Sessions Variables
β
Step 1. psychological characteristics Prior suicide attempts CES-D total score
.29 .12
Step 2. treatment barriers Family barriers Service barriers
R2
F
0.16
6.51**
0.14
7.27**
–.38 –.09
Note: CES-D = Center for Epidemiologic Studies-Depression Scale. ** p < .01.
and treatment barriers both significantly predicted treatment attendance and accounted for an almost equal amount of the variance, 16% versus 14%, respectively. DISCUSSION
Lack of adherence to treatment is a significant problem in psychotherapy research and has been shown to be particularly problematic with adolescent suicide attempters. The compliance enhancement intervention in this study was effective in increasing treatment adherence compared with standard disposition planning only when the barriers to service in the community were controlled. Thus, problem-solving interventions with families were not sufficient to overcome barriers to service. When barriers to service were covaried in the analyses, the intervention resulted in significantly greater treatment adherence (eight versus five sessions) compared with the standard disposition-planning group. This three-session improvement is comparable with that reported by Rotheram-Borus et al. (2000) in their ED intervention. The intervention provided here addressed a broader range of factors related to treatment adherence than previous studies. Not only were adolescent and parental expectations about treatment and understanding of suicidal behavior addressed in the present study, but also the barriers families encountered to obtaining services. The latter area was addressed most specifically during the follow-up telephone calls. Thus it is surprising that even with follow-up assistance for up to 2 months by doctoral-level clinicians, these same families could not overcome the barriers to receiving treatment in the community. A study with adult suicide attempters in Germany (Torhorst et al., 1987) also found that special motivation procedures did not improve treatment adherence when patients had to change therapists or institutions. Similarly, a recent study J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 4 , A P R I L 2 0 0 2
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in Finland reported inadequate psychopharmacological and psychotherapeutic treatment following suicide attempts in adults that could not be attributed to patient nonadherence (Suominen et al., 1998). Could other factors, such as patient characteristics, have affected the efficacy of the intervention? A prior suicide attempt was not related to better treatment attendance. Although the compliance enhancement group reported significantly higher levels of hopelessness than the standard disposition-planning group, when hopelessness was controlled in the analyses, there was no effect on treatment adherence. Family barriers to participation in treatment, such as expectations about treatment, have been shown to affect adherence in other studies (Kazdin and Wassell, 1999). These factors were addressed in the compliance enhancement intervention, but they did not affect treatment adherence. It is possible that the results could be a factor of other family variables not measured, such as adverse family living arrangements. For example, Rotheram-Borus et al. (2000) reported that family adaptability characterized the families of adolescents who attended three to six sessions versus those who attended zero to two sessions. One factor was related to treatment adherence: a brief psychiatric hospitalization after the attempt did result in greater treatment attendance at follow-up. This may have been related to the fact that adolescents who were hospitalized were also prescribed medication more frequently than those referred to outpatient care. Thus they were more likely to have contact with mental health professionals because they had therapy and medication appointments as outpatients. The hospitalized patients were also likely to be more seriously ill, which may have resulted in more attention to aftercare by their families. Alternatively, the hospitalization itself may have impressed upon families the seriousness of the suicide attempt and the need to follow through with outpatient treatment. Limitations
Several limitations should be considered in evaluating these findings. First, the groups were relatively small, limiting the power to detect differences in outcome. Similarly, the small number of subjects affects regression analyses and the stability of the β weight coefficients. Second, the experimental group may have been more sensitized to reporting barriers at follow-up because they participated in an intervention that helped them solve problems related to service access. Alternatively, respondents in the experJ . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 4 , A P R I L 2 0 0 2
imental group may have reported more barriers to service to rationalize their failure to attend therapy. Third, perceptions of the adolescent and family toward the treating clinician, another potential barrier, was not assessed in this study. Clinical Implications
A recent study in Britain (Hawton et al., 2000) of 174 cases of completed suicide in youths under 25 years of age found that almost half of the suicide victims had attempted suicide in the year before their death. This finding led Hawton et al. (2000) to emphasize the need to ensure that clinical services for adolescents who harm themselves is of high quality. Indeed, not completing an adequate course of therapy was found to be more common in adults with mood disorders who eventually completed suicide than in those who did not complete suicide (Dahlsgaard et al., 1998). A brief inpatient psychiatric stay following the suicide attempt was related to both higher use of psychotropic medication and more contact with mental health professionals in the 3 months following a suicide attempt. Because hospitalization in this study was not controlled, we cannot infer causality with regard to the relationship between inpatient care and subsequent treatment compliance. Nonetheless, adolescent suicide attempters may best be served by a brief psychiatric stay, even in the absence of acute ongoing suicide risk, immediately following a suicide attempt because many families minimize the seriousness of the attempt and do not view ongoing outpatient treatment as important. Other studies, e.g., Peterson et al. (1996), have found that hospitalization of suicidal children at the time of their initial medical visit reduced the rate of repeated suicidality in subsequent ED visits. Once stabilized, a partial hospitalization program designed specifically to treat suicide attempters might significantly improve the care of these adolescents. The fact that half of the sample did not have a DISC-derived diagnosis suggests that these treatment programs should be directed specifically at suicidal behavior rather than at a psychiatric disorder. Limited access to service stands out in this study; more than half of the families in this study reported access to services as a major problem. Other studies with adolescents have also found service process characteristics to account for adolescent participation in treatment (Tolan et al., 1998). The reduction in funds for psychosocial treatment and the low reimbursement rates for psychotherapy may result in reduced access to services beyond that provided 441
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to stabilize a patient during an immediate crisis. The community mental health services that are available are often overburdened, and maintaining patients in treatment to complete a reasonable course of therapy may no longer be a priority. Nor is there any incentive, financial or otherwise, for therapists to follow these patients once a crisis has stabilized because of the large waiting lists at most agencies and clinics. In an adequate service delivery system, further investigation of individual and family characteristics that affect treatment adherence is indicated. Unfortunately, service delivery characteristics and barriers to service in this study were the most formidable obstacles to patients obtaining treatment. It is these service barriers that need to be addressed in the future. In conclusion, the type of intervention described here, which is designed to primarily affect family and individual barriers to participation in treatment, may be useful, but only if there are enough resources devoted to ensuring adequate access to services. In the Surgeon General’s recently published Call to Action to Prevent Suicide, one key recommendation was to “eliminate barriers in public and private insurance programs for provision of quality mental and substance abuse disorder treatments” (US Public Health Service, 1999). The findings reported here underscore just how critical it is to eliminate service barriers for adolescents who have attempted suicide and are seeking treatment. REFERENCES Beck AT, Schuyler D, Herman I (1974), Development of suicidal intent scales. In: The Prediction of Suicide, Beck AT, Resnik HLP, Lettiere DJ, eds. Philadelphia: Charles Press, pp 45–56 Byles J, Byrne C, Boyle MH, Offord DR (1988), Ontario Child Health Study: reliability and validity of the General Functioning subscale of the McMaster Family Assessment Device. Fam Process 27:97–104 Dahlsgaard K, Beck AT, Brown G (1998), Inadequate response to therapy as a predictor of suicide. Suicide Life Threat Behav 28:197–204 Epstein NB, Baldwin LM, Bishop DS (1983), The McMaster Family Assessment Device. J Marital Fam Ther 9:171–180 Farmer E, Angold A, Burns B, Costello EJ (1994), Reliability of self-reported service use: test-retest consistency of children’s responses to the Child and Adolescent Services Assessment. J Child Fam Stud 3:307–325 Fisher P, Shaffer D, Piacentini J et al. (1993), Sensitivity of the Diagnostic Interview for Children, second edition (DISC-2.1) for specific diagnoses of children and adolescents. J Am Acad Child Adolesc Psychiatry 32:666–673
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