Commentary on the National Comorbidity Survey Replication

Jill Littrell, PhD
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An article by Benedict Carey in the New York Times on January 9, 2013 and also the PBS Newshour that same day reported on a publication by lead author Matthew Nock in JAMA Psychiatry. The article presented the results of a reanalysis of data from the National Comorbidity Survey Replication Adolescent Supplement. The main finding was that of the 6483 adolescents between the ages of 13 to 18 surveyed, 12% reported suicidal ideation, 4.0% had planned a suicide, and 4.1% had attempted suicide. 55.3% of those reporting suicidal ideation had received treatment prior to suicidal ideation. 61.7% of those planning suicide had received treatment prior to making plans. Of those adolescents who made a suicide attempt, 67.1% had received treatment either at least one year before the attempt or during the same year (15.2%). Almost all of those attempting suicide were in treatment at some point during the study (94.2%). Initiating treatment after the suicide attempt was the case for only 11.9%, as most were already in treatment.

Nock et al. did raise the question regarding whether current treatments are efficacious. Unfortunately, in their analysis, Nock et al. did not differentiate treatments involving pharmaceuticals from treatments in which pharmaceuticals were not involved. Moreover, the question of whether treatment worsens outcome was not raised. Answering such a question could only be addressed through random assignment of those meeting inclusion-criteria to treatment or not. However, the FDA blackbox warning for suicidal ideation on antidepressants implies that pharmacological treatment may indeed be a causal factor in the elevated rates of suicidal behavior exhibited by adolescents in the U.S. With regard to another interesting finding from the study, Nock et al. also reported that adolescents whose parents had not gone to college were less likely to have contemplated suicide.

It is frustrating that so little can be definitively gleaned from the Nock et al. study. The results do, however, suggest that the vast majority of those adolescents who might attempt suicide are already in treatment. This should discourage efforts to identify even more children at risk and get them in to treatment if the rationale for screening is to prevent suicide attempts. Another obvious bottom-line from this study is that efforts should be made to identify those treatments which are efficacious in preventing suicidal ideation. The finding that adolescents with less well educated parents exhibit lower rates of suicidal behavior also raises questions about the current culture’s obsession with mental health. According to the World Health Organization, suicide rates have increased by 60% over the past 45 years. There is little evidence that the culture’s increased awareness of the symptoms of mental illness has been useful in preventing suicide.

Carey, B. (2013, January 9). Study questions effectiveness of therapy for suicidal teenagers. New York Times, A11.

Ifill, G. (2013, January 9). Study shows many teens at risk for suicidal behavior despite mental health help. PBS Newshour.

Nock, M.K., Green, J. G., Hwang, I., McLaughlin, K. A., Sampson, N. A., Zaslavsky, A. M., & Kessler, R. C. (2013). Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents. JAMA Psychiatry, doi.10.1001/2013.jamapsychiatry.55

2 COMMENTS

  1. Even from faraway Down Under I’ve noticed that this study is getting a lot of media attention. Here’s one from Reuters where the lead author, Matthew Nock, is quoted as saying:

    “… we don’t have any evidence-based treatments for suicidal behavior.”

    And one of the experts interviewed by PBS, psychologist Brian Daly, made the following comment on the study:

    “And I think we’re seeing some new evidence that suggests even though we’re able to reduce some of these symptoms of depression, it doesn’t necessarily mean that thoughts of suicide or suicide plans are going to drop as well.”

    http://www.pbs.org/newshour/bb/health/jan-june13/suicide_01-09.html

    The experts seem bewildered, and the media understandably concerned, that treatments for depression that are promoted as “safe and effective” don’t seem to help prevent suicide and suicidal thoughts. And then, of course, there is the question of whether these treatments might trigger suicidal feelings.

  2. “The finding that adolescents with less well educated parents exhibit lower rates of suicidal behavior also raises questions about the current culture’s obsession with mental health. According to the World Health Organization, suicide rates have increased by 60% over the past 45 years. There is little evidence that the culture’s increased awareness of the symptoms of mental illness has been useful in preventing suicide.”

    Wow Jill. It’s sad to realize the anti-intellectualism of the grown kids of many of us formally educated Boomers is a deserved reaction to the hubris, greed and heavy handedness with which we’ve applied our so-called knowledge.