CBT for Child Anxiety May Confer Long-Term Protection From Suicidality

Successful cognitive-behavioral therapy (CBT) for childhood anxiety disorder may confer long-term benefits for suicide prevention, according to a report published online in the Journal of the Academy of Child and Adolescent Psychiatry on December 17, 2014.

Evidence for an independent relationship between anxiety and suicidality has been mixed, but a study, “Cognitive-Behavioral Therapy for Child Anxiety Confers Long-Term Protection From Suicidality,” appears to show a correlation between anxiety and later suicidality and between treatment response and suicidality.

“The [study] is the first to demonstrate the protective function of successful evidence-based treatment for childhood anxiety disorders on suicidal ideation in late adolescence and young adulthood,” said Courtney Benjamin Wolk, Ph.D., and colleagues at the Center for Mental Health Policy and Services Research at the University of Pennsylvania Perelman School of Medicine.

They analyzed follow-up data on a sample of children drawn from two separate randomized, controlled trials evaluating CBT for child anxiety reported in the Journal of Consulting and Clinical Psychology in 1997 and 2008. A total of 155 young people were eligible to participate, of whom 66 were located and participated in follow-up.

At posttreatment evaluation, 40 (60.6 percent) subjects were classified as treatment responders (defined as the principal anxiety disorder at pretreatment no longer present at posttreatment), and 26 (39.4 percent) were treatment nonresponders. At 7- to 19-year follow-up, treatment responders had significantly lower rates of panic disorder, alcohol dependence, and drug abuse in adulthood when compared with treatment nonresponders.

Information regarding suicidality at follow-up was obtained via the World Mental Health Survey Initiative Version of the World Health Organization Composite International Diagnostic Interview (CIDI) and the Beck Depression Inventory.

At 7- to 19-year follow-up, 18 (27.3 percent) participants reported experiencing suicidal ideation in their lifetime, nine (13.6 percent) endorsed having made one or more suicide plans, and six (9.1 percent) described one or more suicide attempts in their lifetime on the CIDI. A retrospective report indicated that suicidal ideation had a mean age of onset of 15.83 and had occurred most often at a mean age of 19.61.

Statistical analysis demonstrated that treatment response significantly predicted lifetime suicidal ideation endorsement on the CIDI, such that those who were treatment nonresponders were more likely to report having experienced suicidal ideation at 7- to 19-year follow-up. This remained significant when controlling for additional pretreatment variables hypothesized to predict increased risk for suicidality, including primary diagnosis and presence/absence of a childhood depressive disorder.

Moreover, those who were treatment nonresponders were significantly more likely than responders to report having experienced suicidal ideation in the past 12 months and past two weeks at 7- to 19-year follow-up.

The researchers acknowledged that there was no control group, so it is not appropriate to infer causation from the study results. Moreover, suicide plans and attempts were infrequently endorsed in the sample, which may have limited the ability to detect differences between treatment responders and nonresponders.

Nonetheless, the researchers said the results are important. “It was particularly noteworthy that no participants who were CBT treatment responders endorsed experiencing suicidal ideation in the past month or past two weeks at 7- to 19-year follow-up,” they stated. “Conversely, treatment nonresponders were more likely to endorse lifetime and recent suicidal ideation, suggesting more chronic and enduring patterns of suicidal ideation, which potentially confers risk for suicidal plans, attempts, and completion. This pattern was observed for both self-report and interview report of suicidal ideation, strengthening confidence in the robustness of this finding. The findings add to a growing literature suggesting that successful CBT for a childhood anxiety disorder confers protection from later sequelae.”

They added that timing emerged as an important pattern in suicidality. “In those individuals who experienced suicidality, suicidal ideation reportedly manifested in midadolescence and, importantly, did so several years prior to suicidal plans and/or attempts,” they stated. “Cross-sectional studies have previously indicated that the conversion from suicidal ideation to attempts typically occurs within one year of ideation onset, suggesting a potentially longer conversion window among youth with anxiety disorders with respect to suicidal ideation. This window may be a critical time for suicidality prevention and intervention occurring in mid- to late adolescence.”

The study was supported by the National Institute of Mental Health. ■