Feasibility of an Integrated Treatment Approach for Youth with Depression, Suicide Attempts, and Substance Use Problems

Abstract

Depression, suicidal behaviors and substance use problems frequently co-occur, and treatment for youth with these co-occurring problems is often fragmented and challenging. An integrated cognitive-behavioral treatment approach that builds upon a relapse prevention framework and applies common core skills, language, and approach for treating these related problems may be clinically beneficial. Following a description of the integrated approach, we present results of a pilot trial (n = 13) to examine the acceptability and feasibility of the Cognitive-Behavioral Therapy – Relapse Prevention (CBT-RP) intervention plus enhanced treatment as usual (TAU) compared to enhanced TAU alone. The feasibility of the CBT-RP + TAU intervention was reflected by high rates of retention (86%). The acceptability was reflected in positive evaluations regarding the helpfulness of the intervention by adolescents and families. The majority of youth in both CBT-RP + TAU and TAU alone groups evidenced reductions in depression and suicide ideation from study entry to Week 20. Patterns of reduction were more consistent, however, for youth receiving CBT-RP + TAU, and reductions were slower to emerge for some youth receiving TAU alone. Reductions in alcohol and marijuana problems were similar, but half of the youth in TAU alone (and none in the CBT-RP + TAU group) had emergency department visits related to psychiatric crises or substance related problems. These findings, although based on a small sample, underscore the feasibility and acceptability of an integrated cognitive-behavioral relapse prevention approach for youth with depression, suicide attempt histories, and substance use problems.

Suicidal behavior among youth is multiply determined and associated with heterogeneous developmental pathways and contextual factors (Foley et al., 2006; Goldston et al., 2009; 2016). One of the factors often associated with suicidal behaviors, particularly as youth get older, is substance use problems (Goldston et al., 2009). Rates of suicidal behaviors are higher among individuals with substance use problems, especially those with more severe difficulties (Esposito-Smythers & Spirito, 2004; Goldston, 2004). Conversely, individuals with suicidal behaviors often have higher rates of substance use problems than the general population (Esposito-Smythers & Spirito, 2004).

Depression also co-occurs both with suicidal behaviors (Goldston et al., 2009) and with substance use disorders (Conner, Bagge, et al., 2014; Conner, Gamble, et al., 2014). Substance use can affect mood (Volkow, Koob, et al., 2016), and decrease motivation for behaviors that might be protective against depression (Volkow, Koob, et al., 2016; Volkow, Swanson, et al., 2016). On the other hand, some individuals may try to “self-medicate” with substances in order to relieve their depression (Esposito-Smythers & Goldston, 2008). Individuals who are depressed may be more likely to perceive fewer reasons for living and to have greater hopelessness about the future, both of which are risk factors for suicide attempts among adolescents (Goldston et al., 2001). These interrelationships were illustrated in the Treatment for Adolescents with Depression Study (TADS) in that lower severity of suicide ideation at baseline was predictive of positive response to short-term treatment for depression (Curry et al., 2006). Positive response to treatment, in turn, was associated with lower rates of subsequent substance use disorders (but not alcohol use disorders) among adolescents (Curry et al., 2012).

Youth with these co-occurring sets of problems can be particularly challenging to treat. For example, youth with substance use problems may be more impulsive and likely to act on suicidal thoughts, and substance use can worsen levels of depression (Esposito-Smythers & Goldston, 2008). Adolescents with substance use or with suicidal behaviors may have considerable ambivalence about being in treatment, and they may be less likely to follow through with treatment recommendations or more likely to discontinue treatment prematurely (Esposito-Smythers & Goldston, 2008). Even when they do receive treatment, these youth often receive fragmented, uncoordinated care with different clinicians focusing on mental health and on substance use issues (Esposito-Smythers & Goldston, 2008).

Nonetheless, despite the challenges of this population, and the interrelationship among the difficulties, there have been few interventions developed for youth with these co-occurring problems. In one promising exception, Esposito-Smythers and colleagues (Esposito-Smythers et al., 2011) developed the Integrated Cognitive-Behavioral Therapy (I-CBT) intervention for suicidal youth with alcohol/substance use problems and their parents. I-CBT is an integrated intervention that utilizes motivational enhancement and cognitive-behavioral therapeutic approaches, and requires two therapists – one therapist working with the youth and a separate therapist with the parents. In a randomized trial, the I-CBT intervention was found to be associated with lower rates of suicide attempts; fewer heavy drinking days and days of marijuana use; and lower rates of emergency department visits, psychiatric hospitalizations, and arrests, relative to treatment as usual (Esposito-Smythers et al., 2011). Dialectical Behavioral Therapy (DBT; Linehan, 1993) also has been shown to be effective in reducing suicide attempts and self-harm in adolescent populations (McCauley et al., 2018), and an adaptation of DBT also has been shown to have effects in adults on substance use (Linehan et al, 1999; Linehan et al., 2002).

Goldston (2004) and Goldston, Tunno, and Esposito-Smythers (2019) described how an integrated functional approach to co-occurring substance use and suicidal behaviors could be used to inform treatment strategies. Using a functional analysis (Goldfried & Sprafkin, 1974), triggers, vulnerability and protective factors, and consequences of suicidal behavior, depression, and substance use can be identified. Building on this analysis, the data regarding functional relationships can be used to understand the association between these areas of difficulty, as well as promising points of cognitive-behavioral intervention that might affect different sets of problems.

Information gained via a careful functional analysis can be integrated with a cognitive behavioral relapse prevention (RP) approach to intervention (Marlatt & Gordon, 1985), particularly given the fact that substance use, suicidal behaviors, and co-occurring depression all may be recurring problems for some individuals. Drawing upon cognitive-behavioral principles, this approach suggests that several sets of factors contribute to relapse including (1) immediate determinants (i.e., high risk situations), (2) coping skills and outcome expectancies, (3) the abstinence violation effect (i.e., the lack of self-efficacy that often occurs following problem behavior), and (4) lifestyle factors such as the balance between stresses and pleasurable or fulfilling activities, and availability of alternatives to target behaviors (Larimer, Palmer, & Marlatt, 1999; Marlatt & Gordon, 1985; Witkiewitz & Marlatt, 2004).

Integrated interventions grounded in the relapse prevention model (RP) can focus on each of these sets of factors. For example, in addressing high-risk situations, interventions may focus on increasing awareness of the paths leading to, and decisions related to problematic behavior (Larimer et al., 1999; Marlatt & Gordon, 1985). Hand-in-hand with this approach, an RP-focused intervention may help facilitate skill development and encouragement of alternative behavioral patterns that do not involve substances or self-harming behavior and might relieve depression. To the extent that someone who uses alcohol or other substances anticipates positive social consequences, or relief from unpleasant emotions when they use, this integrated, RP-focused approach might focus on the development of other ways to relieve distress or to receive positive social support, as well as greater awareness of both the positive and negative consequences of use. In a similar manner, if someone anticipates escape from unpleasant emotions or intolerable life circumstances when they engage in suicidal behavior, a RP-focused intervention could help the individual expand their coping tools to help promote the realization that suicidal behavior is not the only approach for managing difficult-to-tolerate and painful emotions. This integrated, RP-focused approach also may encourage the patient to engage in activities that are associated with improved mood, engender hope, and underscore reasons for living. Individuals who have been trying to eliminate or reduce certain behaviors, but have lapses, may begin to feel that they do not or cannot have control over their problem behavior (Larimer et al., 1999; Marlatt & Gordon, 1985). Because this lack of self-efficacy can erode motivation to continue trying to engage in more positive coping or alternative behaviors, a RP-focused approach may encourage enhancement of self-efficacy and preparation for the possibility of occasional recurrences of difficulties (Larimer et al., 1999; Marlatt & Gordon, 1985). Lastly, a RP-focused approach may encourage individuals to have greater lifestyle balance, helping them consider ways of reducing stress and demands, and ways of increasing involvement with (non-alcohol- or drug-related) activities that provide pleasure and/or a sense of control (i.e., activities that individuals “want to do,” rather than activities they believe they “have to do;” Larimer et al., 1999; Marlatt & Gordon, 1985).

Interventions targeting motivation and mindfulness also are very compatible with a RP approach (Witkiewitz & Marlatt, 2004) and both can be used with clients who are experiencing substance use and/or suicidal thoughts or behaviors. For instance, Motivational Enhancement Therapy can help address the ambivalence often experienced by individuals with substance use and/or suicidal thoughts and behaviors about using or cutting back on use, living or dying, or engaging in treatment while emphasizing the client’s control over the process. Similarly, mindfulness can help the individual “step back” in order to recognize the thoughts, emotions, and behavioral patterns that contribute to risk, and the changes needed to enact more advantageous behavioral decisions.

For youth who have depression, suicidal behavior histories, and substance use problems, an integrated relapse prevention approach potentially provides a common framework, a common way to think about skills, and an approach for identifying parallels in use of alcohol/substances and suicidal behaviors. The purpose of the current project was to develop and preliminarily evaluate the feasibility and acceptability of such an integrated intervention for youth with co-occurring depression, suicidal behavior, and substance use problems.

Following the process for behavioral treatment development described by Rounsaville and colleagues (2001), a phased and iterative approach was taken to treatment development. First, the manual was developed, emphasizing an integrated approach with concepts from the relapse prevention model of Marlatt and Gordon (1985). This process included adapting modules from several sources to ensure consistency with an integrated approach and the relapse prevention model, as well as creating new modules. This draft manual was then shared with several clinicians and national experts who provided feedback that was then used to refine the manual. A small open trial with 13 cases was then conducted, in which study investigators served as therapists. To ensure that all participants in the trial received at least the level of mental health treatment they typically would receive in the community, the new therapeutic approach was developed as an augmenting intervention (i.e., as a complement to treatment as usually delivered). Based on experiences in the open trial, there were several additional revisions to the manual (e.g., addition of the possibility of more frequent sessions in first two weeks to address acute risk; new adolescent and parent modules).

Thereafter, we conducted a small pilot randomized controlled trial with an additional 13 individuals to examine feasibility and acceptability of the integrated approach. This report describes the cognitive-behavioral relapse prevention (CBT-RP) approach and the results of the pilot randomized controlled trial examining feasibility and acceptability of this augmenting intervention. Feasibility, as defined in the context of implementation science, refers to “the extent to which a new treatment, or an innovation, can be successfully used or carried out within a given agency or setting” (Lewis et al., 2015). For feasibility, we examined data regarding recruitment and retention in the study. Acceptability refers to the “perception among implementation stakeholders that a given treatment, service, practice, or innovation is agreeable, palatable, or satisfactory” (Lewis et al., 2015). To document acceptability, we examined data regarding youth and family impressions of the intervention approach. To provide a preliminary indication of whether the intervention was having intended effects, we examined individual-level patterns of change in the key outcomes.

Method

The Cognitive-Behavioral Therapy Relapse Prevention Intervention

Overview of the Integrated CBT-RP Intervention.

CBT-RP focused on four contributors to the maintenance of behavior change: (1) enhanced ability to anticipate, reduce, or cope with high-risk situations (i.e., emphasis on behavioral pathways, the consequences of different decisions, and choice points); (2) use of alternative behaviors to suicidal and substance use that are self-reinforcing or receive reinforcement from the environment; (3) increased self-efficacy and reasons for living and for quitting substances; and (4) cultivation of a positive lifestyle balance. The intervention included a focus on reduction of active problems (depression, suicidal thoughts, and substance related problems) as well as the focus on reducing recurrence of difficulties.

Choice of Modules.

The modules for CBT-RP, categorized by their frequency of use in the pilot RCT, are listed in Table 1. Certain modules were required for all adolescents. These included the module on understanding the context of suicidal and substance use behaviors, and the interrelationship between depression, suicide risk, and substance use (the functional analyses), safety planning, identifying reasons for living and reasons for quitting substances, motivational interviewing, problem-solving, and thought monitoring.

Table 1.

Cognitive-Behavioral Therapy – Relapse Prevention (CBT-RP) Modules

I. Modules Used With Almost Every CBT-RP Patient in Pilot Randomized Trial*
A. Crisis Management, Listening to the Story, and Working with the Depressed, Suicidal, and Substance Using Teen
B. Developing and Refining the Suicide Safety Plan
C. Motivational Interviewing
D. Increasing Reasons for Living, and Increasing Reasons for Quitting Drugs and Alcohol
E. Developing the Functional Analyses of Depression/Suicidal Thoughts and Behavior, and Alcohol and Substance Use
F. Psychoeducation about Depression, Suicide Risk, Alcohol and Substance Use, and Their Interrelationship
G. Using the Functional Analysis to Plan for Difficulties
H. Cognitive Restructuring for Depression, Suicidal Urges, or Alcohol and Substance Use
I. Mood Monitoring and Affect Regulation
J. Problem-Solving and Considering Consequences
K. Increasing (Non-Substance Using) Pleasant Activities and Establishing a Positive Lifestyle Balance
L. Increasing Positive Supports (Who Support Reduction in Alcohol and Substance Use)
M. Coping with Cravings and Urges
N. Parental Monitoring and Consequences
O. Parental Positive Consequences and Attending
II. Modules Used with Some But Not All CBT-RP Participants in the Pilot Randomized Trial
A. Reinforcing Self-Efficacy and Challenging the Abstinence Violation Effect
B. Coping with Peer Pressure (Refusal Skills)
C. Mindfulness Meditation
D. Coping with Anxiety
E. Coping with Anger
F. Coping with Non-Suicidal Self-Harm
III. Modules Available But Not Used or Infrequently Used in the Pilot Randomized Trial
A. Anchoring Change to Values
B. Coping with Criticism
C. Family Communication Skills
D. Family Problem-Solving
E. Parent Emotion Regulation
F. Parent Beliefs
G. Parent Substance Abuse
H. Parent Self-Care

^*Note: CBT-RP = Cognitive-Behavioral Therapy – Relapse Prevention. Modules used with “almost every CBT-RP participant” were used in full or in part with five or six of the CBT-RP participants who completed treatment. Modules used with “some but not all CBT-RP participants” were used with two to four participants. Modules “available but not used or infrequently used” referred to modules used once or not at all in the pilot randomized trial. CBT-RP modules were chosen in a flexible manner depending on identified needs of the youth and families, as described in the section on “Choice of Modules.”

Similar to other cognitive-behavioral interventions that have been developed for youth with suicide risk (Asarnow et al., 2017; Esposito-Smythers et al., 2011; Stanley et al., 2009), CBT-RP was flexible and could be individualized based on the functional analysis of participant’s difficulties, despite some parameters regarding treatment and some required therapeutic tasks. In addition, the intervention was process-oriented insofar as the principles of CBT-RP were seen as more important in driving treatment than specific content areas delivered in specific sessions in a pre-determined manner. Different modules could be used with each adolescent depending on their treatment needs, or the same modules could be emphasized over multiple sessions. This approach was used to increase the individual relevance of treatment and to enhance engagement with the adolescents and families in the treatment process. Within each therapeutic module, however, there were suggested goals and a suggested structure that could be followed by the therapist.

Given multiple areas of difficulty, the therapist generally focused first on modules related to safety, motivation, and understanding the context of problems. For example, after establishment of safety, information for initial functional analyses (including triggers, vulnerability and protective factors, and consequences of target behaviors) was gathered or clarified by the clinician in a CBT-RP session to help better understand the context of problems, commonalities in factors related to them, and the interrelationship between issues of concern. These functional analyses were updated throughout the course of treatment as new information emerged. The therapist then prioritized modules that (a) would affect multiple problems areas (e.g., depression, suicidal thoughts or behaviors, and substance use problems), (b) would have the potential for the largest or quickest impact on problematic behaviors from the perspective of the therapist, and/or (c) would lay the foundation for subsequent needed modules. As an example, if a teenager was having significant problems with sleep, the therapist might introduce this as one of the early modules. In our clinical experience, and as documented in the research literature (Palmer et al., 2018), disrupted sleep is associated with poor emotion regulation, as well as poor problem-solving and decision-making. As such, sleep problems could potentially make the other work in CBT-RP more challenging. In a second example, although the early sessions of CBT-RP draw explicitly upon motivational interviewing approaches, the CBT-RP therapist had the flexibility to use these approaches at any point when resistance or ambivalence was encountered in therapy, particularly given the ambivalence experienced by many suicidal and substance using clients.

Parallels in Approach to Treatment of Depression, Suicidal Behaviors, and Substance Use.

There were multiple points of convergence in the integrated relapse prevention approach for depression, suicidal behaviors, and substance use (Goldston et al., 2019). First, when developing the functional analysis of suicidal behaviors, depression, and substance use, and when refining and referring back to these functional analyses, there was an emphasis on the interrelationship between these problem areas, and on common triggers and risk factors for the related issues. Second, in CBT-RP, the understanding and management of risk for both suicidal behavior and substance use were framed in terms of behavioral pathways and choice points.

Third, when possible in CBT-RP, there was an emphasis on coping skills that could address depressive symptoms, as well as risk for both substance use and suicidal behaviors. The clinicians used their judgment and experience, and knowledge obtained from the functional analyses, in identifying which cognitive behavioral skills might be helpful for multiple problem areas. When patients identified areas they wanted to work on, the CBT-RP clinician in a collaborative manner was responsive to this request, while pointing out how new skills could be used to address multiple areas of difficulty. For example, as affect regulation was important for both suicidal risk and substance use, a mood thermometer was used to monitor affect and identify high-risk situations. Cognitive restructuring was used to focus on patterns of thoughts associated with high levels of affect and other risk situations, and problem-solving was used to help consider various ways of managing these risky situations and to reduce impulsive responding. Fourth, increasing pleasant activities that do not involve substances (and especially, those that increase social connections to new peers and/or underscore reasons for living or future goals) and establishing a positive lifestyle balance were seen as essential for both reducing depression, as well as the likelihood of substance use and suicide risk.

Fifth, in CBT-RP, a parallel was drawn between suicidal thoughts and urges/cravings to use substances. Suicidal thoughts were externalized (e.g., suicidal thoughts were urges to escape from distress, but the patient had control over whether to act on these thoughts), similar to substance use urges and cravings. In this regard, triggers and methods of coping (e.g., distraction, challenging thoughts, seeking support, acceptance and labeling of the thoughts, urge surfing) were identified for managing both sets of problems.

Sixth, in CBT-RP, it was acknowledged that clients may have difficulties in taking steps to reduce depression, suicidal thoughts and behaviors, or substance use. In the face of difficulties or setbacks, clients often lose a sense of self-efficacy about their ability to change and could feel hopeless. They may even experience the loss of self-efficacy as a rationale for abandoning efforts toward positive changes. For both suicidal thoughts/behaviors and substance use, steps were taken in CBT-RP to increase self-efficacy, to help clients learn from setbacks and challenges to prevent or manage future difficulties, and to anticipate and resist catastrophic thinking related to future challenges or problems.

Seventh, motivation for change was implicitly identified as an important factor for addressing the ambivalence associated with substance use reduction, with reasons for living and dying, and with the decision to remain in treatment for a sufficient period of time. To this end, motivational interviewing was used throughout the CBT-RP intervention with both youth and families. Adolescents identified both reasons for living and reasons for quitting substances as methods for underscoring the motivation for change.

Lastly, mindfulness meditation approaches (although not used with all adolescents due to their own preferences) were taught to patients as methods for managing stress and improving affect regulation. These approaches were also used to help patients separate from (“let go of”) ruminative thoughts or thoughts with urgency attached to them, including suicidal and substance use urges, allowing patients to shift focus and increase their sense of control in the face of these thoughts.

Individual and Parent Focus in CBT-RP.

Although the primary focus in CBT-RP was on work with the adolescent, the intervention also included family content. At the outset of CBT-RP, the parents provided information that was used in developing the functional analyses, participated in development of a safety plan, and were provided psychoeducation as needed regarding depression, substance use, and suicidal thoughts and behaviors, as well as their interrelationships. Parents also were provided guidance regarding effective monitoring of their adolescent, and the provision of positive consequences and attending. Additional modules for family communication and problem-solving, parental emotion regulation, parental beliefs, and parental self-care were also available.

There was an effort to coordinate CBT-RP work with adolescents and parents, particularly in reduction of risk. For example, if an adolescent’s depression, and suicidal and substance use urges occurred in reaction to family conflicts, the therapist could work with the adolescent regarding their reactions or interpretations of these difficulties, as well as ways of managing resulting anger and hopelessness. The therapist could also work with parents to encourage them to use parenting techniques that reduce chances of escalation and negative “expressed emotion” (a type of angry, personalized, blaming communication that often is associated with relapse of various mental health conditions; Goldstein & Doane, 1982; Miklowitz et al., 1988; Vaughn & Leff, 1976).

Source Material for the CBT-RP Intervention.

Although CBT-RP was based on the foundation of the cognitive-behavioral relapse prevention framework for treatment of alcohol and substance use by Marlatt & Gordon (1985), some material for CBT-RP was adapted from other sources as well. These included (1) the Treatment for Adolescents with Depression Study (TADS) Cognitive Behavioral Therapy Manual – Introduction, Rationale, and Adolescent Sessions (Curry et al., 2000); (2) the group and family therapy manuals for the Family and Coping Skills intervention for youth with comorbid depression and substance use (Curry, Wells, Lochman, Craighead, et al., 2003; Curry, Wells, Lochman, Nagy, et al., 1997; Wells & Curry, 1997); (3) the manuals for Motivational Enhancement Therapy / Cognitive-Behavioral Therapy (MET/CBT) for youth with cannabis use (Sampl & Kadden, 2001; Webb et al., 2002); (4) the Treatment of Youth Alcohol Abuse and Suicidality Therapist Manual (for optional sessions on helping parents; Esposito-Smythers et al., 2011); and (5) the book, Mindfulness-Based Cognitive Therapy for Depression: A New Approach for Prevention of Relapse (for optional mindfulness meditation exercises; Segal et al., 2002).

Duration and Frequency of Intervention.

Cognitive-Behavioral Therapy Relapse Prevention (CBT-RP) was a 20-week augmenting intervention that consisted of up to 23 scheduled therapy sessions. There was at least one session per week for the first 12 weeks, with an optional second session during each of the first three weeks for youth and families considered by clinicians to be in especially high need (e.g., due to safety concerns). From week 12 to 20, sessions either continued weekly or tapered to every other week depending on whether mild or less severe symptoms were evidenced in the targeted areas (substance use, suicidal thoughts, depression) at Week 12. There could be up to six additional sessions for emergencies and/or to prevent attrition. The first two sessions were scheduled to last 75–90 minutes each in duration, and subsequent sessions were scheduled at 60 minutes, but could be longer if there had been a recent high-risk or crisis situation. Therapists used random urine drug screens to provide objective evidence that could be provided to participants of progress toward substance use goals. Between sessions, therapists could make brief phone calls to adolescents and families to check on and reinforce progress, particularly when problems were reported or anticipated. Adolescents and their parents could also call the therapist in-between scheduled appointments. Phone calls included coaching and problem solving as well as crisis management in the context of safety planning.

Enhanced Treatment as Usual

As noted above, regardless of whether they were randomized to CBT-RP, all patients in the study received outpatient treatment in the community as usually delivered. Families were expected to pay for or file insurance for the treatment received in the community. If adolescents and families needed assistance in finding providers, they were given a list of providers in the community who typically see patients with similar clinical presentations. In addition, on a monthly basis, a case manager checked in with adolescents and families to identify treatment needs and to determine if they needed additional referrals. Assistance with these referrals was provided as needed. With written consent from participants and their parents/guardians, information from evaluations was shared with community providers. Moreover, for participants assigned to CBT-RP, study therapists communicated as needed with community providers about treatment to coordinate care.

Participants in the Pilot Randomized Controlled Trial

Participants were eligible for the pilot randomized controlled trial if they: (1) were between 13 and 19 years of age; (2) had either made an actual, aborted, or interrupted suicide attempt as defined by the Columbia Suicide Severity Rating Scale (C-SSRS; Posner et al., 2011) or suicide plan in the last four weeks, or had a score of >30 on the Suicide Ideation Questionnaire; SIQ; Reynolds, 1988) and past suicidal behavior or plan; (3) met DSM-IV criteria both for an alcohol or cannabis abuse/dependence disorder, and for a depressive disorder (major depression, dysthymic disorder, or depressive disorder NOS); (4) were English-speaking and living with an English-speaking parent or guardian; and, (5) were participating in treatment or were willing to receive a referral for treatment in the community. The inclusion SIQ score of 30 for youth with prior suicidal behavior is the conservative cut-off that was found by Reynolds (1991) to identify suicidal youth with 100% sensitivity in the standardization sample. Exclusion criteria for this study included: (1) a psychiatric issue other than depression, substance use, or suicide risk that should be the primary focus of treatment; (2) DSM-IV substance dependence disorder other than cannabis, alcohol, or nicotine dependence; (3) imminent risk of suicidal behavior; (3) a recent disclosure of physical and/or sexual abuse not being addressed in treatment in the community; (4) not living with a parent or guardian immediately after hospital discharge; and (5) evidence of delayed intellectual functioning as reflected in school placement or poor receptive vocabulary as indicated by scores on the PPVT of <70. Participants were recruited from various sites, including three inpatient psychiatric units, local providers, and community sites. CBT-RP was delivered as an outpatient intervention.

Of the 19 individuals who were referred and who had high potential for study eligibility based on results of phone screen, two individuals did not follow-up with the baseline evaluation and four individuals did not meet criteria following the baseline evaluation (e.g., due to denial of suicidal thoughts and behavior, insufficient depressive symptoms, or insufficient recent substance use). Thirteen individuals were eligible for the study following baseline evaluation and were randomized to either the CBT-RP + TAU or to TAU alone. Baseline characteristics of the sample are presented in Table 2.

Table 2.

Characteristics of Sample at Baseline

Variable	CBT-RP +TAU	TAU Only
Age	16.43 (15.07–17.44)	16.56 (15.49–17.30)
Gender (M/F)	4/3	1/5
Race	5 White, 1 Black, 1 Asian	4 White, 2 Black
Single or Repeat Attempts	5 Single, 2 Repeat	4 Single, 2 Repeat
Depressive Diagnoses	Major Depression (5), Depressive Disorder NOS (2)	Major Depression (5), Dysthymic Disorder (1)
Substance Use Diagnoses	Cannabis (7), Alcohol (2), Opioid (1)	Cannabis (6), Alcohol (5), Opioid (1), Sedative (1)
Alcohol or Cannabis Primary Other Diagnoses	Cannabis (7), Alcohol (0) ADHD (4), Anxiety (3), Conduct Disorder (3)	Cannabis (3), Alcohol (3) ADHD (1), Anxiety (3), Conduct Disorder (3)
Trauma Exposure (Yes/No)	4/3	4/2
Medication (Yes/No)	6/1	6/0

Screening and Outcome Measures

Assessments were conducted by an independent evaluator who was not aware of participant treatment condition. Following their phone screen and consent, participants were evaluated for inclusion/exclusion criteria including significant intellectual disability or poor receptive language functioning, presence of a DSM-IV depressive disorder and alcohol/substance use disorders, and current and past suicidal thoughts and behaviors. The primary outcomes of interest were assessed at baseline, 10 weeks after randomization (the midpoint of CBT-RP), 20 weeks after randomization (corresponding to the end of CBT-RP), and 3 months following the end of the treatment period. These outcomes included severity of suicidal ideation, depressive symptoms, and alcohol and/or cannabis related problems. We also examined suicide attempts during this period. Measures used to assess screening and outcome variables are described below.

Cognitive Functioning.

Adolescents were screened to ensure that they did not have intellectual disabilities that could have interfered with their ability to participate in therapy. History of school placement for intellectual disability was assessed with a structured screening questionnaire. Poor receptive language skills were assessed with the Peabody Picture Vocabulary Test – III (PPVT-III), an instrument that correlates highly with the Wechsler verbal intelligence scales (Dunn & Dunn, 2007). Standardized scores below 70 were considered evidence of poor receptive vocabulary or verbal ability.

Depressive and other Psychiatric Disorders.

The School-Aged Schedule for Affective Disorders and Schizophrenia: Present and Lifetime Version (K-SADS-PL; Kaufman et al., 1997) is a semi-structured diagnostic interview that was used for assessing DSM-IV mood, substance use, and exclusion disorders. The K-SADS-PL has demonstrated reliability and validity (Ambrosini, 2000) and was administered to adolescents and parents.

Suicide Ideation and Behavior.

The Suicide Ideation Questionnaire (SIQ; Reynolds, 1988) score was the primary outcome measure of severity of suicidal thoughts. The SIQ is a 30-item internally consistent and valid self-report questionnaire (Reynolds, 1988) that has predictive validity (Yen et al., 2013) and has been used previously in treatment studies targeting suicidal ideation in youth (Esposito-Smythers et al., 2011).

Items from the Columbia Suicide Severity Rating Scale (C-SSRS; Posner et al., 2011) were used to assess suicide attempts, aborted attempts, interrupted attempts, and suicide plans at screening and follow-up assessments. The C-SSRS has been shown to be a valid and internally consistent scale that is sensitive to change (Posner et al., 2011).

Depressive Symptoms.

The Children’s Depression Rating Scale - Revised (CDRS-R) (Poznanski et aI., 1985) was the primary outcome measure of severity of depressive symptoms. The CDRS-R is a reliable interview-based measure administered to both youth and parents that has been used in multiple studies and shown to be sensitive to change (e.g., The TADS Team, 2007).

Substance Use Problems.

The primary outcome measures of substance use problems were the Rutgers Marijuana Problem Index (RMPI) and the Rutgers Alcohol Problem Index (RAPI) (White et al., 2005; White & Labouvie, 1989). The RMPI and RAPI are identical except for the references to alcohol or marijuana. They have been used previously in treatment studies of youth with suicidal ideation and alcohol or cannabis related problems (Esposito-Smythers et al., 2011). Both of these reliable and valid scales consist of 23 items used to rate the frequency of problems (e.g., problems in school, neglect of responsibilities, conflict with family or friends) experienced by participants. Because participants differed in whether alcohol or marijuana use were their primary problems, the scale corresponding to patients’ primary problem area (i.e., whichever was associated with the most severe problems at baseline) was used as the outcome measure.

Service Use.

Service use, including individual therapy, family therapy, group therapy, emergency services, hospitalization, and residential treatment were assessed with questions adapted from the Child and Adolescent Services Assessment (CASA; Ascher et al., 1996; Burns et al., 2008). The CASA and adaptations of the CASA have been used to assess mental health service use in multiple studies (e.g., Brenner et al., 2015; Esposito et al., 2011; King et al., 2015).

Feedback Regarding the Intervention.

At their final assessment, adolescents and their families also were administered a questionnaire about their experiences in the program. Participants were asked to indicate their agreement or disagreement with statements about the program on a five-point Likert scale. They also were asked a series of open-ended questions such as, “What helped you most in the program?;” “What did you like best about the program?;” “What did you like least about the program?;” and “What did you learn in the program that may help you in the future?”

Therapists

CBT-RP therapists were minimally expected to have at least a Master’s degree, two years of experience in working with adolescents with psychiatric and substance use problems, and previous training and experience with cognitive-behavioral therapy. Five M.S.W. and Ph.D. level clinicians served as therapists for the study in the open trial and the pilot RCT. Sessions were recorded for purposes of supervision and case consultation. Supervision and case consultation occurred weekly, or more often, as needed to address high-risk situations.

Procedure

The study was approved by the Institutional Review Boards (IRB) of the participating institutions prior to initiation of participant recruitment and received monitoring from a Data and Safety Monitoring Board. After consent, families were randomized to either the experimental augmenting condition (CBT-RP) in addition to TAU (n = 7) or the enhanced TAU only condition (n = 6). All participants received monthly phone check-in calls by study coordinators and were provided with treatment referrals upon request. The initial study period was 20 weeks. Formal assessments were scheduled at Week 10 (the midpoint of CBT-RP), Week 20 (the end of CBT-RP), and at a three month follow-up. Participants were provided with compensation for completing study evaluations.

Results

Study Completion and Service Use

Five of the six participants who completed the study in each condition were receiving psychotropic medication at the time that they entered the study. One additional participant in the TAU only condition began taking medication before the midpoint assessment. All participants in the CBT-RP + TAU condition who completed the study were receiving at least some outpatient therapy in the community at study entry. Five of six participants in the TAU alone condition were receiving therapy at the study entry; the sixth participant began receiving outpatient therapy between study entry and the midpoint evaluation for the study. For five of six participants in both the CBT-RP + RP and in the TAU only condition, the therapy included elements of cognitive or behavioral approaches by parents’ descriptions. Three of the six youth in the TAU only condition, and none of the youth in the CBT-RP + TAU condition had emergency psychiatric crises requiring visits to the emergency department in the first 20 weeks.

Feasibility

All youth and families who were found to meet eligibility criteria agreed to the study. Out of the 13 participants who were randomized at the outset of the study, one individual in the CBT-RP condition discontinued participation prior to the midpoint of the study (i.e., attrition rate of 8%). This participant discontinued after additional court-ordered therapeutic services were initiated as a consequence of legal charges that were pending when the study began. The remaining six CBT-RP + TAU participants continued to receive the intervention through week 20, supporting the feasibility of an integrated augmenting intervention for youth with co-occurring substance use problems, depression, and suicidal thoughts and behavior.

Outcomes

Given the potential unreliability of estimates of effects with small sizes, we did not attempt to compute effect sizes or test between-group differences in the pilot study. However, as seen in Figures 1, 2, and 3, we did depict the individual change patterns among individuals receiving the CBT-RP + TAU intervention, and among youth receiving TAU alone.

Figure 1.

Individual Suicide Ideation Trajectories in CBT-RP + TAU and TAU Alone Groups

Note. SIQ = Suicide Ideation Questionnaire

Figure 2.

Individual Depression Trajectories in CBT-RP + TAU and TAU Alone Groups

Note. CDRS-R = Children’s Depression Rating Scale – Revised

Figure 3.

Individual Trajectories of Alcohol/Substance Use Problems in CBT-RP + TAU and TAU Alone Groups

Note: RAPI = Rutgers Alcohol Problem Index, RMPI =Rutgers Marijuana Problem Index; Most Severe Problem Area (Alcohol or Marijuana) at Baseline Used

As shown in Figure 1, all six of the participants in the CBT-RP + TAU condition evidenced notable and consistent declines in severity of suicide ideation by Week 20, as reflected in the SIQ scores. In the TAU alone condition, four of six youth also reported declines in SIQ scores by Week 20, but declines were slower to emerge for some youth, as illustrated by the fact that only two youth had significantly reduced their suicide ideation by Week 10. With the exception of two participants in the TAU alone condition, all participants largely maintained their reductions in suicidal ideation (within 5 points) or evidenced further reductions in suicide ideation from Week 20 to the three-month follow-up.

During the first 20 weeks, five of the six participants in the CBT-RP + TAU condition had notable reductions in severity of depressive symptoms. Participants in the TAU alone condition also had reductions in symptoms of depression, but these declines were slower to emerge for some youth. For example, three youth in the TAU alone condition actually had increases in depressive symptoms from study entry to Week 10. All participants across both conditions maintained the reductions evident at Week 20 (within 5 points) or showed further decreases in depression severity scores at the three-month follow-up, with the exception of one participant in the TAU alone condition who had a 6-point increase in CDRS-R scores.

In terms of the severity of alcohol or cannabis use problems, five of six participants in CBT-RP + TAU reported notable reductions in problems during the first 20 weeks. All six participants in the TAU only condition evidenced reductions in substance and alcohol related problems by Week 20. All participants either maintained reductions in alcohol/substance problems or had further reductions in problems by the three-month follow-up.

The rate of suicide attempts did not differ between conditions. Specifically, one participant in each condition attempted suicide during the study. No participants died by suicide.

Acceptability

Parents were asked to rate several statements about the program on a 1 (strongly agree) to 5 (strongly disagree) rating scale. Four parents agreed with the statement that the program helped their adolescent reduce alcohol or drug use, one parent had “mixed feelings,” and one parent reported that she did not know. Five of six parents agreed with the statement that the program helped their adolescent reduce depression and suicidal thoughts, and five of six said that they would recommend the program to others. One parent’s ratings were in the opposite direction for both of these questions, but her narrative answers suggested that she may have misinterpreted the scale for those items (“You were a life-saving team. Don’t think we could have made it without your help.” “Not one complaint.”).

Youth also provided ratings to the same items. Five of six youth reported that the program helped with depression and suicidal thoughts, and the sixth youth reported mixed feelings. Three youth reported that the program helped them reduce alcohol and drug problems, and a fourth reported mixed feelings. Three of six youth agreed or strongly agreed that they would recommend the program to others and two others had mixed feelings.

In narrative feedback about the program, comments were generally very positive. When asked what was most helpful to them, parents commented on the support in weekly sessions, psychoeducation, the availability of the therapists, and the accepting attitude of therapists. When parents were asked what was most helpful to their teenagers, they commented on the learning of coping skills, the encouragement and support offered by the therapist, sense of greater control, the education about substances, and the realization that there were other choices and options. When asked what was most helpful to them, adolescents commented on the “open minds” of the therapists as well as their non-judgmental stance, the “optimistic advice,” coping thoughts and strategies for dealing with stress, the opportunity to talk about problems, problem-solving, and drug testing.

When asked what they learned from the program, parents reported learning about their adolescents’ “triggers,” the importance of being more of a support to their adolescent, talking more positively with their adolescent, development of a safety plan, learning to “look at all possibilities and their repercussions before making a decision,” recognizing that they want their teen to be drug-free but realizing now that it is ultimately up to the teens, and understanding that a “lot of things can be worked out” with good communication. The most common answer from adolescent participants regarding what was most helpful was better life and coping skills, and skills for managing emotions. Adolescents also commented on the realization that drugs can have negative effects on their lives, as well as the importance of positive thoughts around patience and forgiveness.

Discussion

In this study, we successfully demonstrated the feasibility and acceptability of an integrated approach for treating youth with co-occurring substance use problems, depression, and suicide risk. In the pilot RCT, only one youth in the CBT-RP + TAU condition failed to remain in the treatment, underscoring the feasibility of the augmenting intervention. Moreover, feedback from both the adolescents and their parents who received the integrated treatment approach was very positive, and youth in particular commented on the helpfulness of the skills-based approach, which was applied to the multiple problems. Although the pilot sample was small, preliminary indications were that youth participating in the CBT-RP intervention had quicker and more reliable reductions in depressive symptoms as well as suicide ideation, and comparable levels of reduction in alcohol and substance use problems. Moreover, none of the adolescents receiving the integrated treatment intervention, but half of the youth receiving TAU alone required emergency department visits during the study period for mental health or substance use related crises.

Although the study was not sufficiently powered for formally testing hypotheses, the addition of this integrated approach to treatment - with a common set of core skills, a common approach to problems, and a largely common language for addressing substance use and other problems - has promise in augmenting usual interventions and bringing about positive changes in individuals with depression, suicidal behaviors, and substance use problems. For example, adolescents in CBT-RP were encouraged to externalize suicidal ideation, and to recognize this as a set of thoughts not dissimilar to substance use urges and cravings. Similarly, adolescents in CBT-RP were encouraged to learn from lapses and the set-backs and difficulties they experienced in managing situations, and to focus on a sense of self-efficacy and positive lifestyle balance, which could help in reduction of relapses across multiple areas. These findings are particularly notable given the challenges often noted in treating individuals with substance use and co-occurring problems (Esposito-Smythers & Goldston, 2008). Findings from the pilot study dovetail with results from an RCT of a two-therapist integrated CBT intervention for youth with both suicidal thoughts and behaviors, and co-occurring alcohol and/or cannabis use problems, which resulted in reductions for both outcomes relative to youth treated as usual in the community (Esposito-Smythers et al., 2011).

Although the general approach of providing integrated treatment, and using shared language and skills for addressing suicide risk and co-occurring substance use problems appeared to have utility, three clinical matters deserve discussion. The first is that this population often had problems in multiple areas, not only with the family, but also in school, the legal system, and within the greater community. As a result, these youth and families had a high level of case management and crisis management needs. Other studies have similarly noted a high amount of crises and case management needs among adolescents with co-occurring substance use and depression (Curry et al., 2003). If implemented on a larger basis, we would recommend that clinicians have after-hours and case management support, and consultation groups similar to those offered in DBT to process cases and minimize secondary traumatic stress (Linehan, 1993).

The second clinical issue is the relatively high rates of trauma exposure (e.g., sexual trauma, physical abuse, violence in the home) among youth with co-occurring substance use problems and suicide risk. In some cases, trauma experiences were identified at the time of the baseline diagnostic interview, but at other times, the trauma histories were revealed later in therapy. Some youth with trauma exposure used substances in part to “feel better” in the face of negative emotion. Nonetheless, some youth, when inebriated, actually were more likely to be overwhelmed with memories, thoughts, and emotions stemming from earlier traumatic experiences, which on occasion precipitated suicidal urges. Moreover, there were some cases in which use of alcohol and drugs was related to situations in which clients had higher risk for re-victimization. Although the most important immediate considerations in working with such youth are safety and stabilization, these findings do underscore the fact that many of the youth in this study would ultimately likely benefit from more trauma-focused treatment after the more acute treatment for depression, suicide risk, and substance use problems.

The third clinical issue is the fact that two participants (one in each condition, or approximately 15% of the sample) made an additional suicide attempt during the course of the study. This finding was not entirely unexpected given that the risk for suicide attempts is especially high in the first three to six months after hospitalization (Goldston et al., 1999). In our longitudinal study of 180 youths who had been psychiatrically hospitalized, for instance, approximately 20% of youth with a prior attempt and a mood disorder attempted suicide within the first six months of discharge. Moreover, in our clinical experience, youth with co-occurring depression, suicidal behavior, and alcohol or substance use problems tend to be even more impulsive and unpredictable in their risk for suicidal behavior than many other youths with histories of suicide attempts (Esposito-Smythers & Goldston, 2008). These outcomes underscore the high-risk nature of such treatment development and clinical trial work with this clinical population, but also the importance of work to reduce the risk among these young people. For further studies in this area, close monitoring, safety planning and procedures for maintaining safety, and oversight are among some of the steps necessary to mitigate risk in research with individuals at risk for suicidal behavior (National Institute of Mental Health, n.d.).

This study had several limitations that should be acknowledged. First, this was a pilot randomized trial, primarily useful for demonstrating feasibility, but not sufficiently well-powered to test hypotheses about effects or mechanisms related to change. Second, in this study, about half the youth in the TAU only condition had more problems with alcohol than with cannabis, whereas cannabis was the primary problem area for all of the CBT-RP + TAU youth. In addition, there were proportionately more females in the TAU only condition than in the CBT-RP + TAU condition. It is possible that differences between primary problems and gender distribution between the CBT-RP + TAU, and the TAU alone groups may have contributed to some of the patterns observed. Third, in this treatment development study, we cannot rule out the fact that findings were not specific to the CBT-RP condition but rather were simply reflective of a “dose effect” (i.e., greater number of sessions and greater time in sessions). Relatedly, we did not systematically track the number of phone calls between sessions from therapist to adolescent or parent or from adolescent or parent to therapist. These additional contacts as well as the monthly check-in call may have further increased the “dose effects” by providing additional clinical support and guidance to adolescents and families. Fourth, clinicians for CBT-RP participants could administer (and provide results for) urine drug screens, but we did not monitor the degree to which clinicians in the community used urine drug screens. Likewise, although we assessed whether youth received treatment in the community, we did not assess the number of therapy sessions attended. Although the majority of youth in both groups received outpatient therapy, it is possible that the frequency of urine drug screens, or the number of sessions differed across youth in the different conditions and could have affected results.

These limitations notwithstanding, the integrated approach to treatment of co-occurring depression, suicidal ideation, and substance use showed promise as an acceptable, feasible, and promising intervention for a challenging population. Although we examined CBT-RP as a specific augmenting intervention, the principles of the intervention are not unique, and an integrated relapse approach could be used to complement many cognitive-behavioral approaches for youth with these co-occurring problems in outpatient settings or higher levels of care. Putting this study in context, it is often the case that youth with co-occurring problems receive fragmented services, with different mental health providers focusing on mental health needs and other providers focusing on substance use issues (Esposito-Smythers & Goldston, 2008). In such cases, there is often a lack of coordination of services. The current study illustrates the potential utility of an integrated framework for treatment and relapse prevention for multiple problem areas.