Effectiveness of a brief psychotherapeutic intervention compared with treatment as usual for adolescent nonsuicidal self-injury: a single-centre, randomised controlled trial

Two-year course of non-suicidal self-injury in an adolescent clinical cohort: The role of childhood adversity in interaction with cortisol secretion

AIM

Non-suicidal self-injury (NSSI) is a highly prevalent phenomenon during adolescence. Nonetheless, research on predictors of the clinical course of NSSI over time is still scarce. The present study aimed at investigating the impact of adverse childhood experiences (ACE) and hypothalamus-pituitary-adrenal (HPA) axis functioning on the longitudinal course of NSSI.

METHODS

In a sample of n = 51 help-seeking adolescents engaging in NSSI, diurnal cortisol secretion (CAR, cortisol awakening response; DSL, diurnal slope), hair cortisol concentrations and ACE were assessed at baseline. Clinical outcome was defined by change in the frequency of NSSI in the past 6 months measured 12 and 24 months after the baseline assessments. Mixed-effects linear regression models were used to test for effects of ACE and HPA axis functioning on the course of NSSI.

RESULTS

ACE and HPA axis functioning did not show main but interaction effects in the prediction of NSSI frequency over time: Adolescents with a low severity of ACE and either an increased CAR or a flattened DSL showed a steep decline of NSSI frequency in the first year followed by a subsequent increase of NSSI frequency in the second year.

CONCLUSIONS

Our findings could be interpreted in the sense of high diurnal cortisol concentrations in the absence of ACE being favorable for clinical improvement on the short-term but bearing a risk of allostatic load and subsequent increase of NSSI frequency. In contrast, adolescents with severe ACE may benefit from elevated cortisol concentrations leading to slower but lasting decreases of NSSI frequency.

Reducing self-harm in adolescents: the RISA-IPD individual patient data meta-analysis and systematic review

Background

Self-harm is common in adolescents and a major public health concern. Evidence for effective interventions is lacking. An individual patient data meta-analysis has the potential to provide more reliable estimates of the effects of therapeutic interventions for self-harm than conventional meta-analyses, to explore which treatments are best suited to certain groups.

Method

A systematic review and individual patient data meta-analysis of randomised controlled trials of therapeutic interventions to reduce repeat self-harm in adolescents who had a history of self-harm and presented to clinical services. Primary outcome was repetition of self-harm. The methods employed for searches, study screening and selection, and risk of bias assessment are described, with an overview of the outputs of the searching, selection and quality assessment processes. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance is followed.

Results

We identified a total 39 eligible studies, from 10 countries, where we sought Individual Patient Data (IPD), of which the full sample of participants were eligible in 18 studies and a partial sample of participants were eligible in 21 studies. We obtained IPD from 26 studies of 3448 eligible participants. For our primary outcome, repetition of self-harm, only 6 studies were rated as low risk of bias with 10 rated as high risk (although 2 of these were for secondary outcomes only).

Conclusions

Obtaining individual patient data for meta-analyses is possible but very time-consuming, despite clear guidance from funding bodies that researchers should share their data appropriately. More attention needs to be paid to seeking appropriate consent from study participants for (pseudo) anonymised data-sharing and institutions need to collaborate on agreeing template data-sharing agreements. Researchers and funders need to consider issues of research design more carefully. Our next step is to analyse all the data we have collected to see if it will tell us more about how we might prevent repetition of self-harm in young people.

Funding

This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 17/117/11. A plain language summary of this research article is available on the NIHR Journals Library Website https://doi.org/10.3310/GTNT6331.

The evaluation of a stepped care approach for early intervention of borderline personality disorder

BACKGROUND

The current study evaluated the stepped care approach applied in AtR!Sk; a specialized outpatient clinic for adolescents with BPD features that offers a brief psychotherapeutic intervention (Cutting Down Program; CDP) to all patients, followed by a more intensive Dialectical Behavioral Therapy for Adolescents (DBT-A) for those whose symptoms persist.

METHODS

The sample consisted of 127 patients recruited from two AtR!Sk clinics. The number of BPD criteria, psychosocial functioning, severity of overall psychopathology, number of days with non-suicidal self-injury (NSSI; past month), and the number of suicide attempts (last 3 months) were assessed at clinic entry (T0), after CDP (T1), and at 1- and 2-year follow-up (T2, T3). Based on the T1 assessment (decision criteria for DBT-A: ≥ 3 BPD criteria & ZAN-BPD ≥ 6), participants were allocated into three groups; CDP only (n = 74), CDP + DBT-A (eligible and accepted; n = 36), CDP no DBT-A (eligible, but declined; n = 17).

RESULTS

CDP only showed significantly fewer BPD criteria (T2: β = 3.42, p < 0.001; T3: β = 1.97, p = 0.008), higher levels of psychosocial functioning (T2: β = -1.23, p < 0.001; T3: β = -1.66, p < 0.001), and lower severity of overall psychopathology (T2: β = 1.47, p < 0.001; T3: β = 1.43, p = 0.002) over two years compared with CDP no DBT-A, while no group differences were found with regard to NSSI and suicide attempts. There were no group differences between CDP + DBT-A and CDP no DBT-A, neither at T2 nor at T3.

DISCUSSION

The findings support the decision criterion for the offer of a more intense therapy after CDP. However, there was no evidence for the efficacy of additional DBT-A, which might be explained by insufficient statistical power in the current analysis.

Differential outcomes of outpatient only versus combined inpatient/outpatient treatment in early intervention for adolescent borderline personality disorder

Clinical guidelines for adults with borderline personality disorder (BPD) recommend outpatient psychotherapy as first-line treatment. Little is known whether this recommendation is also applicable to adolescents. The current study examined the relationship between treatment setting and the outcome of early intervention for adolescents with BPD pathology. One-hundred and seventy-eight adolescents from a specialized outpatient clinic were assessed at baseline, and at 1- and 2-year follow-up. Sixty-three participants who received inpatient treatment during the first year were assigned to the "combined inpatient/outpatient group", 115 participants to the "outpatient only group". Generalized linear and mixed models with inverted probability weights to adjust for baseline differences were applied to examine the impact of group on clinical changes over time. Both groups demonstrated a significant decrease in BPD features, depressive symptoms, psychopathological distress, non-suicidal self-injury (NSSI), suicidal thoughts, suicide attempts, and overall illness severity, and a significant increase in quality of life and psychosocial functioning from baseline to follow-up 2. The decrease in NSSI and overall illness severity, and the increase in psychosocial functioning from baseline to follow-up 1 were greater in the outpatient only group, with comparable improvements between groups from follow-up 1 to follow-up 2. Both outpatient treatment and combined outpatient/inpatient treatment resulted in clinical improvements over time, with some indication for faster changes in the outpatient only setting. The findings provide preliminary evidence that the recommendation of outpatient psychotherapy as the first-line treatment for BPD also holds true for adolescents.

Young adults looking back at their experiences of treatment and care for nonsuicidal self-injury during adolescence: a qualitative study

BACKGROUND

Nonsuicidal self-injury (NSSI) is associated with stigma, and negative attitudes among healthcare professionals toward NSSI have been reported. A person-centered approach that focuses on how individuals with lived experience of NSSI perceive the treatment and care they receive is invaluable in reducing barriers to help-seeking and improving treatment and mental healthcare services. The aim of the current qualitative study was to explore the perceptions of young adults when they look back upon their experiences of psychiatric treatment for NSSI during adolescence.

METHODS

Twenty-six individuals with lived experience of NSSI who were in contact with child and adolescent psychiatry during adolescence were interviewed. The interviews were analyzed using thematic analysis.

RESULTS

Three main themes were developed: Changed perceptions in retrospect, The importance of a collaborative conceptualization and Lasting impression of the relationship. Participants' perception of themselves as well as the treatment changed over time. The importance of a joint understanding of NSSI and an agreed-upon treatment focus was emphasized. The relationship to the mental health professionals, and experiences of how NSSI was communicated, were salient several years later.

CONCLUSIONS

Healthcare professionals need to communicate about NSSI in a respectful manner and include the perspective of the adolescent with lived experience of NSSI in a joint conceptualization of NSSI and treatment focus.

Frequency and predictors of individual treatment outcomes (response, remission, exacerbation, and relapse) in clinical adolescents with nonsuicidal self-injury

BACKGROUND

Nonsuicidal self-injury (NSSI) is prevalent in adolescent clinical samples. There is evidence that NSSI can be treated effectively but data on individual treatment outcomes is limited. The goal of this study was to examine response, remission, exacerbation, and relapse rates over one and two years, respectively, among a clinical sample of adolescents with NSSI. Furthermore, we aimed to identify clinically relevant predictors of NSSI trajectories.

METHODS

The sample consists of n = 203 adolescents (12-17 y., 94% female) from a specialized outpatient clinic for risk-taking and self-harming behavior with NSSI on at least five days in the six months before first assessment. Assessments were completed at baseline and one (FU1) and two (FU2) years later using structured clinical interviews and self-report questionnaires.

RESULTS

At FU1, 75% reported a reduction in NSSI frequency by at least 50% (treatment response); among those, one third (25% of the entire sample) achieved a remission (0 NSSI); an exacerbation (⩾50% more NSSI) was observed in 11% of patients. Of those in remission, 41% relapsed one year later. Predictors of non-response or non-remission were inpatient treatment and depressive symptoms. Adolescents with lower NSSI frequency at baseline had a higher risk of exacerbation. Due to limited sample size at FU2 no prediction model for relapse was established.

CONCLUSIONS

While most adolescents presenting with NSSI achieved significant improvement, more attention should be paid to the rather low rates of full remission. Prediction and early detection of individuals who deteriorate during or relapse after treatment is critical.

A longitudinal investigation of non-suicidal self-injury persistence patterns, risk factors, and clinical outcomes during the college period

BACKGROUND

Although non-suicidal self-injury (NSSI) is known typically to begin in adolescence, longitudinal information is lacking about patterns, predictors, and clinical outcomes of NSSI persistence among emerging adults. The present study was designed to (1) estimate NSSI persistence during the college period, (2) identify risk factors and high-risk students for NSSI persistence patterns, and (3) evaluate the association with future mental disorders and suicidal thoughts and behaviors (STB).

METHODS

Using prospective cohorts from the Leuven College Surveys (n = 5915), part of the World Mental Health International College Student Initiative, web-based surveys assessed mental health and psychosocial problems at college entrance and three annual follow-up assessments.

RESULTS

Approximately one in five (20.4%) students reported lifetime NSSI at college entrance. NSSI persistence was estimated at 56.4%, with 15.6% reporting a high-frequency repetitive pattern (≥five times yearly). Many hypothesized risk factors were associated with repetitive NSSI persistence, with the most potent effects observed for pre-college NSSI characteristics. Multivariate models suggest that an intervention focusing on the 10-20% at the highest predicted risk could effectively reach 34.9-56.7% of students with high-frequency repetitive NSSI persistence (PPV = 81.8-93.4, AUC = 0.88-0.91). Repetitive NSSI persistence during the first two college years predicted 12-month mental disorders, role impairment, and STB during the third college year, including suicide attempts.

CONCLUSIONS

Most emerging adults with a history of NSSI report persistent self-injury during their college years. Web-based screening may be a promising approach for detecting students at risk for a highly persistent NSSI pattern characterized by subsequent adverse outcomes.

Interventions for youth suicide and suicide-related behaviour: An update to a systematic review

OBJECTIVE

To update our 2018 review with the latest evidence from randomised controlled trials (RCTs) on the effectiveness of interventions to prevent youth suicide and suicide-related behaviour.

METHOD

In keeping with our 2018 review, Embase, PsycInfo, and Medline were searched using relevant key words. Included trials were RCTs evaluating the impact of an intervention or approach designed to prevent or reduce youth suicide and suicide-related behaviour. Key data were extracted, and results synthesised narratively.

RESULTS

Thirty RCTs were included across clinical (n = 13), educational (n = 8), and community settings (n = 9). No trials were conducted in workplace or primary care settings, or with indigenous populations, and few trials involved partnerships with young people. There were some concerns or a high risk of bias for most trials.

CONCLUSION

While a relatively large number of RCTs have been published in recent years, knowledge gaps remain. Further high-quality RCTs are needed, including those focussing on vulnerable population groups. Meaningful consumer involvement and a stronger emphasis on implementation are also recommended.

Brief Psychotherapeutic Intervention Compared with Treatment as Usual for Adolescents with Nonsuicidal Self-Injury: Outcomes over a 2-4-Year Follow-Up

INTRODUCTION

The "Cutting Down Programme" (CDP), a brief psychotherapeutic intervention for treating nonsuicidal self-injury (NSSI) in adolescents, was comparable to high-quality treatment as usual (TAU) in a previous randomized controlled trial (RCT).

OBJECTIVE

The aim of the study was to evaluate the long-term outcomes of the CDP over up to 4 years.

METHODS

Assessments of NSSI, suicide attempts, borderline personality disorder (BPD), depression, and quality of life took place 2 to 4 years (T3) after enrollment in a RCT. The evolution of NSSI, suicide attempts, depression, and quality of life was analyzed using (generalized) linear mixed-effects models. Ordered logistic regression was used for analyzing BPD diagnoses. Data from T0, T2, and T3 are reported.

RESULTS

Out of 74 patients, 70 (95%) were included in the T3 assessment. The frequency of NSSI events alongside with suicide attempts and depression further decreased between T2 and T3 and BPD between T0 and T3 in both groups. Quality of life remained stable in both groups between T2 and T3. Both groups received substantial but comparable additional treatment between T2 and T3. More treatment sessions during the follow-up period were linked to larger improvements of NSSI.

CONCLUSIONS

The CDP was found to be as effective as TAU in promoting recovery from NSSI and comorbid symptoms in the long term. Results suggest that treatment effects from a brief psychotherapeutic intervention may endure and even further improve after completion of the program. However, additional treatment seems to improve chances for recovery independent from CDP versus TAU.

Efficacy of psychotherapeutic interventions for non-suicidal self-injury in adolescent population: Systematic review and meta-analysis

Non-suicidal self-injury (NSSI) is the deliberate and self-inflicted damage to body tissue in the absence of fatal intent, and has become a serious health problem among adolescents. The aim of this study was to evaluate the efficacy of treatment for NSSI in this population through a systematic revision and meta-analysis (PROSPERO ID: 252355). Studies with therapies that reduced NSSI were included. The search was performed in the Medline, APA PsycINFO and PubPsych databases. The synthesis of measures for the main outcome (NSSI reduction) and for secondary outcomes (global functioning change and depressive symptomatology reduction) was performed using a random effects model. The search identified a total of 1881 studies. The systematic review included five studies and the meta-analysis four studies. The summary effect estimate for the standardized mean difference in NSSI was -0.53 (95% CI: -0.82, -0.25), in global functioning it was 0.62 (95% CI: 0.34, 0.91), and in depressive symptomatology it was -0.59 (95% CI: -0.82, -0.36). The certainty of the evidence using the GRADE method is low. We conclude that therapies specifically aimed at reducing NSSI are effective in reducing both NSSI and depressive symptoms while increasing global functioning.

Die Borderline-Persönlichkeitsstörung im Jugendalter

Zusammenfassung: Die Borderline-Persönlichkeitsstörung (BPS) ist eine schwere psychische Erkrankung, die durch hohe Morbidität und Mortalität gekennzeichnet ist sowie mit einem niedrigen psychosozialen Funktionsniveau einhergeht. Die BPS zeigt sich oft mit Beginn der frühen Adoleszenz (ab dem 12. Lebensjahr). Neben repetitiver Selbstverletzung und Suizidalität bestehen häufig sowohl Symptome internalisierender (Depression und Angst) als auch externalisierender Störungen (Hyperaktivität und Substanzkonsum). Daher kommt einer differentialdiagnostischen Abklärung und der Diagnosestellung mit dem Ziel der Frühintervention im klinischen Alltag eine besondere Rolle zu. Die Psychotherapie stellt bei der BPS eine äußerst wirksame Behandlungsmethode dar, Belege für die Wirksamkeit von pharmakologischen Intervention fehlen. Der Schlüssel zu einer Verbesserung der Versorgung für Jugendliche mit BPS liegt in einer Generierung von Wissen zu Vorläufersymptomen sowie einer evidenzbasierten, stadienspezifischen Behandlung (frühe Behandlung bereits subklinischer BPS mit Behandlungsintensität abgestuft nach dem Schweregrad). Dieser Übersichtsartikel beleuchtet den aktuellen Stand der Forschung und gibt Empfehlungen für die therapeutische Arbeit in der klinischen Praxis.

Early Intervention for Personality Disorder

Both the DSM-5 Section III Alternative Model for Personality Disorders and the ICD-11 have introduced a genuinely developmental approach to personality disorder. Among young people with personality disorder, compelling evidence demonstrates a high burden of disease, substantial morbidity, and premature mortality, as well as response to treatment. Yet, early diagnosis and treatment for the disorder have struggled to emerge from its identity as a controversial diagnosis to a mainstream focus for mental health services. Key reasons for this include stigma and discrimination, lack of knowledge about and failure to identify personality disorder among young people, along with the belief that personality disorder must always be addressed through lengthy and specialized individual psychotherapy programs. In fact, evidence suggests that early intervention for personality disorder should be a focus for all mental health clinicians who see young people and is feasible by using widely available clinical skills.

Revisiting Social Stigma in Non-suicidal Self-injury: A Narrative Review

Non-suicidal self-injury (NSSI) is highly prevalent in our community. Yet, there is a significant discrepancy between the number of individuals engaging in NSSI and those who seek treatment for NSSI. This discrepancy can be due to the high social stigma associated with the behavior. The impact of NSSI stigma is significant and can impair the quality of life in the individuals engaging in NSSI, delay help-seeking, reduce access to mental health care and further fuel misinformation. Even though the symptomatology, risks, and demographics of NSSI have received attention in terms of research, there is limited literature on NSSI stigma and its consequences. With that background set, this review provides a bird's-eye view of the different levels of stigma in NSSI (public, self, and health care), associated discrimination, the various aspects of such stigmatization (NSSI-related language, physical scarring, misinformation, the media), and, finally, the collaborative clinical-outreach interventions for mitigating NSSI-associated social stigma. If NSSI is indeed recognized as a clinical disorder, future research would need to focus on these constructs of stigma and treat them with the same importance as the one given to clinical studies of intervention and symptomatology in NSSI.

Psychotherapeutic interventions specifically developed for NSSI in adolescence: A systematic review

Non-suicidal self-injury (NSSI) is a clinically significant behavior with high relevance and prevalence, especially affecting approximately 17-18% of the adolescent population worldwide. The aim of this study is to perform a systematic review to evaluate the effectiveness of the available Specific Psychotherapeutic Interventions (SPI) focused on the reduction of NSSI behaviors. A systematic review was performed analyzing PsychINFO, MEDLINE, Web of Science, PubMed and Cochrane CentralRegister of Controlled Trials to identify studies of interest from January 2010 to December 2020. According to PRISMA guidelines, only 13 studies were included in the review. Six SPI were found to specifically and significantly reduce NSSI in adolescents: Developmental Group Psychotherapy (DGP), Therapeutic Assessment (TA), Cutting Down Program (CDP), Emotional Regulation Individual Therapy for Adolescents (ERITA), Treatment for Self-Injurious Behaviors (T-SIB) and Intensive Contextual Treatment (ICT). Furthermore, relevant improvements in anxiety and depression symptoms were observed. The results of this review demonstrate the effectiveness of these interventions, mainly the CPD and T-SIB, which are the only SPI that have been studied using Randomized Controlled Trial (RCT). Considering the clinical relevance and associated functional impairment of NSSI, more research is needed to replicate the results and to increase knowledge about SPIs.

[Non-suicidal self-injurious Behaviour: Insights into a littleknown Patient Population in Plastic Surgery]

BACKGROUND

Despite its high prevalence in adolescents and young adults, non-suicidal self-injury (NSSI) is poorly known and understood in areas other than psychiatry. Due to this lack of knowledge, affected patients often face a lack of understanding as well as rejection and discrimination when seeking help from medical professionals. This not only hampers a lasting improvement of NSSI and the development of a trustful physician-patient relationship but may also lead to traumatisation of affected patients. Based on our patients' data, this article aims to inform interested plastic surgeons about NSSI and thus to support the treatment of affected patients.

PATIENTS AND METHODS

600 patients with scars from NSSI presenting to our outpatient clinic for the first time during the past five years were enrolled in this study. Extensive data collected during the first contact was analysed and compared with the current literature.

RESULTS

95 % of the patients were female; 5 % were male. On average, patients presented 8.4 years after the last NSSI event and with a mean age of 26 years. NSSI scars were most often located on the left forearm (48 %), followed by both forearms (40 %), the left upper arm (20 %), both upper arms (15 %) and both thighs (14 %). In 57 % of patients, scars were only present on one side. A mean of 380 cm2 of the body surface was affected by NSSI scars. 47 % of patients reported having at least one additional diagnosis, with thyroid dysfunction and depression being the most common. 21 % of patients had ongoing psychiatric or psychological therapy at the time of their first consultation in our clinic.

CONCLUSION

Our data provides first insight into a large population of NSSI patients seeking treatment options for their NSSI-associated scars in a plastic surgery outpatient clinic. Most patients were female with scars located on their forearms. A mean of more than 8 years had passed between their last NSSI and their first presentation to our clinic. Our findings offer a data-based approach to a group of patients with a disease pattern that is largely misunderstood in surgical disciplines and needs more attention, especially in the light of its high prevalence and life-long consequences.

DUDE - a universal prevention program for non-suicidal self-injurious behavior in adolescence based on effective emotion regulation: study protocol of a cluster-randomized controlled trial

BACKGROUND

Non-suicidal self-injury (NSSI) has become a substantial public health problem. NSSI is a high-risk marker for the development and persistence of mental health problems, shows high rates of morbidity and mortality, and causes substantial health care costs. Thus, there is an urgent need for action to develop universal prevention programs for NSSI before adolescents begin to show this dangerous behavior. Currently, however, universal prevention programs are lacking.

METHODS

The main objective of the present study is to evaluate a newly developed universal prevention program ("DUDE - Du und deine Emotionen / You and your emotions"), based on a skills-based approach in schools, in 3200 young adolescents (age 11-14 years). The effectiveness of DUDE will be investigated in a cluster-randomized controlled trial (RCT) in schools (N = 16). All groups will receive a minimal intervention called "Stress-free through the school day" as a mental health literacy program to prevent burnout in school. The treatment group (N = 1600; 8 schools) will additionally undergo the universal prevention program DUDE and will be divided into treatment group 1 (DUDE conducted by trained clinical psychologists; N = 800; 4 schools) and treatment group 2 (DUDE conducted by trained teachers; N = 800; 4 schools). The active control group (N = 1600; 8 schools) will only receive the mental health literacy prevention. Besides baseline assessment (T0), measurements will occur at the end of the treatment (T1) and at 6- (T2) and 12-month (T3) follow-up evaluations. The main outcome is the occurrence of NSSI within the last 6 months assessed by a short version of the Deliberate Self-Harm Inventory (DSHI-9) at the 1-year follow-up (primary endpoint; T3). Secondary outcomes are emotion regulation, suicidality, health-related quality of life, self-esteem, and comorbid psychopathology and willingness to change.

DISCUSSION

DUDE is tailored to diminish the incidence of NSSI and to prevent its possible long-term consequences (e.g., suicidality) in adolescents. It is easy to access in the school environment. Furthermore, DUDE is a comprehensive approach to improve mental health via improved emotion regulation.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS) DRKS00018945. Registered on 01 April 2020, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00018945.

[Reduction of Non-Suicidal Self-Injury (NSSI) in Adolescents with Borderline Personality Organization Treated with TFP-A]

This study examines whether transference-focused psychotherapy for adolescents (TFP-A) in a dayclinic setting increases the capability to regulate affects and decreases self-destructive behavior in adolescents with borderline personality organization in comparison to treatment as usual (TAU). A total of 120 adolescents consecutively presenting to the dayclinic were allocated to either TFP-A or TAU. They were assessed for aggression, irritability, depression, self-harm, internalizing behavior and pathological personality traits at baseline and after twelve weeks. TFP-A was more effective than TAU in reducing self-harm. Aggression and irritability was improved within the treatment group. These results can be explained by an improvement in affect regulation through a treatment with TFP-A in a dayclinic setting. Further research is necessary in order to assess whether TFP-A reduces self-harm, aggressive behavior and irritability from a long-term perspective and whether these exploratory results can be replicated in independent samples.

Dialectical Behavior Therapy for Suicidal Self-Harming Youth: Emotion Regulation, Mechanisms, and Mediators

OBJECTIVE

This study evaluated mechanisms, mediation, and secondary/exploratory outcomes in our randomized controlled trial evaluating dialectical behavior therapy (DBT) compared to individual and group supportive therapy (IGST). We expand on previously reported results indicating a DBT advantage at posttreatment on planned suicide/self-harm outcomes, and greater self-harm remission (absence of self-harm, post hoc exploratory outcome) during active-treatment and follow-up periods.

METHOD

This was a multi-site randomized trial of 173 adolescents with prior suicide attempts, self-harm, and suicidal ideation. Randomization was to 6 months of DBT or IGST, with outcomes monitored through 12 months. Youth emotion regulation was the primary mechanistic outcome.

RESULTS

Compared to IGST, greater improvements in youth emotion regulation were found in DBT through the treatment-period [t(498) = 2.36, p = .019] and 12-month study period (t(498) = 2.93, p = .004). Their parents reported using more DBT skills: posttreatment t(497) = 4.12, p < .001); 12-month follow-up t(497) = 3.71, p < .001). Mediation analyses predicted to self-harm remission during the 6- to 12-month follow-up, the prespecified outcome and only suicidality/self-harm variable with a significant DBT effect at follow-up (DBT 49.3%; IGST 29.7%, p = .013). Improvements in youth emotion regulation during treatment mediated the association between DBT and self-harm remission during follow-up (months 6-12, estimate 1.71, CI 1.01-2.87, p = .045). Youths in DBT reported lower substance misuse, externalizing behavior, and total problems at posttreatment/6 months, and externalizing behavior throughout follow-up/12 months.

CONCLUSION

Results support the significance of emotion regulation as a treatment target for reducing self-harm, and indicate a DBT advantage on substance misuse, externalizing behavior, and self-harm-remission, with 49.3% of youths in DBT achieving self-harm remission during follow-up.

CLINICAL TRIAL REGISTRATION INFORMATION

Collaborative Adolescent Research on Emotions and Suicide; https://www.clinicaltrials.gov/; NCT01528020.

Comparative Efficacy and Acceptability of Psychotherapies for Self-harm and Suicidal Behavior Among Children and Adolescents: A Systematic Review and Network Meta-analysis

IMPORTANCE

Self-harm and suicidal behavior are associated with substantial morbidity and mortality among children and adolescents. The comparative performance of psychotherapies for suicidality is unclear because few head-to-head clinical trials have been conducted.

OBJECTIVE

To compare the efficacy of psychotherapies for the treatment of self-harm and suicidality among children and adolescents.

DATA SOURCES

Four major bibliographic databases (PubMed, MEDLINE, PsycINFO, and Embase) were searched for clinical trials comparing psychotherapy with control conditions from inception to September 2020.

STUDY SELECTION

Randomized clinical trials comparing psychotherapies for suicidality and/or self-harm with control conditions among children and adolescents were included after a blinded review by 3 independent reviewers (A.B., M.P., and J.W.).

DATA EXTRACTION AND SYNTHESIS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed for data abstraction, and the Cochrane risk of bias tool was used to evaluate study-level risk of bias. Data abstraction was performed by 1 reviewer (A.B.) and confirmed by 2 independent blinded reviewers (J.W. and M.P.). Data were analyzed from October 15, 2020, to February 15, 2021.

MAIN OUTCOMES AND MEASURES

The primary outcomes were dichotomized self-harm and retention in treatment. The secondary outcomes were dichotomized all-cause treatment discontinuation and scores on instruments measuring suicidal ideation and depressive symptoms. Effect sizes were pooled using frequentist random-effects network meta-analysis models to generate summary odds ratios (ORs) and Cohen d standardized mean differences (SMDs). Negative Cohen d SMDs or ORs less than 1 indicated that the treatment reduced the parameter of interest relative to the control condition (eg, signifying a beneficial association with suicidal ideation).

RESULTS

The systematic search generated 1272 unique records. Of those, 44 randomized clinical trials (5406 total participants; 4109 female participants [76.0%]) from 49 articles were selected (5 follow-up studies were merged with their primary clinical trials to avoid publication bias). The selected clinical trials spanned January 1, 1995, to December 31, 2020. The median duration of treatment was 3 months (range, 0.25-12.00 months), and the median follow-up period was 12 months (range, 1-36 months). None of the investigated psychotherapies were associated with increases in study withdrawals or improvements in retention in treatment compared with treatment as usual. Dialectical behavioral therapies were associated with reductions in self-harm (OR, 0.28; 95% CI, 0.12-0.64) and suicidal ideation (Cohen d SMD, -0.71; 95% CI, -1.19 to -0.23) at the end of treatment, while mentalization-based therapies were associated with decreases in self-harm (OR, 0.38; 95% CI, 0.15-0.97) and suicidal ideation (Cohen d SMD, -1.22; 95% CI, -2.18 to -0.26) at the end of follow-up. The quality of evidence was downgraded because of high risk of bias overall, heterogeneity, publication bias, inconsistency, and imprecision.

CONCLUSIONS AND RELEVANCE

Although some psychotherapeutic modalities appear to be acceptable and efficacious for reducing self-harm and suicidality among children and adolescents, methodological issues and high risk of bias prevent a consistent estimate of their comparative performance.

Interventions for self-harm in children and adolescents

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most countries, often repeated, and associated with suicide. Evidence assessing the effectiveness of interventions in the treatment of SH in children and adolescents is lacking, especially when compared with the evidence for psychosocial interventions in adults. This review therefore updates a previous Cochrane Review (last published in 2015) on the role of interventions for SH in children and adolescents.

OBJECTIVES

To assess the effects of psychosocial interventions or pharmacological agents or natural products for SH compared to comparison types of care (e.g. treatment-as-usual, routine psychiatric care, enhanced usual care, active comparator, placebo, alternative pharmacological treatment, or a combination of these) for children and adolescents (up to 18 years of age) who engage in SH.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Specialized Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic Reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020).

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing specific psychosocial interventions or pharmacological agents or natural products with treatment-as-usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, placebo, alternative pharmacological treatment, or a combination of these, in children and adolescents with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow-up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide.

DATA COLLECTION AND ANALYSIS

We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence internals (CIs). For continuous outcomes, we calculated the mean difference (MD) or standardised mean difference (SMD) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post-intervention) was appraised for each intervention using the GRADE approach.

MAIN RESULTS

We included data from 17 trials with a total of 2280 participants. Participants in these trials were predominately female (87.6%) with a mean age of 14.7 years (standard deviation (SD) 1.5 years). The trials included in this review investigated the effectiveness of various forms of psychosocial interventions. None of the included trials evaluated the effectiveness of pharmacological agents in this clinical population. There was a lower rate of SH repetition for DBT-A (30%) as compared to TAU, EUC, or alternative psychotherapy (43%) on repetition of SH at post-intervention in four trials (OR 0.46, 95% CI 0.26 to 0.82; N = 270; k = 4; high-certainty evidence). There may be no evidence of a difference for individual cognitive behavioural therapy (CBT)-based psychotherapy and TAU for repetition of SH at post-intervention (OR 0.93, 95% CI 0.12 to 7.24; N = 51; k = 2; low-certainty evidence). We are uncertain whether mentalisation based therapy for adolescents (MBT-A) reduces repetition of SH at post-intervention as compared to TAU (OR 0.70, 95% CI 0.06 to 8.46; N = 85; k = 2; very low-certainty evidence). Heterogeneity for this outcome was substantial ( I² = 68%). There is probably no evidence of a difference between family therapy and either TAU or EUC on repetition of SH at post-intervention (OR 1.00, 95% CI 0.49 to 2.07; N = 191; k = 2; moderate-certainty evidence). However, there was no evidence of a difference for compliance enhancement approaches on repetition of SH by the six-month follow-up assessment, for group-based psychotherapy at the six- or 12-month follow-up assessments, for a remote contact intervention (emergency cards) at the 12-month assessment, or for therapeutic assessment at the 12- or 24-month follow-up assessments.

AUTHORS' CONCLUSIONS

Given the moderate or very low quality of the available evidence, and the small number of trials identified, there is only uncertain evidence regarding a number of psychosocial interventions in children and adolescents who engage in SH. Further evaluation of DBT-A is warranted. Given the evidence for its benefit in adults who engage in SH, individual CBT-based psychotherapy should also be further developed and evaluated in children and adolescents.

Heterogeneity of borderline personality disorder symptoms in help-seeking adolescents

BACKGROUND

The heterogeneous presentation of borderline personality disorder (BPD) represents a clinical challenge. There is an ongoing scientific debate whether the heterogeneity can best be understood in terms of qualitative (categorical) or quantitative (dimensional) differences between individuals. The present study examined the latent structure of BPD in adolescents.

METHODS

Five-hundred and six outpatients aged 12 to 17 years with risk-taking and/or self-harming behavior were assessed at baseline and one-year follow-up. Latent class analysis (corresponding with the categorical approach), factor analysis (corresponding with the dimensional approach), and factor mixture models (allowing for both categorical and dimensional aspects) were applied to the DSM-IV BPD criteria.

RESULTS

The best fitting model distinguished between a majority class with high probabilities for all BPD criteria ("borderline group") and a minority class with high probabilities for the impulsivity and anger criteria only ("impulsive group"). Sex significantly affected latent class membership, and both a latent factor and age explained within-class variability. The borderline group primarily consisted of females, frequently reported adverse childhood experiences, scored high on the emotion dysregulation and inhibitedness personality traits, and was associated with internalizing psychopathology. In contrast, the impulsive group primarily consisted of males, scored high on the dissocial behavior personality trait, and was associated with externalizing psychopathology. After one year, the two groups showed similar clinical improvement.

CONCLUSIONS

The study provides evidence for two distinct subgroups of adolescents with BPD features that resemble the subtypes of the ICD-10 emotionally unstable personality disorder. More research is needed to further investigate the diagnostic stability of the two groups over time and potential differential treatment indications.

Nonsuicidal Self-Injury in Youth: A Primer for Pediatricians

Nonsuicidal self-injury (NSSI) is a relatively common occurrence in youth, and pediatricians must be prepared to address this behavior in their patients in an open and nonjudgmental way. Although NSSI is done without suicidal intent, its occurrence does increase the risk for suicide and is often found with other diagnosable psychiatric conditions. Screening for NSSI should be accompanied by screening for suicidal ideation and comorbid psychiatric disorders to ensure that the patient's current risk is properly assessed and that they have access to the right resources and treatments. This article is a primer for primary care pediatricians for how to talk about and address NSSI in their patients. [Pediatr Ann. 2021;50(2):e72-e76.].

The Impact of Adverse Childhood Experiences on Therapy Outcome in Adolescents Engaging in Nonsuicidal Self-Injury

Objective: Nonsuicidal self-injury (NSSI) is a prevalent and clinically significant behavior. There is a substantial association between adverse childhood experiences (ACEs) and NSSI. However, there are no studies investigating the impact of ACEs on NSSI treatment (psychotherapy) outcome. The aim of this secondary analysis of a randomized controlled trial (RCT) on psychotherapy of NSSI was to investigate the relationship between ACEs and treatment outcome in adolescents engaging in NSSI. Method: A sample of 74 adolescent outpatients engaging in repetitive NSSI (incidents on ≥ 5 days within the last 6 months) was recruited for a RCT. ACEs were assessed by the Childhood Experience of Care and Abuse (CECA) interview before treatment onset. Based on the CECA, participants were divided in two groups: with a history of ACEs (n = 30) and without a history of ACEs (n = 44). Frequencies of NSSI, depression, and suicide attempts as well as quality of life were measured at three points in time: before treatment onset (baseline; T0), 4 (T1), and 10 months (T2) after treatment onset. Results: Both participants with and without ACEs were able to reduce the frequency of NSSI significantly [χ2 (1) = 26.72; p < 0.001]. Surprisingly, participants with ACEs reached a significantly greater reduction in NSSI frequency within the past 6 months compared to participants without ACEs [χ2 (1) = 5.08; p = 0.024]. There were also substantial and similar improvements regarding depressive symptoms, suicide attempts and quality of life in both groups. Conclusion: ACEs seem to positively predict treatment response in psychotherapy for adolescent NSSI. This is contrary to prior research suggesting ACE as an unfavorable prognostic factor in the treatment of mental disorders. Clinical Trial Registration: Short term therapy in adolescents with self-destructive and risk-taking behaviors; http://www.drks.de; DRKS00003605.

Klinische Stadienmodelle in der Früherkennung und -behandlung der Borderline-Persönlichkeitsstörung

Hintergrund

Die Borderline-Persönlichkeitsstörung (BPS) ist eine schwere psychische Störung, die typischerweise erstmals in der Adoleszenz auftritt und mit einem hohen Leidensdruck, schweren psychosozialen Defiziten bei Betroffenen sowie hohen Kosten für die Gesellschaft verbunden ist. Die Früherkennung und -intervention der BPS haben zum Ziel, die negativen Auswirkungen der Störung frühzeitig zu reduzieren oder zu verhindern und dadurch die Lebensläufe der betroffenen Jugendlichen positiv zu beeinflussen. Klinische Stadienmodelle bieten Orientierung bei der Auswahl einer geeigneten Intervention entsprechend dem aktuellen Krankheitsstadium.

Ziel der Arbeit

In der vorliegenden Arbeit wird das Rationale klinischer Stadienmodelle erläutert. Bestehende Stadienmodelle der BPS werden vorgestellt und diskutiert.

Material und Methoden

Kritische Reflexion vorhandener Forschungsliteratur.

Ergebnisse

Bisher wurden 2 Stadienmodelle der BPS vorgeschlagen, das erste Modell aus dem Jahr 2016 gemeinsam für die BPS und die affektiven Störungen, das neuere, darauf aufbauende Modell aus dem Jahr 2019 mit höherer Spezifität und Fokus auf die Entwicklung von Persönlichkeitsstörungen und sich daraus ergebenden Schwierigkeiten.

Diskussion

Die vorgestellten klinischen Stadienmodelle der BPS bieten Orientierung bei der Beschreibung des typischen Krankheitsverlaufs sowie der Auswahl einer geeigneten Intervention, insbesondere in frühen Krankheitsstadien, da sie dabei helfen können, frühe, unspezifische Anzeichen einer sich entwickelnden Störung wahrzunehmen und eine geeignete Behandlung einzuleiten. Mit weiteren Erkenntnissen über die Entwicklung der BPS und effektive Interventionen können Stadienmodelle in der Zukunft weiter verbessert werden.

Tailoring treatments for adolescents with nonsuicidal self-injury

Nonsuicidal Self-Injury (NSSI) in adolescence is highly prevalent and seems to be on the rise. To deliver evidence-based treatments to a large and growing number of adolescents, it is crucial to provide scaleable, manualized interventions that have the potential to fit into a stepped-care approach. The work by Kaess et al. (2019) was able to show a reduction of NSSI both by the brief intervention "Cutting Down", as well as by regular psychotherapeutic treatment. Future treatment strategies for NSSI should tailor treatment approaches to fit adolescents´ needs.

[Development of an Online Intervention for Adolescents and Young Adults Engaging in Nonsuicidal Self-injury]

Development of an Online Intervention for Adolescents and Young Adults Engaging in Nonsuicidal Self-injury Nonsuicidal self-injury (NSSI) is a prevalent phenomenon in adolescence. Despite the existence of effective psychotherapeutic interventions, the majority of affected adolescents and young adults do not receive any treatment. Structural (e. g., no specific interventions, limited resources, limited accessibility) as well as individual factors (e. g., low help-seeking behavior) impede access to adequate clinical care for adolescent NSSI. Online interventions offer the possibility to provide specific interventions independent of one's location or local healthcare structures. Because of its high confidentiality and accessibility, the Internet also reaches adolescents with low help-seeking behavior. There is already evidence for online interventions concerning different mental health issues, like depression and anxiety. However, regarding NSSI, there are no effective, online interventions. Thus, we developed an online intervention based on an already evaluated short term program specific for adolescents and young adults with NSSI within the German STAR consortium (STAR: Self-Injury - Treatment, Assessment, Recovery). Within a randomised controlled trial, the intervention will be evaluated regarding its efficacy.

Non-Suicidal Self-Injury and Eating Disordered Behaviors: An Update on What We Do and Do Not Know

PURPOSE OF REVIEW

The current report aims to summarize recent advances about the relationship between non-suicidal self-injury (NSSI) and eating disordered (ED) behaviors and highlights meaningful directions for future research.

RECENT FINDINGS

While there is solid evidence indicating a robust cross-sectional association between NSSI and ED behaviors, emerging evidence suggests that the temporal relationship between these behaviors may be bidirectional. Shared functions and risk factors may explain why these behaviors often co-develop. At the same time, little is still known about the psychosocial consequences of comorbid NSSI and ED engagement, and there is a lack of intervention studies that target these behaviors simultaneously. It is well-established that NSSI and ED behaviors frequently co-occur. The field should now turn to longitudinal designs to advance our understanding of the longer-term developmental and the shorter-term momentary relationship of these behaviors in daily life. Providing insight into these areas will help guide the deployment of evidence-based interventions that match the needs of clients who report comorbid NSSI and ED behaviors.

Does treatment method matter? A meta-analysis of the past 20 years of research on therapeutic interventions for self-harm and suicidal ideation in adolescents

BACKGROUND

Self-harm is a clinically relevant and prevalent behaviour which peaks in adolescence. Given the high prevalence of self-harm, the high levels of psychiatric comorbidity, and its role as a risk factor for suicide, delivering evidence-based care is critical.

METHODS

We conducted a systematic review and meta-analysis of the literature on treating self-harm in adolescents (12-19 years) published in the last 20 years, identifying 25 randomised controlled trials. We calculated the effect of treatment interventions relative to active control conditions in reducing self-harm, suicidal ideation and depressive symptoms.

RESULTS

Overall, treatment interventions fared slightly better than active controls in decreasing self-harm (d = 0.13, 95% CI 0.04-0.22, p = .004), suicidal ideation (d = 0.31, 95% CI 0.12-0.50, p = .001) and depressive symptoms (d = 0.22, 95% CI 0.07-0.38, p = .006). Subgroup analysis of specific therapies revealed moderate effects of DBT-A in reducing self-harm (d = 0.51, 95% CI 0.18-0.85, p = .002) and suicidal ideation (d = 0.48, 95% CI 0.17-0.80, p = .003), as well as moderate effects of family-centred therapy in the treating suicidal ideation (d = 0.58, 95% CI 0.01-1.15, p = .049).

CONCLUSIONS

The findings of our meta-analysis indicate that, overall, currently available treatments are effective in treating self-harm, suicidal ideation, and depressive symptoms in adolescence. Although the treatment intervention conditions showed only small to moderate effects in comparison to active controls, these differences were statistically significant and are clinically important. Further research is needed to understand the reduction in self-harm within active controls, which may arise due to the natural course of self-harm, or the potential efficacy of treatment as usual and enhanced usual care. Given the significant reduction of self-harm in active control conditions, delivering effective care to a large number of adolescents with self-harm may require developing stepped-care models in clinical practice. Expensive and poorly available treatments should be targeted at young people who most need them.