Evidence Base Update of Psychosocial Treatments for Self-Injurious Thoughts and Behaviors in Youth

Moderators and Mediators of Treatments for Suicidal Thoughts and Behaviors: A Review of More Than 50 Years of Randomized Controlled Trials

Psychosocial treatments for suicidal thoughts and behaviors (STBs) are in need of improvement, as suicide rates have substantially increased in the last 20 years and current interventions show limited efficacy. One way to potentially boost response rates is to personalize treatments by identifying what works how and for whom to maximize impact across different individuals. A scoping review of all suicide treatment randomized controlled trials was performed on PubMed, PsycInfo, and GoogleScholar through May 2024 to identify moderators and mediators of suicide treatment. Forty-six studies including moderators and 15 studies including mediators were identified and evaluated by at least two independent researchers. The most frequently tested moderators across both adults and adolescents include age, gender/sex, history of STBs, therapeutic alliance, comorbid depression, and comorbid borderline personality disorder diagnoses or symptoms, with the strongest support found for therapeutic alliance in adults. No mediator was tested in more than one trial or research group, but hopelessness, avoidance, mentalization, and number of treatment contacts in adolescents and resilience, anxiety sensitivity, acceptance, and therapeutic relationship in adults showed positive signals. Overall, additional work is needed as heterogeneity, lack of replication attempts, and concerns about moderator and mediator quality currently limit confidence in findings.

Sub-groups of emotion dysregulation in youth with nonsuicidal self-injury: latent profile analysis of a randomized controlled trial

Psychological treatments targeting emotion dysregulation in adolescents reduce nonsuicidal self-injury (NSSI) but predicting treatment outcome remains difficult. Identifying sub-groups based on repeated measurements of emotion dysregulation pre-treatment may guide personalized treatment recommendations. We used data from a recent trial evaluating internet-delivered emotion regulation therapy for adolescents with NSSI (n = 138). Latent profile analysis was used to identify sub-groups based on pre-treatment responses on the 16-item version of the Difficulties in Emotion Regulation Scale. The primary outcome was self-rated NSSI frequency during treatment, and secondary outcome was the proportion of participants with no NSSI 1-month post-treatment. Three sub-groups of emotion dysregulation were identified: low variability and low mean (Group 1), low variability and high mean (Group 2), and high variability and low mean (Group 3). Sub-groups did not differ in NSSI frequency during treatment (Group 2 IRR = 1.06 [95% CI 0.49-2.29], p = .88; Group 3 IRR = 1.22 [95% CI 0.31-4.76], p = .77). However, more participants in Group 1 compared to Group 2 abstained from NSSI at 1-month post-treatment (OR = 3.63 [95% CI 1.16-11.33], p = 0.01). Latent profile analysis identified sub-groups predictive of NSSI absence post-treatment, demonstrating clinical utility.

Life is precious: A quasi-experimental study of a community-based program to prevent suicide among Latina adolescents in New York City

INTRODUCTION

Rising rates of suicidal thoughts and behaviors (STBs) among U.S. Latina adolescents urgently need attention. Life is Precious (LIP) is a culturally responsive, community-based, afterschool-model program offering wellness-support services to supplement outpatient mental health treatment for Latina adolescents experiencing STB's. This 12-month quasi-experimental pilot study explored LIP's impact on clinical outcomes.

METHODS

Latina adolescents newly enrolled in LIP and receiving outpatient treatment (n = 31) and those newly starting outpatient treatment only (n = 12; Usual Care) were assessed for Suicidal Ideation (Suicidal Ideation Questionnaire; SIQ) and depressive symptoms (Patient Health Questionnaire-9). We estimated differences in mean scores using longitudinal linear mixed models and adjusted risk ratios (ARRs) of SIQ-25%, SIQ-50%, and PHQ-9-5-point improvements using exact logistic models.

RESULTS

The direction of the estimated impact of LIP was positive [differences (95% CIs): -15.5 (-34.16, 3.15) for SIQ; -1.16 (-4.39, 2.07) for PHQ-9], with small-to-moderate nonsignificant effect sizes (0.19-0.34). LIP participants saw two to three times higher prevalence than controls of SIQ-25%, SIQ-50%, and PHQ-9-5-point improvements; ARRs (95% CIs) were 1.91 (0.61, 3.45), 3.04 (0.43, 11.33), and 1.97 (0.44, 5.07), respectively. Suicidal behaviors also decreased in LIP.

CONCLUSION

The effects of LIP were in positive directions across clinical outcomes, warranting further research on its effectiveness in decreasing STBs.

Practice experiences for school reintegration: Endorsement for virtual reality with adolescents hospitalized for suicide-related crises

This study applied qualitative methods and a user design approach to develop and iteratively refine a model for a virtual reality intervention designed to supplement standard inpatient treatment for adolescents hospitalized for suicide-related crises: the practice experiences for school reintegration (PrESR). The PrESR model allows patients to practice therapeutic skills within an immersive school environment to increase skill knowledge and skill use and to improve school reintegration. Adolescents previously hospitalized for suicide-related thoughts and behaviors (n = 13), hospital professionals with experience providing supports to hospitalized adolescents (n = 7), and school professionals with experience supporting adolescents with suicide-related risks (n = 12) completed focus group and/or one-on-one interviews to inform the development of the PrESR model. Transcribed interviews were analyzed using content analysis, and structured feedback was analyzed by calculating frequencies. Participating adolescents were between the ages of 13 and 18, identifying their race as White (61%), Asian (7.7%), American Indian and Black (7.7%), or Black (7.7%; note that 15.4% preferred not to answer) and their ethnicity as Hispanic (23%) or non-Hispanic (77%). Adolescents identified their gender as girl or woman (46%), boy or man (38%), or "some other way" (15%). A majority of adolescent and professional participants endorsed the PrESR as holding the potential to promote skill learning. Feedback addressed improvements to scenarios and skills; safety concerns, constraints to consider, and barriers to implementation; and information to include in the treatment manual. Findings also informed the types of difficulties adolescents face in schools and the potential feasibility of a virtual reality intervention to enhance standard inpatient care of adolescents hospitalized for suicide-related crises. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Milieu Management and Therapeutic Groups in Inpatient Child and Adolescent Psychiatry Units

The therapeutic milieu has long been considered an essential mechanism of recovery for youth requiring inpatient psychiatric admissions. However, with increasing demand for crisis services, shrinking length of stay, rising patient acuity, and critical workforce shortages, innovation is necessary to maintain the goals of the therapeutic milieu (and equip the workforce to meet this challenge). This review surveys the evolution of the goals of milieu therapy over time, evidence for increasing challenges, and initial evidence for possible solutions. The study concludes with a case example detailing efforts to improve milieu therapy and empower frontline staff at a Midwestern pediatric hospital.

Comparison between clinician and machine learning prediction in a randomized controlled trial for nonsuicidal self-injury

BACKGROUND

Nonsuicidal self-injury is a common health problem in adolescents and associated with future suicidal behavior. Predicting who will benefit from treatment is an urgent and a critical first step towards personalized treatment approaches. Machine-learning algorithms have been proposed as techniques that might outperform clinicians' judgment. The aim of this study was to explore clinician predictions of which adolescents would abstain from nonsuicidal self-injury after treatment as well as how these predictions match machine-learning algorithm predictions.

METHODS

Data from a recent trial evaluating an internet-delivered emotion regulation therapy for adolescents with nonsuicidal self-injury was used. Clinician predictions of which patients would abstain from nonsuicidal self-injury (measured using the youth version of Deliberate Self-harm Inventory) were compared to a random forest model trained on the same available data from baseline assessments.

RESULTS

Both clinician (accuracy = 0.63) and model-based (accuracy = 0.67) predictions achieved significantly better accuracy than a model that classified all patients as reaching NSSI remission (accuracy = 0.49 [95% CI 0.41 to 0.58]), however there was no statistically significant difference between them. Adding clinician predictions to the random forest model did not improve accuracy. Emotion dysregulation was identified as the most important predictor of nonsuicidal self-injury absence.

CONCLUSIONS

Preliminary findings indicate comparable prediction accuracy between clinicians and a machine-learning algorithm in the psychological treatment of nonsuicidal self-injury in youth. As both prediction approaches achieved modest accuracy, the current results indicate the need for further research to enhance the predictive power of machine-learning algorithms. Machine learning model indicated that emotion dysregulation may be of importance in treatment planning, information that was not available from clinician predictions.

TRIAL REGISTRATION

NCT03353961|| https://www.

CLINICALTRIALS

gov/ , registered 2017-11-21. Preregistration at Open Science Framework: https://osf.io/vym96/ .

A longitudinal study of self-injurious thoughts and behaviors transitions and help-seeking intentions among young adults

PURPOSE

Engagement in self-injurious thoughts and behaviors (SITBs) is associated with low help-seeking intentions. Nevertheless, prior research has primarily relied on cross-sectional data, leaving uncertainties about the longitudinal dynamics between SITBs and help-seeking intentions. This study aims to investigate the longitudinal relationship between SITBs and help-seeking intentions for them.

METHOD

A one-year interval follow-up investigation was conducted among 1788 Chinese students (71.5% girls, Mage = 19.5). Changes in help-seeking intentions were initially analyzed among four SITBs transition groups. Subsequently, a cross-lagged model was employed to explore the possible bidirectional associations.

RESULTS

232 participants (12.90%) experienced changes in SITBs, while 65 participants (3.60%) exhibited sustained SITBs between two measurement time points. Changes in help-seeking intentions varied across SITBs transition groups. Participants whose SITBs faded 1 year later showed a significant increase in help-seeking intentions, whereas those who experienced newly developed SITBs across two measurement time points demonstrated a significant decline. The cross-lagged analysis revealed that help-seeking intentions negatively predicted the subsequent risk of experiencing SITBs.

CONCLUSIONS

Greater help-seeking intentions predicted decreased SITBs 1 year later. Changes in help-seeking intentions serve as a valuable indicator for distinguishing between different types of SITBs transition. These findings underscore the importance of implementing prevention and intervention strategies targeted at enhancing help-seeking intentions to reduce SITBs.

Perceived burdensomeness and thwarted belongingness as mediators of the relation between anxiety and suicidal ideation among adolescents

INTRODUCTION

Anxiety and suicidal ideation have been shown to be positively related in adolescents. However, less is known about the strength of this association across different types of anxiety or the mechanisms through which this relation exists. Joiner's interpersonal theory of suicide suggests that thwarted belongingness (TB) and perceived burdensomeness (PB) lead to suicidal ideation; these constructs may explain a pathway through which anxiety and suicidal ideation are related. It was hypothesized that TB would mediate the relation between social anxiety disorder (SAD) symptoms and suicidal ideation, and PB would mediate the relation between generalized anxiety disorder (GAD) symptoms and suicidal ideation.

METHODS

These longitudinal mediation models were assessed using data collected from 147 depressed adolescents, who were recently hospitalized for suicidal ideation or behavior, enrolled in a randomized controlled trial (RCT).

RESULTS

Consistent with study hypotheses, PB mediated the relation between GAD symptoms and suicidal ideation severity. However, TB did not mediate the relation between SAD symptoms and suicidal ideation severity.

CONCLUSION

These results suggest that screening for and addressing PB among youth with GAD may help reduce risk for suicidal behavior.

Characteristics of Disclosure of Suicidal and Nonsuicidal Behaviors in a Clinical Sample of Adolescents

Many adolescents fear disclosing self-injurious thoughts and behaviors (SITBs) due to stigma or concern about responses from others. The current study examined rates of disclosure for nonsuicidal self-injury (NSSI), suicide ideation, and suicide attempts in a clinical sample of adolescents, and identified the individuals to whom they disclosed their SITBs. Differences in reasons for living (parent and peer support, future optimism, self-acceptance, and fear of suicide) were examined across disclosure groups. The sample included 100 adolescent inpatients (mean age = 14.61). Rates of disclosure were relatively high: 77% for NSSI, 75% for suicide ideation, and 83.7% for suicide attempts. Adolescents who disclosed NSSI reported higher scores on subscales of self-esteem and future optimism compared to those who did not disclose. No differences were found for adolescents disclosing to parents vs. others; only the fear of suicide subscale was significantly different, and was lower for adolescents who disclosed NSSI to peers vs. others. Adolescents with suicide ideation disclosure reported more parent support compared to those who had not disclosed, those with peer disclosure reported lower fear of suicide than those disclosing to others, and there were no differences for disclosing to parents vs. others. For suicide attempts, only self-acceptance subscale scores were significantly different, and lower for adolescents who disclosed to peers vs. others. There were no differences for disclosing suicide attempts to parents versus other people. The willingness to disclose self-harm behaviors seems influenced by the perception of safety and anticipated support from parents or others to whom adolescents disclose.

Prevalence of self-harm among children and adolescents in the Republic of Ireland: a systematic review

OBJECTIVES

Youth self-harm (SH) is viewed as a public health concern and one of the main reasons for urgent psychiatry assessment. This systematic review sought to establish prevalence of SH among youth in Ireland.

METHODS

A systematic review using pre-defined search terms was conducted (Jan 1980-March 2024).

RESULTS

From a total of 204 papers identified, 18 were included. Significant variation in rates of SH was found. Limiting data to adolescent years (15-18), best estimates for overall lifetime rates of SH ranged from 1.5% (when rates of SH were reported based on a two-stage study design), to 23% (where SH was limited to non-suicidal SH). SH was typically higher in females, impulsive in nature, and occurred in the home setting. Whilst almost half of youth sought help before (43.7%) or after (49.8%) the SH episode, this was most often to a friend or family member. Overall rates of professional help seeking were low.

CONCLUSIONS

Robust studies using clear definitions of terms, separately capturing SH with and without suicidal intent, and distinguishing SH in the context of a mental illness, are required to inform service developments. Given the frequent occurrence of SH among youth accompanied by predominance of help seeking via friends and family, it is imperative that psychoeducation is delivered to families and peers. Out of hours community and specialist mental health services are essential to address this important issue.

Adolescent, caregivers, and therapists' experiences of youth and family suicide intervention: A qualitative study

OBJECTIVE

This study explores the experience of an individual and family therapy youth suicide intervention from the perspectives of seven psychotherapy triads (young people aged 12-18, their parents/caregivers and therapists).

METHOD

Data were collected through semi-structured individual interviews and analyzed using consensual qualitative research methods.

RESULTS

Four domains were identified: Focusing on the youth-parent relationship, individual therapy for young people and their parents, conjoint therapy, and public service structures and systemic practice that facilitated tailored treatment. All participant groups valued intervention that improved the youth-parent relationship; however, they held different views about its influence on suicidality and recovery. Separate youth and parent therapy was crucial for facilitating the tailoring of treatment and enhancing the reparative potential of conjoint therapy. Barriers to productive intervention included inaccessible, fragmented, and siloed treatment that excluded parents, stigmatizing clinician responses, and acute care that was not attuned to need or developmental context. Helpful intervention was systemically and attachment-informed, multi-disciplinary, individually tailored, and integrated freely available specialist therapy with crisis and inpatient care.

CONCLUSION

A relational, nuanced, and flexible approach is needed to tailor youth suicide treatment in the context of the complexity of youth-parent relationships.

A systematic review of interpersonal processes and their measurement within experience sampling studies of self-injurious thoughts and behaviours

Self-injurious thoughts and behaviours (SITBs) are a leading cause of death, and interpersonal processes (IPs) appear to play a role in SITBs. This systematic review synthesises the literature on IPs and SITBs in daily life and addresses four critical questions: (1) Which IPs have been assessed and how, (2) How are differences in IPs between individuals associated with SITBs?, (3) How are differences in IPs within individuals associated with SITBs? and (4) Do IPs relate differently to self-injurious thoughts than behaviours? Our review followed PRISMA guidelines and eligible literature was screened until 25 April 2024. We identified 58 Experience Sampling studies (32.76% daily-diary studies) of which most focused on IPs from major SITBs theories (e.g., thwarted belongingness) but largely used inconsistent operationalizations. Results from 39 studies investigating within-person associations were mixed. Based on 26 studies, whether differences in IPs between individuals relate to SITBs remains unclear. Three studies have investigated whether IPs relate to the transition from thoughts to behaviours, but temporal models are needed to draw firm conclusions. Studies investigating IPs and SITBs in daily life are largely inconclusive. Psychometrically validated measures are warranted, and future daily-life studies would benefit from drawing on ideation-to-action frameworks.

Psychological interventions for suicidal behavior in adolescents: a comprehensive systematic review

BACKGROUND

Recent evidence indicates that the risk of death by suicide in teenagers has increased significantly worldwide. Consequently, different therapeutic interventions have been proposed for suicidal behavior in this particular population. Therefore, the main objective of this study is to provide an updated review of the existing psychological interventions for the treatment of suicide attempts (SA) in adolescents and to analyze the efficacy of such interventions.

METHODS

A systematic review was conducted following PRISMA guidelines. The studies were identified by searching PubMed, PsychINFO, Web of Science, and Scopus databases from 2016 to 2022. According to the inclusion criteria, a total of 40 studies that tested the efficacy of different psychological interventions were selected.

RESULTS

Various psychological interventions for adolescents with suicidal behaviors were identified. Most of those present promising results. However, to summarize results from recent years, dialectical behavior therapy (DBT) was the most common and the only treatment shown to be effective for adolescents at high risk of suicide and SA. In contrast, empirical evidence for other psychological interventions focusing on deliberate self-harm (SH) is inconclusive.

CONCLUSIONS

Interventions specifically designed to reduce suicidal risk in adolescents have multiplied significantly in recent years. There are a few promising interventions for reducing suicidal behaviors in adolescents evaluated by independent research groups. However, replication and dismantling studies are needed to identify the effects of these interventions and their specific components. An important future challenge is to develop brief and effective interventions to reduce the risk of death by suicide among the adolescent population.

Caregiver-Youth intergeneration acculturation conflict moderates the relationship between depression severity and suicidality among female Mexican-Descent college students

OBJECTIVE

Suicide is the second leading cause of death among college-age students in the U.S., with disparities in suicide ideation and attempts among Latinas. The current study aims to examine if depression severity predicts suicide ideation and attempts and to examine if caregiver intergeneration acculturation conflict (IAC) moderates this link.

PARTICIPANTS

A sample of 246 Mexican-descent female college students.

METHODS

Self-reported measures for depression severity, male and female caregiver IAC, and suicide ideation and attempts in the previous 12-months were ascertained.

RESULTS

In our sample, 31.1% endorsed suicide ideation and 15.9% suicide attempts. Controlling for age, both male and female caregiver IAC moderated the relationship between depression severity and suicide ideation. A similar moderation pattern emerged for the suicide attempts outcome.

CONCLUSIONS

Understanding this exacerbating contextual factor can help inform prevention/intervention efforts targeting Mexican-descent college students who are experiencing depressive symptoms by focusing on decreasing IAC with both caregivers.Suicide is the second leading cause of death among emerging adults, defined as 18-29-year-olds,1 in the United States (U.S.) and is responsible for more deaths than any single major medical illness.2 Significant gender and ethnic/racial disparities have been well-documented and highlight that Latina emerging adults experience some of the highest rates of suicide ideation (SI) and suicide attempts (SA) and the greatest increases in SA over time, when compared to non-Latinx White, female emerging adults.3,4 In fact, recent research suggests that Latina college students report a 1.7% prevalence rate of suicide attempts compared to 1.2% among non-Latina White college students and data trends report a nearly double increase in the percent of suicide attempts from 2011 to 2015 (from 0.9% to 1.7%) for Latinas versus a minimal change (from 1.1% to 1.2%) among non-Latina White college students.4 Key research examining this disparity have cited that elevated depressive symptoms, which are also experienced at higher levels among Latinx groups in the U.S.,5 are strongly linked to SI and SA among Latinx college students and emerging adults.6,7 Developmentally, the highest risk period for the onset of SI and SA is during late adolescence or emerging adulthood8 and deaths due to suicide increase as adolescents move into emerging adulthood.2,9 Emerging adulthood is an even riskier developmental period for minoritized college students, like Latinx college students, because this period is marked by identity formation processes that are exacerbated by intercultural interactions on college campuses and cultural expectations at home.10 These data underscore the significance of detecting how unique contextual factors may interact with elevated depressive symptoms, and importantly, how these factors are associated with the increased suicide risk among Latinx college-age youth, as they represent a high-risk developmental and ethnic group.

The relationship between future time perspective and suicide ideation in college students: Multiple mediating effects of anxiety and depression

Background

Suicide ideation has high prevalence in adolescents, better future time perspective is considered a protective role for anxiety, depression, and suicide ideation. However, the impact of future time perspective on suicide ideation remains unclear, especially when anxiety and depression as mediating roles.

Methods

A cross-sectional study of college students was performed in Chongqing, China. There are 851 students enrolled in this study and we distribute questionnaires through the WeChat platform to obtain data in 2023. We conducted Pearson correlation analysis and descriptive statistics. Model 6 in PROCESS 4.0 was used to test the multiple mediating effect.

Results

College students who have higher future time perspective are associated with a lower risk of anxiety, depression, and suicide ideation. Future time perspective not only affects suicide ideation directly, but also influence it by means of two mediating pathways: ①depression, the mediation effect is 37.41 %; ②the multiple mediating effects of anxiety and depression with a mediating effect of 29.68 %.

Conclusion

Higher future time perspective functions as a protective role in anxiety, depression, and suicide ideation; future time perspective can affect and predict the occurrence of suicide ideation by influencing anxiety and depression in college students. This conclusion will be a novel and insightful part of adolescent mental health research, and provide a new perspective to prevent college students from committing suicide in the future.

A multi-modal assessment of self-knowledge in adolescents with non-suicidal self-injury: a research domains criteria (RDoC) study

BACKGROUND

Adolescence is a critical period for brain development, consolidation of self-understanding, and onset of non-suicidal self-injury (NSSI). This study evaluated the RDoC (Research Domain Criteria) sub-construct of Self-Knowledge in relation to adolescent NSSI using multiple units of analysis.

METHODS

One hundred and sixty-four adolescents assigned female at birth (AFAB), ages 12-16 years with and without a history of NSSI entered a study involving clinical assessment and magnetic resonance imaging (MRI), including structural, resting-state functional MRI (fMRI), and fMRI during a self-evaluation task. For imaging analyses, we used an a priori defined Self Network (anterior cingulate, orbitofrontal, and posterior cingulate cortices; precuneus). We first examined interrelationships among multi-level Self variables. We then evaluated the individual relationships between NSSI severity and multi-level Self variables (self-report, behavior, multi-modal brain Self Network measures), then conducted model testing and multiple regression to test how Self variables (together) predicted NSSI severity.

RESULTS

Cross-correlations revealed key links between self-reported global self-worth and self-evaluation task behavior. Individually, greater NSSI severity correlated with lower global self-worth, more frequent and faster negative self-evaluations, lower anterior Self Network activation during self-evaluation, and lower anterior and posterior Self Network resting-state connectivity. Multiple regression analysis revealed the model including multi-level Self variables explained NSSI better than a covariate-only model; the strongest predictive variables included self-worth, self-evaluation task behavior, and resting-state connectivity.

CONCLUSIONS

Disruptions in Self-Knowledge across multiple levels of analysis relate to NSSI in adolescents. Findings suggest potential neurobiological treatment targets, potentially enhancing neuroplasticity in Self systems to facilitate greater flexibility (more frequently positive) of self-views in AFAB adolescents.

Moderators and predictors of treatment outcome following adjunctive internet-delivered emotion regulation therapy relative to treatment as usual alone for adolescents with nonsuicidal self-injury disorder: Randomized controlled trial

Background

Despite the wide-ranging negative consequences of nonsuicidal self-injury (NSSI), there are few evidence-based treatments for NSSI among adolescents and little is known about what treatments that work best for whom. The objective of this study was to investigate moderators (i.e., for whom a specific treatment works) and predictors (i.e., factors associated with treatment outcome independent of treatment type) of treatment outcome in a randomized clinical trial comparing internet-delivered emotion regulation individual therapy for adolescents (IERITA) plus treatment as usual (TAU) to TAU alone.

Methods

Adolescents (N = 166; mean [SD] age = 15.0 [1.2] years) with NSSI disorder were randomized to IERITA plus TAU (n = 84) or TAU-only (n = 82). Adolescent emotion regulation difficulties, suicidality, NSSI frequency, depressive symptoms, sleep difficulties, global functioning, and age, and parental invalidation, were measured pre-treatment and investigated as moderators and predictors of treatment outcome (i.e., NSSI frequency during treatment and for 4 weeks post-treatment). A zero-inflated negative binomial generalized linear mixed effects regression model was used to estimate the rate of NSSI change as a function of both treatment condition and moderator/predictor.

Results

No significant moderators of treatment outcome were found. Parental invalidation was a significant predictor of treatment outcome regardless of treatment condition, such that high levels of parental invalidation pre-treatment were associated with a less favorable NSSI frequency.

Conclusions

We did not find evidence of a differential treatment effect as a function of any of the examined client factors. Future research should investigate moderation in larger samples and with sufficient statistical power to detect moderation effects of smaller magnitude. Results suggest that parental invalidation may have a negative impact on treatment response and highlight the importance of further investigating parental invalidation in the context of NSSI treatments.

Long-term impact of the Fostering Healthy Futures for Preteens program on suicide-related thoughts and behaviors for youth in out-of-home care: A randomized controlled trial

Youth in out-of-home care are at high risk for suicide-related thoughts and behaviors (STB), yet there are no known efficacious interventions that reduce STB for this population. Fostering Healthy Futures for Preteens (FHF-P) is a 9-month community-based mentoring and skills training preventive intervention for children in out-of-home care. A randomized controlled trial enrolled 156 participants aged 9-11 years who were placed in out-of-home care over the prior year. Participants were 48.9% female, 54.1% Hispanic, 30.1% Black, and 27.1% American Indian. Follow-up interviews, conducted 7-12 years postintervention (85.2% retention rate), asked young adult participants, aged 18-22, to self-report lifetime STB as indexed by non-suicidal self-injury, suicidal thoughts, plans, and/or attempts. There was a nonsignificant reduction in the odds of STB for the intervention group at follow-up (OR = 0.74; CI, 0.32, 1.69). However, FHF-P significantly moderated the effect of baseline STB; control youth who reported baseline STB had 10 times the odds of young adult STB (OR = 10.44, CI, 2.28, 47.78), but there was no increase in the odds of adult-reported STB for intervention youth. Findings suggest that FHF-P buffers the impact of pre-existing STB on young adult STB for care-experienced youth. Further research is needed to identify mechanisms that may reduce STB in this population.

Practice-based insights from specialized clinicians into youth suicide risk assessment and psychotherapy: A qualitative study

Objective: The experience of frontline clinicians is an underutilized source of knowledge about improving youth suicide intervention. This qualitative study explored the perspectives of highly experienced, specialized mental health clinicians on the practical application of risk assessment, stabilization, and treatment and their experience of working in this practice area.Method: Data were collected from seven focus groups with 28 clinicians and analyzed using consensual qualitative research methods.Results: Four domains emerged, describing 1) youth suicide intervention as relationally focused and attachment-informed, 2) the need for flexible and tailored care balancing individual and family intervention in the context of family complexity and fractured relationships, 3) a nuanced, therapeutic approach to managing the complexity and uncertainty of adolescent suicide risk, and 4) working in youth suicide intervention as emotionally demanding and facilitated or hampered by the organizational and systems context.Conclusion: The importance of harnessing family systems and attachment-informed approaches to alliance, risk assessment, and treatment was emphasized, along with the parallel need for systemic clinician support and consideration of the potential negative consequences of administrative and risk management protocols.

Which Psychosocial Strengths Could Combat the Adolescent Suicide Spectrum? Dissecting the Covitality Model

Objective: Covitality is a meta-construct of positive intra/interpersonal self-schemas that organize and process life experiences. Its synergy favors psychosocial adjustment and prevents mental health problems during adolescence. At these ages, suicide is one of the leading causes of death worldwide. The purpose of this study was to determine which psychosocial strengths of the covitality model could combat adolescent suicide spectrum. Method: Participants were 5,528 Spanish adolescents aged 12-18 years, 50.74% females. The assessment protocol was completed in schools, under the supervision of the research staff. Statistical analyses were conducted using hurdle models, i.e., modeling zero-inflated count data. This process provided two sets of outcomes: the association - in probabilistic terms - between psychosocial strengths and the absence of suicide indicators (i.e., non-occurrence) and the association of these assets - via regression coefficients - with increased experimentation (i.e., duration/quantity). Results: All psychosocial strengths of the covitality model were related to the non-ocurrence of suicidal thoughts and behaviors, but not all to a shorter duration/quantity of their phenotypic manifestations. Covitality obtained greater association values on suicidal tendencies than its components analyzed independently. Belief in self and engaged living were the second-order factors with the higher estimating capacity. Specifically, emotional self-awareness, enthusiasm, gratitude, family support, and behavioral self-control were key first-order assets. Conclusions: These findings suggest that training adolescents in covitality assets could be an effective strategy for universal prevention against premature suicide. Moreover, this study provide evidence on which psychosocial strengths could counteract each phenotypic manifestation of suicide in order to customize selective and indicated preventive actions.

Clinical study on the characteristics and related influencing factors of deliberate drug ingestion in adolescents

Objective

To analyze the characteristics of deliberate drug ingestion in adolescents and its related influencing factors.

Method

This was a retrospective study. A total of 158 cases of deliberate drug ingestion as observation group and 160 cases of other diseases in adolescents as control group were treated in the Emergency Department of Baoding Hospital of Beijing Children's Hospital Affiliated to Capital Medical University from January 2020 to December 2022. The clinical characteristics of adolescents who engaged in deliberate drug ingestion were analyzed, and various factors that could potentially influence deliberate drug ingestion in adolescents were subjected to both univariate and multivariate analysis.

Result

There was a progressive increase in the number of patients presenting with mental health issues year by year. Univariate analysis showed that family type, guardian's education level, place of residence, whether they were only children, parents' knowledge of medication, awareness of medication safety, depression/anxiety, negative life events, and social support were risk factors for deliberate drug ingestion in adolescents (all p<0.05). Logistic regression analysis showed that family type, parents' knowledge of medication, awareness of medication safety, whether they were depressed/anxious, negative life events, and social support were independent risk factors for deliberate drug ingestion in adolescents (p<0.05).

Conclusion

The incidence of deliberate drug ingestion in adolescents is increasing year by year, and their behavior is influenced by multiple factors. Interventions should be targeted at controllable influencing factors to prevent or reduce deliberate drug ingestion in adolescents.

Testing the modifiability of episodic future thinking and episodic memory among suicidal and nonsuicidal adolescents

Background

Despite increased attention on treatment and prevention for suicidal adolescents, we know little about potential intervention targets. Episodic future thinking-the ability to imagine detailed, personal, and future-oriented events-is a modifiable cognitive process that has been linked with suicidal ideation (SI) in adolescents. However, until now its modifiability has only been tested in adults.

Method

Adolescents (N = 176, ages 15-19; 71% SI) completed performance-based measures of episodic future thinking (i.e., Experimental Recombination Paradigm) and memory immediately before and after an Episodic Specificity Induction (ESI).

Results

Adolescents produced a greater number of future episodic details after (vs. before) the ESI but showed no change in non-episodic details (e.g., semantic information). Patterns of change in episodic future thinking were not moderated by SI history. Adolescents overall did not demonstrate change in past episodic detail counts after the ESI. However, there were select moderating effects of SI history on this effect.

Conclusion

Results show that episodic future thinking can change immediately following an episodic specificity induction among adolescents, regardless of whether they have previously experienced SI. This demonstration of within-person change constitutes a foundational first step in examining malleability of episodic future thinking in adolescents and offers preliminary evidence of a cognitive mechanism that may be leveraged in service of reducing adolescents' SI.

Remission, Recovery, Relapse, and Recurrence Rates for Suicide Attempts and Nonsuicidal Self-Injury for Suicidal Youth Treated With Dialectical Behavior Therapy or Supportive Therapy

OBJECTIVE

To evaluate rates of remission, recovery, relapse, and recurrence in suicidal youth who participated in a clinical trial comparing Dialectical Behavior Therapy (DBT) and Individual and Group Supportive Therapy (IGST).

METHOD

Participants were 173 youth, aged 12 to 18 years, with repetitive self-harm (including at least 1 prior suicide attempt [SA]) and elevated suicidal ideation (SI). Participants received 6 months of DBT or IGST and were followed for 6 months post-treatment. The sample was 95% female, 56.4% White, and 27.49% Latina. Remission was defined as absence of SA or nonsuicidal self-injury (NSSI) across one 3-month interval; recovery was defined across 2 or more consecutive intervals. Relapse and recurrence were defined as SA or NSSI following remission or recovery. Cross-tabulation with χ2 was used for between-group contrasts.

RESULTS

Over 70% of the sample reported remission of SA at each treatment and follow-up interval. There were significantly higher rates of remission and recovery and lower rates of relapse and recurrence for SA in DBT than for IGST. Across treatments and time points, SA had higher remission and recovery rates and lower relapse and recurrence rates than NSSI. There were no significant differences in NSSI remission between conditions; however, participants receiving DBT had significantly higher NSSI recovery rates than those receiving IGST for the 3- to 9-month, 3- to 12-month, and 6- to 12-month intervals.

CONCLUSION

Results showed higher percentages of SA remission and recovery for DBT as compared to IGST. NSSI was less likely to remit than SA.

PLAIN LANGUAGE SUMMARY

This study examined rates of remission, recovery, relapse, and recurrence of suicide attempts (SA) and nonsuicidal self-injury (NSSI) among the participants in the CARES Study, a randomized clinical trial of 6 months of Dialectical Behavior Therapy or Individual and Group Supportive Therapy. 173 youth aged 12 to 18 years participated in the study and were followed for 6 months post treatment. Over 70% of the sample reported remission of SA at each treatment and follow-up interval. There were significantly higher rates of remission and recovery and lower rates of relapse and recurrence for SA among participants who received Dialectical Behavioral Therapy. Across both treatments, remission and recovery rates were lower and relapse and recurrence rates were higher for NSSI than for SA. These results underscore the value of Dialectical Behavioral Therapy as a first line treatment for youth at high risk for suicide.

DIVERSITY & INCLUSION STATEMENT

We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants.

CLINICAL TRIAL REGISTRATION INFORMATION

Collaborative Adolescent Research on Emotions and Suicide (CARES); https://www.

CLINICALTRIALS

gov/; NCT01528020.

Neural Markers of Emotion Reactivity and Regulation Before and After a Targeted Social Rejection: Differences Among Girls With and Without Suicidal Ideation and Behavior Histories

BACKGROUND

Suicidal thoughts and behaviors (STBs) are common among adolescent girls and increase risk for suicide death. Emotion regulation difficulties are linked with STBs, particularly in response to targeted social rejection. However, neural correlates of this link have not been investigated and may identify novel targets for interventions. Here, we examined neural correlates of emotion regulation before and after an experimentally delivered targeted social rejection in adolescent girls with STBs and girls without STBs (i.e., control participants).

METHODS

Girls (N = 138; age range, 9-15 years; mean [SD] age = 11.6 [1.79] years) completed a functional neuroimaging emotion regulation task. In the middle of the task, participants were socially rejected by an unfamiliar confederate whom the participants had elected to meet. Participants also completed a multimethod STB assessment.

RESULTS

Before rejection, girls with a history of STBs, compared with control participants, showed greater activation in the right superior frontal gyrus when passively viewing negative stimuli, and girls with suicidal behavior (SB) versus those without SB showed less activation in the right frontal pole during emotion regulation attempts. Following the rejection, girls with STBs, compared with control participants, showed greater activation in the right inferior frontal gyrus during emotion regulation.

CONCLUSIONS

Before social rejection, girls with SB versus without SB may not activate brain regions implicated in emotion regulation, suggesting a vulnerability to poor regulation at their baseline emotional state. After social rejection, girls with any history of STBs showed altered activation in a brain region strongly associated with inhibition and emotion regulation success, possibly reflecting increased effort at inhibiting emotional responses during regulation following stress exposure.

Socio-Cognitive Behavioral Therapy for Latinx Adolescent with Suicidal Behaviors: A Pilot Randomized Trial

Evidence-based treatment for Latinx/Hispanic (L/H) with suicidal behaviors (SB) is scarce. This study evaluated the acceptability and preliminary efficacy of a socio-cognitive-behavioral therapy protocol for SB (SCBT-SB) with L/H adolescents and the feasibility of conducting a randomized controlled trial (RCT) of SCBT-SB compared to treatment-as-usual (TAU). A pilot RCT was conducted with 46 L/H teens. The target outcomes included suicidal ideation (SI), suicide attempts (SAs), and depressive/internalizing symptoms. Results indicated that the SCBT-SB was acceptable and an RCT with diverse L/H families is feasible to implement. Within group analyses showed reductions over time for each group in SI and depressive/internalizing symptoms. Intent-to-treat between-group analyses showed a medium effect for the SCBT-SB at the twelve-month follow-up for depressive/internalizing symptoms and a large effect for SA. Although results must be interpreted cautiously given the small sample size, outcomes suggest that SCBT-SB may be a promising psychosocial treatment for depressive/internalizing symptoms, and SAs in L/H youth.

A Brief Cognitive Analytic Therapy-Informed Approach for Young People That Have Self-Injured (CATCH-Y): A Case Series

BACKGROUND

Non-suicidal self-injury (NSSI) presents an increasingly prevalent problem for young people; however, there remains a scarce evidence base for effective, scalable treatments for adolescents. This study aimed to assess the feasibility and acceptability of a brief, cognitive analytic therapy (CAT)-informed intervention for young people who engage in NSSI (CATCH-Y).

METHODS

A case series design recruited 13 young people who met the inclusion and exclusion criteria to participate in the five-session intervention. Eligible participants were aged 13-17 years (M = 15.15, SD = 1.28) and had engaged in NSSI at least once in the previous 6 months. Feasibility and acceptability were measured via recruitment, retention, qualitative feedback and missing data. The secondary outcome measures of personal recovery and motivation were administered pre- and post-assessment, with measures of depressive symptoms and urges to self-injure.

RESULTS

The intervention was found to be largely feasible and acceptable with high rates of recruitment, retention and pre-/post-assessment data completeness. Measures showed preliminary support for positive change in rates of NSSI, urges to self-harm, low mood and personal recovery, although results were mixed. Completion rates for remote assessments were low.

CONCLUSIONS

The findings of this study support further evaluation of the CATCH-Y intervention on a larger scale. In-person assessments may be preferable to remote to ensure good completion rates.

Abbreviated Dialectical Behavior Therapy Virtual Skills Group for Caregivers of Adolescents: An Exploratory Study of Service User and Clinical Outcomes

Prior work emphasizes involving caregivers in youth mental health services. To support youth with emotion dysregulation, dialectical behavior therapy for adolescents (DBT-A) includes a multi-family skills group, wherein adolescents and caregivers learn skills together. However, limited work has examined the impact of caregiver involvement within DBT-A. The current study examines outcomes of two caregiver-only DBT-A skills groups adapted for abbreviated telehealth delivery. We report on caregivers' (N = 11, 100% mothers, 55% Hispanic) service user outcomes (e.g. self-efficacy at skill usage, group cohesion, therapeutic alliance) and clinical outcomes (i.e. their own emotion functioning, criticism, responses to their adolescent's negative emotions). Results indicate caregiver-only groups were feasible and acceptable, and suggest preliminary efficacy, including improvements in caregiver emotion functioning, distress during interactions with their adolescents, and adolescent-reported criticism. Caregivers also reported reductions in unsupportive responses with their adolescents. Overall, while we caution interpretation due to a small sample size, findings support the preliminary feasibility and efficacy of modifying caregiver participation in DBT-A to be less time-consuming and administered via telehealth.

Disclosures of self-injurious thoughts and behaviors to parents in the context of adolescent therapy: A qualitative investigation

Self-injurious thoughts and behaviors (SITBs), including suicidal thoughts, suicide attempts, and nonsuicidal self-injury, are highly prevalent among adolescents. Identifying adolescents at risk for SITBs relies on their disclosure, and these disclosures commonly occur in therapy context. Moreover, therapists often breach confidentiality to inform adolescents' parent or guardian when they disclose SITBs. Research has explored rates of and barriers to disclosure among adolescents, yet no studies have examined adolescents' experiences of disclosure in the therapy context. Further, no studies have examined adolescents' experiences when their parents are then informed. In this study, we examined qualitative responses from 1495 adolescents who had experienced a SITB disclosure in the therapy context. Qualitative questions included asking adolescents to describe how the SITB disclosure occurred, how their parents were informed, and their parents' reactions. Using open and axial coding, several themes emerged. Adolescents described therapist breaches of confidentiality as collaborative, noncollaborative, or unclear. Adolescents described their parents' affective responses, communication about SITBs, validating and invalidating responses, treatment-oriented responses, and ways that parents restricted their access to people, places, and activities. Findings have implications for the development of clinical guidelines when adolescents disclose SITBs in therapy and highlight areas for future research in adolescent SITB disclosure.

Non-suicidal Self-injurious Thoughts and Behaviors Among Adolescent Inpatients

Non-suicidal self-injury (NSSI) is a serious public health concern that typically onsets during early adolescence. Adolescents (N = 980, ages 12-19 years) admitted for acute, residential psychiatric treatment completed baseline clinical interviews assessing mental disorders and questionnaires measuring demographics, early life adversity, and symptom severity. Prevalence rates of NSSI for lifetime (thoughts: 78%; behaviors: 72%), past year (thoughts: 74%; behaviors: 65%), and past month (thoughts: 68%; behaviors: 51%) were high. Although effect sizes were modest, the presence of a lifetime depressive disorder, sexual abuse, and comorbidity (i.e., three or more current disorders) were significant correlates of experiencing NSSI thoughts and behaviors. Furthermore, lifetime depressive disorder, current anxiety disorder, and comorbidity were associated with a greater odds of persistent NSSI thoughts and/or behaviors. Longitudinal studies are needed to determine whether targeting these factors reduces the persistence of NSSI thoughts and behaviors.

Systematic Review: Patient Outcomes in Transdiagnostic Adolescent Partial Hospitalization Programs

OBJECTIVE

Partial hospitalization programs (PHPs) are designed to help stabilize patients with acute mental health problems and are considered more cost-effective than inpatient care for patients who do not require 24-hour monitoring. Many PHPs treat transdiagnostic adolescents to reduce suicidality, self-harm, and other high-risk behaviors; however, the effectiveness of such programs is unknown. We aimed to review the existing evidence for the effects of PHPs on adolescent mental health symptoms and functioning.

METHOD

We retrieved peer-reviewed evaluations of PHPs treating adolescents with a range of disorders that reported quantitative clinical outcomes. We followed PRISMA guidelines for systematic reviews and included studies published since 2000.

RESULTS

Fifteen studies of 10 PHPs in North America, Europe, Asia, and Australia met inclusion criteria, 5 of which used comparison groups. Most participants were White and female with depressive disorders. All studies found improvements in adolescents' functioning and mental health from admission to discharge; however, only 1 study tested PHP relative to other levels of care, and only 1 study included follow-up data. Dialectical behavior therapy (DBT) may be an effective theoretical orientation for PHP settings, but evidence is limited.

CONCLUSION

Evidence for effectiveness of PHPs relative to other models is limited. Currently available research suggests that many high-risk transdiagnostic adolescents tend to improve during PHP treatment; however, controlled studies with follow-up data are needed to determine whether partial hospitalization is effective and, if so, how effective, and whether treatment gains persist after discharge.

Prevalence of suicide attempts across the African continent: A systematic review and meta-analysis

BACKGROUND

Over 700,000 people worldwide lose their lives through suicide every year. The prevalence of suicide has increased, especially in low- and middle-income countries such as many African countries. For every fatal suicidal attempt, there are approximately 20 other non-fatal suicide attempts within the population. The purpose of this study is to investigate the prevalence of attempts of suicides in the African continent through a systematic review and meta-analysis.

METHODS

To identify relevant sources, the PubMed, Scopus, Web of Science, Embase, ScienceDirect and Google Scholar repositories and databases were systematically searched without a lower time limit and until July 2023. The heterogeneity of the studies was checked with the I2 index, and accordingly random effects model was adopted to perform the analysis. Data analysis was conducted within the Comprehensive Meta-Analysis software (v.2).

RESULTS

In the review of 48 studies with a sample size of 244,701 people, the prevalence of suicide attempts in Africa was found to be 9.9% (95%CI: 8.5%-11.6%). With the increase in the year of study, the prevalence of suicide attempt in the African continent increases. Also, with the increase in the sample size, the prevalence of suicide attempts in Africa decreases. The suicide attempt prevalence among African men and woman slightly differed with 7.6% and 8.2%, respectively.

CONCLUSION

Suicide attempt is an important public health concern in Africa. The findings of this study are important not only for African health policy making, but also to contribute to the accuracy of global estimates with respect to suicide attempts.

Correlates of Informant Discrepancies in Self-Harm Among Youth Involved in Child Protective Services

Youth involved with child protective services (CPS) are at elevated risk for engaging in self-harm. Participation in interventions or treatments that may reduce youths' self-harm behaviors often depends on the accurate reporting of their self-injurious behaviors. However, informants often disagree on the presence or severity of self-harm engagement, making the identification of youth in need of treatment more challenging. The current study aims to characterize discrepancies between youth and caregiver reports of children's self-harm among a sample of youth with a history of CPS involvement, and to identify factors (e.g., demographics, youth and caregiver psychological impairments, aspects of the caregiving environment) associated with these discrepancies. Participants (N = 258) were drawn from a large, nationally representative sample of youth under the age of 18 (mean age = 13.8) and their caregivers who were investigated by CPS. Multinomial logistic regressions were used to examine correlates of discrepancies in caregiver and youth reports of youth self-harm. Results indicated that 10% of caregiver-child dyads agreed on children's engagement in self-harm. In 33% of cases, only the child reported self-harm and in 57% of cases, only the caregiver reported youth self-harm. Being a biological caregiver, child female sex, higher levels of internalizing symptoms; higher post-traumatic stress disorder (PTSD) symptoms; and greater caregiver alcohol use was associated with a lower likelihood of caregivers reporting self-harm only. Older child age; lower externalizing symptoms; higher PTSD symptoms, and greater levels of caregiver emotional security and structure were linked to lower odds of children reporting self-harm only. These results underscore important factors to consider when assessing self-harm among youth involved with CPS and have potential implications for practice guidelines in this population.

Using Wearable Devices and Speech Data for Personalized Machine Learning in Early Detection of Mental Disorders: Protocol for a Participatory Research Study

BACKGROUND

Early identification of mental disorder symptoms is crucial for timely treatment and reduction of recurring symptoms and disabilities. A tool to help individuals recognize warning signs is important. We posit that such a tool would have to rely on longitudinal analysis of patterns and trends in the individual's daily activities and mood, which can now be captured through data from wearable activity trackers, speech recordings from mobile devices, and the individual's own description of their mental state. In this paper, we describe such a tool developed by our team to detect early signs of depression, anxiety, and stress.

OBJECTIVE

This study aims to examine three questions about the effectiveness of machine learning models constructed based on multimodal data from wearables, speech, and self-reports: (1) How does speech about issues of personal context differ from speech while reading a neutral text, what type of speech data are more helpful in detecting mental health indicators, and how is the quality of the machine learning models influenced by multilanguage data? (2) Does accuracy improve with longitudinal data collection and how, and what are the most important features? and (3) How do personalized machine learning models compare against population-level models?

METHODS

We collect longitudinal data to aid machine learning in accurately identifying patterns of mental disorder symptoms. We developed an app that collects voice, physiological, and activity data. Physiological and activity data are provided by a variety of off-the-shelf fitness trackers, that record steps, active minutes, duration of sleeping stages (rapid eye movement, deep, and light sleep), calories consumed, distance walked, heart rate, and speed. We also collect voice recordings of users reading specific texts and answering open-ended questions chosen randomly from a set of questions without repetition. Finally, the app collects users' answers to the Depression, Anxiety, and Stress Scale. The collected data from wearable devices and voice recordings will be used to train machine learning models to predict the levels of anxiety, stress, and depression in participants.

RESULTS

The study is ongoing, and data collection will be completed by November 2023. We expect to recruit at least 50 participants attending 2 major universities (in Canada and Mexico) fluent in English or Spanish. The study will include participants aged between 18 and 35 years, with no communication disorders, acute neurological diseases, or history of brain damage. Data collection complied with ethical and privacy requirements.

CONCLUSIONS

The study aims to advance personalized machine learning for mental health; generate a data set to predict Depression, Anxiety, and Stress Scale results; and deploy a framework for early detection of depression, anxiety, and stress. Our long-term goal is to develop a noninvasive and objective method for collecting mental health data and promptly detecting mental disorder symptoms.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48210.

Long-term Effects of the Family Check-Up on Suicidality in Childhood and Adolescence: Integrative Data Analysis of Three Randomized Trials

This study employed integrative data analysis techniques to examine the long-term effects of the family check-up (FCU) on changes in youth suicide risk using three randomized prevention trials, including one trial initiated in early childhood and two initiated in early adolescence. Data were harmonized across studies using moderated nonlinear factor analysis, and intervention effects were tested using an autoregressive latent trajectory model examining changes in suicide risk across long-term follow-up. Across trials, significant long-term effects of the FCU on reductions in suicide risk were observed, although differences between intervention and control group trajectories declined over time. No moderation of intervention effects was observed by youth gender or race/ethnicity or across samples. While results offer further support for the benefits of the FCU for suicide risk reduction, they also suggest that such effects may wane over time, underscoring the need for continued development of the FCU to enhance longer-term durability of effects on suicide-related behaviors.

Approach-avoidance biases to self-harm cues in young people with self-harm

BACKGROUND

The urge to self-harm can be likened to craving in addictive behaviours. However, it remains unclear whether cognitive mechanisms involved in craving, such as attentional biases to cues, also underpin the urge to self-harm.

METHODS

A Dot Probe Task was used to investigate attentional biases to self-harm cues in young people aged 16-25 with self-harm. Cues were shown for either 0.2 s or 2 s. Dot Probe Task performance in the Self-harm group (N = 50) was compared with age-matched Healthy Controls (N = 50) and age- and negative-affect (Depression Anxiety Stress Scale-21) matched controls with no self-harm (N = 50).

RESULTS

The Self-harm group showed significantly greater avoidance of self-harm cues than Healthy Controls at 2 s. The Negative Affect group showed significantly less difficulty disengaging from self-harm cues than the Self-harm group and Healthy Controls at 2 s. There were no between-group differences in attentional bias at 0.2 s.

LIMITATIONS

Study limitations that may affect attentional biases in the Self-harm group include not measuring indicators of recovery and recruiting only from the community potentially missing more severe self-harm presentations in clinical settings.

CONCLUSIONS

Avoidance of self-harm cues in young people with self-harm may reflect conflict around self-harm behaviour, consistent with ambivalence models of craving. An ability to disengage from self-harm cues may be a protective factor in young people with higher levels of negative affect who do not self-harm. Whether these attentional biases represent a quantifiable marker of treatment response or susceptibility to relapse in individuals with self-harm remains an area for future investigation.

Practitioner Review: Common elements in treatments for youth suicide attempts and self-harm - a practitioner review based on review of treatment elements associated with intervention benefits

BACKGROUND

Adopting a common elements approach, this practitioner review aims to highlight specific treatment elements that are common to interventions with demonstrated benefits in randomized controlled trials (RCTs) for reducing suicide attempts and self-harm in youth. Identification of common treatment elements among effective interventions offers a key strategy for clarifying the most robust features of effective interventions and improving our ability to implement effective treatment and decrease the lag between scientific advances and clinical care.

METHODS

A systematic search of RCTs evaluating interventions targeting suicide/self-harm in youth (ages 12-18) yielded a total of 18 RCTs assessing 16 different manualized interventions. An open coding process was used to identify common elements present within each intervention trial. Twenty-seven common elements were identified and classified into format, process, and content categories. All trials were coded for the inclusion of these common elements by two independent raters. RCTs were also classified into those where trial results supported improvements in suicide/self-harm behavior (n = 11 supported trials) and those without supported evidence (n = 7 unsupported trials).

RESULTS

Compared with unsupported trials, the 11 supported trials shared the following elements: (a) inclusion of therapy for both the youth and family/caregivers; (b) an emphasis on relationship-building and the therapeutic alliance; (c) utilization of an individualized case conceptualization to guide treatment; (d) provided skills training (e.g. emotion regulation skills) to both youth and their parents/caregivers; and (e) lethal means restriction counseling as part of self-harm monitoring and safety planning.

CONCLUSIONS

This review highlights key treatment elements associated with efficacy that community practitioners can incorporate in their treatments for youth presenting with suicide/self-harm behaviors.

Future Directions in Youth Irritability Research

Research on irritability in children and adolescents has proliferated over the last 20 years. The evidence shows the clinical and developmental significance of irritable mood and behavior in youth, and it has led to significant changes in mental health classification, diagnosis, and services. At the same time, this research (including our own) has led to relatively little new in terms of practical, empirically based guidance to improve interventions and outcomes. In this article, we briefly summarize some of these developments and current evidence-based practices. We then put forth two key substantive challenges (the "whats") for future research to address: (a) the need for more effective treatments, especially evaluating and adapting evidence-based treatments that are already well-established for problems related to irritability (e.g., cognitive-behavioral therapies for internalizing and externalizing problems); and (b) the need for a better mechanistic understanding of irritability's phenomenology (e.g., phasic vs. tonic irritability, how frustration unfolds) and putative underlying mechanisms (e.g., cognitive control, threat and reward dysfunction). Lastly, we suggest three methodological approaches (the "hows") that may expedite progress in such areas: (a) ecological momentary assessment, (b) digital health applications, and (c) leveraging existing datasets. We hope this article will be useful for students and early-career researchers interested in tackling some of these important questions to better meet the needs of severely irritable youth.

Predictors of suicide coping self-efficacy among youth presenting to a psychiatric emergency department

INTRODUCTION

Low levels of youth-reported self-efficacy to cope with suicidal urges have been shown to prospectively predict repeat emergency department (ED) visits and suicide attempts, yet little is known about how self-efficacy may change following receipt of crisis services or about factors that may strengthen self-efficacy. Protective factors (e.g., parent-reported youth competence, parent-family connectedness, and receipt of mental health services) were examined in relation to self-efficacy at the time of a psychiatric ED visit and 2 weeks later.

METHODS

Participants were 205 youth (ages 10-17), presenting to a psychiatric ED due to a suicide-related concern. Youth primarily identified as biological female (63%) and White (87%). Multivariate hierarchical linear regressions were used to examine candidate protective factors in relation to initial and follow-up suicide coping self-efficacy.

RESULTS

Self-efficacy significantly improved in the 2 weeks following the ED visit. Parent-family connectedness was positively related to suicide coping self-efficacy at the time of the ED visit. Parent-family connectedness and receipt of inpatient psychiatric care following the ED visit were associated with higher follow-up suicide coping self-efficacy.

CONCLUSIONS

During the adolescent developmental period when suicidal thoughts and behaviors notably increase, study findings highlight potential malleable intervention targets, including parent-family connectedness, that may strengthen suicide coping self-efficacy.

Use of research electronic data capture (REDCap) in a sequential multiple assignment randomized trial (SMART): a practical example of automating double randomization

BACKGROUND

Adaptive interventions are often used in individualized health care to meet the unique needs of clients. Recently, more researchers have adopted the Sequential Multiple Assignment Randomized Trial (SMART), a type of research design, to build optimal adaptive interventions. SMART requires research participants to be randomized multiple times over time, depending upon their response to earlier interventions. Despite the increasing popularity of SMART designs, conducting a successful SMART study poses unique technological and logistical challenges (e.g., effectively concealing and masking allocation sequence to investigators, involved health care providers, and subjects) in addition to other challenges common to all study designs (e.g., study invitations, eligibility screening, consenting procedures, and data confidentiality protocols). Research Electronic Data Capture (REDCap) is a secure, browser-based web application widely used by researchers for data collection. REDCap offers unique features that support researchers' ability to conduct rigorous SMARTs. This manuscript provides an effective strategy for performing automatic double randomization for SMARTs using REDCap.

METHODS

Between January and March 2022, we conducted a SMART using a sample of adult (age 18 and older) New Jersey residents to optimize an adaptive intervention to increase COVID-19 testing uptake. In the current report, we discuss how we used REDCap for our SMART, which required double randomization. Further, we share our REDCap project XML file for future investigators to use when designing and conducting SMARTs.

RESULTS

We report on the randomization feature that REDCap offers and describe how the study team automated an additional randomization that was required for our SMART. An application programming interface was used to automate the double randomizations in conjunction with the randomization feature provided by REDCap.

CONCLUSIONS

REDCap offers powerful tools to facilitate the implementation of longitudinal data collection and SMARTs. Investigators can make use of this electronic data capturing system to reduce errors and bias in the implementation of their SMARTs by automating double randomization.

TRIAL REGISTRATION

The SMART study was prospectively registered at Clinicaltrials.gov; registration number: NCT04757298, date of registration: 17/02/2021.

Effect of Internet-Delivered Emotion Regulation Individual Therapy for Adolescents With Nonsuicidal Self-Injury Disorder: A Randomized Clinical Trial

Importance

Nonsuicidal self-injury is prevalent in adolescence and associated with adverse clinical outcomes. Effective interventions that are brief, transportable, and scalable are lacking.

Objective

To test the hypotheses that an internet-delivered emotion regulation individual therapy for adolescents delivered adjunctive to treatment as usual is superior to treatment as usual only in reducing nonsuicidal self-injury and that improvements in emotion regulation mediate these treatment effects.

Design, Setting, and Participants

This 3-site, single-masked, randomized superiority trial enrolled participants from November 20, 2017, to April 9, 2020. Eligible participants were aged between 13 and 17 years and met diagnostic criteria for nonsuicidal self-injury disorder; they were enrolled as a mixed cohort of consecutive patients and volunteers. Parents participated in parallel to their children. The primary end point was at 1 month after treatment. Participants were followed up at 3 months posttreatment. Data collection ended in January 2021.

Interventions

Twelve weeks of therapist-guided, internet-delivered emotion regulation individual therapy delivered adjunctive to treatment as usual vs treatment as usual only.

Main Outcomes and Measures

Primary outcome was the youth version of the Deliberate Self-harm Inventory, both self-reported by participants prior to treatment, once every week during treatment, and for 4 weeks posttreatment, and clinician-rated by masked assessors prior to treatment and at 1 and 3 months posttreatment.

Results

A total of 166 adolescents (mean [SD] age, 15.0 [1.2] years; 154 [92.8%] female) were randomized to internet-delivered emotion regulation therapy plus treatment as usual (84 participants) or treatment as usual only (82 participants). The experimental intervention was superior to the control condition in reducing clinician-rated nonsuicidal self-injury (82% vs 47% reduction; incidence rate ratio, 0.34; 95% CI, 0.20-0.57) from pretreatment to 1-month posttreatment. These results were maintained at 3-month posttreatment. Improvements in emotion dysregulation mediated improvements in self-injury during treatment.

Conclusions and Relevance

In this randomized clinical trial, a 12-week, therapist-guided, internet-delivered emotion regulation therapy delivered adjunctive to treatment as usual was efficacious in reducing self-injury, and mediation analysis supported the theorized role of emotion regulation as the mechanism of change in this treatment. This treatment may increase availability of evidence-based psychological treatments for adolescents with nonsuicidal self-injury.

Trial Registration

ClinicalTrials.gov Identifier: NCT03353961.

Effects of Group Psychotherapy for Nonsuicidal Self-Injury: A Meta-Analysis

Nonsuicidal self-injury (NSSI) is prevalent and concerning among adolescents and adults. Although prior meta-analytic work has considered the efficacy of individual psychotherapy for reducing NSSI, the efficacy of group psychotherapy remains unclear. We conducted a systematic meta-analysis of group psychotherapy studies with NSSI measures. We identified a total of eight studies, including published articles (n = 6) or dissertations (n = 2) with 10 total effect sizes for group interventions. Overall, random-effects meta-analysis suggests that group psychotherapies have a significant small effect on NSSI. However, when corrected for publication bias, the effect is no longer significant. This meta-analysis cautiously suggests that group psychotherapies, which are cost-effective and efficient, hold promise for attenuating NSSI. The field would benefit from further study and treatment refinement, including consideration of what works for whom.

Brief Interventions for Self-injurious Thoughts and Behaviors in Young People: A Systematic Review

Rates of self-injurious thoughts and behaviors (SITBs) increase sharply across adolescence and remain high in young adulthood. Across 50 years of research, existing interventions for SITBs remain ineffective and inaccessible for many young people in particular need of mental healthcare. Briefer intervention options may increase access to care. However, many traditional interventions for SITBs take 6 months or more to complete-making it difficult for providers to target SITBs under real-world time constraints. The present review (1) identifies and (2) summarizes evaluations of brief psychosocial interventions for SITBs in young people, ages 10-24 years. We conducted searches for randomized and quasi-experimental trials conducted in the past 50 years that evaluated effects of "brief interventions" (i.e., not exceeding 240 min, or four 60-min sessions in total length) on SITBs in young people. Twenty-six articles were identified for inclusion, yielding a total of 23 brief interventions. Across all trials, results are mixed; only six interventions reported any positive intervention effect on at least one SITB outcome, and only one intervention was identified as "probably efficacious" per standard criteria for evidence-based status. While brief interventions for SITBs exist, future research must determine if, how, and when these interventions should be disseminated.

Caring for a friend or family member who has experienced suicidal behaviour: A systematic review and qualitative synthesis

PURPOSE

Friends and family members can be important sources of support for people who are or have been suicidal. This review aimed to synthesise qualitative evidence regarding carers' perspectives of supporting someone who has experienced suicidal behaviour.

METHODS

Five electronic databases (Web of Science, CINAHL, PsychINFO, MEDLINE, and SocINDEX) were searched from inception to May 2022. Eligible qualitative studies were published in English and investigated the caring experiences of friends or family members of people who had experienced suicidal behaviour, defined as any form of suicidal ideation and/or attempts. Studies focused on non-suicidal self-injury or suicide bereavement were excluded. Data from 19 eligible studies were analysed using thematic synthesis.

RESULTS

Initial carer reactions to suicidal behaviour included profound anxiety and intensive monitoring for signs of increased suicide risk amongst those they supported. Carers also reported significant challenges with understanding how to provide effective interpersonal support following suicidal crises. Professional support was perceived to be most effective when provided in a timely, interpersonally sensitive and safety-focused manner. However, several studies detailed carers' difficulties accessing appropriate support and challenges managing their own distress.

CONCLUSIONS

Carers face significant challenges with knowing how to respond to suicidal behaviour, where to find appropriate help, and how to manage their own distress. Future research should seek to investigate the effectiveness of easily accessible methods of information provision and support tailored for carers of people who have experienced suicidal behaviour.

Assisted Suicide and Euthanasia in Mental Disorders: Ethical Positions in the Debate between Proportionality, Dignity, and the Right to Die

The admission of people suffering from psychiatric and neurocognitive disorders to euthanasia and physician-assisted suicide (E/PAS) in some European and non-European countries represents a controversial issue. In some countries, the initial limitation of E/PAS to cases of severe physical illness with poor prognosis in the short term has been overcome, as it was considered discriminatory; thus, E/PAS has also been made available to subjects suffering from mental disorders. This decision has raised significant ethical questions regarding the capacity and freedom of self-determination; the family, social, and economic contexts; the social consideration of the sense of dignity and the pressure on the judgment of one's personal value; the contextual therapeutic possibilities; the identification of figures involved in the validation and application; as well as the epistemological definitions of the clinical conditions in question. To these issues must be added the situation of legislative vacuum peculiar to different countries and the widespread lack of effective evaluation and control systems. Nonetheless, pessimistic indicators on global health status, availability of care and assistance, aging demographics, and socioeconomic levels suggest that there may be further pressure toward the expansion of such requests. The present paper aims to trace an international overview with the aim of providing ethical support to the debate on the matter. Precisely, the goal is the delimitation of foundations for clinical practice in the complex field of psychiatry between the recognition of the irreversibility of the disease, assessment of the state of physical and mental suffering, as well as the possibility of adopting free and informed choices.

Adolescent non-suicidal self-injury during the COVID-19 pandemic: A prospective longitudinal study of biological predictors of maladaptive emotion regulation

BACKGROUND

Non-suicidal self-injury (NSSI) in adolescence is thought to stem from interactions between vulnerability in developing biological systems and experience of stressors. The current study assesses whether multiple levels of the stress system's response to threat could prospectively predict NSSI engagement during the COVID-19 pandemic, a shared, time-locked stressor.

METHODS

Participants were 64 female adolescents (ages 12-16) from community and clinical settings who were oversampled for NSSI histories. Prior to the onset of the COVID-19 pandemic, adolescents completed a protocol that measured hypothalamic-pituitary-adrenal axis response to a social stressor (via salivary cortisol), amygdala volume, amygdala emotion-evoked activation, and frontolimbic resting-state functional connectivity. During early months of the pandemic (Summer 2020), measures of NSSI behavior (Inventory of Statements About Self-Injury), emotion regulation difficulties (Difficulties in Emotion Regulation Scale), perceived stress (Perceived Stress Scale), and pandemic-related stressors (Epidemic Pandemic Impacts Inventory) were collected. Multinomial logistic regression was used to assess if pre-pandemic biomarkers predicted mid-pandemic NSSI engagement: persistence of NSSI (Persist; N = 21), cessation of NSSI (Desist; N = 26), and no history of NSSI (Never; N = 17). Linear regressions explored if pre-pandemic biomarkers predicted mid-pandemic difficulties in emotion regulation and perceived stress.

RESULTS

Higher pre-pandemic overall cortisol response to stress and amygdala emotion-evoked activation characterized adolescents who persisted in NSSI, compared to those who desisted. These findings remained significant when controlling for pandemic related stressors. Lower prepandemic cortisol reactivity predicted more difficulties in emotion regulation during the pandemic. This finding did not remain significant after controlling for pandemic related stressors.

CONCLUSIONS

Findings suggest that patterns in key biological threat response systems may confer vulnerability for risk outcomes including NSSI engagement in adolescent females in the context of a shared, novel, naturally-occurring stressor. The results point to the importance of multi-level, longitudinal approaches for understanding the interface between developing neurobiological systems and experiential stress in at-risk adolescents. Identified patterns give insight into potential risk assessment strategies based on an understanding of the multi-level threat response.

Longitudinal Relations Between Parenting Practices and Adolescent Suicidal Ideation in a High-Risk Clinical Sample: A Moderated Mediation Model

Parenting behaviors are associated with adolescent suicidal ideation (SI), but few studies have examined this relation longitudinally or investigated underlying mechanisms. We investigated a moderated mediation model to evaluate perceived burdensomeness as a mediator in the longitudinal relation between parenting behavior (warmth and verbal hostility) and adolescent SI. We hypothesized that this association would be particularly strong among adolescents with greater functional impairment. The sample included 147 adolescents (Mage = 14.9, Age Range = 12-18 years, 76.2% female) and a primary caregiver (Mage = 43.5, Age Range = 27-60 years, 81.4% female) enrolled in a clinical trial. Caregivers completed measures of warmth and verbal hostility (PCPR) and adolescents completed measures of functional impairment (CDI-2), perceived burdensomeness (INQ), and SI (SIQ-JR) at baseline, 12 and 18 months. Two moderated mediation path analyses, one for each parenting behavior, were conducted. Age, sex, treatment condition, baseline and 12-month SI, baseline perceived burdensomeness, and the alternate baseline parenting behavior were included as covariates. Neither model yielded a significant direct effect between baseline parental verbal hostility or warmth and 18-month SI. However, lower warmth and higher verbal hostility were positively associated with 18-month SI indirectly through greater 12-month perceived burdensomeness among youth with relatively higher levels of functional impairment. Perceptions of burdensomeness are a mechanism by which low parental warmth and high parental verbal hostility contribute to SI, but only among youth with greater functional impairment. Interventions to address youth perceptions of burdensomeness may be beneficial, particularly for the most highly impaired youth.

Suicide in young people: screening, risk assessment, and intervention

Suicide is the fourth leading cause of death among young people worldwide and the third leading cause of death among those in the US. This review outlines the epidemiology of suicide and suicidal behavior in young people. It discusses intersectionality as an emerging framework to guide research on prevention of suicide in young people and highlights several clinical and community settings that are prime targets for implementation of effective treatment programs and interventions aimed at rapidly reducing the suicide rate in young people. It provides an overview of current approaches to screening and assessment of suicide risk in young people and the commonly used screening tools and assessment measures. It discusses universal, selective, and indicated evidence based suicide focused interventions and highlights components of psychosocial interventions with the strongest evidence for reducing risk. Finally, the review discusses suicide prevention strategies in community settings and considers future research directions and questions challenging the field.

Family therapy for adolescents with depression and suicidal ideation: A systematic review and meta-analysis

OBJECTIVE

To systematically review and meta-analyze the effectiveness of family therapy compared to other active treatments for adolescents with depressive disorders or suicidal ideation.

METHOD

We conducted a systematic search of The Cochrane Central Register of Controlled Trials, Medline, Embase, PsycINFO, AMED, CINAHL and Web of Science and performed two meta-analyses of outcomes for depressive symptoms and suicidal ideation.

RESULTS

We screened 5,940 records and identified 10 randomized controlled studies of family therapy for depressive disorder or suicidal ideation in adolescents with an active treatment comparison group. Nine studies reported outcome measures of depressive symptoms and four reported outcome measures of suicidal ideation. The meta-analysis showed no significant difference between family therapy and active comparison treatments for end-of-treatment levels of depression. For suicidal ideation our meta-analysis showed a significant effect in favour of family therapy over comparison treatments for suicidal ideation.

CONCLUSIONS

Based on the current body of research, we found that family therapy is not superior to other psychotherapies in the treatment of depressive disorder. However, family therapy leads to significantly improved outcomes for suicidal ideation, compared to other psychotherapies. The evidence for the treatment of depression is of low quality needs more research.

The lived experiences of parents providing care to young people who self-harm: A meta-aggregative synthesis of qualitative studies

Self-harm, which affects the whole family system, is an international public health concern. Empirical evidence supports the efficacy of interventions incorporating a family/parent training component for self-injurious thoughts and behaviours, and a quantitative synthesis of these empirical studies has been undertaken and updated. A qualitative synthesis of the experiences of parents whose child self-harms remains limited. This report aimed to systematically review qualitative research about the experiences, preferences, and expectations of parents whose children self-harmed. A comprehensive search was conducted across ten databases and four grey literature sources, along with the manual search of reference lists and relevant websites. Study screening, data extraction, and quality appraisal were all performed by two independent researchers. Twenty-four articles, two of which were mixed-methods studies, were included and analysed using a meta-aggregation approach. Five synthesized findings were identified: initial negative reactions to the discovery of their child's self-harm, the ongoing impact of self-harm on parents and the wider family, parents' various coping strategies, parents' negative experiences with mental health professionals expectations, and the lack of and need for psychoeducational resources. Our review finds that parents express keen interest in engaging with the treatment process, and our results support family-based therapy. However, with the overwhelming emotions most parents experience, clinicians should approach them with sensitivity, empathy and finesse. Psychoeducational self-help resources should also be made readily available to parents who are reluctant to seek help.

Practitioner Review: Treatment for Suicidal and Self-Harming Adolescents-Advances in Suicide Prevention Care

Background

Suicide is a leading cause of death globally in youths, and suicidal behavior and self-harm are major clinical concerns. This article updates the previous practitioner review (2012) with the aims of integrating new research evidence, including that reported in this Special Issue.

Methods

The article reviews scientific evidence related to steps in the care pathway for identifying and treating youths with elevated suicide/self-harm risk, specifically: (a) screening and risk assessment; (b) treatment; and (c) community-level suicide prevention strategies.

Results

Review of current evidence indicates that major advances have been achieved in knowledge regarding clinical and preventive practices for reducing suicide and self-harm risk in adolescents. The evidence supports the value of brief screeners for identifying youths with elevated suicide/self-harm risk and the efficacy of some treatments for suicidal and self-harm behavior. Dialectical behavior therapy currently meets Level 1 criteria (2 independent trials supporting efficacy) as the first well-established treatment for self-harm, and other approaches have shown efficacy in single randomized controlled trials. The effectiveness of some community-based suicide prevention strategies for reducing suicide mortality and suicide attempt rates has been demonstrated.

Conclusions

Current evidence can guide practitioners in delivering effective care for youth suicide/self-harm risk. Treatments and preventive interventions that address the psychosocial environment and enhance the ability of trusted adults to protect and support youths, while also addressing the psychological needs of youths appear to yield the greatest benefits. Although additional research is needed, our current challenge is to do our best to effectively utilize new knowledge to improve care and outcomes in our communities.Reprinted from J Child Psychol Psychiatry 2019; 60:1046-1054, with permission from John Wiley and Sons. Copyright © 2019.