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Taylor PJ, Adeyemi I, Marlow K, Cottam S, Airnes Z, Hartley S, Howells V, Dunn BD, Elliott RA, Hann M, Latham C, Robinson C, Turpin C, Kellett S. The Relational Approach to Treating Self-Harm (RELATE): study protocol for a feasibility randomised controlled trial study of cognitive analytic therapy for adults who self-harm versus treatment at usual. Pilot Feasibility Stud 2024; 10:101. [PMID: 39026281 PMCID: PMC11256374 DOI: 10.1186/s40814-024-01526-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 07/01/2024] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND Self-harm is a prevalent behaviour that has a major detrimental impact on a person's life. Psychological therapies have the potential to help, but evidence of effective interventions remains limited. Access and acceptability of interventions can also be a significant challenge, with individuals either being unable to access help or having to endure long waiting lists. Cognitive analytic therapy (CAT) is a time-limited and relationally-focused psychotherapy that may provide a valuable treatment option for people who self-harm. This protocol outlines the methodology for the first feasibility randomised controlled trial (RCT) of CAT for adults that self-harm. The trial will aim to determine the feasibility, acceptability and safety of undertaking larger-scale evaluations of CAT for self-harm within an RCT context. METHOD An RCT design with 1:1 allocation to CAT plus treatment as usual (TAU) or TAU alone. Participants will be adult outpatients with three or more instances of self-harm in the past year (target sample of n = 60). CAT will be 8 one-to-one weekly 60-min sessions plus a follow-up session up to 8 weeks after the last session. Assessments will occur at baseline, 12 weeks and 18 weeks after randomisation. Qualitative interviews with participants will gain insights into the feasibility and acceptability of CAT. Feasibility outcomes will be judged against progression criteria. DISCUSSION CAT may be an effective and accessible treatment option for people who self-harm, providing a more relationally orientated alternative to more behavioural therapies. The proposed feasibility RCT is an important first step in evaluating CAT as a treatment for self-harm. TRIAL REGISTRATION The trial was pre-registered (21/10/22) on ISR CTN (ISRCTN code: ISRCTN75661422).
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Affiliation(s)
- Peter James Taylor
- Division of Psychology & Mental Health, School of Health Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK.
| | - Isabel Adeyemi
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Katie Marlow
- Rotherham, Doncaster, and South Humber NHS Foundation Trust, Doncaster, UK
| | - Sarah Cottam
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Zerena Airnes
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | | | - Victoria Howells
- Rotherham, Doncaster, and South Humber NHS Foundation Trust, Doncaster, UK
| | | | - Rachel A Elliott
- Division of Psychology & Mental Health, School of Health Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Mark Hann
- Division of Psychology & Mental Health, School of Health Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Cameron Latham
- Division of Psychology & Mental Health, School of Health Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Catherine Robinson
- Division of Psychology & Mental Health, School of Health Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Clive Turpin
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Stephen Kellett
- Rotherham, Doncaster, and South Humber NHS Foundation Trust, Doncaster, UK
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Cottrell D, Wright-Hughes A, Farrin A, Walwyn R, Mughal F, Truscott A, Diggins E, Irving D, Fonagy P, Ougrin D, Stahl D, Wright J. Reducing self-harm in adolescents: the RISA-IPD individual patient data meta-analysis and systematic review. Health Technol Assess 2024:1-42. [PMID: 39024118 DOI: 10.3310/gtnt6331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2024] Open
Abstract
Background Self-harm is common in adolescents and a major public health concern. Evidence for effective interventions is lacking. An individual patient data meta-analysis has the potential to provide more reliable estimates of the effects of therapeutic interventions for self-harm than conventional meta-analyses, to explore which treatments are best suited to certain groups. Method A systematic review and individual patient data meta-analysis of randomised controlled trials of therapeutic interventions to reduce repeat self-harm in adolescents who had a history of self-harm and presented to clinical services. Primary outcome was repetition of self-harm. The methods employed for searches, study screening and selection, and risk of bias assessment are described, with an overview of the outputs of the searching, selection and quality assessment processes. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance is followed. Results We identified a total 39 eligible studies, from 10 countries, where we sought Individual Patient Data (IPD), of which the full sample of participants were eligible in 18 studies and a partial sample of participants were eligible in 21 studies. We obtained IPD from 26 studies of 3448 eligible participants. For our primary outcome, repetition of self-harm, only 6 studies were rated as low risk of bias with 10 rated as high risk (although 2 of these were for secondary outcomes only). Conclusions Obtaining individual patient data for meta-analyses is possible but very time-consuming, despite clear guidance from funding bodies that researchers should share their data appropriately. More attention needs to be paid to seeking appropriate consent from study participants for (pseudo) anonymised data-sharing and institutions need to collaborate on agreeing template data-sharing agreements. Researchers and funders need to consider issues of research design more carefully. Our next step is to analyse all the data we have collected to see if it will tell us more about how we might prevent repetition of self-harm in young people. Funding This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 17/117/11. A plain language summary of this research article is available on the NIHR Journals Library Website https://doi.org/10.3310/GTNT6331.
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Affiliation(s)
- David Cottrell
- Division of Psychological and Social Medicine, Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, UK
| | - Alex Wright-Hughes
- Complex Interventions Division, Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, School of Medicine, University of Leeds, Leeds, UK
| | - Amanda Farrin
- Complex Interventions Division, Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, School of Medicine, University of Leeds, Leeds, UK
| | - Rebecca Walwyn
- Complex Interventions Division, Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, School of Medicine, University of Leeds, Leeds, UK
| | - Faraz Mughal
- School of Medicine, Keele University, Keele, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, Keele University, Keele, UK
| | - Alex Truscott
- Research Department of Clinical, Educational and Health Psychology, University College, London, UK
| | - Emma Diggins
- Division of Psychological and Social Medicine, Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, UK
| | | | - Peter Fonagy
- Research Department of Clinical, Educational and Health Psychology, University College, London, UK
| | - Dennis Ougrin
- Youth Resilience Unit, WHO Collaborating Centre for Mental Health Services Development, Queen Mary University of London, London, UK
| | - Daniel Stahl
- Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK
| | - Judy Wright
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, UK
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Ivanova MY, Hall A, Weinberger S, Buckingham SL, Copeland WE, Crockett P, Dainer-Best J, D'Alberto C, Dewey L, Foret D, Galano M, Goodrich L, Holly L, Lane NE, Leahy M, Lerner M, Marsh J, McGinnis EW, Paiva-Salisbury M, Shaw JS, Swift P, Tinker R, Hudziak JJ. A Pilot Randomized Controlled Trial of the Family Assessment and Feedback Intervention (FAFI): Effects on Mental Health Literacy and Attitudinal Engagement with Health Supports and Services. Child Psychiatry Hum Dev 2024:10.1007/s10578-024-01707-0. [PMID: 38796676 DOI: 10.1007/s10578-024-01707-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2024] [Indexed: 05/28/2024]
Abstract
This randomized controlled trial tested the Family Assessment and Feedback Intervention (FAFI), a new intervention to enhance family engagement with emotional and behavioral health services. The FAFI is a guided conversation with families about results of their multidimensional assessment that is set in the context of motivational enhancement. It differs from other assessment-with-feedback interventions by extending the focus of assessment beyond the target child to parents and the family environment, addressing parental emotional and behavioral problems and competencies, spanning a broad range of children's and parents' strengths and difficulties, and being generalizable to many settings and practitioners. Participants were 81 families in primary care pediatrics. The FAFI was associated with a significant increase in parental mental health literacy and with an increase in parental attitudinal engagement with health supports and services that closely approached statistical significance (p = .052), while controlling for children's age and gender and family socioeconomic status.
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Affiliation(s)
- Masha Y Ivanova
- Department of Psychiatry, University of Vermont, Burlington, VT, USA.
| | - Allison Hall
- Department of Psychiatry, University of Vermont, Burlington, VT, USA
| | | | - Sara L Buckingham
- Department of Psychology, University of Alaska Anchorage, Anchorage, AK, USA
| | | | - Phoenix Crockett
- Department of Psychiatry, University of Vermont, Burlington, VT, USA
| | | | - Casey D'Alberto
- Department of Psychiatry, University of Vermont, Burlington, VT, USA
| | - Lauren Dewey
- Department of Psychological Sciences, University of Vermont, Burlington, VT, USA
| | - DeShan Foret
- Department of Psychiatry, University of Vermont, Burlington, VT, USA
| | - Maria Galano
- Department of Psychological and Brain Sciences, University of Massachusetts at Amherst, Amherst, MA, USA
| | - Lisa Goodrich
- University of Vermont Medical Center, Burlington, VT, USA
| | - Lindsay Holly
- Department of Psychology, Marquette University, Milwaukee, WI, USA
| | - Nalini Emily Lane
- Department of Psychiatry, University of Vermont, Burlington, VT, USA
| | - Maureen Leahy
- University of Vermont Medical Center, Burlington, VT, USA
| | - Mathew Lerner
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jasmine Marsh
- Department of Psychiatry, University of Vermont, Burlington, VT, USA
| | - Ellen W McGinnis
- Department of Psychiatry, University of Vermont, Burlington, VT, USA
| | | | - Judith S Shaw
- Department of Pediatrics, University of Vermont, Burlington, VT, USA
| | - Pamela Swift
- Department of Pediatrics, University of Vermont, Burlington, VT, USA
| | - Rebekah Tinker
- Department of Psychiatry, University of Vermont, Burlington, VT, USA
| | - James J Hudziak
- Department of Psychiatry, University of Vermont, Burlington, VT, USA
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Bossé Chartier G, Lam F, Bergmans Y, Lofchy J, Bolton JM, Klonsky ED, Zaheer J, Kealy D. "Psychotherapy in the Pressure Cooker": A Systematic Review of Single Session Psychosocial Interventions in Emergency Departments for Suicide-related Thoughts or Behaviors. J Psychiatr Pract 2023; 29:291-307. [PMID: 37449827 DOI: 10.1097/pra.0000000000000725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
OBJECTIVES Up to 20% of individuals who die by suicide have visited an emergency department (ED) within 4 weeks of their death. Limited guidance is available regarding the modification of clinical outcomes following a psychosocial intervention in the ED for pediatric and adult populations. METHODS A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted to identify studies focused on single-session psychosocial interventions for pediatric and adult patients experiencing suicide-related thoughts or behaviors (SRTB) in the ED. Two reviewers independently screened articles identified using the key terms suicide/self-harm, emergency department, and interview. Medline, PubMed, Embase, PsycINFO, CINAHL, and CENTRAL were searched from inception to August 2018. RESULTS After screening 3234 abstracts, 29 articles were selected for full-text review and 14 articles, representing 8 distinct studies (N=782), were included. A high level of heterogeneity was present in the included articles, with 7 randomized-controlled trials, 2 nonrandomized-controlled trials, 2 cohort studies, 2 observational studies, and 1 feasibility study. Most of the included studies focused on adolescents (6 articles) or military veterans (7 articles). Strong statistical evidence of ED interventions improving outpatient service linkage was supported (χ2: 81.80, P<0.0001, 7 studies). CONCLUSIONS The findings of this study suggested promising outcomes for patients presenting to the ED with SRTB who receive a single-session psychosocial intervention. All of the studies that measured such outcomes found significantly increased follow-up care in the intervention arm. Further research is needed to strengthen the evidence base, provide better patient representation, and improve our understanding of the mechanisms by which the psychosocial intervention for SRTB in the ED ameliorates patient outcomes (CRD42020156496).
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Affiliation(s)
- Gabrielle Bossé Chartier
- BOSSÉ CHARTIER, LAM, and KEALY: Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada; BERGMANS and ZAHEER: Department of Psychiatry, University of Toronto, Toronto, ON, Canada; LOFCHY: Adult Acute Care Psychiatry, St. Joseph's Health Centre and University of Toronto, Toronto, ON, Canada; BOLTON: Department of Psychiatry, University of Manitoba, and Shared Health Manitoba Crisis Response Centre, Winnipeg, MB, Canada; KLONSKY: Department of Psychology, University of British Columbia, Vancouver, BC, Canada
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Dobias ML, Chen S, Fox KR, Schleider JL. Brief Interventions for Self-injurious Thoughts and Behaviors in Young People: A Systematic Review. Clin Child Fam Psychol Rev 2023; 26:482-568. [PMID: 36715874 PMCID: PMC9885418 DOI: 10.1007/s10567-023-00424-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2023] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Mallory L Dobias
- Department of Psychology, Stony Brook University, Stony Brook, NY, 11794-2500, USA.
| | - Sharon Chen
- Department of Psychology, Stony Brook University, Stony Brook, NY, 11794-2500, USA
| | - Kathryn R Fox
- Department of Psychology, University of Denver, Denver, CO, 80210, USA
| | - Jessica L Schleider
- Department of Psychology, Stony Brook University, Stony Brook, NY, 11794-2500, USA
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6
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Asarnow JR, Mehlum L. Practitioner Review: Treatment for Suicidal and Self-Harming Adolescents-Advances in Suicide Prevention Care. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2023; 21:209-216. [PMID: 37201143 PMCID: PMC10172564 DOI: 10.1176/appi.focus.23021005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
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.
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Affiliation(s)
- Joan Rosenbaum Asarnow
- Department of Psychiatry and Behavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA (Asarnow); National Centre for Suicide Research and Prevention, University of Oslo, Oslo, Norway (Mehlum)
| | - Lars Mehlum
- Department of Psychiatry and Behavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA (Asarnow); National Centre for Suicide Research and Prevention, University of Oslo, Oslo, Norway (Mehlum)
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7
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Viswanathan M, Wallace IF, Cook Middleton J, Kennedy SM, McKeeman J, Hudson K, Rains C, Vander Schaaf EB, Kahwati L. Screening for Depression and Suicide Risk in Children and Adolescents: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2022; 328:1543-1556. [PMID: 36219399 DOI: 10.1001/jama.2022.16310] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Depression, suicidal ideation, and self-harm behaviors in youth are associated with functional impairment and suicide. Objective To review the evidence on screening for depression or suicide risk in children and adolescents to inform the US Preventive Services Task Force (USPSTF). Data Sources PubMed, Cochrane Library, PsycINFO, CINAHL, and trial registries through July 19, 2021; references, experts, and surveillance through June 1, 2022. Study Selection English-language, randomized clinical trials (RCTs) of screening for depression or suicide risk; diagnostic test accuracy studies; RCTs of psychotherapy and first-line pharmacotherapy; RCTs, observational studies, and systematic reviews reporting harms. Data Extraction and Synthesis Two reviewers assessed titles/abstracts, full-text articles, and study quality and extracted data; when at least 3 similar studies were available, meta-analyses were conducted. Main Outcomes and Measures Test accuracy, symptoms, response, remission, loss of diagnosis, mortality, functioning, suicide-related events, and adverse events. Results Twenty-one studies (N = 5433) were included for depression and 19 studies (N = 6290) for suicide risk. For depression, no studies reported on the direct effects of screening on health outcomes, and 7 studies (n = 3281) reported sensitivity of screening instruments ranging from 0.59 to 0.94 and specificity from 0.38 to 0.96. Depression treatment with psychotherapy was associated with improved symptoms (Beck Depression Inventory pooled standardized mean difference, -0.58 [95% CI, -0.83 to -0.34]; n = 471; 4 studies; and Hamilton Depression Scale pooled mean difference, -2.25 [95% CI, -4.09 to -0.41]; n = 262; 3 studies) clinical response (3 studies with statistically significant results using varying thresholds), and loss of diagnosis (relative risk, 1.73 [95% CI, 1.00 to 3.00; n = 395; 4 studies). Pharmacotherapy was associated with improvement on symptoms (Children's Depression Rating Scale-Revised mean difference, -3.76 [95% CI, -5.95 to -1.57; n = 793; 3 studies), remission (relative risk, 1.20 [95% CI, 1.00 to 1.45]; n = 793; 3 studies) and functioning (Children's Global Assessment Scale pooled mean difference, 2.60 (95% CI, 0.78 to 4.42; n = 793; 3 studies). Other outcomes were not statistically significantly different. Differences in suicide-related outcomes and adverse events for pharmacotherapy when compared with placebo were not statistically significant. For suicide risk, no studies reported on the direct benefits of screening on health outcomes, and 2 RCTs (n = 2675) reported no harms of screening. One study (n = 581) reported on sensitivity of screening, ranging from 0.87 to 0.91; specificity was 0.60. Sixteen RCTs (n = 3034) reported on suicide risk interventions. Interventions were associated with lower scores for the Beck Hopelessness Scale (pooled mean difference, -2.35 [95% CI, -4.06 to -0.65]; n = 644; 4 RCTs). Findings for other suicide-related outcomes were mixed or not statistically significantly different. Conclusion and Relevance Indirect evidence suggested that some screening instruments were reasonably accurate for detecting depression. Psychotherapy and pharmacotherapy were associated with some benefits and no statistically significant harms for depression, but the evidence was limited for suicide risk screening instruments and interventions.
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Affiliation(s)
- Meera Viswanathan
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Ina F Wallace
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Jennifer Cook Middleton
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Sara M Kennedy
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Joni McKeeman
- Department of Psychiatry, University of North Carolina at Chapel Hill
| | - Kesha Hudson
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Caroline Rains
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Emily B Vander Schaaf
- Division of General Pediatrics and Adolescent Medicine, University of North Carolina at Chapel Hill
| | - Leila Kahwati
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
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Calvo N, García-González S, Perez-Galbarro C, Regales-Peco C, Lugo-Marin J, Ramos-Quiroga JA, Ferrer M. Psychotherapeutic interventions specifically developed for NSSI in adolescence: A systematic review. Eur Neuropsychopharmacol 2022; 58:86-98. [PMID: 35325633 DOI: 10.1016/j.euroneuro.2022.02.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/18/2022] [Accepted: 02/24/2022] [Indexed: 11/27/2022]
Abstract
Non-suicidal self-injury (NSSI) is a clinically significant behavior with high relevance and prevalence, especially affecting approximately 17-18% of the adolescent population worldwide. The aim of this study is to perform a systematic review to evaluate the effectiveness of the available Specific Psychotherapeutic Interventions (SPI) focused on the reduction of NSSI behaviors. A systematic review was performed analyzing PsychINFO, MEDLINE, Web of Science, PubMed and Cochrane CentralRegister of Controlled Trials to identify studies of interest from January 2010 to December 2020. According to PRISMA guidelines, only 13 studies were included in the review. Six SPI were found to specifically and significantly reduce NSSI in adolescents: Developmental Group Psychotherapy (DGP), Therapeutic Assessment (TA), Cutting Down Program (CDP), Emotional Regulation Individual Therapy for Adolescents (ERITA), Treatment for Self-Injurious Behaviors (T-SIB) and Intensive Contextual Treatment (ICT). Furthermore, relevant improvements in anxiety and depression symptoms were observed. The results of this review demonstrate the effectiveness of these interventions, mainly the CPD and T-SIB, which are the only SPI that have been studied using Randomized Controlled Trial (RCT). Considering the clinical relevance and associated functional impairment of NSSI, more research is needed to replicate the results and to increase knowledge about SPIs.
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Affiliation(s)
- Natalia Calvo
- Psychiatry Department, Hospital Universitari Vall d'Hebron, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain; Psychiatry, Mental Health and Addictions Group, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Psychiatry and Legal Medicine Department, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain; Grup TLP Barcelona.
| | - Sara García-González
- Psychiatry Department, Hospital Universitari Vall d'Hebron, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain
| | - Citlalli Perez-Galbarro
- Psychiatry Department, Hospital Universitari Vall d'Hebron, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain
| | - Christina Regales-Peco
- Psychiatry Department, Hospital Universitari Vall d'Hebron, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain
| | - Jorge Lugo-Marin
- Psychiatry Department, Hospital Universitari Vall d'Hebron, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain; Psychiatry, Mental Health and Addictions Group, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Josep-Antoni Ramos-Quiroga
- Psychiatry Department, Hospital Universitari Vall d'Hebron, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain; Psychiatry, Mental Health and Addictions Group, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Psychiatry and Legal Medicine Department, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain; Grup TLP Barcelona
| | - Marc Ferrer
- Psychiatry Department, Hospital Universitari Vall d'Hebron, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain; Psychiatry, Mental Health and Addictions Group, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Psychiatry and Legal Medicine Department, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain; Grup TLP Barcelona
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9
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Itzhaky L, Davaasambuu S, Ellis SP, Cisneros-Trujillo S, Hannett K, Scolaro K, Stanley BH, Mann JJ, Wainberg ML, Oquendo MA, Sublette ME. Twenty-six years of psychosocial interventions to reduce suicide risk in adolescents: Systematic review and meta-analysis. J Affect Disord 2022; 300:511-531. [PMID: 34974074 PMCID: PMC11085995 DOI: 10.1016/j.jad.2021.12.094] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 12/10/2021] [Accepted: 12/20/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND During adolescence, suicide risk increases; effective treatments are needed to reduce risk. METHODS Databases were searched (1995-2020) for randomized controlled trials (RCTs) concerning psychosocial treatments for suicide prevention in adolescents (10-18 yrs). Data were extracted from the timepoint closest to 6 months. Cohen's ds were estimated for reducing suicidal ideation (SI), self-harming behaviors (SHB) excluding strictly non-suicidal self-injury, and suicide attempts (SA) and analyzed using generalized least square regression. Meta-analytic innovations included within-person correlations to reflect trait suicidality; annualization to control for exposure; estimated lifetime risk based on ages; and modeling inclusion/exclusion criteria. Alternate approaches included relative risk and comparison of intervention and control treatments to baseline. RESULTS Of 30 RCTs, 6 assessing SHB (4 measuring SA), and 7 assessing SI demonstrated treatment effectiveness. Overall, interventions decreased SI (n = 25) with low effect size (d = 0.08, p = 0.01), non-significant after controlling for publication bias (d = 0.05, p = 0.1); interventions were non-significant for SHB (n = 25, d = 0.001, p = 0.97) or SA (n = 18, d = 0.03, p = 0.52). To prevent one SHB, the number needed to treat (NNT) was 45[26,156]; for SA, NNT=42[24,149]. Non-superiority may relate to effectiveness of control treatments. Thus, experimental and control treatments also were compared to baseline: both reduced SI (p < 0.0001), and effectiveness improved for SHB (NNT=12) and SA (NNT=11). LIMITATIONS Study heterogeneity and inconsistent statistical reporting limited meta-analysis. CONCLUSIONS Psychosocial interventions for suicide risk in adolescents showed little effectiveness compared with control treatments; suicide outcomes improved in both groups compared to baseline. Different approaches may be needed, including precision medicine methodologies and standardized statistical reporting criteria.
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Affiliation(s)
- Liat Itzhaky
- Department of Psychiatry, Columbia University, New York, NY 10032, USA; New York State Psychiatric Institute, 1051 Riverside Drive, Unit 42, New York, NY, USA; Geha Mental Health Center, Petah-Tikva, Israel
| | - Sara Davaasambuu
- Department of Psychiatry, Columbia University, New York, NY 10032, USA
| | - Steven P Ellis
- Department of Psychiatry, Columbia University, New York, NY 10032, USA; New York State Psychiatric Institute, 1051 Riverside Drive, Unit 42, New York, NY, USA
| | | | - Katrina Hannett
- New York State Psychiatric Institute, 1051 Riverside Drive, Unit 42, New York, NY, USA
| | | | - Barbara H Stanley
- Department of Psychiatry, Columbia University, New York, NY 10032, USA; New York State Psychiatric Institute, 1051 Riverside Drive, Unit 42, New York, NY, USA
| | - J John Mann
- Department of Psychiatry, Columbia University, New York, NY 10032, USA; New York State Psychiatric Institute, 1051 Riverside Drive, Unit 42, New York, NY, USA; Department of Radiology, Columbia University, New York, NY, USA
| | - Milton L Wainberg
- Department of Psychiatry, Columbia University, New York, NY 10032, USA; New York State Psychiatric Institute, 1051 Riverside Drive, Unit 42, New York, NY, USA
| | - Maria A Oquendo
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - M Elizabeth Sublette
- Department of Psychiatry, Columbia University, New York, NY 10032, USA; New York State Psychiatric Institute, 1051 Riverside Drive, Unit 42, New York, NY, USA.
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10
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Strand M, Bäärnhielm S. Could the DSM-5 Cultural Formulation Interview Hold Therapeutic Potential? Suggestions for Further Exploration and Adaptation Within a Framework of Therapeutic Assessment. Cult Med Psychiatry 2022; 46:846-863. [PMID: 34881417 PMCID: PMC9596502 DOI: 10.1007/s11013-021-09761-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2021] [Indexed: 10/19/2022]
Abstract
The Cultural Formulation Interview (CFI), included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, is a person-centered instrument for systematically appraising the impact of cultural factors in psychiatric assessment. A number of key areas in the future development of the CFI have been identified in order to ensure further clinical uptake. In this paper, we suggest that applying a Therapeutic Assessment (TA) approach in using the CFI-i.e., framing the interview in a way that gives primacy to its self-transformative potential by explicitly focusing on those issues that are seen as the most urgent, relevant, and meaningful by the patient-could prove helpful in alleviating patients' suffering beyond what is achieved by merely collecting relevant cultural information that may inform diagnosis and subsequent treatment interventions. The TA methodology has been designed as a collaborative approach to psychological assessment in which the assessment procedure itself is meant to induce therapeutic change. This is achieved by explicitly focusing on the particular questions and queries that patients have about themselves with respect to their mental health problems or psychosocial well-being; these questions are then allowed to guide the assessment process and the interpretation of the findings. We suggest a number of potential modifications to the related Outline for Cultural Formulation and to the CFI content that could strengthen a TA-inspired focus. With this paper, we do not claim to offer a definitive integration of the TA approach in using the CFI but hope to further the discussion of a therapeutic potential of the instrument.
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Affiliation(s)
- Mattias Strand
- Transcultural Centre, Stockholm Health Care Services, Region Stockholm, Solnavägen 4, 113 65, Stockholm, Sweden. .,Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, 171 77, Stockholm, Sweden.
| | - Sofie Bäärnhielm
- grid.467087.a0000 0004 0442 1056Transcultural Centre, Stockholm Health Care Services, Region Stockholm, Solnavägen 4, 113 65 Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, 171 77 Stockholm, Sweden
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11
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Safer DJ. A Critique on Psychiatric Inpatient Admissions for Suicidality in Youth. J Nerv Ment Dis 2021; 209:467-473. [PMID: 34170857 DOI: 10.1097/nmd.0000000000001335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT For the last few decades, psychiatric inpatient admissions for the treatment of suicidality in US youth have been increasing. Nonetheless, since 2007, the national rate of completed suicides by youth has steadily and sizably increased. Therefore, a literature review was performed to evaluate the usefulness of the psychiatric inpatient admission of suicidal youths. The analysis concluded that suicidality is surprisingly common in youth, completed suicide is very uncommon in early adolescence, suicidal ideation is a major reason in early adolescence for inpatient admission, girls are admitted to psychiatric inpatient units three times more than boys even though boys complete suicide four times more than girls, inpatient stays average 6 days and are quite expensive, and repeat attempts after inpatient treatment are common. Thus, filling more beds for youth with suicidality lacks evidence of a public health, long-term benefit. Expanding the focus in psychiatry to population efforts including means reductions is recommended.
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Affiliation(s)
- Daniel J Safer
- Departments of Psychiatry and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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12
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Bahji A, Pierce M, Wong J, Roberge JN, Ortega I, Patten S. Comparative Efficacy and Acceptability of Psychotherapies for Self-harm and Suicidal Behavior Among Children and Adolescents: A Systematic Review and Network Meta-analysis. JAMA Netw Open 2021; 4:e216614. [PMID: 33861328 PMCID: PMC8052594 DOI: 10.1001/jamanetworkopen.2021.6614] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Self-harm and suicidal behavior are associated with substantial morbidity and mortality among children and adolescents. The comparative performance of psychotherapies for suicidality is unclear because few head-to-head clinical trials have been conducted. OBJECTIVE To compare the efficacy of psychotherapies for the treatment of self-harm and suicidality among children and adolescents. DATA SOURCES Four major bibliographic databases (PubMed, MEDLINE, PsycINFO, and Embase) were searched for clinical trials comparing psychotherapy with control conditions from inception to September 2020. STUDY SELECTION Randomized clinical trials comparing psychotherapies for suicidality and/or self-harm with control conditions among children and adolescents were included after a blinded review by 3 independent reviewers (A.B., M.P., and J.W.). DATA EXTRACTION AND SYNTHESIS The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed for data abstraction, and the Cochrane risk of bias tool was used to evaluate study-level risk of bias. Data abstraction was performed by 1 reviewer (A.B.) and confirmed by 2 independent blinded reviewers (J.W. and M.P.). Data were analyzed from October 15, 2020, to February 15, 2021. MAIN OUTCOMES AND MEASURES The primary outcomes were dichotomized self-harm and retention in treatment. The secondary outcomes were dichotomized all-cause treatment discontinuation and scores on instruments measuring suicidal ideation and depressive symptoms. Effect sizes were pooled using frequentist random-effects network meta-analysis models to generate summary odds ratios (ORs) and Cohen d standardized mean differences (SMDs). Negative Cohen d SMDs or ORs less than 1 indicated that the treatment reduced the parameter of interest relative to the control condition (eg, signifying a beneficial association with suicidal ideation). RESULTS The systematic search generated 1272 unique records. Of those, 44 randomized clinical trials (5406 total participants; 4109 female participants [76.0%]) from 49 articles were selected (5 follow-up studies were merged with their primary clinical trials to avoid publication bias). The selected clinical trials spanned January 1, 1995, to December 31, 2020. The median duration of treatment was 3 months (range, 0.25-12.00 months), and the median follow-up period was 12 months (range, 1-36 months). None of the investigated psychotherapies were associated with increases in study withdrawals or improvements in retention in treatment compared with treatment as usual. Dialectical behavioral therapies were associated with reductions in self-harm (OR, 0.28; 95% CI, 0.12-0.64) and suicidal ideation (Cohen d SMD, -0.71; 95% CI, -1.19 to -0.23) at the end of treatment, while mentalization-based therapies were associated with decreases in self-harm (OR, 0.38; 95% CI, 0.15-0.97) and suicidal ideation (Cohen d SMD, -1.22; 95% CI, -2.18 to -0.26) at the end of follow-up. The quality of evidence was downgraded because of high risk of bias overall, heterogeneity, publication bias, inconsistency, and imprecision. CONCLUSIONS AND RELEVANCE Although some psychotherapeutic modalities appear to be acceptable and efficacious for reducing self-harm and suicidality among children and adolescents, methodological issues and high risk of bias prevent a consistent estimate of their comparative performance.
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Affiliation(s)
- Anees Bahji
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Matthew Pierce
- Department of Psychiatry, Queen’s University, Kingston, Ontario, Canada
- Division of Child and Youth Mental Health, Queen’s University, Kingston, Ontario, Canada
| | - Jennifer Wong
- Department of Psychiatry, Queen’s University, Kingston, Ontario, Canada
- Division of Child and Youth Mental Health, Queen’s University, Kingston, Ontario, Canada
| | - Johanne N. Roberge
- Department of Psychiatry, Queen’s University, Kingston, Ontario, Canada
- Division of Child and Youth Mental Health, Queen’s University, Kingston, Ontario, Canada
| | - Iliana Ortega
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Scott Patten
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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13
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Witt KG, Hetrick SE, Rajaram G, Hazell P, Taylor Salisbury TL, Townsend E, Hawton K. Interventions for self-harm in children and adolescents. Cochrane Database Syst Rev 2021; 3:CD013667. [PMID: 33677832 PMCID: PMC8094399 DOI: 10.1002/14651858.cd013667.pub2] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Self-harm (SH; intentional self-poisoning or self-injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most countries, often repeated, and associated with suicide. Evidence assessing the effectiveness of interventions in the treatment of SH in children and adolescents is lacking, especially when compared with the evidence for psychosocial interventions in adults. This review therefore updates a previous Cochrane Review (last published in 2015) on the role of interventions for SH in children and adolescents. OBJECTIVES To assess the effects of psychosocial interventions or pharmacological agents or natural products for SH compared to comparison types of care (e.g. treatment-as-usual, routine psychiatric care, enhanced usual care, active comparator, placebo, alternative pharmacological treatment, or a combination of these) for children and adolescents (up to 18 years of age) who engage in SH. SEARCH METHODS We searched the Cochrane Common Mental Disorders Specialized Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic Reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020). SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing specific psychosocial interventions or pharmacological agents or natural products with treatment-as-usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, placebo, alternative pharmacological treatment, or a combination of these, in children and adolescents with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow-up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide. DATA COLLECTION AND ANALYSIS We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence internals (CIs). For continuous outcomes, we calculated the mean difference (MD) or standardised mean difference (SMD) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post-intervention) was appraised for each intervention using the GRADE approach. MAIN RESULTS We included data from 17 trials with a total of 2280 participants. Participants in these trials were predominately female (87.6%) with a mean age of 14.7 years (standard deviation (SD) 1.5 years). The trials included in this review investigated the effectiveness of various forms of psychosocial interventions. None of the included trials evaluated the effectiveness of pharmacological agents in this clinical population. There was a lower rate of SH repetition for DBT-A (30%) as compared to TAU, EUC, or alternative psychotherapy (43%) on repetition of SH at post-intervention in four trials (OR 0.46, 95% CI 0.26 to 0.82; N = 270; k = 4; high-certainty evidence). There may be no evidence of a difference for individual cognitive behavioural therapy (CBT)-based psychotherapy and TAU for repetition of SH at post-intervention (OR 0.93, 95% CI 0.12 to 7.24; N = 51; k = 2; low-certainty evidence). We are uncertain whether mentalisation based therapy for adolescents (MBT-A) reduces repetition of SH at post-intervention as compared to TAU (OR 0.70, 95% CI 0.06 to 8.46; N = 85; k = 2; very low-certainty evidence). Heterogeneity for this outcome was substantial ( I² = 68%). There is probably no evidence of a difference between family therapy and either TAU or EUC on repetition of SH at post-intervention (OR 1.00, 95% CI 0.49 to 2.07; N = 191; k = 2; moderate-certainty evidence). However, there was no evidence of a difference for compliance enhancement approaches on repetition of SH by the six-month follow-up assessment, for group-based psychotherapy at the six- or 12-month follow-up assessments, for a remote contact intervention (emergency cards) at the 12-month assessment, or for therapeutic assessment at the 12- or 24-month follow-up assessments. AUTHORS' CONCLUSIONS Given the moderate or very low quality of the available evidence, and the small number of trials identified, there is only uncertain evidence regarding a number of psychosocial interventions in children and adolescents who engage in SH. Further evaluation of DBT-A is warranted. Given the evidence for its benefit in adults who engage in SH, individual CBT-based psychotherapy should also be further developed and evaluated in children and adolescents.
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Affiliation(s)
- Katrina G Witt
- Orygen, Parkville, Melbourne, Australia
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Sarah E Hetrick
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- Children and Young People Satellite, Cochrane Common Mental Disorders, The University of Auckland, Auckland, New Zealand
| | - Gowri Rajaram
- Orygen, Parkville, Melbourne, Australia
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Philip Hazell
- Speciality of Psychiatry, University of Sydney School of Medicine, Sydney, Australia
| | - Tatiana L Taylor Salisbury
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ellen Townsend
- Self-Harm Research Group, School of Psychology, University of Nottingham, Nottingham, UK
| | - Keith Hawton
- Centre for Suicide Research, Department of Psychiatry, University of Oxford, Oxford, UK
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14
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Taylor PJ, Fien K, Mulholland H, Duarte R, Dickson JM, Kullu C. Pilot service evaluation of a brief psychological therapy for self-harm in an emergency department: Hospital Outpatient Psychotherapy Engagement Service. Psychol Psychother 2021; 94 Suppl 1:64-78. [PMID: 32338445 DOI: 10.1111/papt.12277] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 02/14/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Brief psychological therapies may be helpful for people who have recently self-harmed. The current paper reports on a service evaluation of a novel brief therapy service based within an Emergency Department, Hospital Outpatient Psychotherapy Engagement (HOPE) Service. This service combines elements of psychodynamic interpersonal and cognitive analytic therapy to help people who present with self-harm-related difficulties. The primary aim of this service evaluation was to ascertain the feasibility of HOPE in terms of attendance rates. The study also examined variables associated with engagement, and change over time in psychological distress for those attending the service. METHOD The HOPE service was evaluated over a ten-month period. Consenting patients completed measures of psychological distress and working alliance across four therapy sessions and one follow-up session. Measures of emotion regulation style and self-harm function were also completed at the point of referral. RESULTS Eight-nine patients were referred to the service (83 eligible referrals). Fifty-three (64%) attended at least one therapy session. Baseline variables did not distinguish people who attended and people who did not. Psychological distress decreased significantly across the sessions. Most people reported a good working alliance with their therapist. CONCLUSIONS The results of this service evaluation support the feasibility of the HOPE service, demonstrating good engagement rates given the complexity of the population and context. Whilst there was evidence of reductions in distress, randomized controlled trials are needed to determine if HOPE has clinical efficacy. PRACTITIONER POINTS Rates of engagement with HOPE suggest the service is feasible in an Emergency Department context Working alliance scores were positive for the majority of patients The HOPE service shows promise as a brief intervention for people who self-harm but requires further evaluation Randomized controlled trials are needed to determine the clinical efficacy of the HOPE service.
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Affiliation(s)
- Peter J Taylor
- Division of Psychology & Mental Health, School of Health Sciences, Manchester Academic Health Sciences Centre, University of Manchester, UK
| | - Kirsten Fien
- Institute of Population Health Sciences, University of Liverpool, UK
| | - Helen Mulholland
- Institute of Population Health Sciences, University of Liverpool, UK
| | - Rui Duarte
- Institute of Population Health Sciences, University of Liverpool, UK.,Liverpool Reviews and Implementation Group, University of Liverpool, UK
| | - Joanne M Dickson
- Division of Psychology, School of Arts and Humanities, Edith Cowan University, Perth, Western Australia, Australia
| | - Cecil Kullu
- Mersey Care NHS Foundation Trust, Merseyside, UK
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15
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Storebø OJ, Stoffers-Winterling JM, Völlm BA, Kongerslev MT, Mattivi JT, Jørgensen MS, Faltinsen E, Todorovac A, Sales CP, Callesen HE, Lieb K, Simonsen E. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev 2020; 5:CD012955. [PMID: 32368793 PMCID: PMC7199382 DOI: 10.1002/14651858.cd012955.pub2] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Over the decades, a variety of psychological interventions for borderline personality disorder (BPD) have been developed. This review updates and replaces an earlier review (Stoffers-Winterling 2012). OBJECTIVES To assess the beneficial and harmful effects of psychological therapies for people with BPD. SEARCH METHODS In March 2019, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication. SELECTION CRITERIA Randomised controlled trials comparing different psychotherapeutic interventions with treatment-as-usual (TAU; which included various kinds of psychotherapy), waiting list, no treatment or active treatments in samples of all ages, in any setting, with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. There were 11 secondary outcomes, including individual BPD symptoms, as well as attrition and adverse effects. DATA COLLECTION AND ANALYSIS At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's 'Risk of bias' tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis. MAIN RESULTS We included 75 randomised controlled trials (4507 participants), predominantly involving females with mean ages ranging from 14.8 to 45.7 years. More than 16 different kinds of psychotherapy were included, mostly dialectical behaviour therapy (DBT) and mentalisation-based treatment (MBT). The comparator interventions included treatment-as-usual (TAU), waiting list, and other active treatments. Treatment duration ranged from one to 36 months. Psychotherapy versus TAU Psychotherapy reduced BPD symptom severity, compared to TAU; standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -0.70 to -0.33; 22 trials, 1244 participants; moderate-quality evidence. This corresponds to a mean difference (MD) of -3.6 (95% CI -4.4 to -2.08) on the Zanarini Rating Scale for BPD (range 0 to 36), a clinically relevant reduction in BPD symptom severity (minimal clinical relevant difference (MIREDIF) on this scale is -3.0 points). Psychotherapy may be more effective at reducing self-harm compared to TAU (SMD -0.32, 95% CI -0.49 to -0.14; 13 trials, 616 participants; low-quality evidence), corresponding to a MD of -0.82 (95% CI -1.25 to 0.35) on the Deliberate Self-Harm Inventory Scale (range 0 to 34). The MIREDIF of -1.25 points was not reached. Suicide-related outcomes improved compared to TAU (SMD -0.34, 95% CI -0.57 to -0.11; 13 trials, 666 participants; low-quality evidence), corresponding to a MD of -0.11 (95% CI -0.19 to -0.034) on the Suicidal Attempt Self Injury Interview. The MIREDIF of -0.17 points was not reached. Compared to TAU, psychotherapy may result in an improvement in psychosocial functioning (SMD -0.45, 95% CI -0.68 to -0.22; 22 trials, 1314 participants; low-quality evidence), corresponding to a MD of -2.8 (95% CI -4.25 to -1.38), on the Global Assessment of Functioning Scale (range 0 to 100). The MIREDIF of -4.0 points was not reached. Our additional Trial Sequential Analysis on all primary outcomes reaching significance found that the required information size was reached in all cases. A subgroup analysis comparing the different types of psychotherapy compared to TAU showed no clear evidence of a difference for BPD severity and psychosocial functioning. Psychotherapy may reduce depressive symptoms compared to TAU but the evidence is very uncertain (SMD -0.39, 95% CI -0.61 to -0.17; 22 trials, 1568 participants; very low-quality evidence), corresponding to a MD of -2.45 points on the Hamilton Depression Scale (range 0 to 50). The MIREDIF of -3.0 points was not reached. BPD-specific psychotherapy did not reduce attrition compared with TAU. Adverse effects were unclear due to too few data. Psychotherapy versus waiting list or no treatment Greater improvements in BPD symptom severity (SMD -0.49, 95% CI -0.93 to -0.05; 3 trials, 161 participants), psychosocial functioning (SMD -0.56, 95% CI -1.01 to -0.11; 5 trials, 219 participants), and depression (SMD -1.28, 95% CI -2.21 to -0.34, 6 trials, 239 participants) were observed in participants receiving psychotherapy versus waiting list or no treatment (all low-quality evidence). No evidence of a difference was found for self-harm and suicide-related outcomes. Individual treatment approaches DBT and MBT have the highest numbers of primary trials, with DBT as subject of one-third of all included trials, followed by MBT with seven RCTs. Compared to TAU, DBT was more effective at reducing BPD severity (SMD -0.60, 95% CI -1.05 to -0.14; 3 trials, 149 participants), self-harm (SMD -0.28, 95% CI -0.48 to -0.07; 7 trials, 376 participants) and improving psychosocial functioning (SMD -0.36, 95% CI -0.69 to -0.03; 6 trials, 225 participants). MBT appears to be more effective than TAU at reducing self-harm (RR 0.62, 95% CI 0.49 to 0.80; 3 trials, 252 participants), suicidality (RR 0.10, 95% CI 0.04, 0.30, 3 trials, 218 participants) and depression (SMD -0.58, 95% CI -1.22 to 0.05, 4 trials, 333 participants). All findings are based on low-quality evidence. For secondary outcomes see review text. AUTHORS' CONCLUSIONS Our assessments showed beneficial effects on all primary outcomes in favour of BPD-tailored psychotherapy compared with TAU. However, only the outcome of BPD severity reached the MIREDIF-defined cut-off for a clinically meaningful improvement. Subgroup analyses found no evidence of a difference in effect estimates between the different types of therapies (compared to TAU) . The pooled analysis of psychotherapy versus waiting list or no treatment found significant improvement on BPD severity, psychosocial functioning and depression at end of treatment, but these findings were based on low-quality evidence, and the true magnitude of these effects is uncertain. No clear evidence of difference was found for self-harm and suicide-related outcomes. However, compared to TAU, we observed effects in favour of DBT for BPD severity, self-harm and psychosocial functioning and, for MBT, on self-harm and suicidality at end of treatment, but these were all based on low-quality evidence. Therefore, we are unsure whether these effects would alter with the addition of more data.
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Affiliation(s)
- Ole Jakob Storebø
- Child and Adolescent Psychiatric Department, Region Zealand, Roskilde, Denmark
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Department of Psychology, Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | | | - Birgit A Völlm
- Department of Forensic Psychiatry, Center for Neurology, University Rostock, Rostock, Germany
| | - Mickey T Kongerslev
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Department of Psychology, Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | - Jessica T Mattivi
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Mie S Jørgensen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| | - Erlend Faltinsen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| | - Adnan Todorovac
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| | - Christian P Sales
- Duncan MacMillan House, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
- Institute of Mental Health, Department of Psychiatry & Applied Psychology, Nottingham, UK
| | | | - Klaus Lieb
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Erik Simonsen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
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16
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Kothgassner OD, Robinson K, Goreis A, Ougrin D, Plener PL. Does treatment method matter? A meta-analysis of the past 20 years of research on therapeutic interventions for self-harm and suicidal ideation in adolescents. Borderline Personal Disord Emot Dysregul 2020; 7:9. [PMID: 32426138 PMCID: PMC7216729 DOI: 10.1186/s40479-020-00123-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 04/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Self-harm is a clinically relevant and prevalent behaviour which peaks in adolescence. Given the high prevalence of self-harm, the high levels of psychiatric comorbidity, and its role as a risk factor for suicide, delivering evidence-based care is critical. METHODS We conducted a systematic review and meta-analysis of the literature on treating self-harm in adolescents (12-19 years) published in the last 20 years, identifying 25 randomised controlled trials. We calculated the effect of treatment interventions relative to active control conditions in reducing self-harm, suicidal ideation and depressive symptoms. RESULTS Overall, treatment interventions fared slightly better than active controls in decreasing self-harm (d = 0.13, 95% CI 0.04-0.22, p = .004), suicidal ideation (d = 0.31, 95% CI 0.12-0.50, p = .001) and depressive symptoms (d = 0.22, 95% CI 0.07-0.38, p = .006). Subgroup analysis of specific therapies revealed moderate effects of DBT-A in reducing self-harm (d = 0.51, 95% CI 0.18-0.85, p = .002) and suicidal ideation (d = 0.48, 95% CI 0.17-0.80, p = .003), as well as moderate effects of family-centred therapy in the treating suicidal ideation (d = 0.58, 95% CI 0.01-1.15, p = .049). CONCLUSIONS The findings of our meta-analysis indicate that, overall, currently available treatments are effective in treating self-harm, suicidal ideation, and depressive symptoms in adolescence. Although the treatment intervention conditions showed only small to moderate effects in comparison to active controls, these differences were statistically significant and are clinically important. Further research is needed to understand the reduction in self-harm within active controls, which may arise due to the natural course of self-harm, or the potential efficacy of treatment as usual and enhanced usual care. Given the significant reduction of self-harm in active control conditions, delivering effective care to a large number of adolescents with self-harm may require developing stepped-care models in clinical practice. Expensive and poorly available treatments should be targeted at young people who most need them.
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Affiliation(s)
- Oswald D Kothgassner
- 1Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria
| | - Kealagh Robinson
- 2School of Psychology, Victoria University of Wellington, Wellington, New Zealand
| | - Andreas Goreis
- 3Department of Clinical and Health Psychology, Faculty of Psychology, University of Vienna, Vienna, Austria.,4Outpatient Unit for Research, Teaching and Practice, Faculty of Psychology, University of Vienna, Vienna, Austria
| | - Dennis Ougrin
- 5Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Paul L Plener
- 1Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria.,6Department of Child- and Adolescent Psychiatry and Psychotherapy, Medical University of Ulm, Ulm, Germany
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English O, Wellings C, Banerjea P, Ougrin D. Specialized Therapeutic Assessment-Based Recovery-Focused Treatment for Young People With Self-Harm: Pilot Study. Front Psychiatry 2019; 10:895. [PMID: 31920749 PMCID: PMC6915197 DOI: 10.3389/fpsyt.2019.00895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 11/13/2019] [Indexed: 02/02/2023] Open
Abstract
Background: Suicide is the second leading cause of death in young people worldwide. Self-harm is the strongest predictor of death by suicide. There is increasing evidence that psychological therapies are efficacious in treating self-harm in adolescents. However, studies so far have predominantly focused on highly selective groups of adolescents and have investigated interventions that require intensive training and considerable expense. Methods: We conducted a pilot study of a novel psychological therapy package, Specialized Therapeutic Assessment-Based Recovery-Focused Treatment (START) that consists of Therapeutic Assessment followed by treatment in one of three modules, depending on adolescents' needs and preferences: Solution Focused Brief Therapy, Cognitive Behavior Therapy (CBT), or Mentalization Based Treatment. Adolescents (12-17) with at least one self-harm episode in the previous 6 months referred for community treatment, who had no intellectual disability, psychosis or autism were eligible for START. The primary outcome measure was the number of self-harm (regardless of suicidal intent) episodes 6 months before and 6 months after commencing START. Secondary outcomes included measures of psychopathology, functional impairment and family satisfaction. Results: Twenty-one consecutively referred adolescents were recruited and 15 received a therapeutic module of START: three received Solution Focused Brief Therapy, nine CBT, and three Mentalization Based Treatment. There was a statistically significant reduction in the number of self-harm episodes from a mean of 7.93 (SD = 12.26) to 1.00 (SD = 1.47), p < 0.02 following START. There was also a significant reduction in self-harm episodes, Revised Children's Anxiety and Depression Scale scores and a statistically significant improvement in Children Global Assessment Scale scores for the CBT group alone. There were no significant differences in any other outcomes. Most families were somewhat or very much satisfied with the intervention. Conclusion: The results show that START was associated with a reduction in self-harm and depression and anxiety symptoms, which could indicate that START should be rigorously studied in a randomized control trial (RCT). However, the model had difficulties in its implementation, with CBT being only module that was offered to enough young people to allow before and after analysis. CBT appears to be the most promising module in treating adolescents with self-harm referred to community mental health services.
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Affiliation(s)
- Oliver English
- The Institute of Psychiatry, Psychology, Child & Adolescent Psychiatry Department, King’s College London, London, United Kingdom
| | - Christy Wellings
- Southwark Child & Adolescent Mental Health Service, South London & Maudsley NHS Foundation Trust, Maudsley Hospital, London, United Kingdom
| | - Partha Banerjea
- Southwark Child & Adolescent Mental Health Service, South London & Maudsley NHS Foundation Trust, Maudsley Hospital, London, United Kingdom
| | - Dennis Ougrin
- The Institute of Psychiatry, Psychology, Child & Adolescent Psychiatry Department, King’s College London, London, United Kingdom
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Asarnow JR, Mehlum L. Practitioner Review: Treatment for suicidal and self-harming adolescents - advances in suicide prevention care. J Child Psychol Psychiatry 2019; 60:1046-1054. [PMID: 31512763 PMCID: PMC6880954 DOI: 10.1111/jcpp.13130] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2019] [Indexed: 12/25/2022]
Abstract
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.
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Affiliation(s)
- Joan Rosenbaum Asarnow
- Department of Psychiatry and Behavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
| | - Lars Mehlum
- National Centre for Suicide Research and Prevention, University of Oslo, Oslo, Norway
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Biagiarelli M, Curto M, Listanti G, Andraos MP, Pazzelli F, Aprile V, Pelaccia S, Mantovani B, Caccia F, Carpentieri R, Trabucchi G, Tambelli R, Girardi P, Ferracuti S, Baldessarini RJ, Sarlatto C. Efficacy of the Cooperative Assessment Method (COOPAS) to Improve the Psychiatric Care of Help-Seeking Adolescents. CLINICAL NEUROPSYCHIATRY 2019; 16:189-196. [PMID: 34908955 PMCID: PMC8650201 DOI: 10.36131/clinicalnpsych2019050601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective Effective treatment of adolescents with psychopathological disorders is essential to reduce later morbidity and disability. To evaluate the clinical value of a new adolescent Cooperative Assessment scheme (COOPAS) as indicated by establishing therapeutic alliance, improving symptoms, and particularly by reducing dropouts. Method Consecutive help-seeking adolescents (N=136) were recruited, evaluated with an 8-week COOPAS protocol and followed for 6 months to document dropouts during treatment. Clinical rating scales [Hamilton Depression and Anxiety scales (HAM-D, HAM-A), Global Functioning Role and Social Scales (GF-RS, GF-SS), Structured Interview for Prodromal Symptoms (SIPS), Clinical Global Impression (CGI), Working Alliance Inventory-Therapist version (WAI-T), Therapist Response Questionnaire (TRQ), Psychotherapy Relationship Questionnaire (PRQ)] were administered at intake, 4 weeks later, and at the end of COOPAS evaluation (8 weeks). Results Final HAM-A and HAM-D scores improved by 25%; CGI, GF-SS and GF-RS also improved significantly. Similarly, WAI-T showed significant improvements in all three subscales, and patient-clinician relationships (PRQ) showed decreases in Anxious/Preoccupied and Avoidant/Counterdependent dimensions with increases of the Secure/Engaged measure. After 6 months, dropout rate was 8.82%. Conclusions COOPAS assessment was followed by reduced depressive and anxiety symptoms, good therapeutic alliance, and low dropout in adolescents.
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Affiliation(s)
- Mario Biagiarelli
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy.,Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Rome, Italy
| | - Martina Curto
- Department of Human Neurosciences, Sapienza University of Rome, Italy.,International Consortium for Mood and Psychotic Disorders Research, Mailman Research Center, McLean Hospital, Belmont, Massachusetts, USA
| | - Giulia Listanti
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
| | - Maria Paola Andraos
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
| | - Floriana Pazzelli
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
| | - Veronica Aprile
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
| | - Simona Pelaccia
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
| | - Beatrice Mantovani
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
| | - Federica Caccia
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
| | - Renato Carpentieri
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
| | - Guido Trabucchi
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
| | - Renata Tambelli
- Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Rome, Italy
| | - Paolo Girardi
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
| | - Stefano Ferracuti
- Department of Human Neurosciences, Sapienza University of Rome, Italy
| | - Ross J Baldessarini
- International Consortium for Mood and Psychotic Disorders Research, Mailman Research Center, McLean Hospital, Belmont, Massachusetts, USA.,Department of Psychiatry, McLean Hospital, Harvard Medical School
| | - Cinzia Sarlatto
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
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20
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Böge I, Schepker R, Fegert JM. [Intensive psychiatric care of children and adolescents in their natural environment : Alternatives to inpatient treatment]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019; 62:195-204. [PMID: 30627734 DOI: 10.1007/s00103-018-2874-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Mental health disorders are one of the main diseases in children and adolescents, the persistence rate into adulthood being around 50%. Early intervention is therefore essential. However, present treatment options reach only 50% of children and adolescents with mental health problems.The objective of this article is to depict why legal deficits complicated the establishment of outreach treatment in the past and to illustrate recent legal changes that now allow innovative outreach treatment programs that meet the need of children and adolescents with mental health issues.This review is based on pertinent publications that were retrieved by a selective literature search in PubMed and Cochrane Library concerning types of home treatment in child and adolescent psychiatry, with due reference to the authors' own experience with intensive home treatment.The literature shows that outreach work has been effective in many other countries. In Germany however, clear separation in finances between outpatient and inpatient treatment did not allow the establishment of outreach teams in the past. On 01.01.2017 a new law, the PsychVVG, entered into force, and now provides a sound legal basis for outreach work. Home treatment in the form of, for example, intensive outreach work that equals the intensity and frequency of inpatient treatment (StäB) or continuum of care school (CCSchool), a project that joins school-based diagnostic elements with school-based treatment, can now be installed and evaluated.Intensive outreach work, especially in child and adolescent psychiatry, will now be a good alternative to inpatient treatment that integrates parents into the treatment approach.
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Affiliation(s)
- Isabel Böge
- KJPP, Universität Ulm, Steinhövelstraße 5, 89075, Ulm, Deutschland. .,KJPP, ZfP Südwürttemberg, Weingartshoferstraße 2, 88214, Ravensburg, Deutschland.
| | - Renate Schepker
- KJPP, Universität Ulm, Steinhövelstraße 5, 89075, Ulm, Deutschland.,KJPP, ZfP Südwürttemberg, Weingartshoferstraße 2, 88214, Ravensburg, Deutschland
| | - Jörg M Fegert
- KJPP, Universität Ulm, Steinhövelstraße 5, 89075, Ulm, Deutschland
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21
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Briggs S, Netuveli G, Gould N, Gkaravella A, Gluckman NS, Kangogyere P, Farr R, Goldblatt MJ, Lindner R. The effectiveness of psychoanalytic/psychodynamic psychotherapy for reducing suicide attempts and self-harm: systematic review and meta-analysis. Br J Psychiatry 2019; 214:320-328. [PMID: 30816079 DOI: 10.1192/bjp.2019.33] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Preventing suicide and self-harm is a global health priority. Although there is a growing evidence base for the effectiveness of psychoanalytic and psychodynamic psychotherapies for a range of disorders, to date there has been no systematic review of its effectiveness in reducing suicidal and self-harming behaviours.AimsTo systematically review randomised controlled trials of psychoanalytic and psychodynamic psychotherapies for suicidal attempts and self-harm. METHOD We searched PubMed, PsycINFO, Psycharticles, CINAHL, EMBASE and the Cochrane Central Register of Controlled Trials for randomise controlled trials of psychoanalytic and psychodynamic psychotherapies for reducing suicide attempts and self-harm. RESULTS Twelve trials (17 articles) were included in the meta-analyses. Psychoanalytic and psychodynamic therapies were effective in reducing the number of patients attempting suicide (pooled odds ratio, 0.469; 95% CI 0.274-0.804). We found some evidence for significantly reduced repetition of self-harm at 6-month but not 12-month follow-up. Significant treatment effects were also found for improvements in psychosocial functioning and reduction in number of hospital admissions. CONCLUSIONS Psychoanalytic and psychodynamic psychotherapies are indicated to be effective in reducing suicidal behaviour and to have short-term effectiveness in reducing self-harm. They can also be beneficial in improving psychosocial well-being. However, the small number of trials and moderate quality of the evidence means further high-quality trials are needed to confirm our findings and to identity which specific components of the psychotherapies are effective.Declaration of interestNone.
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Affiliation(s)
- Stephen Briggs
- Professor of Social Work,Centre for Social Work Research,University of East London,UK
| | - Gopalakrishnan Netuveli
- Professor of Public Health,Institute for Health and Human Development,University of East London,UK
| | - Nick Gould
- Professor Emeritus,Department of Social and Policy Sciences,University of Bath,UK
| | - Antigone Gkaravella
- Senior Clinical Teaching Fellow,University College,Great Ormond Street Institute of Child Health,UK
| | - Nicole S Gluckman
- Research Assistant,Centre for Social Work Research,University of East London,UK
| | - Patricia Kangogyere
- Research Assistant,Institute for Health and Human Development, University of East London,UK
| | - Ruby Farr
- Research Assistant,Institute for Health and Human Development, University of East London,UK
| | - Mark J Goldblatt
- Associate Clinical Professor of Psychiatry,Harvard Medical School; Clinical Associate,McLean Hospital; and Faculty Member,Boston Psychoanalytic Society,USA
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22
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Glenn CR, Esposito EC, Porter AC, Robinson D. Evidence Base Update of Psychosocial Treatments for Self-Injurious Thoughts and Behaviors in Youth. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2019; 48:357-392. [PMID: 31046461 PMCID: PMC6534465 DOI: 10.1080/15374416.2019.1591281] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The current review provides an evidence base update of psychosocial treatments for self-injurious thoughts and behaviors (SITBs) in youth. A systematic search was conducted of 2 major scientific databases (PsycInfo and PubMed) and ClinicalTrials.gov for relevant randomized controlled trials (RCTs) published prior to June 2018. The search identified 26 RCTs examining interventions for SITBs in youth: 17 were included in the 2015 review and 9 trials were new to this update. The biggest change since the prior review was the evaluation of Dialectical Behavior Therapy for adolescents (DBT-A) as the first Level 1: Well-established intervention for reducing deliberate self-harm (composite of nonsuicidal and suicidal self-injury) and suicide ideation in youth and Level 2: Probably efficacious for reducing nonsuicidal self-injury and suicide attempts. Five other interventions were rated as Level 2: Probably efficacious for reducing SITBs in youth, with the new addition of Integrated Family Therapy. This evidence base update indicates that there are a few promising treatments for reducing SITBs in youth. Efficacious interventions typically include a significant family or parent training component as well as skills training (e.g., emotion regulation skills). Aside from DBT-A, few treatments have been examined in more than one RCT. Given that replication by independent research groups is needed to evaluate an intervention as Well-established, future research should focus on replicating the five promising interventions currently evaluated as Probably efficacious. In addition, an important future direction is to develop brief efficacious interventions that may be scalable to reach large numbers of youth.
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23
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Yuan SNV, Kwok KHR, Ougrin D. Treatment Engagement in Specific Psychological Treatment vs. Treatment as Usual for Adolescents With Self-Harm: Systematic Review and Meta-Analysis. Front Psychol 2019; 10:104. [PMID: 30778310 PMCID: PMC6369209 DOI: 10.3389/fpsyg.2019.00104] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 01/14/2019] [Indexed: 01/03/2023] Open
Abstract
Background: Self-harm is a major public health problem. It is one of the best predictors of suicide in adolescents. Despite recent advances in the understanding of self-harm, poor treatment engagement remains a significant clinical obstacle. Objectives: The purpose of this meta-analysis is to update and extend previous research investigating treatment engagement with specific psychological treatments (SPT) vs. treatment as usual (TAU) in adolescents who self-harm. Methods: Data sources were identified by searching the Medline, PsychINFO, EMBASE, and PubMed databases as of October 2017. Randomized Controlled Trials (RCTs) comparing SPT and TAU in adolescents (through age 18 years) with self-harm were included. Results: The results show that 12 RCTs investigating 1,255 young people were included in the meta-analysis. The proportion of adolescents not completing four or more sessions in SPT was significantly lower (28.4%, 179/630) than TAU (45.9%, 287/625), RR = 0.64 (95% CI:0.51 -0.79), p < 0.0001. There were significantly more adolescents engaged with SPT than TAU. Conclusions: Specific psychological treatments should be offered to adolescents with self-harm to maximize treatment engagement. Engaging adolescents with psychological treatment is necessary although not sufficient to achieve treatment goals.
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24
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Inagaki M, Kawashima Y, Yonemoto N, Yamada M. Active contact and follow-up interventions to prevent repeat suicide attempts during high-risk periods among patients admitted to emergency departments for suicidal behavior: a systematic review and meta-analysis. BMC Psychiatry 2019; 19:44. [PMID: 30683075 PMCID: PMC6347824 DOI: 10.1186/s12888-019-2017-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 01/07/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND There is evidence that several intervention types, including psychotherapy, reduce repeat suicide attempts. However, these interventions are less applicable to the heterogeneous patients admitted to emergency departments (EDs). The risk of a repeat suicide attempt is especially high in the first 6 months after the initial attempt. Therefore, it is particularly important to develop effective ED interventions to prevent repeat suicide attempts during this 6-month period. METHODS We systematically reviewed randomized controlled trials of ED-initiated interventions for suicidal patients admitted to EDs using the databases MEDLINE, PsychoINFO, CINAHL, and EMBASE up to January 2015 in accordance with an a priori published protocol (PROSPERO: CRD42013005463). Interventions were categorized into four types, including active contact and follow-up interventions (intensive care plus outreach, brief interventions and contact, letter/postcard, telephone, and composite of letter/postcard and telephone), and a meta-analysis was conducted to determine pooled relative risks (RRs) and 95% confidence intervals (CIs) of a repeat suicide attempt within 6 months. RESULTS Of the 28 selected trials, 14 were active contact and follow-up interventions. Two of these trials (n = 984) reported results at 6 months (pooled RR = 0.48; 95% CI: 0.31 to 0.76). There were not enough trials of other interventions to perform meta-analysis. Some trials included in the meta-analysis were judged as showing risk of bias. CONCLUSION Active contact and follow-up interventions are recommended for suicidal patients admitted to an ED to prevent repeat suicide attempts during the highest-risk period of 6 months. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42013005463 (27 August 2013).
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Affiliation(s)
- Masatoshi Inagaki
- Department of Psychiatry, Faculty of Medicine, Shimane University, 89-1, Enya-cho, Izumo-shi, Shimane, 693-8501, Japan.
| | - Yoshitaka Kawashima
- 0000 0000 9832 2227grid.416859.7Department of Neuropsychopharmacology, National Institute of Mental Health, National Center of Neurology and Psychiatry, 4-1-1, Ogawahigashimachi, Kodaira, Tokyo, 187-8553 Japan
| | - Naohiro Yonemoto
- 0000 0004 0372 2033grid.258799.8Department of Biostatistics, Kyoto University School of Public Health, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501 Japan
| | - Mitsuhiko Yamada
- 0000 0000 9832 2227grid.416859.7Department of Neuropsychopharmacology, National Institute of Mental Health, National Center of Neurology and Psychiatry, 4-1-1, Ogawahigashimachi, Kodaira, Tokyo, 187-8553 Japan
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25
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Weinstein SM, Cruz RA, Isaia AR, Peters AT, West AE. Child- and Family-Focused Cognitive Behavioral Therapy for Pediatric Bipolar Disorder: Applications for Suicide Prevention. Suicide Life Threat Behav 2018; 48:797-811. [PMID: 29044718 PMCID: PMC5902658 DOI: 10.1111/sltb.12416] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 08/16/2017] [Indexed: 12/14/2022]
Abstract
Despite high rates of suicide ideation (SI) and behavior in youth with pediatric bipolar disorder (PBD), little work has examined how psychosocial interventions impact suicidality among this high-risk group. The current study examined SI outcomes in a randomized clinical trial comparing Child- and Family-Focused Cognitive Behavioral Therapy (CFF-CBT) for PBD versus psychotherapy treatment-as-usual (TAU). Although not designed for suicide prevention, CFF-CBT addresses child and family factors related to suicide risk and thus was hypothesized to generalize to the treatment of suicidality. Participants included 71 youth aged 7-13 years (M = 9.17, SD = 1.60) with DSM-IV-TR bipolar I, II, or not otherwise specified randomly assigned, with parent(s), to receive CFF-CBT or TAU. Both treatments consisted of 12 weekly and 6 monthly booster sessions. Suicide ideation was assessed via clinician interview at baseline, posttreatment, and 6-month follow-up. Results indicated that SI was prevalent pretreatment: 39% of youth reported current suicidal thoughts. All youth significantly improved in the likelihood and intensity of ideation across treatment, but group differences were not significant. Thus, findings suggest that early intervention for these high-risk youth may reduce SI, and at this stage of suicidality, youth may be responsive to even nonspecialized treatment.
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Affiliation(s)
- Sally M. Weinstein
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL,Corresponding Author: Sally M. Weinstein, Ph.D., Department of Psychiatry, University of Illinois at Chicago, 1747 W Roosevelt Road, Chicago, IL, 60608, , Phone: 312-413-7551, Fax: 312-413-7757
| | - Rick A. Cruz
- Department of Psychology, Utah State University, Logan, UT
| | - Ashley R. Isaia
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL
| | - Amy T. Peters
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL
| | - Amy E. West
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL
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26
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Iyengar U, Snowden N, Asarnow JR, Moran P, Tranah T, Ougrin D. A Further Look at Therapeutic Interventions for Suicide Attempts and Self-Harm in Adolescents: An Updated Systematic Review of Randomized Controlled Trials. Front Psychiatry 2018; 9:583. [PMID: 30532713 PMCID: PMC6266504 DOI: 10.3389/fpsyt.2018.00583] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 10/24/2018] [Indexed: 11/23/2022] Open
Abstract
Background: Suicide attempts (SA) and other types of self-harm (SH) are strong predictors of death by suicide in adolescents, emphasizing the need to investigate therapeutic interventions in reduction of these and other symptoms. We conducted an updated systematic review of randomized controlled trials (RCTs) from our previous study reporting therapeutic interventions that were effective in reducing SH including SA, while additionally exploring reduction of suicidal ideation (SI) and depressive symptoms (DS). Method: A systematic literature search was conducted across OVID Medline, psycINFO, PubMed, EMBASE, and Cochrane Library from the first available article to October 22nd, 2017, with a primary focus on RCTs evaluating therapeutic interventions in the reduction of self-harm. Search terms included self-injurious behavior; self-mutilation; suicide, attempted; suicide; drug overdose. Results: Our search identified 1,348 articles, of which 743 eligible for review, yielding a total of 21 studies which met predetermined inclusion criteria. Eighteen unique therapeutic interventions were identified among all studies, stratified by individual-driven, socially driven, and mixed interventions, of which 5 studies found a significant effect for primary outcomes of self-harm and suicide attempts (31.3%), and 5 studies found a significant effect for secondary outcomes of suicidal ideation and depressive symptoms (29.4%) for therapeutic intervention vs. treatment as usual. Collapsing across different variations of Cognitive Behavior Therapy (CBT), and classifying Dialectical Behavior Therapy for Adolescents (DBT-A) as a type of CBT, CBT is the only intervention with replicated positive impact on reducing self-harm in adolescents. Conclusion: While the majority of studies were not able to determine efficacy of therapeutic interventions for both primary and secondary outcomes, our systematic review suggests that individual self-driven and socially-driven processes appeared to show the greatest promise for reducing suicide attempts, with benefits of combined self-driven and systems-driven approaches for reducing overall self-harm. Further RCTs of all intervention categories are needed to address the clinical and etiological heterogeneity of suicidal behavior in adolescents, specifically suicidal ideation and depressive symptoms.
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Affiliation(s)
- Udita Iyengar
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology, and Neuroscience (IoPPN), King's College London, London, United Kingdom
| | - Natasha Snowden
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology, and Neuroscience (IoPPN), King's College London, London, United Kingdom
| | - Joan R. Asarnow
- Semel Institute of Neuroscience and Behavior, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Paul Moran
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, United Kingdom
- Department of Population Health Sciences, Centre for Academic Mental Health, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Troy Tranah
- Institute of Psychiatry, Psychology, and Neuroscience (IoPPN), London, United Kingdom
| | - Dennis Ougrin
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology, and Neuroscience (IoPPN), King's College London, London, United Kingdom
- South London and Maudsley National Health Service (NHS) Foundation Trust, London, United Kingdom
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27
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Robinson J, Bailey E, Witt K, Stefanac N, Milner A, Currier D, Pirkis J, Condron P, Hetrick S. What Works in Youth Suicide Prevention? A Systematic Review and Meta-Analysis. EClinicalMedicine 2018; 4-5:52-91. [PMID: 31193651 PMCID: PMC6537558 DOI: 10.1016/j.eclinm.2018.10.004] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 10/14/2018] [Accepted: 10/15/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Young people require specific attention when it comes to suicide prevention, however efforts need to be based on robust evidence. METHODS We conducted a systematic review and meta-analysis of all studies examining the impact of interventions that were specifically designed to reduce suicide-related behavior in young people. FINDINGS Ninety-nine studies were identified, of which 52 were conducted in clinical settings, 31 in educational or workplace settings, and 15 in community settings. Around half were randomized controlled trials. Large scale interventions delivered in both clinical and educational settings appear to reduce self-harm and suicidal ideation post-intervention, and to a lesser extent at follow-up. In community settings, multi-faceted, place-based approaches seem to have an impact. Study quality was limited. INTERPRETATION Overall whilst the number and range of studies is encouraging, gaps exist. Few studies were conducted in low-middle income countries or with demographic populations known to be at increased risk. Similarly, there was a lack of studies conducted in primary care, universities and workplaces. However, we identified that specific youth suicide-prevention interventions can reduce self-harm and suicidal ideation; these types of intervention need testing in high-quality studies.
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Affiliation(s)
- Jo Robinson
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Road, Vic 3052, Australia
| | - Eleanor Bailey
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Road, Vic 3052, Australia
| | - Katrina Witt
- Turning Point, Eastern Health Clinical School, Monash University, 110 Church Street, Richmond, VIC 3121, Australia
| | - Nina Stefanac
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Road, Vic 3052, Australia
| | - Allison Milner
- Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, 235 Bouverie Street, Vic 3010, Australia
| | - Dianne Currier
- Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, 235 Bouverie Street, Vic 3010, Australia
| | - Jane Pirkis
- Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, 235 Bouverie Street, Vic 3010, Australia
| | - Patrick Condron
- University Library, The University of Melbourne, Parkville, Vic 3010, Australia
| | - Sarah Hetrick
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Road, Vic 3052, Australia
- Department of Psychological Medicine, Faculty of Medicine and Health Sciences, University of Auckland, Support Building Auckland Hospital, 2 Park Rd, Auckland 1142, New Zealand
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Steeg S, Carr M, Emsley R, Hawton K, Waters K, Bickley H, Ness J, Geulayov G, Kapur N. Suicide and all-cause mortality following routine hospital management of self-harm: Propensity score analysis using multicentre cohort data. PLoS One 2018; 13:e0204670. [PMID: 30261030 PMCID: PMC6161837 DOI: 10.1371/journal.pone.0204670] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 09/12/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Observational studies are suited to examining links between the routine hospital management of self-harm and future suicide and all-cause mortality due to their large scale. However, care must be taken when attempting to infer causal associations in non-experimental settings. METHODS Data from the Multicentre Study of Self-Harm in England were used to examine associations between four types of hospital management (specialist psychosocial assessment, general hospital admission, psychiatric outpatient referral and psychiatric admission) following self-harm and risks of suicide and all-cause mortality in the subsequent 12 months. Missing data were handled by multiple imputation and propensity score (PS) methods were used to address observed differences between patients at baseline. Unadjusted, PS stratified and PS matched risk ratios (RRs) were calculated. RESULTS The PSs balanced the majority of baseline differences between treatment groups. Unadjusted RRs showed that all four treatment types were associated with either increased risks or no change in risks of suicide and all-cause mortality within a year. None of the four types of hospital management were associated with lowered risks of suicide or all-cause mortality following propensity score stratification (psychosocial assessment and medical admission) and propensity score matching (psychiatric outpatient referral and psychiatric admission), though there was no longer an increased risk among people admitted to a psychiatric bed. Individuals who self-cut were at an increased risk of death from any cause following psychosocial assessment and medical admission. Medical admission appeared to be associated with reduced risk of suicide in individuals already receiving outpatient or GP treatment for a psychiatric disorder. CONCLUSIONS More intensive forms of hospital management following self-harm appeared to be appropriately allocated to individuals with highest risks of suicide and all-cause mortality. PS adjustment appeared to attenuate only some of the observed increased risks, suggesting that either differences between treatment groups remained, or that some treatments had little impact on reducing subsequent suicide or all-cause mortality risk. These findings are in contrast to some previous studies that have suggested psychosocial assessment by a mental health specialist reduces risk of repeat self-harm. Future observational self-harm studies should consider increasing the number of potential confounding variables collected.
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Affiliation(s)
- Sarah Steeg
- Centre for Mental Health and Safety, School of Health Sciences,
University of Manchester, Manchester Academic Health Science Centre, Manchester,
United Kingdom
| | - Matthew Carr
- Centre for Mental Health and Safety, School of Health Sciences,
University of Manchester, Manchester Academic Health Science Centre, Manchester,
United Kingdom
| | - Richard Emsley
- Biostatistics and Health Informatics, Institute of Psychiatry, King’s
College London, London, United Kingdom
| | - Keith Hawton
- Centre for Suicide Research, University of Oxford Department of
Psychiatry, Warneford Hospital, Oxford, United Kingdom
| | - Keith Waters
- Centre for Self-Harm and Suicide Prevention Research, Derbyshire
Healthcare NHS Foundation Trust, Derby, United Kingdom
| | - Harriet Bickley
- Centre for Mental Health and Safety, School of Health Sciences,
University of Manchester, Manchester Academic Health Science Centre, Manchester,
United Kingdom
| | - Jennifer Ness
- Centre for Self-Harm and Suicide Prevention Research, Derbyshire
Healthcare NHS Foundation Trust, Derby, United Kingdom
| | - Galit Geulayov
- Centre for Suicide Research, University of Oxford Department of
Psychiatry, Warneford Hospital, Oxford, United Kingdom
| | - Nav Kapur
- Centre for Mental Health and Safety, School of Health Sciences,
University of Manchester, Manchester Academic Health Science Centre, Manchester,
United Kingdom
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, United
Kingdom
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Stewart A, Hughes ND, Simkin S, Locock L, Ferrey A, Kapur N, Gunnell D, Hawton K. Navigating an unfamiliar world: how parents of young people who self-harm experience support and treatment. Child Adolesc Ment Health 2018; 23:78-84. [PMID: 32677335 DOI: 10.1111/camh.12205] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Self-harm in young people is a common reason for contact with clinical services. However, there is little research focusing on parents' perspectives of care following self-harm. The aim of this study was to explore parents' experiences of treatment and support for the young person and for themselves. METHODS A qualitative design was used to explore parents' perspectives. Semi-structured narrative interviews were conducted across the UK with 37 parents of young people who had self-harmed. Thematic analysis was undertaken to identify themes relating to how parents experienced the help and treatment received. RESULTS Parents reported differing reactions to contact with helping services. Many found these helpful, particularly in keeping the young person safe, developing a trusting relationship with the young person, encouraging skills in managing self-harm and giving them an opportunity to talk about and find solutions to their difficulties. They spoke about the importance of practical help including prompt access to care, the right intensity of care, practical strategies and information and support. Some aspects of services were perceived as unhelpful, particularly a judgmental approach by professionals, lack of early access to treatment, inadequate support or failure to listen to the perspective of parents. CONCLUSIONS Parents' views highlight the need for clinicians to consider carefully the perspective of parents, involving them wherever possible and providing practical help and support, including written information. The need for training of clinicians in communicating with young people and parents following self-harm is also highlighted.
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Affiliation(s)
- Anne Stewart
- Central Oxon CAMHS, Oxford Health NHS Foundation Trust, Oxford, OX3 7LQ, UK.,Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | | | - Sue Simkin
- Department of Psychiatry, Centre for Suicide Research, University of Oxford, Warneford Hospital, Oxford, UK
| | - Louise Locock
- Health Experiences Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Anne Ferrey
- Department of Psychiatry, Centre for Suicide Research, University of Oxford, Warneford Hospital, Oxford, UK
| | - Navneet Kapur
- Centre for Suicide Prevention, University of Manchester and Manchester Mental Health and Social Care Trust, Manchester, UK
| | - David Gunnell
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Keith Hawton
- Department of Psychiatry, Centre for Suicide Research, University of Oxford, Warneford Hospital, Oxford, UK
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30
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Aggarwal S, Patton G. Engaging families in the management of adolescent self-harm. EVIDENCE-BASED MENTAL HEALTH 2018; 21:16-22. [PMID: 29311249 PMCID: PMC10270450 DOI: 10.1136/eb-2017-102791] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 11/07/2017] [Accepted: 12/05/2017] [Indexed: 11/03/2022]
Abstract
Adolescent self-harm is an emerging public health challenge. It is associated with later psychiatric and substance use disorders, unemployment and suicide. Family interventions have been effective in a range of adolescent mental health problems and for that reason were reviewed for their effectiveness in the management of adolescent self-harm. The search identified 10 randomised and 2 non-randomised controlled trial conducted in the high-income countries. For the most part the evidence is of low quality. The interventions were classified as brief single session, intermediate-level and intensive family interventions depending on the intensity and duration of treatment. Brief interventions did not reduce adolescent self-harm. Intermediate interventions such as the Resourceful Adolescent Parent Programme, Safe Alternatives for Teens and Youth Programme and attachment-based family treatment were effective in reducing suicidal behaviour (effect size 0.72), suicide attempts (P=0.01) and suicidal ideations (effect size 0.95), respectively in the short-term with an absence of long-term follow-up data. Intensive adolescent interventions such as dialectical behaviour therapy and mentalisation-based therapy reduced suicidal ideation (effect size 0.89) and self-harm (56% vs 83%, P=0.01), respectively. The persistence of effects beyond the intervention end point is not known in many interventions. Early involvement of the family, an evaluation of the risks at the end of an acute crisis episode and a stepped-care model taking into account level of suicide risk and resources available to an adolescent and her/his family are likely to promote better outcomes in adolescents who self-harm.
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Affiliation(s)
- Shilpa Aggarwal
- Deakin University, IMPACT Strategic Research Centre, School of Medicine, Geelong, Victoria, Australia
| | - George Patton
- Department of Pediatrics, Royal Children’s Hospital, Melbourne, Victoria, Australia
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
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31
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Steeg S, Emsley R, Carr M, Cooper J, Kapur N. Routine hospital management of self-harm and risk of further self-harm: propensity score analysis using record-based cohort data. Psychol Med 2018; 48:315-326. [PMID: 28637535 DOI: 10.1017/s0033291717001702] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The care received by people presenting to hospital following self-harm varies and it is unclear how different types of treatment affect risk of further self-harm. METHOD Observational cohort data from the Manchester Self-Harm Project, UK, included 16 456 individuals presenting to an Emergency Department with self-harm between 2003 and 2011. Individuals were followed up for 12 months. We also used data from a smaller cohort of individuals presenting to 31 hospitals in England during a 3-month period in 2010/2011, followed up for 6 months. Propensity score (PS) methods were used to address observed confounding. Missing data were imputed using multiple imputation. RESULTS Following PS stratification, those who received a psychosocial assessment had a lower risk of repeat hospital attendance for self-harm than those who were not assessed [RR 0.87, 95% confidence interval (CI) 0.80-0.95]. The risk was reduced most among people less likely to be assessed. Following PS matching, we found no associations between risks of repeat self-harm and admission to a medical bed, referral to outpatient psychiatry or admission to a psychiatric bed. We did not find a relationship between psychosocial assessment and repeat self-harm in the 31 centre cohort. CONCLUSIONS This study shows the potential value of using novel statistical techniques in large mental health datasets to estimate treatment effects. We found that specialist psychosocial assessment may reduce the risk of repeat self-harm. This type of routine care should be provided for all individuals who present to hospital after self-harm, regardless of perceived risk.
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Affiliation(s)
- S Steeg
- Division of Psychology and Mental Health,Centre for Suicide Prevention, University of Manchester, Manchester Academic Health Science Centre,Manchester,UK
| | - R Emsley
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre,Manchester,UK
| | - M Carr
- Division of Psychology and Mental Health,Centre for Suicide Prevention, University of Manchester, Manchester Academic Health Science Centre,Manchester,UK
| | - J Cooper
- Division of Psychology and Mental Health,Centre for Suicide Prevention, University of Manchester, Manchester Academic Health Science Centre,Manchester,UK
| | - N Kapur
- Division of Psychology and Mental Health,Centre for Suicide Prevention, University of Manchester, Manchester Academic Health Science Centre,Manchester,UK
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Brown RC. [Psychotherapeutic interventions for suicidal adolescents – a systematic review of the current literature]. ZEITSCHRIFT FUR KINDER-UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2017; 45:499-508. [PMID: 28771078 DOI: 10.1024/1422-4917/a000538] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Although suicidal thoughts and behaviors are common in adolescents, the German guidelines for suicidality in children and adolescents state a lack of evidence for the effectiveness of specific psychotherapies for those patients. The aim of this systematic review was to summarize and critically discuss newest advances in the evaluation of specific therapeutic approaches for suicidality in youths. Building on other recent systematic reviews, 11 manuscripts published between 2013 and 2017 were included in this review. Included are studies on interventions in emergency departments, psychotherapeutic approaches specifically targeting suicidality despite other psychopathology, interventions for youth with specific disorders or risk-factors, and one study evaluating an online-intervention. First positive effects can be claimed for family interventions in emergency departments (regarding lower hospitalization rates) as well as cognitive-behavioral, dialectical-behavioral, and family-oriented interventions (regarding reducing suicidality). Promising results were also found in a pilot study on an online-intervention. However, further research is necessary, as replication of outcomes has not been attempted or published in most cases and studies including large sample sizes with long-term follow-up evaluation are very rare.
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Affiliation(s)
- Rebecca C Brown
- 1 Klinik für Kinder- und Jugendpsychiatrie und -psychotherapie, Universitätsklinikum Ulm
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Lockwood J, Daley D, Townsend E, Sayal K. Impulsivity and self-harm in adolescence: a systematic review. Eur Child Adolesc Psychiatry 2017; 26:387-402. [PMID: 27815757 PMCID: PMC5364241 DOI: 10.1007/s00787-016-0915-5] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 10/27/2016] [Indexed: 12/20/2022]
Abstract
Research supports an association between impulsivity and self-harm, yet inconsistencies in methodology across studies have complicated understanding of this relationship. This systematic review examines the association between impulsivity and self-harm in community-based adolescents aged 11-25 years and aims to integrate findings according to differing concepts and methods. Electronic searches of EMBASE, MEDLINE, PsychINFO, CINAHL, PubMed and The Cochrane Library, and manual searches of reference lists of relevant reviews identified 4496 articles published up to July 2015, of which 28 met inclusion criteria. Twenty-four of the studies reported an association between broadly specified impulsivity and self-harm. However, findings varied according to the conception and measurement of impulsivity and the precision with which self-harm behaviours were specified. Specifically, lifetime non-suicidal self-injury was most consistently associated with mood-based impulsivity-related traits. However, cognitive facets of impulsivity (relating to difficulties maintaining focus or acting without forethought) differentiated current self-harm from past self-harm. These facets also distinguished those with thoughts of self-harm (ideation) from those who acted on thoughts (enaction). The findings suggested that mood-based impulsivity is related to the initiation of self-harm, while cognitive facets of impulsivity are associated with the maintenance of self-harm. In addition, behavioural impulsivity is most relevant to self-harm under conditions of negative affect. Collectively, the findings indicate that distinct impulsivity facets confer unique risks across the life-course of self-harm. From a clinical perspective, the review suggests that interventions focusing on reducing rash reactivity to emotions or improving self-regulation and decision making may offer most benefit in supporting those who self-harm.
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Affiliation(s)
- Joanna Lockwood
- Division of Psychiatry & Applied Psychology, Institute of Mental Health, University of Nottingham, Innovation Park, Triumph Road, Nottingham, NG7 2TU, UK.
- Centre for ADHD and Neurodevelopmental Disorders Across the Lifespan, (CANDAL) Institute of Mental Health, University of Nottingham, Nottingham, UK.
| | - David Daley
- Division of Psychiatry & Applied Psychology, Institute of Mental Health, University of Nottingham, Innovation Park, Triumph Road, Nottingham, NG7 2TU, UK
- Centre for ADHD and Neurodevelopmental Disorders Across the Lifespan, (CANDAL) Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Ellen Townsend
- School of Psychology, University of Nottingham, Nottingham, UK
| | - Kapil Sayal
- Division of Psychiatry & Applied Psychology, Institute of Mental Health, University of Nottingham, Innovation Park, Triumph Road, Nottingham, NG7 2TU, UK
- Centre for ADHD and Neurodevelopmental Disorders Across the Lifespan, (CANDAL) Institute of Mental Health, University of Nottingham, Nottingham, UK
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Hughes JL, Anderson NL, Wiblin JL, Asarnow JR. Predictors and Outcomes of Psychiatric Hospitalization in Youth Presenting to the Emergency Department with Suicidality. Suicide Life Threat Behav 2017; 47:193-204. [PMID: 27371938 DOI: 10.1111/sltb.12271] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 02/24/2016] [Indexed: 11/29/2022]
Abstract
Youth suicide attempters presenting to the emergency department (ED) are frequently admitted to psychiatric inpatient hospitals, yet little is known about how clinicians decide which youths to admit versus discharge to outpatient care. We examine predictors of inpatient hospitalization and describe service use outcomes associated with hospitalization in 181 youths drawn from consecutive ED admissions for suicidality. Predictors of hospitalization include ED site, suicide plan, and parent report of problems. Hospitalization was associated with improved linkage to outpatient treatment and more intensive service use. Future research is needed to understand the best service delivery and treatments for these high-risk youth.
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Affiliation(s)
| | - Nicholas L Anderson
- Psychiatry and Biobehavioral, University of California at Los Angeles, Los Angeles, CA, USA
| | - Jessica L Wiblin
- Psychiatry and Biobehavioral, University of California at Los Angeles, Los Angeles, CA, USA
| | - Joan R Asarnow
- Psychiatry and Biobehavioral, University of California at Los Angeles, Los Angeles, CA, USA
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35
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Diggins E, Kelley R, Cottrell D, House A, Owens D. Age-related differences in self-harm presentations and subsequent management of adolescents and young adults at the emergency department. J Affect Disord 2017; 208:399-405. [PMID: 27810724 DOI: 10.1016/j.jad.2016.10.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 10/03/2016] [Accepted: 10/17/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Characteristics of self-harm differ across ages, but there is little work identifying age-related differences in younger people. Young people entering adolescence face emotionally and developmentally different challenges to those entering adulthood. This study investigates how Emergency Department (ED) presentations and management of self-harm differ through adolescence and early adulthood. METHODS 3782 consecutive self-harm episodes involving 2559 people aged 12-25 years were identified from an existing database of Leeds ED attendances from 2004 to 2007. Odds ratios for each of four age bands were compared to the remaining young people. RESULTS The female to male ratio was 6.3:1 at 12-14 years old, decreasing with successive age groups to 1.2:1 at 22-25 years old. Self-poisoning was commoner in those under 18 years old. 18-25 year olds were more likely to self-poison with prescribed medications, mixed overdoses, alcohol or recreational drugs. 18-25 year olds more often required medical treatment for the effects of the self-harm. 12-14 year olds were more often seen urgently by ED medical staff and offered high intensity mental health aftercare. Repetition of self-harm was commonest in 12-14 year olds, although multiple repetition of self-harm was commonest in 22-25 year olds. LIMITATIONS Data were not collected on whether the aftercare offered was received. The study sample included hospital attenders only. CONCLUSIONS The large excess of females over males in young people's self-harm is only true at the younger age range. Older adolescents present with more severe acts of self-harm, yet receive the lowest intensity of assessment and after care.
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Carter G, Page A, Large M, Hetrick S, Milner AJ, Bendit N, Walton C, Draper B, Hazell P, Fortune S, Burns J, Patton G, Lawrence M, Dadd L, Dudley M, Robinson J, Christensen H. Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the management of deliberate self-harm. Aust N Z J Psychiatry 2016; 50:939-1000. [PMID: 27650687 DOI: 10.1177/0004867416661039] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To provide guidance for the organisation and delivery of clinical services and the clinical management of patients who deliberately self-harm, based on scientific evidence supplemented by expert clinical consensus and expressed as recommendations. METHOD Articles and information were sourced from search engines including PubMed, EMBASE, MEDLINE and PsycINFO for several systematic reviews, which were supplemented by literature known to the deliberate self-harm working group, and from published systematic reviews and guidelines for deliberate self-harm. Information was reviewed by members of the deliberate self-harm working group, and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to successive consultation and external review involving expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest and expertise in deliberate self-harm. RESULTS The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for deliberate self-harm provide up-to-date guidance and advice regarding the management of deliberate self-harm patients, which is informed by evidence and clinical experience. The clinical practice guidelines for deliberate self-harm is intended for clinical use and service development by psychiatrists, psychologists, physicians and others with an interest in mental health care. CONCLUSION The clinical practice guidelines for deliberate self-harm address self-harm within specific population sub-groups and provide up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.
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Affiliation(s)
- Gregory Carter
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Centre for Translational Neuroscience and Mental Health, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia Department of Consultation Liaison Psychiatry, Calvary Mater Newcastle Hospital, Waratah, NSW, Australia
| | - Andrew Page
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Centre for Health Research, Western Sydney University, Richmond, NSW, Australia
| | - Matthew Large
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia School of Psychiatry, The University of New South Wales, Sydney, NSW, Australia
| | - Sarah Hetrick
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC, Australia
| | - Allison Joy Milner
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Centre for Population Health Research, School of Health and Social Development, Deakin University, Burwood VIC, Australia Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Nick Bendit
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia School of Psychology, Faculty of Science and Information Technology, The University of Newcastle, Callaghan, NSW, Australia
| | - Carla Walton
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Centre for Psychotherapy, Hunter New England Mental Health Service and Centre for Translational Neuroscience and Mental Health, The University of Newcastle, Callaghan, NSW, Australia
| | - Brian Draper
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia School of Psychiatry, The University of New South Wales, Sydney, NSW, Australia Academic Department for Old Age Psychiatry, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Philip Hazell
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Discipline of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Sarah Fortune
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia The University of Auckland, Auckland, New Zealand University of Leeds, Leeds, UK Kidz First, Middlemore Hospital, Auckland, New Zealand
| | - Jane Burns
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Young and Well Cooperative Research Centre, The University of Melbourne, Melbourne, VIC, Australia Brain & Mind Research Institute, The University of Sydney, Sydney, NSW, Australia Orygen Youth Health Research Centre, Melbourne, VIC, Australia
| | - George Patton
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia National Health and Medical Research Council, Canberra, ACT, Australia Centre for Adolescent Health, The Royal Children's Hospital, Melbourne, VIC, Australia Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Mark Lawrence
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Tauranga Hospital, Bay of Plenty, New Zealand
| | - Lawrence Dadd
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Mental Health & Substance Use Service, Hunter New England, NSW Health, Waratah, NSW, Australia Awabakal Aboriginal Medical Service, Hamilton, NSW, Australia Pital Tarkin, Aboriginal Medical Student Mentoring Program, The Wollotuka Institute, The University of Newcastle, Callaghan, NSW, Australia Specialist Outreach NT, Darwin, Northern Territory, Australia
| | | | - Jo Robinson
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC, Australia
| | - Helen Christensen
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Black Dog Institute, The University of New South Wales, Sydney, NSW, Australia
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Howson S, Huline-Dickens S. Do interventions reduce the risk of repeat self-harm or suicide in young people? BJPSYCH ADVANCES 2016. [DOI: 10.1192/apt.22.5.287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SummaryAs in adults, self-harm in children and young people is common. It results in much distress to families and carers, and considerable morbidity among children and young people. Although much more common than completed suicide, it is strongly linked to repeated self-harm and suicide. The conclusions in this review are limited by the small number of studies included, no studies of pharmacological interventions at all and most of the included interventions being evaluated in a single study. One moderately sized study of mentalisation in adolescents with comorbid depression showed a significant effect on scores on a self-harm measure, indicating fewer self-reported episodes of self-harm. No other intervention showed a significant reduction in reported self-harm, although trials may have been too small to show statistical significance.
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A systematic review of psychosocial suicide prevention interventions for youth. Eur Child Adolesc Psychiatry 2016; 25:467-82. [PMID: 26472117 DOI: 10.1007/s00787-015-0783-4] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 10/05/2015] [Indexed: 01/12/2023]
Abstract
Youth suicide is a significant public health problem. A systematic review was conducted to examine the effectiveness of school, community and healthcare-based interventions in reducing and preventing suicidal ideation, suicide attempts and deliberate self-harm in young people aged 12-25 years. PsycInfo, PubMed and Cochrane databases were searched to the end of December 2014 to identify randomised controlled trials evaluating the effectiveness of psychosocial interventions for youth suicide. In total, 13,747 abstracts were identified and screened for inclusion in a larger database. Of these, 29 papers describing 28 trials fulfilled the inclusion criteria for the current review. The results of the review indicated that just over half of the programs identified had a significant effect on suicidal ideation (Cohen's d = 0.16-3.01), suicide attempts (phi = 0.04-0.38) or deliberate self-harm (phi = 0.29-0.33; d = 0.42). The current review provides preliminary support for the implementation of universal and targeted interventions in all settings, using a diverse range of psychosocial approaches. Further quality research is needed to strengthen the evidence-base for suicide prevention programs in this population. In particular, the development of universal school-based interventions is promising given the potential reach of such an approach.
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Hawton K, Witt KG, Taylor Salisbury TL, Arensman E, Gunnell D, Townsend E, van Heeringen K, Hazell P. Interventions for self-harm in children and adolescents. Cochrane Database Syst Rev 2015; 2021:CD012013. [PMID: 26688129 PMCID: PMC8786270 DOI: 10.1002/14651858.cd012013] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Self-harm (SH; intentional self-poisoning or self-injury) is common in children and adolescents, often repeated, and strongly associated with suicide. This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for deliberate SH first published in 1998 and previously updated in 1999. We have now divided the review into three separate reviews; this review is focused on psychosocial and pharmacological interventions for SH in children and adolescents. OBJECTIVES To identify all randomised controlled trials of psychosocial interventions, pharmacological agents, or natural products for SH in children and adolescents, and to conduct meta-analyses (where possible) to compare the effects of specific treatments with comparison types of treatment (e.g., treatment as usual (TAU), placebo, or alternative pharmacological treatment) for children and adolescents who SH. SEARCH METHODS For this update the Cochrane Depression, Anxiety and Neurosis Group (CCDAN) Trials Search Co-ordinator searched the CCDAN Specialised Register (30 January 2015). SELECTION CRITERIA We included randomised controlled trials comparing psychosocial or pharmacological treatments with treatment as usual, alternative treatments, or placebo or alternative pharmacological treatment in children and adolescents (up to 18 years of age) with a recent (within six months) episode of SH resulting in presentation to clinical services. DATA COLLECTION AND ANALYSIS Two reviewers independently selected trials, extracted data, and appraised study quality, with consensus. For binary outcomes, we calculated odds ratios (OR) and their 95% confidence intervals (CI). For continuous outcomes measured using the same scale we calculated the mean difference (MD) and 95% CI; for those measured using different scales we calculated the standard mean difference (SMD) and 95% CI. Meta-analysis was only possible for two interventions: dialectical behaviour therapy for adolescents and group-based psychotherapy. For these analyses, we pooled data using a random-effects model. MAIN RESULTS We included 11 trials, with a total of 1,126 participants. The majority of participants were female (mean = 80.6% in 10 trials reporting gender). All trials were of psychosocial interventions; there were none of pharmacological treatments. With the exception of dialectical behaviour therapy for adolescents (DBT-A) and group-based therapy, assessments of specific interventions were based on single trials. We downgraded the quality of evidence owing to risk of bias or imprecision for many outcomes.Therapeutic assessment appeared to increase adherence with subsequent treatment compared with TAU (i.e., standard assessment; n = 70; k = 1; OR = 5.12, 95% CI 1.70 to 15.39), but this had no apparent impact on repetition of SH at either 12 (n = 69; k = 1; OR 0.75, 95% CI 0.18 to 3.06; GRADE: low quality) or 24 months (n = 69; k = 1; OR = 0.69, 05% CI 0.23 to 2.14; GRADE: low quality evidence). These results are based on a single cluster randomised trial, which may overestimate the effectiveness of the intervention.For patients with multiple episodes of SH or emerging personality problems, mentalisation therapy was associated with fewer adolescents scoring above the cut-off for repetition of SH based on the Risk-Taking and Self-Harm Inventory 12 months post-intervention (n = 71; k = 1; OR = 0.26, 95% CI 0.09 to 0.78; GRADE: moderate quality). DBT-A was not associated with a reduction in the proportion of adolescents repeating SH when compared to either TAU or enhanced usual care (n = 104; k = 2; OR 0.72, 95% CI 0.12 to 4.40; GRADE: low quality). In the latter trial, however, the authors reported a significantly greater reduction over time in frequency of repeated SH in adolescents in the DBT condition, in whom there were also significantly greater reductions in depression, hopelessness, and suicidal ideation.We found no significant treatment effects for group-based therapy on repetition of SH for individuals with multiple episodes of SH at either the six (n = 430; k = 2; OR 1.72, 95% CI 0.56 to 5.24; GRADE: low quality) or 12 month (n = 490; k = 3; OR 0.80, 95% CI 0.22 to 2.97; GRADE: low quality) assessments, although considerable heterogeneity was associated with both (I(2) = 65% and 77% respectively). We also found no significant differences between the following treatments and TAU in terms of reduced repetition of SH: compliance enhancement (three month follow-up assessment: n = 63; k = 1; OR = 0.67, 95% CI 0.15 to 3.08; GRADE: very low quality), CBT-based psychotherapy (six month follow-up assessment: n = 39; k = 1; OR = 1.88, 95% CI 0.30 to 11.73; GRADE: very low quality), home-based family intervention (six month follow-up assessment: n = 149; k = 1; OR = 1.02, 95% CI 0.41 to 2.51; GRADE: low quality), and provision of an emergency card (12 month follow-up assessment: n = 105, k = 1; OR = 0.50, 95% CI 0.12 to 2.04; GRADE: very low quality). No data on adverse effects, other than the planned outcomes relating to suicidal behaviour, were reported. AUTHORS' CONCLUSIONS There are relatively few trials of interventions for children and adolescents who have engaged in SH, and only single trials contributed to all but two comparisons in this review. The quality of evidence according to GRADE criteria was mostly very low. There is little support for the effectiveness of group-based psychotherapy for adolescents with multiple episodes of SH based on the results of three trials, the evidence from which was of very low quality according to GRADE criteria. Results for therapeutic assessment, mentalisation, and dialectical behaviour therapy indicated that these approaches warrant further evaluation. Despite the scale of the problem of SH in children and adolescents there is a paucity of evidence of effective interventions. Further large-scale trials, with a range of outcome measures including adverse events, and investigation of therapeutic mechanisms underpinning these interventions, are required. It is increasingly apparent that development of new interventions should be done in collaboration with patients to ensure that these are likely to meet their needs. Use of an agreed set of outcome measures would assist evaluation and both comparison and meta-analysis of trials.
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Affiliation(s)
- Keith Hawton
- Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, Oxford, UK, OX3 7JX
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Parents of youth who self-injure: a review of the literature and implications for mental health professionals. Child Adolesc Psychiatry Ment Health 2015; 9:35. [PMID: 26421058 PMCID: PMC4586015 DOI: 10.1186/s13034-015-0066-3] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 06/25/2015] [Indexed: 11/18/2022] Open
Abstract
Non-suicidal self-injury (NSSI) is a common mental health concern among youth, and parents can be valuable supports for these youth. However, youth NSSI can have a significant impact on parents' wellbeing, which may in turn alter parents' ability to support the youth. To date, no single article has consolidated the research on parents of youth who self-injure. This review synthesizes the literature on parent factors implicated in youth NSSI risk, the role of parents in help-seeking and intervention for youth NSSI, and the impact of youth NSSI on parent wellbeing and parenting. Clinical implications for supporting parents as they support the youth are also discussed, and recommendations for future research are outlined.
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Herbert A, Gilbert R, González-Izquierdo A, Li L. Violence, self-harm and drug or alcohol misuse in adolescents admitted to hospitals in England for injury: a retrospective cohort study. BMJ Open 2015; 5:e006079. [PMID: 25667148 PMCID: PMC4322205 DOI: 10.1136/bmjopen-2014-006079] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Of adolescents in the general population in England, we aimed to determine (1) the proportion that has an emergency admission to hospital for injury related to adversity (violence, self-harm or drug or alcohol misuse) and (2) the risk of recurrent emergency admissions for injury in adolescents admitted with adversity-related injury compared with those admitted with accident-related injury only. DESIGN We used longitudinally linked administrative hospital data (Hospital Episode Statistics) to identify participants aged 10-19 years with emergency admissions for injury (including day cases lasting more than 4 h) in England in 1998-2011. We used the Office for National Statistics mid-year estimates for population denominators. RESULTS Approximately 4.3% (n=141 248) of adolescents in the general population (n=3 254 046) had one or more emergency admissions for adversity-related injury (girls 4.6%, boys 4.1%), accounting for 50% of all emergency admissions for injury in girls and 29.1% in boys. Admissions for self-harm or drug or alcohol misuse commonly occurred in the same girls and boys. Recurrent emergency admissions for injury were more common in adolescents with adversity-related injury (girls 17.3%, boys 16.5%) than in those with accident-related injury only (girls 4.7%, boys 7.4%), particularly for adolescents with adversity-related injury related to multiple types of adversity (girls 21.1%, boys 24.2%). CONCLUSIONS Hospital-based interventions should be developed to reduce the risk of future injury in adolescents admitted for adversity-related injury.
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Affiliation(s)
- Annie Herbert
- Population, Policy & Practice Programme, University College London Institute of Child Health, London, UK
| | - Ruth Gilbert
- Population, Policy & Practice Programme, University College London Institute of Child Health, London, UK
| | - Arturo González-Izquierdo
- Population, Policy & Practice Programme, University College London Institute of Child Health, London, UK
| | - Leah Li
- Population, Policy & Practice Programme, University College London Institute of Child Health, London, UK
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Ougrin D, Tranah T, Stahl D, Moran P, Asarnow JR. Therapeutic interventions for suicide attempts and self-harm in adolescents: systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry 2015; 54:97-107.e2. [PMID: 25617250 DOI: 10.1016/j.jaac.2014.10.009] [Citation(s) in RCA: 261] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 10/20/2014] [Accepted: 10/23/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Suicidal behavior and self-harm are common in adolescents and are associated with elevated psychopathology, risk of suicide, and demand for clinical services. Despite recent advances in the understanding and treatment of self-harm and links between self-harm and suicide and risk of suicide attempt, progress in reducing suicide death rates has been elusive, with no substantive reduction in suicide death rates over the past 60 years. Extending prior reviews of the literature on treatments for suicidal behavior and repetitive self-harm in youth, this article provides a meta-analysis of randomized controlled trials (RCTs) reporting efficacy of specific pharmacological, social, or psychological therapeutic interventions (TIs) in reducing both suicidal and nonsuicidal self-harm in adolescents. METHOD Data sources were identified by searching the Cochrane, Medline, PsychINFO, EMBASE, and PubMed databases as of May 2014. RCTs comparing specific therapeutic interventions versus treatment as usual (TAU) or placebo in adolescents (through age 18 years) with self-harm were included. RESULTS Nineteen RCTs including 2,176 youth were analyzed. TIs included psychological and social interventions and no pharmacological interventions. The proportion of the adolescents who self-harmed over the follow-up period was lower in the intervention groups (28%) than in controls (33%) (test for overall effect z = 2.31; p = .02). TIs with the largest effect sizes were dialectical behavior therapy (DBT), cognitive-behavioral therapy (CBT), and mentalization-based therapy (MBT). There were no independent replications of efficacy of any TI. The pooled risk difference between TIs and TAU for suicide attempts and nonsuicidal self-harm considered separately was not statistically significant. CONCLUSION TIs to prevent self-harm appear to be effective. Independent replication of the results achieved by DBT, MBT, and CBT is a research priority.
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Affiliation(s)
- Dennis Ougrin
- Institute of Psychiatry, King's College London and South London and Maudsley National Health Service (NHS) Foundation Trust.
| | - Troy Tranah
- South London and Maudsley NHS Foundation Trust
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Rowe SL, French RS, Henderson C, Ougrin D, Slade M, Moran P. Help-seeking behaviour and adolescent self-harm: a systematic review. Aust N Z J Psychiatry 2014; 48:1083-95. [PMID: 25335872 DOI: 10.1177/0004867414555718] [Citation(s) in RCA: 129] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Self-harm is common in adolescence, but most young people who self-harm do not seek professional help. The aim of this literature review was to determine (a) the sources of support adolescents who self-harm access if they seek help, and (b) the barriers and facilitators to help-seeking for adolescents who self-harm. METHOD Using a pre-defined search strategy we searched databases for terms related to self-harm, adolescents and help-seeking. Studies were included in the review if participants were aged 11-19 years. RESULTS Twenty articles met criteria for inclusion. Between a third and one half of adolescents who self-harm do not seek help for this behaviour. Of those who seek help, results showed adolescents primarily turned to friends and family for support. The Internet may be more commonly used as a tool for self-disclosure rather than asking for help. Barriers to help-seeking included fear of negative reactions from others including stigmatisation, fear of confidentiality being breached and fear of being seen as 'attention-seeking'. Few facilitators of help-seeking were identified. CONCLUSIONS Of the small proportion of adolescents who seek help for their self-harm, informal sources are the most likely support systems accessed. Interpersonal barriers and a lack of knowledge about where to go for help may impede help-seeking. Future research should address the lack of knowledge regarding the facilitators of help-seeking behaviour in order to improve the ability of services to engage with this vulnerable group of young people.
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Affiliation(s)
- Sarah L Rowe
- King's College London, Health Service and Population Research Department, Institute of Psychiatry, London, UK
| | - Rebecca S French
- London School of Hygiene and Tropical Medicine, Department of Social and Environmental Health Research, Faculty of Public Health & Policy, London, UK
| | - Claire Henderson
- King's College London, Health Service and Population Research Department, Institute of Psychiatry, London, UK
| | - Dennis Ougrin
- King's College London, Child and Adolescent Psychiatry Department, Institute of Psychiatry, London, UK
| | - Mike Slade
- King's College London, Health Service and Population Research Department, Institute of Psychiatry, London, UK
| | - Paul Moran
- King's College London, Health Service and Population Research Department, Institute of Psychiatry, London, UK
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Glenn CR, Franklin JC, Nock MK. Evidence-based psychosocial treatments for self-injurious thoughts and behaviors in youth. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2014; 44:1-29. [PMID: 25256034 PMCID: PMC4557625 DOI: 10.1080/15374416.2014.945211] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The purpose of this study was to review the current evidence base of psychosocial treatments for suicidal and nonsuicidal self-injurious thoughts and behaviors (SITBs) in youth. We reviewed major scientific databases (HealthSTAR, MEDLine, PsycINFO, PubMed) for relevant studies published prior to June 2013. The search identified 29 studies examining interventions for suicidal or nonsuicidal SITBs in children or adolescents. No interventions currently meet the Journal of Clinical Child and Adolescent Psychology standards for Level 1: well-established treatments. Six treatment categories were classified as Level 2: probably efficacious or Level 3: possibly efficacious for reducing SITBs in youth. These treatments came from a variety of theoretical orientations, including cognitive-behavioral, family, interpersonal, and psychodynamic theories. Common elements across efficacious treatments included family skills training (e.g., family communication and problem solving), parent education and training (e.g., monitoring and contingency management), and individual skills training (e.g., emotion regulation and problem solving). Several treatments have shown potential promise for reducing SITBs in children and adolescents. However, the probably/possibly efficacious treatments identified each have evidence from only a single randomized controlled trial. Future research should focus on replicating studies of promising treatments, identifying active treatment ingredients, examining mediators and moderators of treatment effects, and developing brief interventions for high-risk periods (e.g., following hospital discharge).
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Abstract
Self-harm is a common problem among young people with many presenting to clinical services via general hospitals, but many more do not come to the attention of clinical services at all. Self-harm is strongly associated with completed suicide so it is extremely important that patients are assessed and treated for this problem effectively. Despite the scale of the problem in young people, there is a very limited evidence base on what interventions may help them to recover from self-harm. The evidence is discussed here and some recommendations are made about how to engage clinically with young people who self-harm from assessment to therapeutic intervention.
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Brent DA, McMakin DL, Kennard BD, Goldstein TR, Mayes TL, Douaihy AB. Protecting adolescents from self-harm: a critical review of intervention studies. J Am Acad Child Adolesc Psychiatry 2013; 52:1260-71. [PMID: 24290459 PMCID: PMC3873716 DOI: 10.1016/j.jaac.2013.09.009] [Citation(s) in RCA: 135] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 09/17/2013] [Accepted: 09/26/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To review the studies that test treatments targeting adolescent suicidal ideation, suicide attempts, or self-harm, and to make recommendations for future intervention development. METHOD The extant randomized clinical trials that aim to reduce the intensity of suicidal ideation or the recurrence of suicide attempts or self-harm were reviewed with respect to treatment components, comparison treatments, sample composition, and outcomes. RESULTS The majority of studies that showed any effect on suicidal ideation, attempts, or self-harm had some focus on family interactions or nonfamilial sources of support. Two of the most efficacious interventions also provided the greatest number of sessions. Some other treatment elements associated with positive effects include addressing motivation for treatment and having explicit plans for integrating the experimental treatment with treatment as usual. In many studies, suicidal events tend to occur very early in the course of treatment prior to when an effective "dose" of treatment could be delivered. Important factors that might mitigate suicidal risk, such as sobriety, healthy sleep, and promotion of positive affect, were not addressed in most studies. CONCLUSION Interventions that can front-load treatment shortly after the suicidal crisis, for example, while adolescent suicide attempters are hospitalized, may avert early suicidal events. Treatments that focus on the augmentation of protective factors, such as parent support and positive affect, as well as the promotion of sobriety and healthy sleep, may be beneficial with regard to the prevention of recurrent suicidal ideation, attempts, or self-harm in adolescents.
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Affiliation(s)
- David A. Brent
- University of Pittsburgh and Western Psychiatric Institute and Clinic
| | - Dana L. McMakin
- University of Pittsburgh and Western Psychiatric Institute and Clinic
| | | | - Tina R. Goldstein
- University of Pittsburgh and Western Psychiatric Institute and Clinic
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