A Further Look at Therapeutic Interventions for Suicide Attempts and Self-Harm in Adolescents: An Updated Systematic Review of Randomized Controlled Trials.

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.

Therapeutic interventions for suicide attempts and self-harm in adolescents: systematic review and meta-analysis.

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.

Practitioner review: Self-harm in adolescents.

BACKGROUND: Repeated self-harm in adolescents is common and associated with elevated psychopathology, risk of suicide, and demand for clinical services. Despite recent advances in the understanding and treatment of self-harm there have been few systematic reviews of the topic. AIMS: The main aim of this article is to review randomised controlled trials (RCTs) reporting efficacy of specific pharmacological, social or psychological therapeutic interventions (TIs) in reducing self-harm repetition in adolescents presenting with self-harm. METHOD: Data sources were identified by searching Medline, PsychINFO, EMBASE, and PubMed from the first available year to December 2010. RCTs comparing specific TIs versus treatment as usual or placebo in adolescents presenting with self-harm were included. RESULTS: Fourteen RCTs reported efficacy of psychological and social TIs in adolescents presenting with self-harm. No independently replicated RCTs have been identified reporting efficacy of TIs in self-harm reduction. Developmental Group Psychotherapy versus treatment as usual was associated with a reduction in repeated self-harm, however, this was not replicated in subsequent studies. Multisystemic Therapy (MST) versus psychiatric hospitalisation was associated with a reduction of suicidal attempts in a sample of adolescents with a range of psychiatric emergencies. However, analyses focusing only on the smaller subgroup of adolescents presenting with deliberate self-harm at the initial psychiatric emergency, did not indicate significant benefits of MST versus hospitalisation. CONCLUSIONS: Further research is urgently needed to develop TIs for treating self-harm in adolescents. MST has shown promise but needs to be evaluated in a sample of adolescents with self-harm; dialectic behavioural therapy and cognitive behavioural therapy for self-harm require RCTs to evaluate efficacy and effectiveness.

Cognitive vulnerability to depression in young people in secure accommodation: the influence of ethnicity and current suicidal ideation.

Young people in secure accommodation are at high risk of depression and self-harm. This study investigates the relationship between depressive symptoms, negative self-schemas and the cognitive vulnerability to depression in 38 young people in secure accommodation. The impact of a) current suicidal ideation and b) a previous history of self-harm behaviour on latent negative self-schemas was examined using a mood induction task. The low mood condition indicated these young people had a latent cognitive vulnerability to depression. However, this vulnerability was exacerbated in the context of current suicidal ideation but not by a history of self-harm behaviours. An unexpected finding was the negative self-schemas of young people from ethnic minority backgrounds were particularly susceptible to the mood induction. The findings are discussed both in terms of the cognitive vulnerabilities of adolescents detained in secure accommodation and the role of participant characteristics on the validity of mood induction studies in adolescence.

Cognitive-behavioral therapy for PTSD in children and adolescents: a preliminary randomized controlled trial.

OBJECTIVE: To evaluate the efficacy of individual trauma-focused cognitive-behavioral therapy (CBT) for treating posttraumatic stress disorder (PTSD) in children and young people. METHOD: Following a 4-week symptom-monitoring baseline period, 24 children and young people (8-18 years old) who met full DSM-IV PTSD diagnostic criteria after experiencing single-incident traumatic events (motor vehicle accidents, interpersonal violence, or witnessing violence) were randomly allocated to a 10-week course of individual CBT or to placement on a waitlist (WL) for 10 weeks. RESULTS: Compared to the WL group, participants who received CBT showed significantly greater improvement in symptoms of PTSD, depression, and anxiety, with significantly better functioning. After CBT, 92% of participants no longer met criteria for PTSD; after WL, 42% of participants no longer met criteria. CBT gains were maintained at 6-month follow-up. Effects of CBT were partially mediated by changes in maladaptive cognitions, as predicted by cognitive models of PTSD. CONCLUSIONS: Individual trauma-focused CBT is an effective treatment for PTSD in children and young people.

Conduct problems in adolescence: three domains of inhibition and effect of gender.

Behavioral and neuropsychological evidence has often shown that children with conduct disorder drawn from clinical populations show problems with impulsivity and are impaired in motor tasks of inhibitory control. We explored the relation between conduct problems and inhibitory deficits in a community sample. Three domains of inhibition were explored in 54 adolescents with conduct problems compared to 53 age, IQ, sex, school, and ethnicity matched controls in 2 geographical areas. Motor response inhibition was assessed using the Stop task, verbal inhibition using the Hayling Sentence Completion test, and cognitive interference inhibition using the Stroop task. Adolescents with conduct problems showed deficits in executive and inhibitory processes of the motor response inhibition task, but were unimpaired in cognitive or verbal inhibitory control. No sex differences were observed and impairments were independent of IQ or geographical location. Findings suggest that motor deficits, rather than higher cognitive forms of inhibitory control, are a specific deficit in children with conduct problems, that girls are as affected as boys, and that motor impulsiveness is a dimensional trait associated with conduct problems, as it is also observed in the community.

Social climate within an adolescent medium-secure facility.

The objectives of the study were to investigate the social climate of two different types of units (open vs. secure) contained within the same South London adolescent medium-secure facility. Two hypotheses were generated: (a) adolescents would rate the social climate of the whole facility in a more negative direction than staff and (b) adolescents and staff would rate the social climate of the open units in a more positive direction than the social climate of the secure units. 43 adolescents and 49 staff members from the open units and the secure units were recruited and completed the Correctional Institutions Environment Scale (CIES), a measure of social climate. Overall, adolescents tended to rate the facility in a more negative direction. All participants rated the open units in a more positive direction than secure units. However, on selected subscales there were differences. The findings of this study suggest that adolescents and staff may perceive their shared social climate differently. This may have implications for those attempting to develop positive social climates within secure services.