Therapeutic Interventions for Suicide Attempts and Self-Harm in Adolescents: Systematic Review and Meta-Analysis

doi:10.1016/j.jaac.2014.10.009

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 54, Issue 2, February 2015, Pages 97-107.e2

https://doi.org/10.1016/j.jaac.2014.10.009 Get rights and content

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.

Section snippets

Method

For clarity, we state whether the results of the studies reviewed in this article apply to adolescents with self-harm, suicide attempts, or NSSI where these distinctions are clear. When we refer to “self-harm,” we are referring to the broad definition used in the United Kingdom and Europe that includes NSSI, suicide attempts, and self-harm with undetermined intent. Self-harm is the primary outcome measure in this meta-analysis.

Included Studies

The original search resulted in the retrieval of 389 articles (Figure 1), and 23 of these were RCTs of TIs in children and adolescents with the presenting problem of self-harm; there were also 5 further RCTs in progress.32, 33, 34, 35, 36 Nineteen of the studies met the inclusion criteria, including 1 study accepted for publication in July 2014.³⁷ Selected characteristics of these studies are presented in Table 1.37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55 Of the

Discussion

The results of the present study support the value of TIs in the reduction of self-harm as a global category (including any self-harm), and show that when the effects of TIs are examined separately for suicide attempts and NSSI, effects are weaker, with the strongest effect for NSSI and a weaker effect for suicide attempts. Although the results on self-harm as a global category are encouraging, particularly given data from 3 major studies indicating that NSSI is a strong predictor of future

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Les comportements auto-dommageables sans intention suicidaire (CADSIS) et les conduites suicidaires (CS), incluant le suicide accompli, sont des problèmes de santé publique majeurs chez les adolescents et les jeunes adultes. Ils sont constatés de manière ubiquitaire, aussi bien dans des populations cliniques que communautaires. Bien que ces deux comportements coexistent fréquemment, les distinguer clairement reste complexe. En effet, les différences entre CADSIS et CS ont été davantage investiguées que leurs liens sous-jacents, tout comme les facteurs contribuant à la transition entre CADSIS et CS. Cette revue de littérature narrative vise à rendre compte de l’état actuel des connaissances concernant les articulations entre CADSIS et CS, à la lumière du modèle intégré de Hamza et al. qui propose des hypothèses de liens entre ces comportements. En addition à cet article, notre revue se base sur des articles postérieurs ou non-cités par Hamza et al., décrivant des études transversales, longitudinales et des méta-analyses ciblant les liens et/ou les différences entre CADSIS et CS chez des adolescents et jeunes adultes âgés de 12 à 25 ans. Au vu des différents résultats, le modèle d’Hamza et al. est intéressant car il intègre des facteurs de risques communs et une forme d’habituation pour expliquer la progression fréquente des CADSIS vers des CS. Cependant, si cette trajectoire est fréquente, elle n’est pas la règle. Il s’agirait dès lors de tester les liens et variables qui caractérisent potentiellement la relation CADSIS-CS selon leur modèle.
Non-suicidal self-injuries (NSSI) and suicidal conduct (SC), including completed suicide, are major public health problems among adolescents and young adults. They are seen ubiquitously in both clinical and community populations. Although these two behaviors frequently co-exist, distinguishing them clearly remains complex. Indeed, the differences between NSSI and CS have been investigated more than their underlying relationships, as have the factors contributing to the transition between NSSI and CS. This narrative literature review aims to report on the current state of knowledge regarding the articulations between NSSI and CS, in light of Hamza et al.’s integrated model that proposes hypotheses of links between these behaviors. In addition to this article, our review is based on later articles or articles not cited by Hamza et al., describing cross-sectional, longitudinal, and meta-analyses targeting the links and/or differences between CADSIS and CS in adolescents and young adults aged 12 to 25 years. Based on the various findings, Hamza et al.’s model seems interesting because it incorporates common risk factors and a form of habituation to explain the frequent progression from CADSIS to CS. However, if this trajectory is frequent, it is not the rule. It would therefore be necessary to test all the links and variables that potentially mediate the CADSIS-CS relationship according to their model.
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: Clinical guidance is available at the end of this article.

: The authors’ time was paid for by the following institutions: King’s College London (D.O., D.S., P.M.), South London and Maudsley NHS Foundation Trust (T.T.), and University of California, Los Angeles (J.R.A.). Drs. Stahl and Moran were also supported in part by the National Institute for Health Research (NIHR) Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and King’s College London. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health.

: Dr. Stahl served as the statistical expert for this research.

: The authors thank Emily Simonoff, PhD, Bruce Clark, PhD, and Jo Fletcher, of King’s College London and South London and Maudsley NHS Foundation Trust, for facilitating this work.

: Disclosure: Dr. Ougrin has received royalties for the book entitled Self-Harm in Young People: A Therapeutic Assessment Manual from Hodder Arnold Publishing. Dr. Moran has received research grant funding from Guys and St. Thomas' Charity for developing and testing decisional support for young people who self-harm. Dr. Asarnow has received research grant funding from the National Institute of Mental Health and American Foundation of Suicide Prevention. She has also consulted on quality improvement and interventions for depression and suicidal/self-harm behavior. Drs. Tranan and Stahl report no biomedical financial interests or potential conflicts of interest.

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ReviewTherapeutic Interventions for Suicide Attempts and Self-Harm in Adolescents: Systematic Review and Meta-Analysis

Objective

Method

Results

Conclusion

Section snippets

Method

Included Studies

Discussion

Lancet

J Am Acad Child and Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Children Youth Services Rev

Control Clin Trials

Control Clin Trials

J Am Acad Child Adolesc Psychiatry

J Adolesc

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolescent Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

National Action Alliance for Suicide Prevention: Research Prioritization Task Force A prioritized research agenda for suicide prevention: an action plan to save lives

Suicides—United States, 2005-2009

MMWR Surveill Summ

Deliberate self-harm in Oxford, 1990-2000: a time of change in patient characteristics

Psychol Med

Deliberate self-harm in young people: characteristics and subsequent mortality in a 20-year cohort of patients presenting to hospital

J Clin Psychiatry

Adolescent suicide and suicidal behavior

J Child Psychol Psychiatry Allied Discipl

Clinical and psychosocial predictors of suicide attempts and nonsuicidal self-injury in the Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT)

Am J Psychiatry

A longitudinal study of nonsuicidal self-injury in offspring at high risk for mood disorder

J Clin Psychiatry

The prevalence of suicidal phenomena in adolescents: a systematic review of population-based studies

Suicide Life-Threat Behav

Practitioner review: self-harm in adolescents

J Child Psychol Psychiatry

Practitioner review: the aftercare of adolescents with deliberate self-harm

J Child Psychol Psychiatry Allied Discipl

Nonsuicidal self-injury: a review of current research for family medicine and primary care physicians

J Am Board Family Med

Self-Injury

Annu Rev Clin Psychology

Social and interpersonal factors relating to adolescent suicidality: a review of the literature

Arch Suicide Res

Pediatric suicide-related presentations: a systematic review of mental health care in the emergency department

Ann Emerg Med

Preventing suicide in young people: systematic review

Aust N Z J Psychiatry

Review
Therapeutic Interventions for Suicide Attempts and Self-Harm in Adolescents: Systematic Review and Meta-Analysis