Efficacy of Dialectical Behavior Therapy for Adolescents at High Risk for Suicide: A Randomized Clinical Trial

Improving Care Linkage for Racial-Ethnic Minority Youths Receiving Emergency Department Treatment for Suicidality: SAFETY-A

OBJECTIVE

This study evaluated the effects of Safe Alternatives for Teens and Youths-Acute (SAFETY-A), a brief strengths-based, cognitive-behavioral family intervention, on racial-ethnic minority youths receiving emergency department (ED) treatment for suicidal episodes.

METHODS

Participants were 105 racial-ethnic minority youths enrolled in a randomized controlled trial evaluating SAFETY-A versus enhanced usual care for youths receiving ED treatment for suicidal episodes. Analyses examined group effects on care linkage after discharge and adequate treatment dose. A sample of 55 White youths was included for comparison.

RESULTS

Racial-ethnic minority youths who received SAFETY-A had higher treatment linkage rates than those receiving usual care. Adequate treatment dose rates did not differ by group.

CONCLUSIONS

Racial-ethnic minority youths receiving SAFETY-A had higher treatment linkage rates after discharge than those receiving usual care. SAFETY-A is a promising approach to enhance care continuity and mental health equity for racial-ethnic minority youths at risk for suicide.

Acute mental health service use in adolescents with suicidal thoughts and behaviours: Impact on outpatient care

INTRODUCTION

Youth with suicidal thoughts and behaviours often present to acute emergency care settings for assessment. Timely outpatient follow up may reduce return acute care visits. The primary aim of our study was to describe clinical and contextual differences between youth who do and do not use acute care once connected to outpatient services.

METHODS

A 24-month retrospective chart review of suicidal youth aged 13-16 (n = 45) presenting for outpatient mental health treatment. Youth who used acute services during the study period (ASU) or did not (non-ASU) were compared on demographic, risk profile, and mental health service use.

RESULTS

The mean age of participants was 14.6 years (73% female). Suicide risk profile at baseline did not differ between groups, but was significantly higher in ASU youth at 24 months. There were more youth in service at the end of the study period in the ASU group compared to the non-ASU group (11% vs 55%).

CONCLUSION

Youth who do continue to access acute services may be at higher risk of suicidality even after outpatient treatment. Although it is unclear whether this is linked to outpatient engagement, it raises further questions about this population and how they respond to community based mental healthcare.

Acceptability and Feasibility of "Village," a Digital Communication App for Young People Experiencing Low Mood, Thoughts of Self-harm, and Suicidal Ideation to Obtain Support From Family and Friends: Mixed Methods Pilot Open Trial

BACKGROUND

Young people experiencing low mood, thoughts related to self-harm, and suicidal ideation often struggle to communicate their emotions and receive timely support from family and friends. Technologically delivered support interventions may be useful in addressing this need.

OBJECTIVE

This paper aimed to evaluate the acceptability and feasibility of "Village," a communication app co-designed with young people and their family and friends from New Zealand.

METHODS

A mixed methods pilot open trial design was adopted. Participants were primarily recruited via social media advertisements and clinicians in specialist mental health services over an 8-month period. The primary outcomes were acceptability of the app (via thematically analyzed qualitative feedback and retention rates) and feasibility of conducting a larger randomized controlled trial gauged via effectiveness of recruitment methods, completion of chosen outcome measures, and occurrence of unanticipated operational issues. Secondary outcomes were app usability, safety, and changes in symptoms of depression (via the Patient Health Questionnaire-9 modified for adolescents), suicidal ideation (on the Suicidal Ideation Questionnaire), and functioning (using the World Health Organization Disability Assessment Schedule 2.0 or Child and Youth version).

RESULTS

A total of 26 young people ("users") were enrolled in the trial, of which 21 recruited friends and family members ("buddies") and completed quantitative outcome measures at baseline, 4 weeks, and 3 months. Furthermore, 13 users and 12 buddies also provided qualitative feedback about the app, identifying the key themes of appeal of app features and layout, usefulness of its content, and technological challenges (primarily with onboarding and notifications). Users gave Village a mean rating of 3.8 (range 2.7-4.6) out of 5 on a 5-point scale for app quality and an overall star rating of 3.4 out of 5 for subjective quality. Within this limited sample, users reported a clinically significant reduction in depressive symptoms (P=.007), but nonsignificant changes in suicidal ideation and functioning. The embedded risk detection software was activated on 3 occasions, and no additional support was required for users.

CONCLUSIONS

During this open trial, Village was found to be acceptable, usable, and safe. The feasibility of a larger randomized controlled trial was also confirmed after some modifications to the recruitment strategy and app.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Network Registry ACTRN12620000241932p; https://tinyurl.com/ya6t4fx2.

A Relational Agent Intervention for Adolescents Seeking Mental Health Treatment: Protocol for a Randomized Controlled Trial

BACKGROUND

Unmet pediatric mental health (MH) needs are growing as rates of pediatric depression and anxiety dramatically increase. Access to care is limited by multiple factors, including a shortage of clinicians trained in developmentally specific, evidence-based services. Novel approaches to MH care delivery, including technology-leveraged and readily accessible options, need to be evaluated in service of expanding evidence-based services to youths and their families. Preliminary evidence supports the use of Woebot, a relational agent that digitally delivers guided cognitive behavioral therapy (CBT) through a mobile app, for adults with MH concerns. However, no studies have evaluated the feasibility and acceptability of such app-delivered relational agents specifically for adolescents with depression and/or anxiety within an outpatient MH clinic, nor compared them to other MH support services.

OBJECTIVE

This paper describes the protocol for a randomized controlled trial evaluating the feasibility and acceptability of an investigational device, Woebot for Adolescents (W-GenZD), within an outpatient MH clinic for youths presenting with depression and/or anxiety. The study's secondary aim will compare the clinical outcomes of self-reported depressive symptoms with W-GenZD and a telehealth-delivered CBT-based skills group (CBT-group). Tertiary aims will evaluate additional clinical outcomes and therapeutic alliance between adolescents in W-GenZD and the CBT-group.

METHODS

Participants include youths aged 13-17 years with depression and/or anxiety seeking care from an outpatient MH clinic at a children's hospital. Eligible youths will have no recent safety concerns or complex comorbid clinical diagnoses; have no concurrent individual therapy; and, if on medications, are on stable doses, based on clinical screening and as well as study-specific criteria.

RESULTS

Recruitment began in May 2022. As of December 8, 2022, we have randomized 133 participants.

CONCLUSIONS

Establishing the feasibility and acceptability of W-GenZD within an outpatient MH clinical setting will add to the field's current understanding of the utility and implementation considerations of this MH care service modality. The study will also evaluate the noninferiority of W-GenZD against the CBT-group. Findings may also have implications for patients, families, and providers looking for additional MH support options for adolescents seeking help for their depression and/or anxiety. Such options expand the menu of supports for youths with lower-intensity needs as well as possibly reduce waitlists and optimize clinician deployment toward more severe cases.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05372913; https://clinicaltrials.gov/ct2/show/NCT05372913.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44940.

Risk of suicide attempt repetition after an index attempt: A systematic review and meta-analysis

OBJECTIVES

To estimate the risk of suicide attempt repetition among individuals with an index attempt. It also aims to study the role of risk factors and prevention programme in repetition.

METHODS

This systematic review and meta-analysis was conducted in keeping with the PRISMA 2020 guidelines. Studies on attempt repetition (both cohort studies and intervention studies) were searched from inception to 2022.

RESULTS

A total of 110 studies comprising 248,829 attempters was reviewed. The overall repetition rate was 0.20 (0.17, 0.22). Repetition risk linearly increased over time. A higher risk of attempt repetition was associated with female sex and index attempts in which self-cutting methods were used. Moreover, a mental disorder diagnosis was associated with an increasing repetition risk (OR = 2.02, p < .01). The delivery of a preventive programme reduced the repetition risk, OR = 0.76, p < .05; however, this effect was significant for psychotherapy interventions, OR = 0.38, p < .01.

CONCLUSION

One in five suicide attempters will engage in a new suicide attempt. An elevated repetition risk is associated with being female, more severe index methods and psychiatric disorder diagnosis. Preventive programmes, particularly psychotherapy, may contribute to reducing repetition risk and eventually save lives.

Unsound sleep, wound-up mind: a longitudinal examination of acute suicidal affective disturbance features among an eating disorder sample

BACKGROUND

Suicide is one of the most commonly reported causes of death in individuals with eating disorders. However, the mechanisms underlying the suicide and disordered eating link are largely unknown, and current assessments are still unable to accurately predict future suicidal thoughts and behaviors. The purpose of this study is to test the utility of two promising proximal risk factors, sleep quality and agitation, in predicting suicidal ideation in a sample of individuals with elevated suicidal thoughts and behaviors, namely those with eating disorders.

METHODS

Women (N = 97) receiving treatment at an eating disorder treatment center completed weekly questionnaires assessing suicidal ideation, agitation, and sleep. General linear mixed models examined whether agitation and/or sleep quality were concurrently or prospectively associated with suicidal ideation across 12 weeks of treatment.

RESULTS

There was a significant interaction between within-person agitation and sleep quality on suicidal ideation [B(s.e.) = -0.02(0.01), p < 0.05], such that on weeks when an individual experienced both higher than their average agitation and lower than their average sleep quality, they also experienced their highest levels of suicidal ideation. However, neither agitation nor sleep quality prospectively predicted suicidal ideation.

CONCLUSIONS

This study was the first to examine dynamic associations between interpersonal constructs and suicidal ideation in individuals with eating disorders. Results suggest that ongoing assessment for overarousal symptoms, such as agitation and poor sleep quality, in individuals with eating disorders may be warranted in order to manage suicidal ideation among this vulnerable population.

Experiences of dialectical behaviour therapy for adolescents: A qualitative analysis

OBJECTIVES

To explore how former patients in dialectical behaviour therapy for adolescents (DBT-A) experience their treatment, and specifically if there were aspects of the treatment that they retrospectively identify as particularly meaningful, helpful or unhelpful.

DESIGN

From a larger sample of 75 former DBT-A patients 19 were selected for a qualitative semi-structured interview study.

METHODS

Young adults (N = 19; 18 females, one male), who as adolescents had been enrolled in DBT-A due to self-harming behaviours and features of borderline personality disorder, were interviewed up to 8 years (median 6.0; min 1.3; max 8.2) after end of treatment, at mean age 23 years (SD 2.5). Reflexive thematic analysis was implemented.

RESULTS

Six key themes were revealed; (1) The need to be seen, listened to and believed in, (2) the importance of teamwork between patient and therapist, (3) the value of group and structure, (4) therapy as lifesaving and life-changing, (5) the risks of feeling misplaced and (6) the risks of abrupt endings.

CONCLUSION

A trusting relationship with the therapist promoted commitment and motivation for treatment. This relationship was facilitated by the therapist showing explicit care and belief in the patient's own competence in changing their destructive behaviours. Meeting peers in group skill training offered a salient form of validation and was reported to be of particular value. The format of meeting peers and the importance of the dialectical therapeutic stance need to be studied further. Not all youth experienced DBT-A as suitable and the need for sufficient treatment dose was emphasized.

Daily reciprocal relations between emotion dysregulation and non-suicidal self-injury among individuals with a history of sexual assault: The influence of posttraumatic stress symptoms

INTRODUCTION

Non-suicidal self-injury (NSSI) is a serious public health concern that can be understood within an emotion dysregulation framework. The current study adds to the literature by utilizing a micro-longitudinal design and novel statistical modeling to test reciprocal associations between emotion dysregulation and NSSI, as well as the potential moderating effect of posttraumatic stress symptoms (PTSS).

METHODS

Participants were 81 individuals with a history of sexual assault and NSSI (M_age  = 33.80; 67.9% women; 80.2% white) recruited from the community who self-reported on symptoms of emotion dysregulation and NSSI thoughts/behaviors once daily for 7 days. Average compliance rate was 72.8% (SD = 31.3%) and 34 participants (42.0%) endorsed NSSI thoughts/behaviors over the course of the study.

RESULTS

Findings revealed a significant positive effect of NSSI thoughts/behaviors on subsequent abilities to regulate negative emotions. Furthermore, while results did not detect a moderating influence of baseline PTSS on the relation between emotion dysregulation and NSSI thoughts/behaviors over time, individuals with higher baseline PTSS were found to experience heightened levels of NSSI thoughts/behaviors and emotion dysregulation on average.

CONCLUSION

Information from this study may be useful for future research and intervention development focused on the intersection of NSSI, PTSS, and emotion dysregulation.

Key features of adolescent inpatient units and development of a checklist to improve consistency in reporting of settings

WHAT IS KNOWN ON THE SUBJECT?: Little is known about adolescent inpatient units, key features which define them, and how these essential services operate and deliver care. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Adolescent inpatient unit studies are limited in their descriptions of settings in terms of how they operate and key features. The proposed preliminary checklist is a practical tool to assist clinicians, policy makers, and researchers when reporting to ensure comprehensive descriptions of adolescent inpatient settings. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This could be used to inform service design processes for inpatient and other mental health service models which is of critical importance in the context of reforms and implementation of these in Australia currently. Greater attention to operational models, services, and philosophies of practice will improve reporting and allow for the advancement of knowledge, comparison of study results, and a clearer direction for mental health nursing clinicians and researchers. ABSTRACT: Introduction Adolescent inpatient units care for vulnerable population groups; however, little is known about how these essential services operate and deliver care. Aims To examine the descriptions of adolescent mental health inpatient units in Australian and international research publications and to identify key features which were used to define them. A secondary aim was to develop a checklist to improve consistency when reporting on the operations and services delivered within adolescent mental health inpatient units (both public and private). Methods Five electronic databases (CINAHL, MEDLINE, ERIC, EMBASE, and PsycINFO) were systematically searched. We included studies that provided descriptions of operations and services within adolescent inpatient units where participants had a mean age between 12 and 25. Narrative synthesis was used to explore the similarities and differences between descriptions of settings. Results Twenty-eight studies were identified, which varied in their descriptions of adolescent inpatient units, providing inconsistent information to inform best practice. Discussion Studies lack consistency and comprehensive detail when describing the operational models within inpatient units, making interpretation challenging. Consequently, a preliminary checklist is proposed to improve reporting of adolescent inpatient units.

Prädiktion von Behandlungsabbrüchen bei Adoleszenten mit Borderline-Persönlichkeitsstörung

Zusammenfassung: Theoretischer Hintergrund: Die Borderline-Persönlichkeitsstöurng (BPS) kann bereits in der Adoleszenz zuverlässig diagnostiziert und wirksam behandelt werden. Eine möglichst frühe Behandlung der BPS durch störungsspezifische Therapien (z. B. Dialektisch-Behaviorale Therapie), erscheint ist sinnvoll, weil hierdurch selbstschädigende Verhaltensweisen und chronische Verläufe mit häufigen suizidalen Krisen verhindert und die langfristige psychosoziale Entwicklung verbessert werden kann. Mehrere Therapiestudien zur Wirksamkeit der Behandlung in der Adoleszenz zeigten sehr hohe Abbruchraten (bis zu 75 %), bisher sind allerdings nur wenig konsistente Ergebnisse zur Prädiktion von Therapieabbrüchen vorhanden. Fragestellung: Das Hauptziel der vorliegenden Studie war daher im Rahmen einer Beobachtungsstudie a) die Abbruchrate in der Realversorgung und b) die möglichen Prädiktoren (klinische und demographische Variablen) des Abbruchs einer stationären Behandlung mit DBT für Adoleszente an N = 172 Patient_innen im Alter von 15 – 18 Jahren zu untersuchen. Methode: In einer logistischen Regression wurden 18 Prädiktoren (u. a. Alter, Anzahl der Diagnosen, Schwere der Symptomatik) in SPSS untersucht, die im Rahmen einer drei monatigen stationären Behandlung in der Routineversorgung erhoben wurden. Ergebnisse: Lediglich ein jüngeres Alter der Patient_innen war statistisch signifikant mit einem erhöhten Risiko für einen Therapieabbruch assoziiert. Keine statistisch bedeutsamen Zusammenhänge mit einem Therapieabbruch fanden sich hingegen für die untersuchten psychiatrischen Komorbiditäten (bspw. für das Vorliegen einer Essstörung), für die Schwere der BPS-spezifischen Psychopathologie und für BPS-typische problematische Verhaltensweisen (bspw. selbstschädigendes Verhalten oder Hochrisikoverhalten). Diskussion und Schlussfolgerung: Unsere Untersuchung ergibt keinen Anhalt dafür, dass bei stark ausgeprägter Symptombelastung eine erhöhte Gefahr für einen Abbruch einer Behandlung mit DBT besteht. Sollte das Ergebnis einer erhöhten Abbruchrate bei jüngeren Jugendlichen in weiteren Studien repliziert werden, wären systematische Untersuchungen zu Variablen notwendig, die bei jüngeren Jugendlichen eine besondere Bedeutung besitzen und mit einem Therapieabbruch in Zusammenhang stehen könnten (bspw. die Beziehung zu wichtigen Bezugspersonen). Hieraus ließen sich ggf. gezielte Therapiemodifikationen ableiten, die Therapieabbrüchen entgegenwirken.

Brief internet-delivered skills training based on DBT for adults with borderline personality disorder - a feasibility study

OBJECTIVE

Borderline personality disorder (BPD) is characterized by instability in emotions, relationships, and behaviors, such as self-injury and suicidal behavior. Dialectical Behavioral Therapy (DBT) is an established intervention for BPD, but there are long waiting times for treatment. This study aimed to explore if a brief internet-delivered DBT skills training program with minimal therapist support is acceptable, that it can be administered, useful, and does not do harm for patients with BPD.

METHODS

Acceptability was measured through data on recruitment and attrition, utilization of the intervention, reported impulses to drop out, and through ratings on self-injury and suicidality. Participants were interviewed about their experiences of the intervention; analyzed with content analysis.

RESULTS

Twenty patients on the waiting list for treatment at a DBT-clinic were invited and nine female patients (age 19-37 years) volunteered. The participants completed a large part of the intervention, which did not appear harmful since ratings of suicidal and self-harming behavior were similar before and after the intervention. In the interviews, participants stated that they had gained new knowledge and skills to manage situations, e.g. to stop and think before acting. Some even reported decreased levels of self-injury. The time spent on patient contact was short, and some patients reported difficulties to practice on their own and requested more support.

CONCLUSIONS

The intervention seems to be acceptable. Future studies should investigate in what ways some BPD patients are more susceptible to internet-delivered skills training than others, and if this intervention could be delivered within a stepped-care model.

Depression and Suicidal Behavior in Adolescents

Depression commonly onsets in adolescence, affecting approximately 1 in 4 female adolescents and 1 in 10 males in the United States. Adolescent depression is a significant risk factor for suicide, the cause of over a third of all American adolescent deaths. Adolescent depression is introduced alongside its developmental and gendered considerations with a focus on important risk factors of adolescent depression, including nonsuicidal self-injury, adverse childhood experiences, and substance abuse. Protective factors and contemporary special topics of the COVID-19 pandemic and social media use are reviewed. Therapeutic options and clinical barriers are highlighted before a summary of findings and conclusion.

Sleep influences daily suicidal ideation through affective reactivity to interpersonal events among high-risk adolescents and young adults

BACKGROUND

Identifying proximal risk factors for suicidal ideation that are modifiable and relevant for adolescents and young adults is critical for suicide prevention. This study used an intensive monitoring approach to examine whether objectively- and subjectively- measured sleep characteristics predict next-day suicidal ideation occurrence and intensity through affective reactivity to interpersonal events in young people at high risk for suicide.

METHODS

Participants included 59 (13-23 years; 76% White; 75% female) adolescents and young adults undergoing intensive outpatient program treatment for depression and suicidality. Participants completed daily ratings of suicidal ideation, sleep quality, and affective reactivity to positive and negative interpersonal events for up to 3 months (M = 56 days, SD = 24.13). Actigraphy captured behavioral sleep duration and timing. Multilevel modeling was used to evaluate within-person fluctuations in sleep and affective reactivity as predictors of suicidal ideation, and multilevel mediation tested the indirect effects of sleep on suicidal ideation via affective reactivity to interpersonal events.

RESULTS

Results indicate significant indirect effects of objectively measured sleep duration and subjective sleep quality on next-day suicidal ideation via affective reactivity to negative and positive interpersonal events, respectively. Shorter-than-usual sleep predicted the presence and intensity of next-day suicidal ideation via heightened affective reactivity to negative interpersonal events. Worse sleep quality than usual predicted next-day suicidal ideation via reduced affective reactivity to positive interpersonal events.

CONCLUSIONS

Affectivity reactivity is a proximal mechanism through which sleep indices may influence risk for suicidal thinking on a daily basis. Findings highlight the utility of targeting sleep and emotion regulation in suicide prevention among adolescents and young adults at high-risk for suicide.

The relationship between anorexia nervosa and bulimia nervosa, attention deficit/hyperactivity disorder, and suicidality in college students

OBJECTIVE

This study aimed to assess the association between anorexia nervosa (AN), bulimia nervosa (BN), attention deficit/hyperactivity disorder (ADHD), and associated impairments (e.g., suicidality).

METHODS

A secondary data analysis of the American College Health Association-National College Health Assessment IIc (Fall 2015-Spring 2019) was conducted to assess the prevalence of comorbid anorexia or bulimia + ADHD, symptoms, and impairments among college student (N = 342,432; M_age  = 20.39, SD = 1.88). Logistic regressions were used to compare eating disorder symptomology, treatment utilisation, and suicidality among college students.

RESULTS

Compared to college students without ADHD, college students with ADHD were 18.30× more likely to be diagnosed with anorexia or bulimia and reported greater use of weight loss techniques (p's < 0.001). College students with comorbid anorexia or bulimia + ADHD reported higher rates of dieting to lose weight (aOR = 1.27, 95% CI: 1.12, 1.43, p < 0.001) and treatment utilisation (aOR = 1.30, 95% CI: 1.06, 1.50, p < 0.001) compared to college students with AN or BN only. The highest level of suicidality was reported in college students with the comorbid AN or BN + ADHD.

CONCLUSION

Elevated eating disorder symptoms and comorbidity is found among college students with ADHD. Increased screening and prevention for anorexia and bulimia is needed among young adults with ADHD to enhance care for those with these eating disorders.

Developing a Mobile App for Young Adults with Nonsuicidal Self-Injury: A Prototype Feedback Study

Nonsuicidal self-injury (NSSI) affects approximately 13% of young adults. Though evidence-based treatments for NSSI exist, most young adults do not receive treatment. Digital interventions can provide access to evidence-based treatments for NSSI at scale. Further, preliminary research suggests the acceptability, feasibility, and potential efficacy of digital interventions for NSSI. To date, however, there are few publicly available digital interventions developed specifically for young adults who engage in NSSI. The aim of this study was to solicit young adults' impressions of early app prototypes to identify ways of improving interactive features and content needs. Building on a prior interview study which explored young adults' self-management of NSSI and their use of technology in self-management, this study involved three waves of iterative app prototype feedback sessions with 10 young adults with past month NSSI. In general, participants responded favorably and provided feedback to augment the app to better meet their needs, including adding new features and functionality as well as increasing opportunities for personalization. We discuss two key design challenges related to the roles of tracking and temporality in digital interventions for NSSI, and then frame design considerations related to these challenges within the lived informatics model.

The Synergistic Effects of Neuroticism and Extraversion on Suicidal Ideation, Single Attempts, and Multiple Attempts in an Inpatient Sample

The current study sought to investigate the differential risk/protective factors of neuroticism and extraversion among individuals with only suicide ideation, those with a single suicide attempt, and those with multiple attempts. We hypothesized that extraversion would moderate the relation between neuroticism and suicide attempts (single and multiple) but not ideation. Patients in a private facility (N = 3343) completed measures assessing suicide history and general personality traits. Four moderation analyses were conducted with extraversion moderating the relationship between neuroticism and suicide ideation, single attempt (compared to zero attempts), and multiple attempts (compared to zero attempts and to single attempts). Extraversion moderated neuroticism only when comparing individuals with multiple suicide attempts to those with no attempts. Individuals who were low in both neuroticism and extraversion had higher levels of attempts than individuals with low neuroticism and high extraversion, highlighting the importance of considering biological predispositions as risk factors for suicide.

Internet based intervention (Emotion Regulation Individual Therapy for Adolescents) as add-on to treatment as usual versus treatment as usual for non-suicidal self-injury in adolescent outpatients: The TEENS randomised feasibility trial

Background

Non-suicidal self-injury (NSSI) is common in adolescents receiving psychiatric treatment and is a significant risk factor for suicidal behavior. There are few randomised clinical trials assessing interventions for NSSI in youth, and knowledge about internet-delivered interventions is limited.

Objective

We assessed the feasibility of Internet based Emotion Regulation Individual Therapy for Adolescents (ERITA) in psychiatric outpatients aged 13-17 years who engaged in NSSI.

Method

A randomised clinical feasibility trial with a parallel group design. Non-suicidal self-injury engaging patients were recruited from Child and Adolescent Mental Health Outpatient Services in the Capital Region of Denmark from May to October 2020. ERITA was provided as add-on to treatment as usual (TAU). ERITA is a therapist-guided, internet-based program of emotion regulation and skills training involving a parent. The control intervention was TAU. Feasibility outcomes were the proportion who completed follow-up interviews at end of intervention; proportion of eligible patients who participated in the trial; proportion of participants completing ERITA. We further investigated relevant exploratory outcomes, including adverse risk-related events.

Results

We included 30 adolescent participants, 15 in each group (ERITA vs. Treatment as usual). 90% (95% CI, 72%-97%) of the participants completed post-treatment interviews; 54% (95% CI, 40%-67%) of the eligible participants were included and randomised; and 87% (95% CI, 58%-98%) of the participants completed at least six out of 11 ERITA modules. We identified no difference for the primary exploratory clinical outcome of NSSI between the two groups.

Conclusion

There are few randomised clinical trials assessing interventions for NSSI in youth, and knowledge about internet-delivered interventions is limited. Based on our results we conclude that a large-scale trial seems feasible and warranted.

Digital cognitive-behavioural therapy to reduce suicidal ideation and behaviours: a systematic review and meta-analysis of individual participant data

QUESTION

Digital interventions based on cognitive-behavioural therapy (iCBT) is associated with reductions in suicidal ideation. However, fine-grained analyses of effects and potential effect-moderating variables are missing. This study aimed to investigate the effectiveness of iCBT on suicidal ideation, effect moderators, effects on suicide attempts and predictors of adherence.

STUDY SELECTION AND ANALYSIS

We systematically searched CENTRAL, PsycINFO, Embase and PubMed for randomised controlled trials that investigated iCBT for suicidal ideation or behaviours. Participants reporting baseline suicidal ideation were eligible. We conducted a one-stage individual participant data (IPD) meta-analysis. Suicidal ideation was the primary outcome, analysed as three indices: severity of suicidal ideation, reliable changes and treatment response.

FINDINGS

We included IPD from nine out of ten eligible trials (2037 participants). iCBT showed significant reductions of suicidal ideation compared with control conditions across all indices (severity: b=-0.247, 95% CI -0.322 to -0.173; reliable changes: b=0.633, 95% CI 0.408 to 0.859; treatment response: b=0.606, 95% CI 0.410 to 0.801). In iCBT, the rate of reliable improvement was 40.5% (controls: 27.3%); the deterioration rate was 2.8% (controls: 5.1%). No participant-level moderator effects were identified. The effects on treatment response were higher for trials with waitlist-controls compared with active controls. There were insufficient data on suicide attempts. Human support and female gender predicted treatment adherence. The main source of potential bias was missing outcome data.

CONCLUSIONS

The current evidence indicates that iCBT is effective in reducing suicidal ideation irrespective of age, gender and previous suicide attempts. Future studies should rigorously assess suicidal behaviour and drop-out reasons.

Dialectical behaviour therapy (DBT) for high-risk transgender and gender diverse (TGD) youth: A qualitative study of youth and mental health providers' perspectives on intervention relevance

OBJECTIVES

Despite the significant mental health challenges and unique treatment needs of transgender and gender diverse (TGD) youth, research on the acceptability of evidence-based treatments for these youth is limited. To address this gap, the current study explored the perceived relevance of dialectical behaviour therapy (DBT) for high-risk TGD youth.

METHODS

Qualitative data were collected from six focus group discussions with a purposive sample of 21 TGD youth aged 18-25 years old who endorsed a history of depression, suicidality or self-harm and individual interviews with 10 mental health treatment providers with prior DBT and TGD client experience. The data were analysed inductively using thematic content analysis.

RESULTS

The results highlighted the perceived relevance of DBT in targeting chronic and acute stressors, some of which are unique to TGD youth such as issues related to gender dysphoria, hormone-related treatment and gender identity. Possible areas for treatment modifications including the adaptation of body awareness exercises and physiological-related coping techniques for youth experiencing gender dysphoria, and the reinforcement of self-care skills, were identified. While interpersonal effectiveness skills were acknowledged as important, treatment providers highlighted a need to prioritize safety over the practice of these skills. This is because TGD youth often experience more hostile and prejudiced interpersonal experiences than their cisgender peers.

CONCLUSION

The study's findings shed light on previously unexplored perspectives of TGD youth and treatment providers on the perceived relevance of DBT and provide treatment providers and implementation researchers with some critical issues to consider when working with high-risk TGD youth.

Stepped care for suicide prevention in teens and young adults: Design and methods of a randomized controlled trial

BACKGROUND

Suicide is the second‑leading cause of death among adolescents and young adults in the United States, with rates rising over much of the last decade. The design, testing, and implementation of interventions to prevent suicide in this population is a public health priority. This manuscript outlines the design and methods for a research study that compares two interventions aimed at reducing suicide and suicide attempts in youth.

METHODS

We will enroll 300 youth aged 12-24 at high risk for suicide in this randomized controlled parallel group superiority trial. Participants will be randomly assigned to one of two study arms: (1) Zero Suicide Quality Improvement (ZSQI) implemented within the Kaiser Permanente Northwest (KPNW) health system, or (2) ZSQI plus a stepped care intervention for suicide prevention (SC-SP), where the services offered (including care management and dialectical behavior therapy [DBT]) increase based on risk level. Outcomes will be assessed at baseline, as well as 3-, 6-, and 12-months post randomization. The study was conceptualized and designed collaboratively by investigators at UCLA and KPNW.

RESULTS

To be reported in future manuscripts.

CONCLUSION

The main objective of the study is to determine whether the SC-SP intervention is superior to ZSQI with regard to lowering rates of fatal and nonfatal suicide attempts. Interventions that incorporate the latest research need to be designed and tested under controlled conditions to make progress toward the goal of achieving zero suicide. The results from this trial will directly inform those efforts.

TRIAL REGISTRATION

CLINICALTRIALS

gov, NCT03092271, https://clinicaltrials.gov/ct2/show/NCT03092271https://clinicaltrials.gov/ct2/show/NCT01379027.

Association between Sleep and Suicidal Ideation in Chinese Undergraduate Students

Suicide is an important global public health issue, which deserves more attention. This study aims to examine the relative independent relationship between suicide ideation and subjective sleep quality, sleep hygiene, and insomnia symptoms in undergraduate students in China. This population-based study included 2379 undergraduate students aged 18-26, randomly recruited from three public universities in Shanghai. The participants completed four questionnaires: the Pittsburgh Sleep Quality Index; Sleep Hygiene Practice Scale; Insomnia Severity Index; and the Symptom Checklist 90 (specifically the depression and anxiety dimensions and Q15-suicide ideation). The results of Spearman's correlation analysis indicate that poor sleep quality, short sleep duration, poor sleep hygiene, and insomnia symptoms were all associated with suicidal ideation in undergraduate students. However, according to the results of the hierarchical linear regression, no experience of sharing a bedroom at home, poor relationship with roommates, short sleep duration, sleep medicine use, and good daytime function were related to suicidal ideation, after controlling for the symptoms of depression and anxiety, which may be important in the identification of suicidal ideation. Sleep problems are highly discoverable and modifiable, and have a low sense of shame, therefore, sleep interventions for individuals with suicidal ideation and poor sleep quality may be an efficient and effective approach to suicide prevention.

Editorial: Suicide prevention in youth

Reducing deaths by suicide in youth is an urgent public health goal and effective treatment approaches remain limited. This editorial reviews new research published in this issue of Child and Adolescent Mental health that may inform youth suicide prevention efforts, including an open trial of a new, family-focused group intervention for youth with suicidal ideation and findings showing that life problems associated with presentation to the emergency department for self-harm vary by age and gender. The need for multi-component treatments that have the flexibility to target a range of life problems/risk factors and to include families in treatment is discussed, along with the need to find a way to make such interventions scalable. Finally, this editorial addresses this issue's debate by discussing the role of mindfulness in dialectical behavior therapy for suicidal youth and the need to carefully monitor and further examine the effectiveness and safety of mindfulness with this patient population.

Building Resilience and Attachment in Vulnerable Adolescents (BRAVA): a brief group intervention for adolescents with mild-to-moderate suicidal ideation and their caregivers

INTRODUCTION

Suicidal Ideation (SI) is common in adolescents and increases the risk of completed suicide. Few brief interventions have been shown to reduce SI in adolescents. The objective of this study was to evaluate the feasibility of a novel brief group intervention, building resilience and attachment in vulnerable adolescents (BRAVA), designed for adolescents and their caregivers to reduce adolescent SI.

METHODS

The study was a pre-post, noncontrolled trial in which 46 adolescents were enrolled in the BRAVA intervention. Adolescents and caregivers completed an intake assessment, six BRAVA group sessions, and an exit assessment 1-week post-BRAVA.

RESULTS

Adolescents' SI decreased significantly after completing the BRAVA treatment (pre-post difference = 18.1, 95% CI = 10.01-26.12). Significant improvements in associated symptoms of depression, anxiety, and perceived stress were also observed. Caregivers had reduced perceived stress (pre-post difference = 2.7, 95% CI = 0.30-5.16) and reduction in attachment avoidance (difference = 1.6, 95% CI = 0.29-2.91). Treatment satisfaction was high across the six modules. The rolling entry feature of the intervention allowed participants to begin treatment approximately 2 weeks sooner compared to waiting for the next group cycle.

CONCLUSIONS

Study results demonstrate that the BRAVA intervention has the potential to reduce SI among adolescents who present to hospital services in crisis. Further studies are required to establish BRAVA's efficacy in a randomized controlled trial.

Perspectives on Dialectical Behavior Therapy and Mentalization-Based Therapy for Borderline Personality Disorder: Same, Different, Complementary?

Current evidence suggests that individuals with borderline personality disorder (BPD) are likely to benefit from specialized, or BPD-specific, treatments. Dialectical behavior therapy (DBT) and mentalization-based treatment (MBT) are currently the most intensively researched BPD treatments. Reviewing the current research, this paper highlights similarities and differences between the two treatments, and discusses possible ways they could complement each other. As the effectiveness of specialized treatments for BPD in general has been determined with some certainty, research now tends towards individualized approaches, identifying predictors of optimal treatment response. However, it is still to be settled who might profit from a combination of or sequential treatment with DBT and MBT.

Antisocial and borderline personality traits and childhood trauma in male prisoners: Mediating effects of difficulties in emotional regulation

OBJECTIVE

To investigate the prevalence of probable antisocial personality disorder (ASPD) and borderline personality disorder (BPD) among prisoners, and further examine the mediating effect of difficulties in emotional regulation (ER) between childhood trauma and symptoms of ASPD and BPD.

METHODS

A total of 1491 male participants (35.4 ± 9.69 years) were recruited from a prison in Guangdong, China. The symptoms of ASPD and BPD, childhood trauma, difficulties in ER, and suicidal behaviors were measured by self-administered structured questionnaires. Logistic regressions were performed to investigate the associations of ASPD and BPD with suicidal behaviors. Path analysis was used to examine the mediating effects of difficulties in ER between childhood trauma and symptoms of ASPD and BPD.

RESULT

Approximately, 21.2 % and 11.2 % of the participants were screened as ASPD and BPD, respectively. Probable ASPD and BPD were associated with higher risk of suicidal behaviors. Childhood trauma and difficulties in ER were significantly associated with suicidal behaviors in prisoners with probable ASPD and BPD. Path analyses showed that partial mediating effects of difficulties in ER were significant in the dimensions of clarity and strategies on ASPD, and in the dimensions of clarity, impulse, and strategies on BPD.

CONCLUSION

ASPD and BPD are two of the common personality disorders in prisoners. Difficulties in ER are key to understanding the relationships between childhood trauma and personality disorders.

MDMA-Assisted Psychotherapy for Borderline Personality Disorder

Borderline personality disorder is a complex psychiatric disorder with limited treatment options that are associated with large heterogeneity in treatment response and high rates of dropout. New or complementary treatments for borderline personality disorder are needed that may be able to bolster treatment outcomes. In this review, the authors comment on the plausibility for research on 3,4-methylenedioxymethamphetamine (MDMA) used in conjunction with psychotherapy for borderline personality disorder (i.e., MDMA-assisted psychotherapy [MDMA-AP]). On the basis of the promise of MDMA-AP in treating disorders overlapping with borderline personality disorder (e.g., posttraumatic stress disorder), the authors speculate on initial treatment targets and hypothesized mechanisms of change that are grounded in prior literature and theory. Initial considerations for designing MDMA-AP clinical trials to investigate the safety, feasibility, and preliminary effects of MDMA-AP for borderline personality disorder are also presented.

Suicidal behaviors are associated with loneliness and decrease during inpatient CBASP treatment for persistent depressive disorder

Suicidal ideation and behavior (SIB) are common in persistent depressive disorder (PDD) and may be related to interpersonal dysfunction. While SIB has been extensively analyzed in other high-risk disorders (e.g., borderline personality disorder, BPD), data on interpersonal risk factors and effects of specific psychotherapy on SIB in PDD are limited. This study aimed at investigating loneliness versus social network size as interpersonal risk factors for SIB in PDD and assess effects of cognitive behavioral analysis system of psychotherapy (CBASP) on this domain. In a prospective naturalistic study, 64 PDD patients were assessed, who underwent a 10-weeks inpatient CBASP program. Our clinical comparison group consisted of 34 BPD patients, who underwent a 10-weeks inpatient dialectical behavioral therapy (DBT) program. SIB was measured with the Columbia-Suicide Severity Rating Scale (C-SSRS), loneliness and social network size with the UCLA Loneliness Scale (UCLA) and the Social Network Index (SNI). Twenty-six PDD patients (40.6% of the PDD sample) showed current SIB at baseline in comparison with 26 BPD patients (76.5% of the BPD sample). While in suicidal PDD patients, SIB was associated with perceived social isolation (UCLA), but not with reduced social network size (SNI), this association was not observed in suicidal BPD patients. In PDD, SIB significantly decreased during CBASP. In conclusion, SIB appears to be associated with interpersonal factors related to loneliness in PDD, but not in BPD. CBASP showed first positive evidence in reducing SIB in PDD, but our pilot data need replication studies.

Trajectories of Treatment Response and Nonresponse in Youth at High Risk for Suicide

OBJECTIVE

To examine trajectories of treatment response in suicidal youth who participated in a randomized controlled trial comparing dialectical behavior therapy (DBT) and individual and group supportive therapy.

METHOD

Using latent class analysis across both treatment conditions, secondary analyses were conducted of data from a multisite randomized controlled trial comprising 173 youths ages 12-18 with repetitive self-harm (SH) (including ≥1 lifetime suicide attempts) and elevated suicidal ideation (SI). The sample was 95% female, 56.4% White, and 27.49% Latina. Participants received 6 months of DBT or individual and group supportive therapy and 6 months of follow-up. Primary outcomes were SH and SI.

RESULTS

Of the sample, 63% and 74% were members of latent classes that showed improvement in SI and SH, respectively; 13% were total nonresponders, with no improvement in SI or SH. SH nonresponse emerged at the midpoint of treatment (3 months), with nonresponders showing a sharp increase in SH over the remainder of treatment and follow-up. Youth receiving DBT were significantly more likely to be an SH responder vs nonresponder than youths in individual and group supportive therapy (ꭓ21 = 6.53, p = .01). An optimal threshold cut point using multivariate predictors of total nonresponse (White, externalizing symptoms, total SH, and SI) predicted total nonresponders to DBT with 100% accuracy.

CONCLUSION

This is the first study to identify trajectories of both SI and SH response to treatment in a sample of adolescents at risk of suicide. Results may inform personalized treatment approaches.

CLINICAL TRIAL REGISTRATION INFORMATION

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

CLINICALTRIALS

gov/; NCT01528020.

Editorial: Dialectical Behavior Therapy: More Is Not Always Better When Different Is Required

The study by Berk et al.1 highlights potential trajectories of response and nonresponse to dialectical behavior therapy (DBT) as compared to individual and group supportive therapy (IGST) for teens with repeated self-harm and suicidal ideation. The authors also posit a testable function to predict responsiveness vs nonresponsiveness and provide critical guidance about when to reassess nonresponders and alter treatment. This is the fourth major article from a large federally funded, randomized controlled trial. Previous publications have highlighted superiority of DBT over IGST,2 reported the moderating factors of treatment outcomes,3 and explored the mechanism of effectiveness for DBT in the treatment of suicidal ideation and self-harm.4 These articles provide useful information given the rising rates of suicidal ideation and suicide attempts among youth5 and recent research suggesting the powerful role of social media in supporting contagion of suicidal behavior among youth.

Borderline personality features influence treatment response to suicide prevention

BACKGROUND

Suicide is a notable risk for individuals with features of borderline personality disorder. Given the centrality of interpersonal difficulties in this disorder, we proposed that the negative interpersonal cognitions (perceived burdensomeness and thwarted belongingness) identified by the Interpersonal Theory of Suicide (IPTS) may explain the associations between suicidal ideation and borderline personality features.

METHOD

Participants were 322 suicidal youth (74% girls) aged 11-18 years (M, SD = 14.74, 1.6) in an intensive outpatient program in the southwest United States. Youth completed measures assessing borderline personality features at program entry, and suicidal ideation and IPTS variables at entry and exit.

RESULTS

Borderline personality features did not moderate associations of IPTS variables and suicidal ideation. For the entire sample, changes in suicidal ideation from entry to discharge occurred in tandem with changes in perceived burdensomeness and depressive symptoms, but not thwarted belongingness. Youth with elevated borderline personality features entered with greater suicidal ideation, but improved more from treatment entry to exit. Regardless of level of borderline personality features, changes in negative interpersonal cognitions over treatment were associated with changes in suicidal ideation.

LIMITATIONS

Self-report measures and lack of sample diversity are study limitations.

CONCLUSIONS

This research highlights the clinical utility of the IPTS variables and the importance of promoting competence and interpersonal connectedness when treating this population. Findings indicate that the IPTS variables carry the same fundamental information for contributing to suicidal ideation, regardless of level of borderline personality features.

Nonsuicidal Self-injury and Barriers to Accessibility of Dialectical Behavior Therapy Among Black Youth

Youth in communities of color are disproportionately affected by the current mental health crisis, as highlighted in the recent Declaration of National Emergency by the American Academy of Child and Adolescent Psychiatry (AACAP), the American Academy of Pediatrics (AAP), and the Children's Hospital Association (CHA).¹ The structural racism that Black youth encounter is a social determinant of health that contributes to inequitable access to evidence-based mental health services. Black youth in the United States experience inequities in financial hardships, access to educational resources, and the undue burden of the coronavirus disease 2019 (COVID-19) pandemic, further exacerbating an already outsized mental health burden.².

Near-Fatal Self-Harm Among Canadian Adolescents

OBJECTIVE

To evaluate the clinical features of Canadian adolescents admitted to the intensive care unit (ICU) for medically serious self-harm.

METHODS

2700 Canadian paediatricians were surveyed monthly over two years (January 2017 to December 2018) through the Canadian Paediatric Surveillance Program to ascertain data from eligible cases.

RESULTS

Ninety-three cases (73 female; age 15.2 ± 1.5) met the case definition. Four provinces reported the majority of cases: Quebec (n = 27), Ontario (n = 26), Alberta (n = 21), and British Columbia (n = 8). There were 10 deaths, 9 by hanging. Overdose and hanging were the most frequently reported methods of self-harm (74.2% and 19.4%, respectively). Overdose was more common in females (80.8% females vs. 50% males; χ² = 7.8 (1), p = .005), whereas hanging was more common in males (35% males vs. 15.1% females, χ² = 3.9 (1), p = .04). More females than males had a past psychiatric diagnosis (79% vs. 58%; χ² = 4.1 (1), p = .06), a previous suicide attempt (55.9% vs. 29.4%, χ² = 3.8 (1), p = .05), and prior use of mental health service (69.7% vs. 27.8%, χ² = 10.4 (1), p = .001). Family conflict was the most commonly identified precipitating factor (43%) of self-harm.

CONCLUSIONS

Among Canadian adolescents admitted to the ICU with medically serious self-harm, females demonstrate a higher rate of suicide attempts and prior mental health care engagement, whereas males are more likely to die by suicide. These findings are consistent with data from other adolescent samples, as well as data from working-age and older adults. Therefore, a sex-specific approach to suicide prevention is warranted as part of a national suicide prevention strategy; family conflict may be a specific target for suicide prevention interventions among adolescents.

Brief modular approach to target perceived burdensomeness in clinic-referred youth

INTRODUCTION

Existing CBT protocols for internalizing disorders target thoughts and behaviors related to anxiety and/or depression, but do not explicitly target other identified risk factors for suicide ideation, including perceived burdensomeness toward others. The aims of the current study were to (1) develop a novel, brief module (the "Give program") targeting perceived burdensomeness toward others that can be embedded within existing CBT protocols for youth internalizing disorders, (2) evaluate the acceptability and feasibility of the module with an eye toward intervention refinement, and (3) examine reductions in perceived burdensomeness.

METHODS

Participants were 18 clinic-referred youths with anxiety or depressive disorders who endorsed burdensomeness. We used a quasi-experimental interrupted time-series design to evaluate changes in burdensomeness scores following the administration of the module.

RESULTS

The module was clinically feasible and well-accepted. Youth burdensomeness scores increased in the first half of the CBT protocol and decreased immediately following the administration of the Give program module. Burdensomeness scores were significantly associated with suicide ideation.

CONCLUSION

The current study is the first to develop and evaluate a module targeting burdensomeness in at-risk youth in an outpatient setting, demonstrating that burdensomeness can be efficiently and effectively targeted within existing evidence-based treatment protocols for internalizing disorders in youth.

Childhood Trauma and Suicide: The Mediating Effect of Stress and Sleep

This study aimed to investigate the relationship between suicide risk, perceived stress, and sleep quality through a structural equation modeling approach. This study used convenience sampling to survey 780 undergraduate and graduate students aged 18–30 years. Students were invited to participate in the online questionnaires, which included the Beck Scale for Suicide Ideation, the Suicidal Behaviors Questionnaire-Revised, the Perceived Stress Scale, the Childhood Trauma Questionnaire-Short Form, and the Pittsburgh Sleep Quality Index. The results showed that suicide ideation and suicidal behavior were positively correlated with childhood trauma, stress, and sleep. A well-fitted structural equation model (χ2 = 1.52, df = 1, χ2/df = 1.52, RMSEA = 0.03, CFI = 1.00, NFI = 1.00) was constructed in this study. The hierarchical regression test showed significance in all the path coefficients of the model. The total effect of emotional abuse on suicide behaviors was 49.5%. The mediating effects accounted for 73.7% of the total effects of emotional abuse on suicidal behaviors. The results demonstrate efforts targeting stress and poor sleep might mitigate the risk of suicidal behaviors among individuals with early emotional abuse experiences.

Dialectical behavior therapy for adolescents (DBT-A): Outcomes among sexual minorities at high risk for suicide

The alarming rates and pervasiveness of suicidal and self-destructive behaviors (e.g., non-suicidal self-injury) among young sexual minorities represent a major public health concern. We set out to examine whether an empirically driven treatment for suicide and self-harm, dialectical behavior therapy for adolescents (DBT-A), provides benefits for adolescents who identify as gay, lesbian, bisexual, or questioning (LGBQ). LGBQ adolescents (n = 16) were compared with non-LGBQ peers (n = 23). Psychological measures were collected before and after participation in a comprehensive DBT-A program. LGBQ participants demonstrated significant improvements in emotion regulation, depression, borderline symptoms, and coping strategies; changes were comparable to their heterosexual peers.

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

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

Trajectories and Processes of Symptom Change Over Time in Dialectical Behavior Therapy for Borderline Personality Disorder

Despite ample evidence for Dialectical Behavior Therapy (DBT) as an effective treatment for borderline personality disorder (BPD), close examination of the trajectory of change in BPD symptoms over the course of DBT is lacking. There also remain questions regarding the directionality of changes in different domains of BPD symptoms, such as improvements in dysfunctional behaviors and thoughts/feelings. In order to provide more fine-grained information about the treatment process in DBT, the current study aimed to (a) examine the trajectories of change of BPD-associated negative thoughts/feelings and behaviors, and positive behaviors, and (b) test the temporal relationship between changes in negative behaviors and thoughts/feelings. The study involved 55 adult clients attending a 6-month outpatient DBT program for BPD who completed assessments of BPD symptoms every four sessions. Growth curve models suggested that clients experienced a faster rate of decrease in negative behaviors during the initial phase of treatment, whereas steady rates of improvement were found for negative thoughts/feelings and positive behaviors, respectively, throughout treatment. Further, a random-intercept cross-lagged panel model found that the within-person fluctuations in negative behaviors preceded the within-person changes in negative thoughts/feelings at a subsequent time point during the later phase of treatment, whereas within-person fluctuations in thoughts/feelings were followed by changes in negative behaviors at the beginning and end of the treatment. These results highlighted the complexity of patterns and processes of change in BPD symptomatology during the course of DBT.

Association of emotion reactivity and distress intolerance with suicide attempts in U.S. Army soldiers

INTRODUCTION

Emotion reactivity (ER) and distress intolerance (DI) may be associated with increased suicide attempt (SA) risk among U.S. Army soldiers.

METHOD

In this case-control study, 74 soldiers recently hospitalized for SA (cases) were compared with 133 control soldiers from the same Army installations selected based on either propensity score matching (n = 103) or reported 12-month suicide ideation (SI) (n = 30). Controls were weighted to represent the total Army population at the study sites and the subpopulation of 12-month ideators. Participants completed questionnaires assessing ER, DI, and other psychosocial variables. Logistic regression analyses examined whether ER and DI differentiated SA cases from the general population and from 12-month ideators before and after controlling for additional important risk factors (sociodemographic characteristics, stressors, mental disorders).

RESULTS

In univariate analyses, ER differentiated SA cases from both the general population (OR = 2.5[95%CI = 1.7-3.6]) and soldiers with 12-month SI (OR = 2.5[95%CI = 1.3-4.6]). DI also differentiated cases from the general population (OR = 2.9[95%CI = 2.0-4.1]) and 12-month ideators (OR = 1.9[95%CI = 1.1-3.5]). These associations persisted after controlling for sociodemographic variables, stressors, and mental disorders.

CONCLUSION

Findings provide evidence that higher ER and DI are associated with increased risk of SA among soldiers, even after adjusting for known risk factors. Prospective research with larger samples is needed.

Dialectical behaviour therapy 'Skills for Living' for young people leaving care: A qualitative exploration of participants' experiences

It is acknowledged that care leavers experience an accelerated transition into adulthood, despite often having complex psychosocial needs with limited support networks. The 'Skills for Living' programme was designed to improve the psychological wellbeing of care leavers and offers an adapted Dialectical Behaviour Therapy skills group as its primary intervention. This paper provides a qualitative evaluation of the programme. Semi-structured interviews were undertaken with 10 participants, and the data were analysed using thematic analysis (Braun & Clarke, 2006). Four key themes emerged: 'Initial Apprehension and Reluctance to Participate', 'Connection, Understanding and Validation', 'Confidence with Social Skills', and 'Emotional Acceptance and Self-Soothing'. Clinical implications and recommendations are discussed.

Suicide and Suicidal Behaviors Among Minoritized Youth

Suicide rates continue to increase among children and adolescents in the United States, with suicide remaining the second leading cause of death for youth aged 10 to 24 years of age. Most studies of suicide among children and adolescents have not focused on youth of color because of research suggesting that suicide was a health threat for white youth. Research showing shifting trends in suicide for minoritized youth of color has increased national focus, revealing disparities in recognition and treatment of suicidal behaviors for racially and culturally diverse youth.

Borderline personality traits mediate the relationship between low perceived social support and non-suicidal self-injury in a clinical sample of adolescents

BACKGROUND

Non-suicidal self-injury (NSSI) is a serious public health concern among adolescents, especially in clinical settings. Social support plays a critical role in the onset and maintenance of NSSI in adolescence. NSSI is closely associated with borderline personality disorder (BPD), yet no previous work has analyzed the mediating role of borderline traits in the relationship between perceived social support (PSS) and NSSI. This study aimed to address this gap.

METHODS

Participants were 228 adolescent patients (12 to 18 years old), who completed a clinical interview and self-report measures of BPD-traits, current psychological distress, emotion dysregulation and PSS. They were grouped based on the presence (vs. absence) of NSSI. Univariate and multivariate logistic regression analyses were used to identify risk factors of NSSI, and a mediation analysis was conducted to examine the intermediary role of borderline traits in the relationship between PSS and NSSI.

RESULTS

NSSI was highly prevalent in our sample (58%) and was associated with higher clinical severity. Low PSS predicted NSSI in univariate, but not multivariate regression. Mediation analyses showed that borderline traits fully accounted for the relationship between low PSS and NSSI, even when controlling for current psychological distress and gender.

LIMITATIONS

Cross-sectional design through self-report assessment.

CONCLUSIONS

Findings suggest that adolescents with low PSS are especially vulnerable for developing NSSI due to elevated BPD traits. In clinical settings, interventions aimed to reduce borderline symptoms may be a promising treatment option for adolescents with NSSI and low PSS.

Impact of online Mindfulness-Based Cognitive Therapy on suicidal ideation: A secondary analysis of a randomized trial of Mindful Mood Balance

BACKGROUND

To address the elevated prevalence of depression, suicide, and suicidal ideation, patients require increased access to effective interventions. Mindfulness-Based Cognitive Therapy has a strong evidence base in relapse prophylaxis and can be delivered digitally through Mindful Mood Balance (MMB).

METHODS

This study was a secondary analysis of the impact of MMB paired with usual depression care (UDC) compared to UDC alone on patients in a randomized clinical trial for residual depression (Segal et al., 2020) who had a history of attempted suicide or reported current suicidal ideation (N = 109).

RESULTS

MMB relative to UDC was associated with a greater rate of reduction in suicidal ideation (SI; t(103) = 2.50, p = 0.014, d = 0.49, 95% CI [0.09-0.88]) and a greater likelihood of being in a lower severity category of SI (t(103) = 2.02, p = 0.046, odds ratio = 3.43, 95% CI [1.02-11.53]). There was also evidence that MMB reduces depression severity outcomes among this at risk group (t(105) = 2.38, p < 0.02, d = 0.46, 95% CI [0.07-0.85]).

LIMITATIONS

Reported findings are based on a subgroup of patients in a clinical trial originally designed to treat residual depressive symptoms.

CONCLUSIONS

Online interventions, such as MMB, may offer one solution to the challenge of expanding the reach of services for patients with residual depression who are at risk of suicidal ideation and behavior.

Twenty-six years of psychosocial interventions to reduce suicide risk in adolescents: Systematic review and meta-analysis

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.

Therapist Adherence to Two Treatments for Adolescent Suicide Risk: Association to Outcomes and Role of Therapeutic Alliance

In psychotherapy research, adherence refers to the extent to which therapists deliver a treatment as intended. This study examined whether therapist adherence to two different manualized treatments was associated with improved client outcomes and whether the association was moderated by therapeutic alliance. The study sample included 320 video recordings of therapy sessions from 118 cases in a randomized controlled trial (RCT) comparing attachment-based family therapy (ABFT) with family-enhanced nondirective supportive therapy (FE-NST). Recordings were selected from early, middle, and late stages of treatment. The adherence measure consisted of 24 items representing essential therapist interventions from both treatments. Trained raters coded tapes from both therapies. Adolescent self-report of alliance was measured at session 4. Adherence to ABFT was associated with a significant increase in family cohesion at mid-treatment but not at posttreatment. Adherence to FE-NST was significantly associated with an increase in suicide ideation posttreatment. Using therapeutic alliance as a moderator, adherence to ABFT was significantly associated with a reduction in suicide ideation, family conflict, and higher client satisfaction posttreatment. Alliance did not positively affect the association of FE-NST adherence to outcomes. Findings suggest that adherence to ABFT interventions may be better linked to treatment outcomes when adolescents feel a strong alliance with their therapist. Implications for future research and therapist training are explored.

Future Directions in Suicide and Self-Injury Revisited: Integrating a Developmental Psychopathology Perspective

The recent rise in suicide rates among children and adolescents has made suicide prevention in youth a major focus of government agencies and mental health organizations. In 2012, Nock presented future directions in the study of self-injurious thoughts and behavior (SITBs), highlighting the need to better examine which risk factors are associated with "each part of the pathway" to suicidal and non-suicidal self-injury in order to inform prevention and intervention efforts. Over the past decade, we have made important advances in understanding the development of SITBs and effective interventions. However, there are still major gaps of knowledge in our understanding of how to prevent suicide. Researchers have recently called for more studies focusing particularly on the pathway from suicidal ideation to suicidal behavior. However, we caution against prioritizing only a part of the suicide risk continuum (e.g., the transition from suicidal ideation to suicidal behavior) while minimizing research focusing on earlier developmental points of the pathway to suicide (e.g., the first development of suicidal ideation). We emphasize that childhood and adolescence represent a critical opportunity to intervene and prevent SITBs by altering developmental trajectories toward persistent and escalating SITBs over time. We advocate for integrating a developmental psychopathology perspective into future youth suicide research that focuses on how and when risk for SITBs first emerges and develops across childhood into emerging adulthood. This research is critical for informing interventions aimed at bending developmental pathways away from all SITBs. Here, we describe the need for future research that integrates key developmental psychopathology principles on 1) the identification of the continuum from developmentally typical to atypical as SITBs first emerge and develop, particularly among young children in early to middle childhood, 2) the way in which expressions of and risk for SITBs change across development, 3) how SITBs dynamically move along a continuum from typical to atypical over time, and 4) suicide prevention efforts. We also offer recommendations for future directions that focus on identifying disparities in SITBs occurring among minoritized youth within a developmental psychopathology perspective.

The temporal relationships between therapist adherence and patient outcomes in dialectical behavior therapy

OBJECTIVE

Although Dialectical Behavior Therapy (DBT) is a well-established evidence-based psychotherapy, little is known about the role of therapist adherence in promoting positive outcomes. This study evaluated the temporal relationships between therapist adherence to DBT and patient outcomes, as well as potential moderators of these relationships.

METHOD

Data were from six clinical trials conducted in research and community settings with a variety of patient populations. In these trials, trained observers rated 83 therapists for adherence during 1,262 DBT individual therapy sessions with 288 patients. Patient outcomes included suicide attempts, nonsuicidal self-injury (NSSI), treatment dropout, psychiatric hospitalizations, and global functioning. Longitudinal mixed-effects models evaluated the time-ordered, bidirectional relationships between adherence and outcomes.

RESULTS

Higher therapist adherence significantly predicted fewer subsequent suicide attempts (p = .002, η = 0.32) and a lower risk of dropout (p = .002, η = 0.33), and the latter relationship was strongest among patients with comorbid opioid dependence. Higher therapist adherence predicted fewer subsequent hospitalizations among community therapists (p = .001, η = 0.35) and patients that were not exclusively suicidal/self-injuring (p < .001, η = 0.41). Conversely, more frequent NSSI (p = .03, η = 0.22) and worse global functioning (p = .01, η = 0.26) predicted higher subsequent therapist adherence, and the latter relationship was moderated by patient population.

CONCLUSIONS

Therapist adherence improves several key patient outcomes and retention, highlighting the importance of delivering DBT with adherence to the manual. Therapists may find it easier to deliver DBT adherently to more severely impaired patients. (PsycInfo Database Record (c) 2022 APA, all rights reserved).