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

Emotional Dysregulation in Children and Adolescents With Psychiatric Disorders. A Narrative Review

Background: Emotional dysregulation (ED) is a transdiagnostic construct defined as the inability to regulate the intensity and quality of emotions (such as, fear, anger, sadness), in order to generate an appropriate emotional response, to handle excitability, mood instability, and emotional overreactivity, and to come down to an emotional baseline. Because ED has not been defined as a clinical entity, and because ED plays a major role in child and adolescent psychopathology, we decided to summarize current knowledge on this topic based on a narrative review of the current literature. Methods: This narrative review is based on a literature search of peer-reviewed journals. We searched the databases ERIC, PsycARTICLES, PsycINFO and PSYNDEX on June 2, 2020 for peer reviewed articles published between 2000 and 2020 in English language for the preschool, school, and adolescent age (2-17 years) using the following search terms: "emotional dysregulation" OR "affect dysregulation," retrieving 943 articles. Results: The results of the literature search are presented in the following sections: the relationship between ED and psychiatric disorders (ADHD, Mood Disorders, Psychological Trauma, Posttraumatic Stress Disorder, Non-suicidal Self-Injury, Eating Disorders, Oppositional Defiant Disorder, Conduct Disorder, Disruptive Disruptive Mood Dysregulation Disorder, Personality Disorders, Substance Use Disorder, Developmental Disorders, Autism Spectrum Disorder, Psychosis and Schizophrenia, and Gaming Disorder), prevention, and treatment of ED. Conclusion: Basic conditions of ED are genetic disposition, the experience of trauma, especially sexual or physical abuse, emotional neglect in childhood or adolescence, and personal stress. ED is a complex construct and a comprehensive concept, aggravating a number of various mental disorders. Differential treatment is mandatory for individual and social functioning.

Suicidality Among Children and Youth With and Without Autism Spectrum Disorder: A Systematic Review of Existing Risk Assessment Tools

Individuals with autism are at heightened risk for experiencing suicidality compared to those without autism. Despite this, it is unknown what tools are used to assess suicide risk in research and clinical practice among children and youth with autism. This systematic review examined tools commonly used to measure suicidality in children and youth with and without autism spectrum disorder. Four databases were searched. We identified five tools (C-SSRS, PSS, SITBI, SIQ-JR, BSS) commonly used with youth in the general population; however, we did not identify any tools that were commonly used autistic children and youth. Results highlight the lack of available tools utilized to measure suicidality in autistic children and youth. We propose a framework to facilitate research to fill this gap.

The process of recovery and change in a dialectical behaviour therapy programme for youth

Dialectical behaviour therapy (DBT) is an effective treatment for borderline personality disorder and suicidal behaviour. However, it is a complex programme involving individual therapy, participation in skills training groups, and phone coaching aimed at improving emotional regulation, distress tolerance, interpersonal effectiveness, and mindfulness. Little is known about what elements contribute to its effectiveness, or the characteristics of those who complete the programme and achieve recovery. In this study, six participants in a dialectical behaviour therapy programme for youth were interviewed at three time points over their recovery journey. The transcribed narratives were analysed using inductive methods, and the core processes related to recovery were elucidated and described: 'Becoming a cheerleader for DBT' and 'Learning the language of DBT and consolidation of skills'. Indicators of recovery included having a sound working alliance with the primary therapist and others involved in the programme and noticing meaningful improvements in problem areas which they attributed to particular skills and improved capacity to regulate emotions. The rich narrative description provided by participants might inspire some to remain engaged in a dialectical behavioural therapy programme or clinicians to consider promoting a positive view of the prognosis for borderline personality disorder.

Sleep in youth with repeated self-harm and high suicidality: Does sleep predict self-harm risk?

OBJECTIVE

To elucidate processes contributing to continuing self-harm in youth at very high risk for suicide, focusing on sleep disturbance, a putative warning sign of imminent suicide risk.

METHOD

101 youth (ages 12-18) selected for high risk of suicide/suicide attempts based on suicidal episodes plus repeated self-harm (suicide attempts and/or nonsuicidal self-injury [NSSI]). Youth were assessed at baseline, 6-, and 12-month follow-ups on measures of self-harm, suicidality, sleep, and depression.

RESULTS

Youth showed high rates of baseline sleep disturbance: 81.2% scored in the clinical range on the Pittsburgh Sleep Quality Index (PSQI); 81.2% reported an evening (night owl) circadian preference. PSQI score was associated with elevated levels of self-harm (suicide attempts and NSSI) contemporaneously and predicted future self-harm within 30 days. Rates of self-harm were high during follow-up: 45.0% and 33.7% at 6 and 12 months, respectively.

CONCLUSIONS

Results underscore the need to move beyond an acute treatment model to prevent recurrent and potentially deadly self-harm, the importance of clarifying mechanisms contributing to elevated suicide/self-harm risk, and the potential promise of engaging sleep as a therapeutic target for optimizing treatment and elucidating mechanistic processes.

Alcohol misuse among adolescents with BPD symptoms: exploring the moderating role of reasons for drinking and perceived coping skills in a clinical adolescent sample

BACKGROUND

Adolescents who experience symptoms of borderline personality disorder (BPD) are at high risk for alcohol misuse, yet little is known about why these adolescents drink and what factors heighten or mitigate this risk. The current study explores factors that may impact risk for alcohol misuse among youth with BPD symptoms: using alcohol to self-medicate or to rebel and perceived coping skills.

METHOD

A sample of 181 psychiatrically hospitalized adolescents (M_age  = 15.04 years, SD = 1.31 years; 71.8% female, 83.4% White) was recruited as part of a larger study from the northeastern United States. Assessments and diagnostic interviews were administered to adolescents.

RESULTS

Use of alcohol for self-medication and perceived coping skills, but not using alcohol for rebellion, moderated the relationship between BPD symptoms and alcohol misuse. A significant positive relationship between BPD symptoms and alcohol frequency and/or problems was only found among adolescents who reported lower use of alcohol for self-medication purposes or higher perceived coping skills.

CONCLUSIONS

Youth with more BPD symptoms are at high risk for alcohol misuse. Moderation effects for self-medication motives and perceived coping skills were counter to hypotheses; lower levels of self-medication motives contributed to greater alcohol problems, as did higher levels of perceived coping skills. Results suggest the importance of assessing how much youth are drinking or experiencing consequences, as well as why they are using alcohol. It is possible adolescents with more BPD symptoms may be reporting more coping skills, but actually exhibiting the phenomenon of apparent competence (i.e., present as 'in control', but actually experiencing extreme distress and lacking sufficient coping skills); collateral reports of adolescents' coping skills may provide a more objective measure of actual skill level.

KEY PRACTITIONER MESSAGE

What is known? Adolescents who experience symptoms of borderline personality disorder (BPD) are at high risk for alcohol misuse, yet little is known about why these adolescents drink and what factors heighten or mitigate this risk. What is new? Adolescents who use alcohol to self-medicate or rebel are at high risk for alcohol problems, regardless of presence of BPD symptoms. Contrary to expectations, higher perceived coping skills strengthened the relation between BPD and alcohol misuse. Apparent competence (i.e., present as 'in control' but lack sufficient skills) may be at play. What is significant for clinical practice? Clinicians are encouraged to assess why adolescents are using alcohol and teach alternative coping strategies when self-medication and/or rebellion is an identified use. Clinicians are encouraged to collect collateral reports of adolescent's coping abilities rather than relying solely on self-report.

Development and efficacy of a family-focused treatment for depression in childhood

BACKGROUND

Depression in childhood frequently involves significant impairment, comorbidity, stress, and mental health problems within the family. Family-Focused Treatment for Childhood Depression (FFT-CD) is a 15-session developmentally-informed, evidence-based intervention targeting family interactions to enhance resiliency within the family system to improve and manage childhood depression.

METHODS

We present the conceptual framework underlying FFT-CD, the treatment development process, the intervention strategies, a case illustration, and efficacy data from a recent 2-site randomized clinical trial (N = 134) of 7-14 year old children randomly assigned to FFT-CD or individual supportive psychotherapy (IP) conditions.

RESULTS

Compared to children randomized to IP, those randomized to FFT-CD showed higher rates of depression response (≥50% Children's Depression Rating Scale-Revised reduction) across the course of acute treatment (77.7% vs. 59.9%, t = 1.97, p = .0498). The rate of improvement overall leveled off following treatment with a high rate of recovery from index depressive episodes in both groups (estimated 76% FFT-CD, 77% IP), and there was an attenuation of observed group differences. By final follow-up (9 months post-treatment), one FFT-CD child and six IP children had suffered depressive recurrences, and four IP children attempted suicide.

LIMITATIONS

Without a no treatment control group it is not possible to disentangle the impact of the interventions from time alone.

CONCLUSIONS

While seldom evaluated, family interventions may be particularly appropriate for childhood depression. FFT-CD has demonstrated efficacy compared to individual supportive therapy. However, findings underscore the need for an extended/chronic disease model to enhance outcomes and reduce risk over time.

A Mobile Health Intervention (LifeBuoy App) to Help Young People Manage Suicidal Thoughts: Protocol for a Mixed-Methods Randomized Controlled Trial

BACKGROUND

Self-help smartphone apps offer a new opportunity to address youth suicide prevention by improving access to support and by providing potentially high fidelity and cost-effective treatment. However, there have been very few smartphone apps providing evidence-based support for suicide prevention in this population. To address this gap, we developed the LifeBuoy app, a self-help smartphone app informed by dialectical behavior therapy (DBT), to help young people manage suicidal thoughts in their daily life.

OBJECTIVE

This study describes the protocol for a randomized controlled trial to evaluate the efficacy of the LifeBuoy app for reducing suicidal thoughts and behaviors, depression, anxiety, and psychological distress, and improving general mental well-being in young adults aged 18 to 25 years.

METHODS

This is a randomized controlled trial recruiting 378 young adults aged between 18 and 25 years and comparing the LifeBuoy app with a matched attention control (a placebo app with the same display but no DBT components). The primary outcome is suicidal thoughts measured by the Suicidal Ideation Attributes Scale (SIDAS). The secondary outcomes are suicidal behavior, depression, anxiety, psychological distress, and general mental well-being. The changes in the levels of insomnia, rumination, suicide cognitions, distress tolerance, loneliness, and help seeking before and after using the app are evaluated in this study. The study also addresses risk factors and responses to the intervention. A series of items assessing COVID-19 experiences is included in the trial to capture the potential impact of the pandemic on this study. Assessments will occur on the following three occasions: baseline, postintervention, and follow-up at 3 months postintervention. A qualitative interview about user experience with the LifeBuoy app will take place within 4 weeks of the final assessment. Using linear mixed models, the primary analysis will compare the changes in suicidal thoughts in the intervention condition relative to the control condition. To minimize risks, participants will receive a call from the team clinical psychologist by clicking a help button in the app or responding to an automated email sent by the system when they are assessed with elevated suicide risks at the baseline, postintervention, and 3-month follow-up surveys.

RESULTS

The trial recruitment started in May 2020. Data collection is currently ongoing.

CONCLUSIONS

This is the first trial examining the efficacy of a DBT-informed smartphone app delivered to community-living young adults reporting suicidal thoughts. This trial will extend knowledge about the efficacy and acceptability of app-based support for suicidal thoughts in young people.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12619001671156; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378366.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/23655.

Future Directions for Optimizing Clinical Science & Safety: Ecological Momentary Assessments in Suicide/Self-Harm Research

OBJECTIVE

Mobile technology has facilitated rapid growth in the use of intensive longitudinal methods (ILM), such as ecological momentary assessments (EMA), that help identify proximal indicators of risk in real-time and real-world settings. To realize the potential of ILM for advancing knowledge regarding suicidal and self-injurious thoughts and behaviors (SITB), this article aims to provide a systematic review of safety protocols in published ILM studies of youth SITB, highlight considerations for maximizing safety, and offer an agenda for future research.

METHOD

We conducted a systematic review of risk management strategies in published studies applying ILM to assess SITB in youth.

RESULTS

The review indicated diverse safety strategies, with near-universal use of preventive strategies before beginning ILM surveys. Strategies for participant protection during the survey period included automated protective messages to seek support when elevated risk was detected; and staff-led strategies, some of which included active outreach to parents/caregivers when youth responses suggested elevated risk. Studies assessing suicidality all provided staff-led follow-up. There was minimal information on youth reactivity to intensive longitudinal assessments of SITB. Available evidence did not suggest increased suicidal ideation, suicide attempts, self-injurious behavior, or deaths with ILM.

CONCLUSIONS

Based on the review, we propose a research agenda to inform safety procedures in ILM research and a model for managing risk in future ILM studies of youth SITB. This model begins with a needs assessment and proposes a "goodness of fit" approach for matching safety procedures to the specific needs of each ILM study.

Development of an early intervention programme for adolescents with emotion dysregulation and their families: Actions for the treatment of adolescent personality (ATraPA)

AIM

Borderline personality disorder and severe emotion dysregulation in adolescence is a major public health concern. Dialectical Behaviour Therapy is a promising treatment for suicidality in adolescents. The aim of this work is to present an adaptation of this intervention to the Spanish national health system, Actions for the Treatment of Adolescent Personality (ATraPA).

METHOD

Data consists of a description of the different ATraPA subprogrammes, including interventions for adolescents aged 13 to 17 and their families. Participants were referred to ATraPA from different hospitals within the region of Madrid, Spain.

RESULTS

ATraPA has been developed as an intensive outpatient treatment and it comprises different subprogrammes. ATraPA-TAI is an intensive outpatient treatment, including a skills-based group, individual therapy and email therapy. ATraPA-FAL is a psychoeducational intervention for families, including emotion regulation strategies for parents themselves. Finally, the Alternatives Group is offered to adolescents during the hospital admission, with the aim of promoting alternative coping skills. The group of therapists provides a support network to the professionals involved in ATraPA.

CONCLUSIONS

ATraPA has been successfully implemented in a Child and Adolescent Psychiatry Service within the Spanish national health system. Future studies should address the efficacy of ATraPA using a controlled design.

Treatments for Self-Injurious Thoughts and Behaviors in Youth: Progress and Challenges

Self-injurious thoughts and behaviors (SITBs) remain a common clinical problem in youth. This article reviews the state of knowledge regarding psychosocial treatments for SITBs in youth. Broadly speaking, psychosocial treatments that incorporate parents/family and that emphasize skills development (including emotion regulation and interpersonal skills) appear to produce the best outcomes. We also describe several challenges to the implementation of evidence-based psychotherapy, as well as potential solutions to these challenges, and provide an illustrative case example. Finally, because even evidence-based psychosocial treatments can take weeks to produce effects, increased attention has been given to biological approaches such as esketamine administration and transcranial direct current stimulation that have potential to yield rapid improvement for acute suicidal ideation, though evidence for the safety and efficacy of these approaches is in the early stages.

Dropout from mentalization-based group treatment for adolescents with borderline personality features: A qualitative study

Objective: Premature termination, or dropout, is a major concern in psychotherapy in general and an issue of particular importance in treatments for borderline personality disorder (BPD). Yet few studies investigating dropout from therapy in adolescent BPD populations exist. This study investigates reasons for dropping out from group-based mentalization-based treatment (MBT-G) for BPD or borderline features in an adolescent population.Method: Ten semi-structured interviews were performed with female adolescents who had dropped out from group-based MBT for BPD. The data were analyzed qualitatively using Systematic Text Condensation.Results: The results point to the existence of a subgroup of adolescent BPD patients who do not perceive the treatment sufficiently helpful or worthwhile, who experienced treatment as emotionally demanding, time-consuming and connected with unpleasant experiences. Positive reasons for early termination were reported in the form of experienced improvement in condition. Dropping out became understood as a process of weighing perceived benefits against perceived costs of staying in treatment. This understanding of dropout as a process implies the existence of a window of time where intervention to prevent dropout is possible, presupposing the detection of at-risk patients.

Borderline personality disorder in young people: state of the art and future plans in Italy

Treatment of Borderline Personality Disorder (BPD) in Italy has a relatively recent history. In the last few years, based on the increasing number of BPD patients admitted in Italian Mental Health Services (MHS), several regions have introduced treatment for BPD among their clinical priorities. A general 'call for action' has been launched within the psychiatric community. The aim of the current review is to describe the state of the art of research and clinical programs for personality disorders in young people. The Italian clinical context will be described with a focus on the transition discontinuity of care between adult and child/adolescent services. Prevention and early intervention programs available in Italy will be reviewed and a new agenda will be discussed.

Self-harm and self-regulation in urban ethnic minority youth: a pilot application of dialectical behavior therapy for adolescents

BACKGROUND

Difficulties in coping with stress and regulating emotions are transdiagnostic risk factors for self-harming behavior. Due to sociocultural stressors, ethnic minority adolescents may be at greater risk for self-regulation difficulties and self-harm. Dialectical behavior therapy for adolescents (DBT-A) frames adaptive skill acquisition as a mechanism of change, but few studies have investigated its impact on ethnic minority adolescents' self-regulation (i.e. coping, emotion regulation). Therefore, this pilot study examined relations between self-regulation and self-harm among ethnic minority adolescents and investigated changes in their self-regulation upon completing DBT-A.

METHODS

A clinically referred sample of 101 ethnic minority adolescents (M_age  = 14.77; female = 69.3%) completed questionnaires about a history of self-harm, coping (DBT Ways of Coping Checklist), and emotion regulation (Difficulties in Emotion Regulation Scale). Of the initial sample, 51 adolescents (M_age  = 14.73; female = 80.4%) entered a 20-week DBT-A program due to self-harm and/or Borderline Personality features.

RESULTS

In a pretreatment sample, the frequency of dysfunctional coping, but not of adaptive coping, differentiated self-injurers from non-self-injurers. Full information maximum likelihood estimation was used to address high attrition (60.8%) from DBT-A. Those who completed DBT-A (n = 20) reported significantly improved emotion regulation. Adaptive coping at pretreatment predicted increased DBT skills use at post-treatment.

CONCLUSIONS

This non-randomized pilot study highlights dysfunctional coping and emotion dysregulation as risk factors for self-harm and suggests that 20-week DBT-A may help improve emotion regulation. Future research should employ a randomized design to further examine the effect of DBT-A on these transdiagnostic processes of psychopathology.

KEY PRACTITIONER MESSAGE

Due to cultural and environmental stressors, ethnic minority adolescents may be at greater risk for developing self-regulatory difficulties - transdiagnostic mechanisms known to underly self-harming behaviors; however, we know little about whether empirically supported treatments for self-harm will improve youth's coping and emotion regulation. In a clinically referred, pretreatment sample of ethnic minority youth, levels of BPD symptomatology, emotion dysregulation, and dysfunctional coping, but not of adaptive coping, differentiated teens who self-harmed from those who did not. Self-harming ethnic minority youth who participated in an uncontrolled, pilot trial of dialectical behavior therapy for adolescents (DBT-A) at an urban mental health clinic reported improved emotion regulation at post-treatment. Baseline emotion regulation skills were not predictive of treatment-related changes, suggesting that other factors, such as DBT-A, may have played a decisive role in improving teens' emotion regulation. In contrast, adaptive coping skills at pretreatment were linked to increased DBT skills use at post-treatment, indicating that patients' baseline coping skills may play a predictive role in psychotherapy outcomes. Future research should employ a randomized control trial to examine the effect of DBT-A on vulnerable ethnic minority youth's development of self-regulation. It should also investigate the hypothesized mediating role of self-regulation in effecting lasting clinical gains.

Do styles of emotion dysregulation differentiate adolescents engaging in non-suicidal self-injury from those attempting suicide?

Emotion dysregulation is implicated in both suicide attempts (SA) and non-suicidal self-injury (NSSI). However, little is known about how emotion dysregulation may differ between adolescents who have made an SA from those engaged in NSSI. We sought to address this gap by comparing emotion dysregulation profiles across three homogenous groups of adolescents (1) SA-only (2) NSSI-only (3) and typically developing controls (TDCs). Mean comparisons suggest that adolescents with a history of NSSI reported significantly lower distress tolerance and higher emotional reactivity when compared to adolescents who made an SA. After controlling for shared variance across emotion dysregulation measures, parent report of affective lability was the only scale to uniquely distinguish between NSSI and SA groups. Accurately distinguishing emotion dysregulation patterns across self-injurious groups has practical implications towards assessment, treatment, course of illness, and prevention.

Moderators of treatment response to an intervention for nonsuicidal self-injury in young adults

Objective: Despite the prevalence and impact of nonsuicidal self-injury (NSSI), there are few treatments developed to treat the behavior specifically, and little is known about moderators of treatment response. The Treatment for Self-Injurious Behaviors (T-SIB), a brief, behavioral intervention, was developed to treat NSSI in young adults; a previous pilot randomized controlled trial (RCT) comparing T-SIB with treatment as usual (TAU) provided support for the intervention. This study examined demographic, clinical, and NSSI-related predictors of treatment outcome in the pilot RCT for T-SIB. Method: Young adults (N = 33) were randomized to receive T-SIB or treatment as usual; all participants were included in intent-to-treat analyses. The primary outcome of NSSI behaviors was assessed at baseline, posttreatment (9 weeks), and 3-month follow up, and potential moderators were assessed at baseline. Results: Greater lifetime and last year NSSI frequency was associated with fewer NSSI behaviors at posttreatment and follow up among participants in T-SIB. Anxious symptoms also moderated treatment outcomes, but other demographic and clinical variables did not. Conclusion: Previous research has shown that T-SIB is more effective than TAU overall; the current study suggests that T-SIB may be effective for individuals with more frequent NSSI and those with elevated anxiety. A larger evaluation of T-SIB is supported. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Drawing the borderline: Predicting treatment outcomes in patients with borderline personality disorder

BACKGROUND

A routinely collected big data set was analyzed to determine the effectiveness of naturalistic inpatient treatment and to identify predictors of treatment outcome and discontinuation.

METHODS

The sample included 878 patients with borderline personality disorder who received non-manualized dialectic behavioral therapy in a psychosomatic clinic. Effect sizes (Hedge's g) were calculated to determine effectiveness. A bootstrap-enhanced regularized regression with 91 potential predictors was used to identify stable predictors of residualized symptom- and functional change and treatment discontinuation. Results were validated in a holdout sample and repeated cross validation.

RESULTS

Effect sizes were small to medium (g = 0.28-0.51). Positive symptom-related outcome was predicted by low affect regulation skills and no previous outpatient psychotherapy. Lower age, absence of work disability, high emotional and physical role limitations and low bodily pain were associated with greater improvement in functional outcome. Higher education and comorbid recurrent depressive disorder were the main predictors of treatment completion. The predictive quality of the models varied, with the best being found for symptom-related outcome (R2 = 18%).

CONCLUSION

While the exploratory process of variable selection replicates previous findings, the validation results suggest that tailoring treatment to the individual patient might not be based solely on sociodemographic, clinical and psychological baseline data.

What works for adolescents with borderline personality disorder: towards a developmentally informed understanding and structured treatment model

The efficacy of treatment of borderline personality disorder in adolescents is an underresearched area. Although increasing research in borderline personality disorder in adolescents has emerged over the last decade there is a paucity of knowledge about how treatment is adequately designed for this group of patients. As a consequence, it is currently difficult to provide evidence-based guidelines and firm recommendations for how to design and implement borderline treatment in adolescence. In this selective review we summarize the most important research findings concerning treatment for adolescents with borderline personality disorder, including a recent mentalisation-based group treatment program. We highlight pivotal developmental obstacles for psychotherapy in adolescence and integrate these into a framework for the understanding and designing of effective treatment of borderline in adolescence.

General psychiatric management for adolescents (GPM-A) with borderline personality disorder

While borderline personality disorder (BPD) has its onset in youth and is highly prevalent in young people, diagnosis and treatment are frequently delayed, leading to disruptions in development. The few treatments for this population are specialized, resource-intensive, and not widely implemented. Generalist treatments could broadly increase early intervention and access to care, at a less intensive level, when symptoms are milder and developmental arrests can be avoided. One generalist treatment for adults with BPD, General Psychiatric Management, has been adapted for adolescents (GPM-A). GPM-A can be flexibly implemented in different settings, and emphasizes psychoeducation, medicalization of the disorder, life-building activities, and conservative prescribing. This paper introduces GPM-A and proposes it serve as a primary intervention for adolescents with BPD.

Self-Injury as an Addictive Disorder

Self-injury is a mental health-related behavior people engage in to feel pain because they feel numb, to experience physical pain to ease their psychological pain, or to experience an emotional release. Self-injury is more common in patients with other co-occurring anxiety or mood disorders. An addictive component to self-injury has been identified related to an increase in dopamine levels from the self-injury, which then disrupts normal dopamine production similar to substance use disorders. Instruments are available to help identify patients who self-injure along with questions that should be asked in the course of a mental health assessment and physical examination. Patients with self-injury should be treated for any underlying mental health disorder as well as for self-injury, which includes therapy strategies and medications. Nurses can play a vital role in identifying and treating this disorder, which carries risk factors including infection, accidental death, and a higher risk of suicide. [Journal of Psychosocial Nursing and Mental Health Services, 58(6), 13-16.].

Imaginator: A Proof-of-Concept Feasibility Trial of a Brief Imagery-Based Psychological Intervention for Young People Who Self-Harm

OBJECTIVES

The Imaginator study tested the feasibility of a short mental imagery-based psychological intervention for young people who self-harm and used a stepped-wedge design to investigate effects on self-harm frequency reduction at 3 and 6 months.

METHOD

A total of 38 participants aged 16-25 were recruited via community self-referral and mental health services. Participants were randomized to immediate delivery of Functional Imagery Training (FIT) or usual care followed by delayed delivery after 3 months. FIT comprised two face-to-face sessions, five phone sessions, and use of a smartphone app. Outcomes' assessment was blind to allocation.

RESULTS

Three quarters of those who began treatment completed face-to-face sessions, and 57% completed five or more sessions in total. Self-harm frequency data were obtained on 76% of the sample at 3 months (primary outcome) and 63% at 6 months. FIT produced moderate reductions in self-harm frequency at 3 months after immediate (d = 0.65) and delayed delivery (d = 0.75). The Immediate FIT group maintained improvements from 3 to 6 months (d = 0.05). Participants receiving usual care also reduced self-harm (d = 0.47).

CONCLUSIONS

A brief mental imagery-based psychological intervention targeting self-harm in young people is feasible and may comprise a novel transdiagnostic treatment for self-harm.

Psychological therapies for people with borderline personality disorder

BACKGROUND

Over the decades, a variety of psychological interventions for borderline personality disorder (BPD) have been developed. This review updates and replaces an earlier review (Stoffers-Winterling 2012).

OBJECTIVES

To assess the beneficial and harmful effects of psychological therapies for people with BPD.

SEARCH METHODS

In March 2019, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication.

SELECTION CRITERIA

Randomised controlled trials comparing different psychotherapeutic interventions with treatment-as-usual (TAU; which included various kinds of psychotherapy), waiting list, no treatment or active treatments in samples of all ages, in any setting, with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. There were 11 secondary outcomes, including individual BPD symptoms, as well as attrition and adverse effects.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's 'Risk of bias' tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis.

MAIN RESULTS

We included 75 randomised controlled trials (4507 participants), predominantly involving females with mean ages ranging from 14.8 to 45.7 years. More than 16 different kinds of psychotherapy were included, mostly dialectical behaviour therapy (DBT) and mentalisation-based treatment (MBT). The comparator interventions included treatment-as-usual (TAU), waiting list, and other active treatments. Treatment duration ranged from one to 36 months. Psychotherapy versus TAU Psychotherapy reduced BPD symptom severity, compared to TAU; standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -0.70 to -0.33; 22 trials, 1244 participants; moderate-quality evidence. This corresponds to a mean difference (MD) of -3.6 (95% CI -4.4 to -2.08) on the Zanarini Rating Scale for BPD (range 0 to 36), a clinically relevant reduction in BPD symptom severity (minimal clinical relevant difference (MIREDIF) on this scale is -3.0 points). Psychotherapy may be more effective at reducing self-harm compared to TAU (SMD -0.32, 95% CI -0.49 to -0.14; 13 trials, 616 participants; low-quality evidence), corresponding to a MD of -0.82 (95% CI -1.25 to 0.35) on the Deliberate Self-Harm Inventory Scale (range 0 to 34). The MIREDIF of -1.25 points was not reached. Suicide-related outcomes improved compared to TAU (SMD -0.34, 95% CI -0.57 to -0.11; 13 trials, 666 participants; low-quality evidence), corresponding to a MD of -0.11 (95% CI -0.19 to -0.034) on the Suicidal Attempt Self Injury Interview. The MIREDIF of -0.17 points was not reached. Compared to TAU, psychotherapy may result in an improvement in psychosocial functioning (SMD -0.45, 95% CI -0.68 to -0.22; 22 trials, 1314 participants; low-quality evidence), corresponding to a MD of -2.8 (95% CI -4.25 to -1.38), on the Global Assessment of Functioning Scale (range 0 to 100). The MIREDIF of -4.0 points was not reached. Our additional Trial Sequential Analysis on all primary outcomes reaching significance found that the required information size was reached in all cases. A subgroup analysis comparing the different types of psychotherapy compared to TAU showed no clear evidence of a difference for BPD severity and psychosocial functioning. Psychotherapy may reduce depressive symptoms compared to TAU but the evidence is very uncertain (SMD -0.39, 95% CI -0.61 to -0.17; 22 trials, 1568 participants; very low-quality evidence), corresponding to a MD of -2.45 points on the Hamilton Depression Scale (range 0 to 50). The MIREDIF of -3.0 points was not reached. BPD-specific psychotherapy did not reduce attrition compared with TAU. Adverse effects were unclear due to too few data. Psychotherapy versus waiting list or no treatment Greater improvements in BPD symptom severity (SMD -0.49, 95% CI -0.93 to -0.05; 3 trials, 161 participants), psychosocial functioning (SMD -0.56, 95% CI -1.01 to -0.11; 5 trials, 219 participants), and depression (SMD -1.28, 95% CI -2.21 to -0.34, 6 trials, 239 participants) were observed in participants receiving psychotherapy versus waiting list or no treatment (all low-quality evidence). No evidence of a difference was found for self-harm and suicide-related outcomes. Individual treatment approaches DBT and MBT have the highest numbers of primary trials, with DBT as subject of one-third of all included trials, followed by MBT with seven RCTs. Compared to TAU, DBT was more effective at reducing BPD severity (SMD -0.60, 95% CI -1.05 to -0.14; 3 trials, 149 participants), self-harm (SMD -0.28, 95% CI -0.48 to -0.07; 7 trials, 376 participants) and improving psychosocial functioning (SMD -0.36, 95% CI -0.69 to -0.03; 6 trials, 225 participants). MBT appears to be more effective than TAU at reducing self-harm (RR 0.62, 95% CI 0.49 to 0.80; 3 trials, 252 participants), suicidality (RR 0.10, 95% CI 0.04, 0.30, 3 trials, 218 participants) and depression (SMD -0.58, 95% CI -1.22 to 0.05, 4 trials, 333 participants). All findings are based on low-quality evidence. For secondary outcomes see review text.

AUTHORS' CONCLUSIONS

Our assessments showed beneficial effects on all primary outcomes in favour of BPD-tailored psychotherapy compared with TAU. However, only the outcome of BPD severity reached the MIREDIF-defined cut-off for a clinically meaningful improvement. Subgroup analyses found no evidence of a difference in effect estimates between the different types of therapies (compared to TAU) . The pooled analysis of psychotherapy versus waiting list or no treatment found significant improvement on BPD severity, psychosocial functioning and depression at end of treatment, but these findings were based on low-quality evidence, and the true magnitude of these effects is uncertain. No clear evidence of difference was found for self-harm and suicide-related outcomes. However, compared to TAU, we observed effects in favour of DBT for BPD severity, self-harm and psychosocial functioning and, for MBT, on self-harm and suicidality at end of treatment, but these were all based on low-quality evidence. Therefore, we are unsure whether these effects would alter with the addition of more data.

Acute psychiatric care for pediatric patients

Higher level or acute psychiatric care for youth is intended to be active but short-term treatment focussing on crisis stabilisation, assessment, safety monitoring, and longer-term treatment planning. The focus of this article is on describing common challenges and the effort to address these challenges through new approaches to acute psychiatric care for children and adolescents. The review finds that (1) inpatient paediatric psychiatry beds are in high demand and often difficult to access, (2) there are a number of common challenges these units face including managing length of stays, readmissions, and adverse events, and (3) there are encouraging therapeutic approaches adapted for this setting. There is still much work to be done to advance the evidence-base for acute psychiatric care for youth particularly in defining and assessing an effective admission. Paediatric psychiatry patients are a vulnerable population and call for our best tools to be put to use to improve the quality and safety of care.

Dialectical Behavior Therapy Decreases Depressive Symptoms Among Adolescents in an Acute-Care Inpatient Unit

Objective: Research has shown that dialectical behavior therapy (DBT) is an effective treatment modality to decrease suicidal ideation, incidents of nonsuicidal self-injurious behavior, and suicide attempts in an adolescent outpatient population. However, research on the impact of DBT on depressive and manic symptoms for adolescents and within an inpatient setting is limited. The purpose of this study is to examine whether DBT significantly decreases depressive and manic symptoms compared with treatment as usual (TAU) for inpatient adolescents. Method: We conducted a retrospective chart review for adolescents receiving inpatient DBT and for a historical control group on the same unit before DBT (i.e., TAU). Group differences for continuous outcomes were analyzed using analysis of covariance (ANCOVA), where discharge scores for Hamilton Depression Rating Scale (HAMD), Young Mania Rating Scale (YMRS), Clinical Global Impressions-Severity for Symptoms (CGI-S), and Dynamic Appraisal of Situational Aggression (DASA) were predicted by treatment condition (i.e., DBT and TAU) while co-varying for admission scores and using a t test for CGI-Improvement (CGI-I) in functioning, which was administered upon discharge. Results: Patients who received DBT had significantly lower HAMD scores, F(1, 409) = 5.272, p = 0.022, η_p² = 0.013, and lower CGI-I scores, t(596) = 2.50, p = 0.00 upon discharge when controlling for admission scores, compared with patients who received TAU. ANCOVAs showed no significant differences on the YMRS, CGI-S, or DASA between the DBT and TAU groups. Conclusion: DBT on an acute-care inpatient unit for adolescents seems to significantly decrease depressive symptoms during a relatively short period of time compared with TAU. DBT may be an effective treatment modality to decrease depressive symptoms for acute-care inpatient units for adolescents.

Diagnosis and Treatment of Borderline Personality Disorder in Young People

PURPOSE OF REVIEW

We review recent research concerning the diagnosis and treatment of borderline personality disorder (BPD) in young people. We examine evidence for the need to define an appropriate age for detection, and the suitability of current classification methods and treatment.

RECENT FINDINGS

Evidence supports early detection and intervention for subsyndromal borderline pathology or categorical BPD across an extended developmental period. A range of structured treatments are effective for BPD in young people, although the role of treatment components in successful outcomes is unclear. Substantial evidence suggests that a stronger focus on functional outcomes, especially social and vocational outcomes, is warranted. Effective treatments for BPD are rarely available internationally. There is a need to assess whether less complex interventions might be developed that are scalable across health systems. A clinical staging model should be considered, addressing clinical distress and co-occurring psychopathology, as well as diagnosis.

A systematic review of interventions for treatment resistant major depressive disorder in adolescents

To update a comparative effectiveness review (1980-2011) of treatments for adolescents whose depressive episode or disorder (MDE/MDD) did not respond to one or more trials of SSRI antidepressants. MEDLINE, Cochrane Central, PsychINFO, Cochrane Database of Systematic Reviews, EMBASE, CINAHL, and AMED were searched in addition to the grey literature. We spanned May 2011 to September 1, 2017 and included only articles in English. 11 new studies were reviewed based on the criteria of having tested a comparative treatment in adolescents with MDD or MDE who were confirmed to have failed one or more SSRI trials. Data were extracted using standardized forms and a reference guide in DistillerSR; a second reviewer verified the accuracy of the data fields and discrepancies were resolved by consensus. One trial (N = 29) found a small benefit of escalating doses of fluoxetine and the treatment of adolescent depression study (TORDIA, N = 334) found significant benefits of combined SSRI or venlafaxine treatment with CBT for most outcomes. No new studies were identified since the previous review (2012). One trial is currently registered that will be a cross over trial of rTMS; other registered trials are open label. Multiple secondary data analyses of TORDIA have identified important predictors of treatment response and relapse. No new comparative studies were identified since the original review. Trials are desperately needed to identify new treatments for youth with SSRI resistant MDD. These youth should not be deemed as treatment resistant until completing one or two failed trials of SSRI combined with evidence-based psychotherapy.

Dialectical behavioral therapy for the treatment of adolescent eating disorders: a review of existing work and proposed future directions

Over the past several decades, Dialectical Behavior Therapy (DBT) has been adapted for a range of presenting problems related to emotion dysregulation. Considerable enthusiasm exists regarding the use of DBT for treating eating disorders; however, to date, there have been no reviews summarizing empirical efforts to adapt DBT for eating disorders in youth. Accordingly, in the present narrative review, we provide a comprehensive summary of existing work testing DBT for adolescent eating disorders. First, we briefly review existing work applying DBT to eating disorders in adults and general adolescent samples. We then review research focused specifically on the use of DBT for adolescent eating disorders, including both those studies applying DBT as the primary treatment and investigations of DBT as an adjunctive treatment. Overall, initial results for DBT-based approaches are promising. However, rigorous empirical work testing DBT for treating adolescent eating disorders remains limited; the majority of existing research is comprised of case series and small-scale studies. Therefore, we close with specific recommendations for future research testing this approach.

Adolescent Suicide Attempt Prevention: Predictors of Response to a Cognitive-Behavioral Family and Youth Centered Intervention

OBJECTIVE

Suicide is a leading cause of adolescent death. Recent data support the efficacy of cognitive-behavioral treatments with strong family components for reducing suicide risk; however, not all youth benefit from current interventions. Identifying predictors of treatment response can inform treatment selection and optimize benefits.

METHOD

This study examines predictors of response to a DBT-informed cognitive-behavioral family treatment (SAFETY), among 50 youth with recent suicide attempts/self-harm. Youth and parents were assessed at baseline and post-treatment.

RESULTS

Results indicated medium-to-large effect sizes for SAFETY on youth suicidal behavior (SB; defined as suicide attempts, aborted attempts, and planning), depression, hopelessness, social adjustment, and parental depression. Classification tree analysis, with a correct classification rate of 93.3%, and follow-up logistic analyses indicated that 35% of youths reporting active SB at baseline reported active SB at post-treatment, whereas post-treatment SB was rare among youths whose active suicidality had resolved by the baseline assessment (5%). Among youths reporting baseline SB, those endorsing sleep problems were more likely to report post-treatment SB (53%) versus those without sleep problems (0%).

CONCLUSIONS

These findings highlight the potential value of personalized treatment approaches based on pretreatment characteristics and the significance of baseline SB and sleep problems for predicting treatment response.

An evaluation of the skills group component of DBT-A for parent/guardians: a mixed methods study

OBJECTIVES

Previous research indicates that dialectical behaviour therapy for adolescents (DBT-A) is effective in treating emotionally dysregulated adolescents with self-harm and/or suicidal ideation. As part of the DBT-A programme, parents attend the weekly skills group with their child. However, few studies have evaluated parental outcomes in DBT-A. This multi-site study aims to explore the outcomes and experiences of parents who participated in a 16-week DBT-A programme in Ireland.

METHODS

This study was conducted in community-based child and adolescent mental health services (CAMHS) in the national public health system in Ireland. Participants were parent/guardians of adolescents attending a DBT-A programme in their local CAMHS. Participants attended the group skills component of the DBT-A programme. This study utilised a mixed methods approach where both quantitative and qualitative data were collected from participants. Self-report measures of burden, grief and parental stress were completed at pre-intervention, post-intervention and 16-week follow-up. Qualitative written feedback was obtained at post-intervention. The data were analysed using multi-level linear mixed-effects models and content analysis.

RESULTS

One hundred participants (76% female) took part in this study. Significant decreases were reported for objective burden, subjective burden, grief and parental stress from pre- to post-intervention (p < 0.01). Participants reported that the skills component of DBT-A was useful in meeting their own needs and the needs of their child.

DISCUSSION

DBT-A shows promise for parents as well as their adolescent child. Future studies should evaluate changes to family relationships following completion of the programme and also include controlled comparison groups.

Evidence-Based Interventions for Youth Suicide Risk

PURPOSE OF REVIEW

To review and discuss recent advances in evidence-based interventions (EBIs) for youth suicide risk.

RECENT FINDINGS

There is a growing body of research on the effectiveness of interventions targeting suicidal ideation and behavior among adolescents. Dialectical Behavioral Therapy-Adolescent has shown effectiveness across two independent randomized controlled trials (RCTs). Several other interventions have shown effectiveness in only one trial and are in need of replication. New interventions are also being developed that incorporate developments in technology and adaptive intervention designs. It is recommended that future research focus on strategies for engaging underserved youth with interventions, consider the broader needs of youth living in poverty, and further tailor interventions to subgroups with distinct risk profiles. Limited EBIs exist for preadolescents, despite evidence for an increasing rate of suicidal behavior for these youth. Several interventions for youth suicide risk are highly promising, but further investigation is necessary. EBIs that are effective for preadolescents are needed, and greater efforts to tailor interventions for distinct subgroups of youth at risk are recommended.

Bipolar depression: a major unsolved challenge

Depression in bipolar disorder (BD) patients presents major clinical challenges. As the predominant psychopathology even in treated BD, depression is associated not only with excess morbidity, but also mortality from co-occurring general-medical disorders and high suicide risk. In BD, risks for medical disorders including diabetes or metabolic syndrome, and cardiovascular disorders, and associated mortality rates are several-times above those for the general population or with other psychiatric disorders. The SMR for suicide with BD reaches 20-times above general-population rates, and exceeds rates with other major psychiatric disorders. In BD, suicide is strongly associated with mixed (agitated-dysphoric) and depressive phases, time depressed, and hospitalization. Lithium may reduce suicide risk in BD; clozapine and ketamine require further testing. Treatment of bipolar depression is far less well investigated than unipolar depression, particularly for long-term prophylaxis. Short-term efficacy of antidepressants for bipolar depression remains controversial and they risk clinical worsening, especially in mixed states and with rapid-cycling. Evidence of efficacy of lithium and anticonvulsants for bipolar depression is very limited; lamotrigine has long-term benefit, but valproate and carbamazepine are inadequately tested and carry high teratogenic risks. Evidence is emerging of short-term efficacy of several modern antipsychotics (including cariprazine, lurasidone, olanzapine-fluoxetine, and quetiapine) for bipolar depression, including with mixed features, though they risk adverse metabolic and neurological effects.

Efficacy of Dialectical Behavior Therapy Versus Treatment as Usual for Acute-Care Inpatient Adolescents

OBJECTIVE

Dialectical behavior therapy (DBT) is an evidence-based treatment that targets suicidal behavior and nonsuicidal self-injury (NSSI) and has been adapted for adolescents. Given the seriousness of these behaviors, many adolescents are psychiatrically hospitalized, but minimal research has been conducted on specific interventions during hospitalization. The goal of this study was to evaluate DBT versus treatment as usual (TAU) for adolescents on an acute-care psychiatric inpatient unit.

METHOD

We conducted a retrospective chart review for adolescents receiving inpatient DBT (n = 425) and for a historical control group treated on the same unit before DBT (ie, TAU, n = 376). Both χ² and t tests were conducted as preliminary analyses to examine differences between groups on diagnosis, sex, and age. Mann-Whitney U tests were conducted to examine differences between groups on outcome variables. The potential benefit of cost savings was analyzed.

RESULTS

Patients who received DBT had significantly fewer constant observation (CO) hours for self-injury; incidents of suicide attempts and self-injury; restraints; and days hospitalized compared to patients who received TAU. Statistically significant differences were not found between DBT and TAU groups for number of CO hours for aggression, incidents of aggression toward patients or staff, seclusions, or readmissions. A cost analysis determined that $251,609 less was spent on staff time for CO hours with DBT compared to TAU.

CONCLUSION

Results provide support for the implementation of DBT in an acute-care adolescent psychiatric inpatient unit for adolescents. Clinical implications, study limitations, and future research directions are discussed.

Editorial: Evaluating the Clinical and Financial Outcomes of Implementing Dialectical Behavior Therapy on a Psychiatric Inpatient Unit: A Change in Practice and Culture

Applying and evaluating evidence-based treatments (EBTs) across the mental health care continuum continues to gain support and cultivate strategies for development, training, implementation, and evaluation.¹ However, there is a disconnect between science and practice, resulting in limited implementation of EBTs in real-world clinical settings, such as outpatient care, partial hospitalization programs, intensive outpatient programs, psychiatric inpatient hospitalization, and residential care. Although some EBTs and associated interventions have been evaluated in outpatient settings, few have been evaluated in acute and intense treatment settings (eg, partial hospitalization programs, inpatient hospitalization).

Does treatment method matter? A meta-analysis of the past 20 years of research on therapeutic interventions for self-harm and suicidal ideation in adolescents

BACKGROUND

Self-harm is a clinically relevant and prevalent behaviour which peaks in adolescence. Given the high prevalence of self-harm, the high levels of psychiatric comorbidity, and its role as a risk factor for suicide, delivering evidence-based care is critical.

METHODS

We conducted a systematic review and meta-analysis of the literature on treating self-harm in adolescents (12-19 years) published in the last 20 years, identifying 25 randomised controlled trials. We calculated the effect of treatment interventions relative to active control conditions in reducing self-harm, suicidal ideation and depressive symptoms.

RESULTS

Overall, treatment interventions fared slightly better than active controls in decreasing self-harm (d = 0.13, 95% CI 0.04-0.22, p = .004), suicidal ideation (d = 0.31, 95% CI 0.12-0.50, p = .001) and depressive symptoms (d = 0.22, 95% CI 0.07-0.38, p = .006). Subgroup analysis of specific therapies revealed moderate effects of DBT-A in reducing self-harm (d = 0.51, 95% CI 0.18-0.85, p = .002) and suicidal ideation (d = 0.48, 95% CI 0.17-0.80, p = .003), as well as moderate effects of family-centred therapy in the treating suicidal ideation (d = 0.58, 95% CI 0.01-1.15, p = .049).

CONCLUSIONS

The findings of our meta-analysis indicate that, overall, currently available treatments are effective in treating self-harm, suicidal ideation, and depressive symptoms in adolescence. Although the treatment intervention conditions showed only small to moderate effects in comparison to active controls, these differences were statistically significant and are clinically important. Further research is needed to understand the reduction in self-harm within active controls, which may arise due to the natural course of self-harm, or the potential efficacy of treatment as usual and enhanced usual care. Given the significant reduction of self-harm in active control conditions, delivering effective care to a large number of adolescents with self-harm may require developing stepped-care models in clinical practice. Expensive and poorly available treatments should be targeted at young people who most need them.

Implementation of Dialectical Behavior Therapy with Suicidal and Self-Harming Adolescents in a Community Clinic

The object of this research was to examine the feasibility and effectiveness of Dialectical Behavior Therapy (DBT) with suicidal and self-harming adolescents treated in a community clinic. A group of 24 adolescents at high risk for suicide were enrolled in 6 months of comprehensive DBT, provided by therapists and trainees at a county-run outpatient mental health clinic serving disadvantaged, ethnic minority clients. Results showed significant pre/post-treatment decreases in suicide attempts, non-suicidal self-injury behaviors (NSSI), and suicidal ideation. Results also showed significant decreases in other suicide risk factors, including emotion dysregulation, depression, impulsivity, BPD symptoms, psychopathology, PTSD symptoms, and substance use, as well as increases in family expressiveness and reasons for living. Treatment retention and satisfaction rates were high. As many youth at risk for suicide will be treated in community settings, findings showing that receiving DBT in a community clinic resulted in significant improvements across a range of suicide risk factors are an important contribution to the adolescent suicide prevention literature.

Psychotherapies for Adolescents with Subclinical and Borderline Personality Disorder: A Systematic Review and Meta-Analysis

BACKGROUND

Evidence regarding the efficacy of psychotherapy in adolescents with borderline personality disorder (BPD) symptomatology has not been previously synthesized.

OBJECTIVE

To conduct a systematic review and meta-analysis of the randomized controlled trials (RCTs) in order to assess the efficacy of psychotherapies in adolescents with BPD symptomatology.

METHODS

Seven electronic databases were systematically searched using the search terms BPD, adolescent, and psychotherapy from database inception to July 2019. Titles/abstracts and full-texts were screened by one reviewer; discrepancies were resolved via consensus. We extracted data on BPD symptomatology, including BPD symptoms, suicide attempts, nonsuicidal self-injury, general psychopathology, functional recovery, and treatment retention. Data were pooled using random-effects models.

RESULTS

Of 536 papers, seven trials (643 participants) were eligible. Psychotherapy led to significant short-term improvements in BPD symptomatology posttreatment (g = -0.89 [-1.75, -0.02]) but not in follow-up (g = 0.06 [-0.26, 0.39]). There was no significant difference in treatment retention between the experimental and control groups overall (odds ratio [OR] 1.02, 95% confidence interval [CI], 0.92 to 1.12, I² = 52%). Psychotherapy reduced the frequency of nonsuicidal self-injury (OR = 0.34, 95% CI, 0.16 to 0.74) but not suicide attempts (OR = 1.03, 95% CI, 0.46 to 2.30).

CONCLUSIONS

There is a growing variety of psychotherapeutic interventions for adolescents with BPD symptomatology that appears feasible and effective in the short term, but efficacy is not retained in follow-up-particularly for frequency of suicide attempts.

Specialized Therapeutic Assessment-Based Recovery-Focused Treatment for Young People With Self-Harm: Pilot Study

Background: Suicide is the second leading cause of death in young people worldwide. Self-harm is the strongest predictor of death by suicide. There is increasing evidence that psychological therapies are efficacious in treating self-harm in adolescents. However, studies so far have predominantly focused on highly selective groups of adolescents and have investigated interventions that require intensive training and considerable expense. Methods: We conducted a pilot study of a novel psychological therapy package, Specialized Therapeutic Assessment-Based Recovery-Focused Treatment (START) that consists of Therapeutic Assessment followed by treatment in one of three modules, depending on adolescents' needs and preferences: Solution Focused Brief Therapy, Cognitive Behavior Therapy (CBT), or Mentalization Based Treatment. Adolescents (12-17) with at least one self-harm episode in the previous 6 months referred for community treatment, who had no intellectual disability, psychosis or autism were eligible for START. The primary outcome measure was the number of self-harm (regardless of suicidal intent) episodes 6 months before and 6 months after commencing START. Secondary outcomes included measures of psychopathology, functional impairment and family satisfaction. Results: Twenty-one consecutively referred adolescents were recruited and 15 received a therapeutic module of START: three received Solution Focused Brief Therapy, nine CBT, and three Mentalization Based Treatment. There was a statistically significant reduction in the number of self-harm episodes from a mean of 7.93 (SD = 12.26) to 1.00 (SD = 1.47), p < 0.02 following START. There was also a significant reduction in self-harm episodes, Revised Children's Anxiety and Depression Scale scores and a statistically significant improvement in Children Global Assessment Scale scores for the CBT group alone. There were no significant differences in any other outcomes. Most families were somewhat or very much satisfied with the intervention. Conclusion: The results show that START was associated with a reduction in self-harm and depression and anxiety symptoms, which could indicate that START should be rigorously studied in a randomized control trial (RCT). However, the model had difficulties in its implementation, with CBT being only module that was offered to enough young people to allow before and after analysis. CBT appears to be the most promising module in treating adolescents with self-harm referred to community mental health services.

Effect of a Motivational Interviewing-Based Intervention on Initiation of Mental Health Treatment and Mental Health After an Emergency Department Visit Among Suicidal Adolescents: A Randomized Clinical Trial

Importance

Emergency department (ED) visits present opportunities to identify and refer suicidal youth for outpatient mental health care, although this practice is not routine.

Objective

To examine whether a motivational interviewing-based intervention increases linkage of adolescents to outpatient mental health services and reduces depression symptoms and suicidal ideation in adolescents seeking emergency care for non-mental health-related concerns who screen positive for suicide risk.

Design, Setting, and Participants

In this randomized clinical trial, adolescents aged 12 to 17 years who screened positive on the Ask Suicide Screening Questions (ASQ) during a nonpsychiatric ED visit at 2 academic pediatric EDs in Ohio were recruited from April 2013 to July 2015. Intention-to-treat analyses were performed from September 2018 to October 2019.

Interventions

The Suicidal Teens Accessing Treatment After an Emergency Department Visit (STAT-ED) intervention included motivational interviewing to target family engagement, problem solving, referral assistance, and limited case management. The enhanced usual care (EUC) intervention consisted of brief mental health care consultation and referral.

Main Outcomes and Measures

Primary outcomes were mental health treatment initiation and attendance within 2 months of ED discharge and suicidal ideation (assessed by the Suicidal Ideation Questionnaire JR) and depression symptoms (assessed by the Center for Epidemiologic Studies-Depression scale) at 2 and 6 months. Exploratory outcomes included treatment initiation and attendance and suicide attempts at 6 months.

Results

A total of 168 participants were randomized and 159 included in the intention-to-treat analyses (mean [SD] age, 15.0 [1.5] years; 126 [79.2%] female; and 80 [50.3%] white). Seventy-nine participants were randomized to receive the STAT-ED intervention and 80 to receive EUC. At 2 months, youth in the STAT-ED group had similar rates of mental health treatment initiation compared with youth in the EUC group as assessed by parent report (29 [50.9%] vs 22 [34.9%]; adjusted odds ratio [OR], 2.08; 95% CI, 0.97-4.45) and administrative data from mental health care agencies (19 [29.7%] vs 11 [19.3%]; adjusted OR, 1.77; 95% CI, 0.76-4.15). At 2 months, youth in the STAT-ED group and the EUC group had similar rates of treatment attendance (1 appointment: 6 [9.7%] vs 2 [3.6%]; adjusted OR, 2.97; 95% CI, 0.56-15.73; ≥2 appointments: 10 [16.1%] vs 7 [12.7%]; adjusted OR, 1.43; 95% CI, 0.50-4.11). There were no significant group × time differences in suicidal ideation (F = 0.28; P = .72) and depression symptoms (F = 0.49; P = .60) during the 6-month follow-up period. In exploratory analyses, at 6 months, STAT-ED participants had significantly higher rates of agency-reported mental health treatment initiation (adjusted OR, 2.48; 95% CI, 1.16-5.28) and more completed appointments (t99.7 = 2.58; P = .01).

Conclusions and Relevance

This study's findings indicate that no differences were found on any primary outcome by study condition. However, STAT-ED was more efficacious than EUC at increasing mental health treatment initiation and attendance at 6 months.

Trial Registration

ClinicalTrials.gov identifier: NCT01779414.

Preventing suicide, promoting resilience: Is this achievable from a global perspective?

Suicide continues to be a major health concern globally despite many initiatives to identify risk factors and methods for suicide prevention. We have carried out a detailed narrative review of the literature from 2016 to 2019 using the headings of Personal resilience (P1), People (P2), Places (P3), Prevention (P4), Promoting collaboration (P5), and Promoting research (P6) in order to support an integrated approach to suicide prevention and the promotion of personal and population resilience. We have made 10 key recommendations on how this can be moved forward.

Recent advances in understanding and managing self-harm in adolescents

Adolescent suicide is a serious public health problem, and non-suicidal self-injury (NSSI) is both highly comorbid with suicidality among adolescents and a significant predictor of suicide attempts (SAs) in adolescents. We will clarify extant definitions related to suicidality and NSSI and the important similarities and differences between these constructs. We will also review several significant risk factors for suicidality, evidence-based and evidence-informed safety management strategies, and evidence-based treatment for adolescent self-harming behaviors. Currently, dialectical behavior therapy (DBT) for adolescents is the first and only treatment meeting the threshold of a well-established treatment for self-harming adolescents at high risk for suicide. Areas in need of future study include processes underlying the association between NSSI and SAs, clarification of warning signs and risk factors that are both sensitive and specific enough to accurately predict who is at imminent risk for suicide, and further efforts to sustain the effects of DBT post-treatment. DBT is a time- and labor-intensive treatment that requires extensive training for therapists and a significant time commitment for families (generally 6 months). It will therefore be helpful to assess whether other less-intensive treatment options can be established as evidence-based treatment for suicidal adolescents.

Practitioner Review: Treatment for suicidal and self-harming adolescents - advances in suicide prevention care

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

Current evidence can guide practitioners in delivering effective care for youth suicide/self-harm risk. Treatments and preventive interventions that address the psychosocial environment and enhance the ability of trusted adults to protect and support youths, while also addressing the psychological needs of youths appear to yield the greatest benefits. Although additional research is needed, our current challenge is to do our best to effectively utilize new knowledge to improve care and outcomes in our communities.