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

Preventing suicide with Safe Alternatives for Teens and Youths (SAFETY): a randomised feasibility trial

BACKGROUND

Suicide attempts are common in youth and have potentially lethal outcomes. Effective treatments targeting suicide attempts are scarce.

OBJECTIVE

To assess the feasibility and preliminary efficacy of a family-based cognitive behavioural treatment relative to an active control for youth with suicidal behaviour.

METHODS

30 youths (93% female; mean (SD) age=14.6 (1.5) years) residing in Sweden with recent suicidal behaviour (last 3 months) and at least one available parent were randomised to 12 weeks of the family-based cognitive behavioural treatment Safe Alternatives for Teens and Youths (SAFETY) or supportive therapy, an active control treatment. Primary endpoint was 3-month post-treatment. Feasibility outcomes included treatment and assessment compliance, adverse events, treatment credibility and treatment satisfaction. Secondary outcomes included suicide attempt, non-suicidal self-injury, anxiety, depression, quality of life and emotion dysregulation.

FINDINGS

Both treatments showed high compliance, satisfaction, credibility and session completion, with few adverse events and dropouts as well as low attrition (7% at primary endpoint). At the primary endpoint, two (14%) participants in SAFETY and four (27%) in supportive therapy had attempted suicide. Non-suicidal self-injury was reduced by 95% (incidence rate ratio=0.05 (95% CI 0.01 to 0.20)) in SAFETY and 69% (incidence rate ratio=0.31 (0.11 to 0.83)) in supportive therapy. Participation in SAFETY, but not in supportive therapy, was associated with moderate-to-large within-group improvements in anxiety and depression (Cohen's d=0.85 [0.33 to 1.40]), quality of life (d=1.01 [0.48 to 1.56]) and emotion dysregulation (d=1.22 [0.45 to 2.03]).

CONCLUSIONS

The results suggest that SAFETY is feasible and promising for youth with suicidal behaviour.

CLINICAL IMPLICATIONS

A large randomised controlled trial is warranted to further examine the efficacy of SAFETY.

TRIAL REGISTRATION NUMBER

NCT05537623.

Nightmares and self-injurious thoughts among clinically acute adolescents: Examining negative affect as a potential mechanism

Nightmares, a specific sleep problem, have been associated with increased risk for suicidal and nonsuicidal self-injurious thoughts, yet mechanisms underlying this relationship remain poorly understood, particularly among adolescents. This study examined negative affect (NA) intensity as a potential mediator between nightmares and self-injurious thoughts in a clinically acute sample of adolescents. Adolescents (N = 86; Mage = 14.30; 48.8% white, 46.51% female) completed an ecological momentary assessment (EMA) study design for 28 days following discharge from acute psychiatric care for suicidal thoughts and behaviors. Daily sleep diaries were used to assess prior night nightmare presence and intensity. EMA was used to assess NA intensity, suicidal thought intensity, and nonsuicidal self-injurious thought intensity multiple times per day. Multilevel structural equation modeling revealed significant between-person mediation effects, whereby adolescents reporting more frequent and intense nightmares exhibited greater NA intensity, which, in turn, was associated with increased suicidal and nonsuicidal self-injurious thought intensity. Mediation effects were not observed at the within-person level, indicating that individual differences, rather than daily fluctuations in nightmares, accounted for these associations. Results identify NA intensity as a person-level mechanism linking nightmares and self-injurious thoughts. Future research should investigate additional mechanisms and employ temporally sensitive designs to clarify dynamic (within-person) processes underlying suicidal and nonsuicidal self-injurious thoughts in adolescents. This study underscores the clinical importance of addressing nightmares and NA intensity in clinically acute adolescents to inform suicide prevention efforts.

Comparative efficacy and acceptability of psychotherapeutic, pharmacological, and combination treatments for non-suicidal self-injury in children and adolescents: a systematic review and network meta-analysis

BACKGROUND

Non-suicidal self-injury (NSSI) is a common and serious injury behavior in children and adolescents, however, its treatment remains controversial. Here, using network meta-analysis (NMA), we compared and ranked all available therapeutic treatment interventions to explore the best treatment strategy for NSSI in children and adolescents.

METHODS

We searched PubMed, Embase, the Cochrane Library and PsycINFO for randomized controlled trials used to reduce the frequency of NSSI in children and adolescents from database inception until Jan. 11, 2025. Primary outcomes were efficacy and acceptability. We estimated summary odds ratios (ORs) with credible intervals (CIs) in random effects models.

RESULTS

We included 28 trials comprising 6496 participants. Dialectical behavior therapy (DBT) was better than other interventions. In subgroup analysis, pharmacotherapy and psychotherapy significantly aggravated the frequency of NSSI in depression (OR = 1.53; 95% CI: 1.10 to 2.14); however, these interventions significantly reduced NSSI in patients with self-harm (OR = 0.53; 95% CI: 0.30 to 0.96). We also found that NSSI was significantly increased in the first 3 months when using SSRIs in treatment but was significantly reduced after 3 months.

CONCLUSION

Psychotherapy seems to be a better choice than pharmacotherapy, especially DBT. DBT was associated with a better reduction in the frequency of NSSI than treatment as usual, with high confidence of evidence. NSSI is frequently used to combat depression symptoms, suggesting that clinicians should pay greater attention to depression symptoms to reduce NSSI, especially in the first 3 months of treatment with SSRIs.

Accuracy of Self-Report Questionnaires and Records-Based Risk Scores to Identify Adolescents' Risk for Self-Harm

OBJECTIVE

This study aimed to evaluate screening strategies for identifying risk for self-harm among adolescents making outpatient health care visits.

METHODS

Health system records were used to identify a prospective cohort of adolescents completing the Patient Health Questionnaire-9 (PHQ-9) at outpatient visits between October 1, 2015, and March 15, 2020, and a retrospective cohort of adolescents experiencing self-harm events (ascertained from health records and state mortality data) during the same period. Self-harm risk scores were computed from health records. Analyses of the prospective sample examined the sensitivity and positive predictive value (PPV) of questionnaires and risk scores, separately and in combination. Analyses of the retrospective sample examined the proportion of self-harm events that could have been detected by different screening strategies.

RESULTS

The prospective sample (N=8,929) included 43,548 questionnaires, with 1,045 questionnaires followed by a self-harm event within 180 days. A score of ≥2 on PHQ-9 item 9 had a sensitivity of 0.37 and a PPV of 0.09 for self-harm within 180 days of a mental health specialty visit, with similar results for primary care visits. In the retrospective sample, 89% of adolescents made a mental health specialty visit or a primary care visit with a recorded psychiatric diagnosis in the 180 days before a self-harm event.

CONCLUSIONS

Responses to PHQ-9 item 9 and risk scores computed from health records accurately identified adolescents needing additional assessment for risk for self-harm. Over 80% of adolescents experiencing self-harm could have been identified by screening during an outpatient health care visit.

Preadolescent Suicidal Thoughts and Behaviors: An Intensive Longitudinal Study of Risk Factors

OBJECTIVE

Dramatic increases in rates of suicidal thoughts and behaviors (STBs) among youth highlight the need to pinpoint early risk factors. This study used intensive longitudinal sampling to assess what the concurrent associations were between risk factors and STB status, how proximal changes in risk factors were related to STB status, and how risk factors prospectively predicted changes in STB status in a preadolescent sample enriched for early childhood psychopathology.

METHOD

A total of 192 participants were included from the Parent-Child Interaction Therapy-Emotional Development (PCIT-ED) Study, a longitudinal study of children with and without preschool depression. Participants 7 to 12 years of age completed a diagnostic interview, followed by 12 months of intensive longitudinal sampling, assessing experiences of suicidal ideation and 11 psychosocial variables with known links to STBs in adolescents and adults. Preadolescents with STB history (high-risk) received surveys weekly, and those without STB history (lower-risk) received surveys monthly.

RESULTS

Female sex, elevated depressive symptoms, greater use of expressive suppression and rumination, emotional clarity, and perceived burdensomeness were uniquely concurrently associated with the likelihood of STB endorsement. Within the high-risk group, (1) increases in depression, expressive suppression, rumination, and perceived burdensomeness, and decreases in positive affect from weekt to weekt+1 were associated with a higher likelihood of a positive STB status at weekt+1; and (2) higher expressive suppression, perceived burdensomeness, and caregiver criticism and conflict at weekt compared to participants' mean levels prospectively predicted increases in the likelihood of a positive STB report from weekt to weekt+1.

CONCLUSION

Psychosocial factors influencing STBs in adolescents and adults also affect preadolescents in day-to-day life. Expressive suppression and perceived burdensomeness consistently emerged as novel risk indicators and potential targets for treatment. In addition, increases in depression, rumination, and caregiver criticism and conflict, as well as decreases in positive affect, might prompt heightened STB screening and assessments for preadolescents with a history of STBs.

PLAIN LANGUAGE SUMMARY

There have been large increases in rates of suicidal thoughts and behaviors (STBs) among youth, highlighting the need to identify early risk factors in preadolescents. Over one year, 192 seven- to 12-year-old Midwestern children, some of whom had a history of STBs, repeatedly reported on several risk factors and occurrence of STBs over the previous week or month. Suppressing one's emotions and feeling like a burden emerged as risk factors and predicted the increased likelihood of the emergence of STBs, suggesting these may be potential targets for treatment. Findings also suggest that increases in depression, rumination, and caregiver criticism and conflict, as well as decreases in positive emotion, should prompt STB screening and assessments for preadolescents with a history of STBs.

DIVERSITY & INCLUSION STATEMENT

We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. While citing references scientifically relevant for this work, we also actively worked to promote sex and gender balance in our reference list.

The Relevance of Generalist Approaches to Early Intervention for Personality Disorder

Significant gains have been made in the treatment of personality disorder among young people. However, effect sizes for evidence-based treatments have been modest, and emerging evidence suggests the potential of generalist approaches to improve outcomes in this population. The aim of this review was to highlight how generalist approaches such as good psychiatric management for adolescents (GPM-A) hold promise for early intervention for personality disorders among young people. The authors discuss recent advances in clinical understanding of the diagnosis and treatment of personality disorder among youths and demonstrate how these advances align with GPM-A. Specifically, the authors show how several of GPM-A's guiding principles-most notably the need for access, common-factor approaches, and a focus on interpersonal hypersensitivity and restoring general functioning-align with these advances. This review suggests that GPM-A provides a timely and promising framework for innovating early interventions for personality disorder among young people.

Sub-groups of emotion dysregulation in youth with nonsuicidal self-injury: latent profile analysis of a randomized controlled trial

Psychological treatments targeting emotion dysregulation in adolescents reduce nonsuicidal self-injury (NSSI) but predicting treatment outcome remains difficult. Identifying sub-groups based on repeated measurements of emotion dysregulation pre-treatment may guide personalized treatment recommendations. We used data from a recent trial evaluating internet-delivered emotion regulation therapy for adolescents with NSSI (n = 138). Latent profile analysis was used to identify sub-groups based on pre-treatment responses on the 16-item version of the Difficulties in Emotion Regulation Scale. The primary outcome was self-rated NSSI frequency during treatment, and secondary outcome was the proportion of participants with no NSSI 1-month post-treatment. Three sub-groups of emotion dysregulation were identified: low variability and low mean (Group 1), low variability and high mean (Group 2), and high variability and low mean (Group 3). Sub-groups did not differ in NSSI frequency during treatment (Group 2 IRR = 1.06 [95% CI 0.49-2.29], p = .88; Group 3 IRR = 1.22 [95% CI 0.31-4.76], p = .77). However, more participants in Group 1 compared to Group 2 abstained from NSSI at 1-month post-treatment (OR = 3.63 [95% CI 1.16-11.33], p = 0.01). Latent profile analysis identified sub-groups predictive of NSSI absence post-treatment, demonstrating clinical utility.

Bibliometric analysis of global research on dialectical behavior therapy from 1987 to 2024

Objective

This study explores researches of dialectical behavior therapy (DBT) in mental health to provide an overview of current knowledge landscape and predict future development trends of DBT.

Method

The bibliometric approach was used in the study. Articles on DBT-related research were retrieved from the Web of Science Core Collection (WoSCC) database up to December 31, 2024, and analyzed using VOSviewer and CiteSpace.

Results

A total of 2,723 articles were analyzed. DBT research has grown significantly since the 1990s, with the United States leading in publication volume, citation impact, and academic collaboration. Research is primarily conducted in developed countries like the United States, the United Kingdom, and Germany, with limited contributions from emerging economies. Cognitive and Behavioral Practice is the most prolific journal in DBT research. Key topics include borderline personality disorder (BPD), suicide, adolescent interventions, forensic psychiatry, and family therapy. Recently, keywords such as "emotion dysregulation" and "mobile phone" have become research hotspots.

Conclusion

DBT research has evolved from early focus areas like BPD and suicide to studies on emotion dysregulation mechanisms and digital interventions. While the United States dominates the field, expanding participation from emerging countries and strengthening global collaboration could advance DBT research and improve mental health accessibility. This bibliometric analysis provides a global perspective and long-term trend insights, highlighting future directions in neurobiological mechanisms, methodological innovation, and technological integration.

Imagining Futures: Evaluation of a blended programme of dialectical behaviour therapy and the creative arts for young women with a history of self-harm

OBJECTIVES

To evaluate an arts-enhanced dialectical behavioural therapy skills group for managing emotions and self-harm, implemented via an innovative public sector/third sector partnership to increase access to care.

DESIGN

This is a pilot mixed-methods study.

METHODS

To assess participant experience in the 'Imagining Futures' programme, we examined self-report questionnaires and qualitative focus group interviews using framework analysis. We collected recruitment, session attendance and programme completion rates. To explore impact, we also report on quantitative psychological outcome measures, including self-harm frequency and overall well-being.

RESULTS

We recruited 45 young women (mean age: 15.9, s.d. = 1.24, range 13.9-18.0 years) with a history of emotional dysregulation, self-harm and other contextual risks who were not receiving support from statutory child and adolescent mental health services in the United Kingdom. Participants were 22% not in education, employment or training and 77% were from United Kingdom racially minoritized backgrounds. The overall completion rate was 62% (n = 28/45). Qualitative data analysed from respondents (n = 25/28 young people and n = 12 parents) suggested high levels of satisfaction with the project. Thirteen themes were identified which described service elements perceived to support engagement and observed impact. There was an important role for relationships and the creative components. Quantitative clinical data indicated reductions in the frequency of self-harming, significant reductions in the perceived impact of difficulties and increased perceived social support.

CONCLUSIONS

This novel delivery of a DBT skills group, incorporating blended psychology arts activities, has the potential to support engagement with psychological supports that improve mental well-being.

A scoping review of suicide prevention interventions for Latinx adults: strategies, gaps, and future directions

Suicide rates among Hispanic/Latina/o/x (Latinx) individuals in the United States have escalated significantly, becoming the fifth leading cause of death by 2020. This trend underscores the necessity for culturally responsive suicide prevention (SP) interventions tailored to Latinx persons' unique sociodemographic characteristics. We synthesized the current literature on suicide prevention (SP) interventions for U.S. Latinx adults (18+ years). Our objective is to identify strategies, culturally sensitive approaches, and interventions that mitigate suicidal ideation, attempts, and deaths among Latinx adults. Following PRISMA guidelines, we conducted a comprehensive search across six electronic databases (CINAHL Complete, PubMed, PsycINFO, SocAbstracts, Sociology Database, and Web of Science), focusing on peer-reviewed articles published between 2000 and 2024 that described or evaluated SP approaches for Latinx adults (ages 18-64) in the United States. The review was structured according to the 2022 CDC Suicide Prevention Resources for Action, Strategies and Approaches to Suicide Prevention. Our search produced 4,739 articles, of which 155 were included for full-text review. During full-text review, 34 articles were included for the final sample. We randomly selected 10 articles and coded them to check for inter-rater reliability (r = 0.90). Analysis revealed that most SP interventions for U.S. Latinx adults align with the CDC strategy to "Identify and Support People at Risk." The majority targeted late adolescents and early adults at the individual level. The predominant cultural adaptation was the translation of existing SP interventions into Spanish. These findings highlight the pressing need for more culturally responsive Latinx SP interventions that address other CDC strategies at the community and structural levels. Future research and intervention development should focus on creating comprehensive, culturally nuanced approaches that extend beyond individual-level interventions and language translation to address the complex factors contributing to Latinx adults' suicide risk.

The association of family functioning and suicide in children and adolescents: positive behavior recognition and non-suicidal self-injury as sequential mediators

Background

Suicide is a major behavioral issue among children and adolescents, and family functioning potentially influencing its occurrence. Furthermore, positive behavior recognition, as a key component of positive youth development, may act as a mediating factor in the relationship between family functioning and suicide. Non-suicidal self-injury (NSSI) often co-occurs with suicide and may also mediate the impact of family functioning on suicide. Therefore, the aim of this study is to examine the role of family functioning in child and adolescent suicide, with positive behavior recognition and NSSI serving as sequential mediating factors.

Methods

The participants in this study were recruited from the Chengdu Positive Child Development (CPCD) cohort study. The analysis was based on the second round of cross-sectional data from the CPCD cohort. They were required to complete questionnaires that included measures of family functioning, suicide, positive behavior recognition, and NSSI. SPSS 26.0 and Mplus 8.3 were used for descriptive statistical analysis, correlation analysis and mediation effect analysis.

Results

A total of 8,124 participants completed the questionnaires, with an average age of 11.00 ± 2.18 years. The sample comprised 4,195 male and 3,929 female participants. The findings indicate that 17.93% of children and adolescents reported suicide thoughts, 10.06% had formulated suicide plans, and 8.64% had attempted suicide. Poor family functioning shows a significant positive correlation with suicide (r = 0.322, p < 0.01). The multiple mediation effect of positive behavior recognition and NSSI in the association between family functioning and suicide was statistically significant (β = 0.034, 95% CI = 0.027, 0.042).

Conclusion

This study found that poor family functioning is a risk factor for suicide in children and adolescents, with positive behavior recognition and non-suicidal self-injury acting as sequential mediating factors.

Differential patterns of emotion regulation in sexual minority adolescents in residential treatment

OBJECTIVE

Sexual minority adolescents experience disproportionate mental health problems, including increased anxiety, depression, and suicidal thoughts and behaviors. Minority Stress Theory posits that sexual minority people experience significantly more stress (e.g., via discrimination or prejudice) in their everyday lives, which can underlie these mental health disparities. Though group differences in mental health symptoms are well-documented, there has been less focus on symptom trajectories, which is critical for identifying effective mental health interventions.

METHOD

Seventy adolescents ages 13-19 years enrolled in a short-term, acute residential psychiatric treatment program provided self-report measures of depressive symptoms, anxiety, and emotion regulation difficulties at baseline, discharge (∼2 weeks), and one-month post-treatment follow-up. Adolescents self-reported sexual orientation and were stratified into sexual minority (SM, n = 37) or heterosexual (n = 33) groups.

RESULTS

Depressive and anxiety symptoms and emotion dysregulation scores were significantly reduced at follow-up, compared to baseline. While there were no significant group x time interactions for depressive and anxiety symptoms, the SM group entered the program with worse emotion dysregulation scores, which improved more over time compared to the heterosexual group.

CONCLUSION

These findings show that although sexual minority individuals can make substantial gains during residential treatment, emotion regulation difficulties are a particularly relevant treatment target. Emotion regulation, a transdiagnostic construct that typically develops substantially during adolescence, might be of critical importance when identifying effective treatment interventions for sexual minority youth.

LIMITATIONS

Adolescents in this sample demonstrated limited racial diversity and likely displayed a higher degree of psychopathology than the general population.

Paved with good intentions: How our systems intersect to create health disparities for multiply marginalized youth

BACKGROUND

Youth who hold multiply marginalized identities often experience barriers in accessing care following psychiatric hospitalization METHODOLOGY: The following commentary piece shares a case amalgamation from a multidisciplinary gender clinic in a tertiary care children's hospital which illustrates the myriad of ways that our current mental healthcare systems fail to connect youth efficiently and effectively to the evidence-based, culturally relevant, and affirming care that they require, particularly youth experiencing overlapping systems of discrimination and disadvantage.

CONCLUSIONS

This piece highlights the inaccessibility of dialectical behavior therapy for multiply marginalized youth, and outlines suggestions for improving access to high-quality care for minoritized youth engaging in suicidal behavior.

A Quality Improvement Initiative to Decrease Behavioral Health Unit Readmission Rates

OBJECTIVE

Youth behavioral health inpatient beds are limited during a time of crisis. Around one-third of youth admitted to a behavioral health unit (BHU) will be readmitted within 1 year of discharge, with 8% to 13% being admitted within 30 days. In one study, they found that more than one-third of patients initially admitted for suicidal ideation or attempt were readmitted within 7 days. Our objective was to decrease 7-day and 30-day readmission rates to our BHU by 20% by May of 2023.

METHODS

We collected baseline data through medical record review for our pediatric BHU readmissions from July 2020 until July 2021. Interventions, such as standardized workflows and checklists, were trialed with Plan-Do-Study-Act (PDSA) cycles beginning October 2021 until November 2022. Performance was analyzed using statistical process control charts (U-charts). Sustainment was tracked through December 2023. Length of stay (LOS) was tracked as a balancing measure. Compliance with our readmission checklist was tracked as a process measure.

RESULTS

Both 7-day and 30-day readmission rates to the pediatric BHU decreased as interventions were initiated and adopted. The rates of patients readmitted within 7 and 30 days decreased from a baseline mean of 5.54 to 2.83 (49%) and 11.52 to 7.38 (36%) per 100 hospitalizations, respectively. The LOS for the BHU decreased from 5.58 to 5.09 days. The readmission checklist was used for 81 out of 83 patients, or 97.5%.

CONCLUSION

Adoption of multiple interventions produced a decrease in readmissions to a pediatric BHU.

Sertraline medications plus dialectical behavior therapy for depressed adolescents with nonsuicidal self-injury behaviors

OBJECTIVE

The study aims to investigate the efficacy of sertraline medication plus dialectical behavior therapy (DBT) in reducing nonsuicidal self-injury (NSSI) behavior and depression among adolescents.

METHODS

Participants were 100 adolescents with depression and NSSI behaviors, 50 of whom received sertraline medication plus DBT and 50 of whom received sertraline medication plus cognitive behavioral therapy (CBT) for 12 weeks.

RESULTS

During 6 months post intervention, 26 (57.8%) participants did not report having engaged in any form of NSSI in the sertraline + DBT group and 15 (32.6%) in the sertraline + CBT group, showing significant difference. The sertraline + DBT group and the sertraline + CBT group exhibited significant difference regarding the proportions of cutting skin and biting self. The scores of anxiety, depression, aggression against self in four modified overt aggression scale categories, and Personal and Social Performance were notably lower in the sertraline + DBT group than those in the sertraline + CBT group at 6 months post intervention.

CONCLUSION

Sertraline medication plus DBT could decrease NSSI episodes and improve symptoms of anxiety and depression for adolescents, and these changes were comparable to those of CBT. More importantly, DBT was demonstrated better clinical improvements at 6-month follow-up.

A Latent Profile Analysis of Psychosis Symptoms to Examine Distress and Depression as Pathways to Suicide Ideation Among Individuals in an Early Phase of Psychosis Illness

BACKGROUND

Suicide rates are high among individuals in first episode psychosis and there is a critical need to better understand drivers of suicide risk to inform treatment efforts. This study identified profiles of psychosis symptoms and examined a mediation model of depression and distress as mechanisms in the relationships between psychosis symptoms and suicide ideation by latent profiles.

METHODS

Data were obtained from the Human Connectome Project for Early Psychosis (n = 166) of individuals between 16 and 35 years of age who had onset of affective or non-affective psychosis within 5 years of consent. Data were analysed using Latent Profile Analysis (LPA) and Structural Equation Modelling in MPlus.

RESULTS

LPA revealed the following groups: (1) relatively lower and more balanced levels of symptoms, (2) highest positive and general symptoms and (3) highest negative symptoms. Findings indicated the relationships in the model differed between by LPA groups. Distress and depression functioned as mediators between psychosis symptoms and suicide ideation for Groups 1 and 2.

CONCLUSIONS

A better understanding of the roles that distress and depression play in the relationships between psychosis symptoms and suicide ideation can help inform modifiable targets of early intervention and subsequently decrease risk for suicide.

Toward improved understanding and treatment of self-injurious behaviors in autistic individuals with profound intellectual disability

Self-injurious behaviors (SIB) commonly occur in autism spectrum disorder (ASD) and span diverse topographies of self-inflicted behaviors ranging from head banging to hitting oneself against hard objects. Despite the high rates of SIB in autistic individuals, relatively little research has focused on psychological factors associated with the development and maintenance of SIB in individuals with autism and moderate-profound intellectual disability (ID). This commentary synthesizes existing literature on SIB and highlights the need for more research focused on psychological correlates and mechanisms in autistic individuals with moderate-profound ID. We highlight the key role of difficulties in emotion regulation (ER) and co-occurring internalizing symptoms in the manifestation of self-harm behaviors in clinical samples and autism. Furthermore, this commentary proposes a framework for understanding the interplay between poor ER and internalizing symptoms in the development and maintenance of SIB in autistic individuals with moderate-profound ID. Specifically, we explore the emergence of SIB in the context of precipitating cues that trigger strong emotions, ER processes and strategy deployment, and co-occurring internalizing symptoms. Future directions and implications for longitudinal research, measurement development, and clinical treatments are discussed.

Systematic Review and Individual Participant Data Meta-analysis: Reducing Self-harm in Adolescents: Pooled Treatment Effects, Study, Treatment, and Participant Moderators

OBJECTIVE

Self-harm is common in adolescents and a major public health concern. Evidence for effective interventions that stop repetition is lacking. This individual participant data (IPD) meta-analysis of randomized controlled trials (RCTs) aimed to provide robust estimates of therapeutic intervention effects and explore which treatments are best suited to different subgroups.

METHOD

Databases and trial registers to January 2022 were searched. RCTs compared therapeutic intervention to control, targeted adolescents ages 11 to 18 with a history of self-harm and receiving clinical care, and reported on outcomes related to self-harm or suicide attempt. Primary outcome was repetition of self-harm 12 months after randomization. Two-stage random-effects IPD meta-analyses were conducted overall and by intervention. Secondary analyses incorporated aggregate data from RCTs without IPD.

RESULTS

The search identified 39 eligible studies; 26 provided IPD (3,448 participants), and 7 provided aggregate data (698 participants). There was no evidence that interventions were more or less effective than controls at preventing repeat self-harm by 12 months in IPD (odds ratio 1.06 [95% CI 0.86, 1.31], 20 studies, 2,949 participants) or IPD and aggregate data (odds ratio 1.02 [95% CI 0.82, 1.27], 22 studies, 3,117 participants) meta-analyses and no evidence of heterogeneity of treatment effects on study and treatment factors. Across all interventions, participants with multiple prior self-harm episodes showed evidence of improved treatment effect on self-harm repetition 6 to 12 months after randomization (odds ratio 0.33 [95% CI 0.12, 0.94], 9 studies, 1,771 participants).

CONCLUSION

This large-scale meta-analysis of RCTs provided no evidence that therapeutic intervention was more, or less, effective than control for reducing repeat self-harm. Evidence indicating more effective interventions in youth with 2 or more self-harm incidents was observed. Funders and researchers need to agree on a core set of outcome measures to include in subsequent studies.

STUDY PREREGISTRATION INFORMATION

Reducing Self-harm in Adolescents: An Individual Participant Data Meta-analysis; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=152119.

Mortality in adolescents after therapeutic intervention for self-harm: A systematic review and meta-analysis

Background

Self-harm in adolescents is an international concern. Evidence highlights that therapeutic intervention (TI), such as cognitive behaviour therapy informed treatments, after self-harm leads to reduced self-harm repetition. However, there is no prior literature about the effects of TI on future mortality in adolescents. We examined the effect of TI on mortality rates in adolescents across RCTs.

Methods

This review was reported in accordance with PRISMA guidance. MEDLINE, EMBASE, PsycINFO, and Cochrane Library were searched to 19 June 2024. Two authors independently screened titles, abstracts, and full texts against predefined criteria. RCTs were included if they compared a TI versus a comparator in adolescents up to 18 years with at least one prior self-harm episode. There was no lower age limit. For the pooled effect size of mortality, the DerSimonian-Laird method was used, and a random effects model for self-harm and suicide attempts. The primary outcome was intra or post-trial mortality in adolescent post TI, and the effect of TIs on self-harm including attempted suicide episodes were secondary outcomes. Analyses were done in Stata.

Results

Twenty-four trials of TIs consisting of 3470 randomised adolescents were included. The pooled risk difference for mortality of participants in the TI group was 0.002 (95% CI -0.003 to 0.008, p = 0.42). There were 6 deaths in the TI group compared to 15 deaths in the comparator group. The pooled risk difference for TI on repeat self-harm was -0.07 (95% CI -0.132 to -0.007, p = 0.028), and -0.05 (95% CI -0.086 to -0.007, p = 0.022) for suicide attempts compared to comparator.

Conclusions

This review found no significant impact of TIs on future mortality in adolescents. We also demonstrated that TIs can reduce suicide attempts which can lead to substantial benefits for adolescents, families, and clinical services.

Editors' Best of 2024

There is, in the content of the Journal, an embarrassment of riches, and picking a "best" seems to demand a certain qualification: is the "best" the most interesting, most surprising, most educational, most important, most provocative, most enjoyable? How to choose? We are hardly unbiased and can admit to a special affection for the ones that we and the authors worked hardest on, modifying version after version into shape. Acknowledging these biases, here are the 2024 articles that we think deserve your attention or at least a second read.

An emotion regulation skills training for adolescents and parents: perceptions and acceptability of methodological aspects

Introduction

Difficulties with emotion regulation are associated with the development and maintenance of psychiatric symptoms. Focusing on emotion regulation can be beneficial when treating symptoms and behavioral problems. Here we describe a seven-session transdiagnostic approach to regulating emotions, delivered jointly to adolescents and parents in a child and adolescent psychiatric outpatient setting, and we explore the perceptions and acceptability of the methodological aspects of the intervention.

Methods

Quantitative and qualitative data were analyzed. Participants (n = 117) were adolescents and parents.

Results

Participants reported positive attitudes toward the skills training and would recommend it to others. Three overarching themes were developed. "Treatment components" relates to the content of the skills training. Participants appreciated focusing on ER skills but had different perceptions of the content. "The learning climate" contains process-related experiences, such as the skills trainers' approach and the timing of the intervention. Participants preferred when skills trainers used self-disclosure. "Pedagogical aspects", describes the structure of the training with perceptions of group constellations, length of sessions and homework. Adolescents particularly requested variety in the pedagogy and found long sessions to be challenging.

Discussion

Recommendations for therapeutic practices are discussed.

The influence of psychotherapy on individuals who have attempted suicide: A systematic review and meta-analysis

INTRODUCTION

Suicide is a serious global public health issue, and a history of attempted suicide is the most critical indicator of suicide risk. There are limited studies on the effectiveness of psychotherapy in individuals who have attempted suicide, and other outcome measures related to suicide risk in suicide attempts have not been explored.

AIM/QUESTION

This study aimed to systematically review and perform a meta-analysis of the effectiveness of psychotherapy on individuals who have attempted suicide.

METHODS

This study conducted a comprehensive literature search of five major databases (PubMed, EMBASE, Cochrane, Web of Science, and Ovid). The protocol for this study is registered with PROSPERO (CRD42023464401) and follows the PRISMA guidelines.

RESULTS

This meta-analysis included a total of 34 trials from 32 literature sources. The study involved a total of 6600 participants. The results showed that psychotherapy had a positive effect on reducing the suicidal tendencies of individuals who have attempted suicide and effectively reduced the number of repeated suicide attempts as well as the levels of suicidal ideation, depression, anxiety and hopelessness.

IMPLICATIONS FOR PRACTICE

This study concludes that psychotherapy is effective in reducing the suicidal tendencies of individuals who have attempted suicide. Psychological therapy for individuals who have attempted suicide are crucial in preventing future suicidal behaviours.

Seeing adolescents grow from many angles using a multilevel approach: A tribute to the contributions of Dante Cicchetti to the field of developmental psychopathology

Dante Cicchetti propelled forward the field of developmental psychopathology by advancing this framework and championing new methods, including emphasizing the central role that multilevel analysis holds for explicating pathways of risk and resilience. His work continues to change the face of existing science. It has also paved the way for the formation of new projects, like the Research Domain Criteria initiative. This paper uses our laboratory's work on multilevel approaches to studying adolescent depression, non-suicidal self-injury, and suicidal thoughts and behaviors to shine a spotlight on Dr Cicchetti's contributions. In addition, we review recent developments, ongoing challenges, and promising future directions within developmental psychopathology as we endeavor to carry on the tradition of growth in the field.

Considerations for the use of dialectical behavior therapy for individuals experiencing oppression

As the popularity of dialectical behavior therapy (DBT) grows, so does its use with increasingly diverse groups of clients. In this article, we demonstrate that DBT in its standard form can incorporate the sequelae of oppression as a target of treatment by providing clients with skills to identify oppression and its impact while responding effectively. To support the use of DBT with individuals experiencing emotion/behavior dysregulation and oppression, we review how each of the primary strategies of DBT can be used within the context of oppression. Specifically, we discuss how dialectical philosophy, the acceptance/change dialectic, communication strategies, and case management strategies can be viewed through an oppression lens. A brief review of DBT research with historically oppressed populations and common pitfalls in treating oppressed individuals is presented. As research in examining and adapting DBT for minoritized groups continues to catch up to clinical need, guidance is presented here for researchers and clinicians interested in using this empirically supported treatment in communities that experience oppression. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Approaches to Reach Trustworthy Patient Education: A Narrative Review

BACKGROUND

Patient education is a cornerstone of modern healthcare. Health literacy improves health-related quality of life and health outcomes of patients, enhanced by effective patient education. Inadequate competency of patient education in healthcare providers triggered this review to summarize common approaches and recent advancements.

METHODS

This narrative review summarizes common approaches and recent advancements in patient education with their relations to health literacy, their strengths, limitations, and practical issues.

RESULTS

This review highlighted the multifaceted approaches to patient education, emphasizing the importance of tailoring methods to meet the diverse needs of patients. By integrating various strategies, including intrapersonal, interpersonal, and societal/community-level interventions, healthcare providers can create a more comprehensive educational experience that addresses the complexities of patient needs, meanwhile improving the health literacy of patients. With the rise of digital media and artificial intelligence, there is an increasing need for innovative educational resources that can effectively reach and engage patients. Ongoing research and collaboration among healthcare professionals and policymakers will be essential to refine educational strategies and adapt to emerging challenges. It is essential to remain vigilant about potential conflicts of interest that may compromise the integrity of educational content.

CONCLUSION

Effective patient education empowers individuals and their contributions to a healthier society by fostering informed decision-making and encouraging proactive health management.

Dialectical Behavior Therapy Programming for Adolescents: A Systematic Review and Meta-Analysis of Clinical and Implementation Outcomes

OBJECTIVE

The purpose of this systematic review and meta-analysis is to provide an updated examination of the adolescent Dialectical Behavioral Therapy (DBT) literature and synthesize study findings across treatment settings (e.g. inpatient, outpatient, school), and treatment levels (e.g. clinical intervention, targeted, universal prevention). We also provide meta-analytic findings of the impact of DBT across key problem behaviors: depression, emotion dysregulation, suicidal and self-harm behaviors, externalizing problems, and eating disorders.

METHOD

A reference database search was used to identify studies conducted on adolescent DBT interventions from 2000 through 2023 (N = 72). In addition to ensuring that the review process conformed to the PRISMA statement, we independently verified that each study met inclusion criteria before triple coding each article to examine variables of interest and extracted outcome data needed to conduct meta-analyses.

RESULTS

DBT appears to demonstrate effectiveness in improving mental health outcomes in adolescents across a range of psychiatric problems. To meet these treatment needs, DBT interventions have been appropriately adapted based on care setting, suggesting empirical support in inpatient, residential, partial hospitalization, and intensive outpatient programs, as well as in outpatient settings, juvenile correctional facilities, and schools.

CONCLUSIONS

The growing evidence base for adolescent DBT appears to reflect its promise and versatile clinical utility. Clinical implications and recommendations for future directions are discussed, including the need for more randomized controls and representation of diverse communities.

Trajectory of Non-suicidal Self-Injury among adolescents with borderline personality disorder over a 5-year period

BACKGROUND

Engagement in Non-Suicidal Self-Injury (NSSI) is high among adolescents with borderline personality disorder (BPD), but the trajectory of NSSI in the transition period from adolescence to adulthood is unclear, and studies that look at predictors of persistence are highly needed.

METHODS

This study followed 111 adolescents aged 14-17 with BPD over a five-year period to observe the prevalence and predictors of NSSI. Information on NSSI was based on both self-report and clinician-administered interviews.

RESULTS

At the outset, 92.8% reported a history of NSSI, with an average of nearly five different types of NSSI. Despite this high initial prevalence, the rates of NSSI within the past two weeks decreased over time from 48% at baseline to 26% after one year, and further to 10% after two years. After five years, 37% reported engaging in NSSI within the past six months. Notably, all but one participant who reported NSSI after five years had engaged in NSSI already at baseline. The study identified that higher adolescent-rated but lower parent-rated BPD severity was associated with engagement in NSSI at baseline. Furthermore, ongoing NSSI after five years was predicted by lower parent-rated BPD severity and externalizing behaviors.

CONCLUSIONS

NSSI is frequent in the early course of BPD, and persists in more than one-third after five years. Our findings highlight that baseline engagement in NSSI is a risk factor for persistence of NSSI in the transition period into early adulthood. Furthermore, the findings underscore the significance of integrating both adolescent and parent perspectives on BPD pathology in the assessment and management of NSSI.

Adolescent, caregivers, and therapists' experiences of youth and family suicide intervention: A qualitative study

OBJECTIVE

This study explores the experience of an individual and family therapy youth suicide intervention from the perspectives of seven psychotherapy triads (young people aged 12-18, their parents/caregivers and therapists).

METHOD

Data were collected through semi-structured individual interviews and analyzed using consensual qualitative research methods.

RESULTS

Four domains were identified: Focusing on the youth-parent relationship, individual therapy for young people and their parents, conjoint therapy, and public service structures and systemic practice that facilitated tailored treatment. All participant groups valued intervention that improved the youth-parent relationship; however, they held different views about its influence on suicidality and recovery. Separate youth and parent therapy was crucial for facilitating the tailoring of treatment and enhancing the reparative potential of conjoint therapy. Barriers to productive intervention included inaccessible, fragmented, and siloed treatment that excluded parents, stigmatizing clinician responses, and acute care that was not attuned to need or developmental context. Helpful intervention was systemically and attachment-informed, multi-disciplinary, individually tailored, and integrated freely available specialist therapy with crisis and inpatient care.

CONCLUSION

A relational, nuanced, and flexible approach is needed to tailor youth suicide treatment in the context of the complexity of youth-parent relationships.

The State of the Science: Dialectical Behavior Therapy

The first randomized clinical trial of dialectical behavior therapy (DBT) for women with borderline personality disorder was published in 1991. Over the past 30 years, research on DBT has proliferated along with interest by clinicians and the public. In this State of the Science review, we provide a brief description of the treatment paradigm and its conceptual and theoretical underpinnings. We also briefly review the research conducted to date on DBT across populations and settings, the vast majority of which demonstrates that it is effective at treating the behaviors that it targets. We also argue that, although DBT has been established as a "gold-standard" treatment for certain populations and behaviors, there is much more research needed to answer critical questions and improve its efficacy.

Caregiver Involvement in Psychotherapy for Young People With Borderline Personality Disorder and Borderline Personality Disorder Features: A Systematic Review

Caregivers of young people with borderline personality disorder (BPD) or BPD features experience significant burden and distress and often lack effective coping strategies. A family environment of pervasive invalidation can contribute to the disorder and work against effective coping. Consequently, some psychotherapy interventions for young people with BPD or BPD features aim to incorporate caregivers in treatment to varying degrees. This review synthesised results of existing studies that included caregivers in psychotherapy alongside their young person and that examined caregiver outcomes using quantitative measures. The review and literature search were conducted in accordance with PRISMA guidelines. Searches of five databases returned a total of 2988 articles, of which 10 met inclusion criteria and only two of which were RCTs. Seven used a dialectical behaviour therapy approach, two used brief psychoeducation, and one was an online social group. Articles examined changes in caregivers regarding treatment feasibility and satisfaction, emotion communication, perceived knowledge of BPD and caregiver mental health, burden and stress. Although there are few studies and results are limited by considerable methodological limitations, results suggest that including caregivers in treatment alongside young people, even in a brief capacity, may improve caregiver outcomes on several measures. Inclusion of caregivers is conceptually particularly pertinent for BPD for young people, and this review reveals important clinical implications and clear future research directions.

Early remission of deliberate self-harm predicts emotion regulation capacity in adulthood: 12.4 years follow-up of a randomized controlled trial of adolescents with repeated self-harm and borderline features

Emotion regulation capacity, critical for adult functioning and mental health, develops strongly during adolescence in healthy individuals. Deficits in emotion regulation is often referred to as emotion dysregulation [ED] and is associated with various mental health problems, including repeated deliberate self-harm [DSH] which peaks in adolescence. Dialectical Behaviour Therapy for adolescents [DBT-A] systematically targets ED through strategies such as changing coping behaviours and has previously been shown to effectively induce DSH remission in adolescents. However, whether such remission is associated with improved emotion regulation capacity in adulthood, and whether this effect is mediated by changes in use of coping strategies has not been previously studied. Prospective long-term follow-up study of an RCT comparing DBT-A with enhanced usual care [EUC] for adolescents presenting to community child and adolescent psychiatric outpatient clinics with borderline personality features and repeated self-harm. Assessments included both structured interviews and self-report at baseline and 1.6, 3.1 and 12.4 years follow-up. In the final follow-up, adult ED was measured and data were collected for 61 (80%) of the original 77 participants. DSH remission was assessed at 1.6 years follow-up, and use of coping strategies at 3.1 and 12.4 years follow-ups. A mediation analysis was conducted within a causal inference framework. Both treatment groups increased their use of functional coping skills from adolescence to adulthood, while only DBT-A was associated with decreases in dysfunctional coping. There was a direct effect of DSH remission 1 year after treatment on adult ED, particularly for participants who did not receive DBT-A. There was a negative association between reductions in dysfunctional coping and adult ED, however this did not mediate the effect of DSH remission. This is the first study to report that early DSH remission in adolescence predicted lower ED in adulthood. These results highlight the importance of early DSH remission and provides new insight into the long-term relationship between DSH and ED. Clinical trial registration information: "Treatment for Adolescents with Deliberate Self-harm"; http://ClinicalTrials.gov/;NCT00675129.

Psychological interventions for suicidal behavior in adolescents: a comprehensive systematic review

BACKGROUND

Recent evidence indicates that the risk of death by suicide in teenagers has increased significantly worldwide. Consequently, different therapeutic interventions have been proposed for suicidal behavior in this particular population. Therefore, the main objective of this study is to provide an updated review of the existing psychological interventions for the treatment of suicide attempts (SA) in adolescents and to analyze the efficacy of such interventions.

METHODS

A systematic review was conducted following PRISMA guidelines. The studies were identified by searching PubMed, PsychINFO, Web of Science, and Scopus databases from 2016 to 2022. According to the inclusion criteria, a total of 40 studies that tested the efficacy of different psychological interventions were selected.

RESULTS

Various psychological interventions for adolescents with suicidal behaviors were identified. Most of those present promising results. However, to summarize results from recent years, dialectical behavior therapy (DBT) was the most common and the only treatment shown to be effective for adolescents at high risk of suicide and SA. In contrast, empirical evidence for other psychological interventions focusing on deliberate self-harm (SH) is inconclusive.

CONCLUSIONS

Interventions specifically designed to reduce suicidal risk in adolescents have multiplied significantly in recent years. There are a few promising interventions for reducing suicidal behaviors in adolescents evaluated by independent research groups. However, replication and dismantling studies are needed to identify the effects of these interventions and their specific components. An important future challenge is to develop brief and effective interventions to reduce the risk of death by suicide among the adolescent population.

Insights and Reflections on Cognitive Behavioural and Dialectical Behavioural Therapies for Adolescent Self-Harm and Suicidal Behavior

No abstract present.

The role of sleep quality and anxiety symptoms in the association between childhood trauma and self-harm attempt: A chain-mediated analysis in the UK Biobank

BACKGROUND

Childhood trauma is a risk factor for self-harm/suicidal behavior, but research on the potential association linking sleep quality and anxiety symptoms to childhood trauma and self-harm attempt is limited. The aim of this study was to describe the mediating role of sleep quality and anxiety symptoms between childhood trauma and self-harm attempt, and to provide a scientific basis for the prevention of self-harm behaviors.

METHODS

This study ultimately included 11,063 study participants who participated in the baseline survey of this large prospective cohort study of the UK Biobank. We used structural equation modeling (SEM) to analyze the chain mediating role of sleep quality and anxiety symptoms in childhood trauma and self-harm attempt while controlling for covariates.

RESULTS

A total of 19.58 % of study participants self-reported self-harm attempt. Sleep quality was negatively correlated with childhood trauma, anxiety symptoms, and self-harm attempt (p < 0.01). Childhood trauma, anxiety symptoms, and self-harm attempt were positively correlated (p < 0.01). In addition, after adjusting for confounders, anxiety symptoms were able to partially mediate the association between childhood trauma and self-harm attempt (effect value: 0.042, p < 0.01), and sleep quality and anxiety symptoms can chain mediate the association between childhood trauma and self-harm attempt (effect value:0.002, p < 0.01), with a total mediating effect of 65.67 % of the total effect. Subgroup analyses further showed that the mediating effects of sleep quality and anxiety symptoms on childhood trauma and self-harm attempt differed across age, gender, ethnicity, and smoking and drinking subgroups.

CONCLUSIONS

This study found a complex relationship between childhood trauma, sleep quality, anxiety symptoms, and self-harm attempt, with sleep quality and anxiety symptoms mediating the relationship between childhood trauma and self-harm attempt. Multiple avenues of intervention, such as the provision of professional psychological interventions and timely monitoring, should be used to improve the sleep quality and mental health of individuals with traumatic childhood experiences and to prevent the occurrence of emotionally harmful behaviors such as self-harm/suicide.

Randomized effectiveness-implementation trial of dialectical behavior therapy interventions for young people with borderline personality disorder symptoms

OBJECTIVES

Dialectical behavior therapy (DBT) is an evidence-based treatment for people with emerging borderline personality disorder (BPD). In "real world" clinical settings, standard DBT is resource intensive. Emerging evidence suggests that group-based DBT skills training alone can lead to promising outcomes. This hybrid type 1 effectiveness-implementation trial directly compared the effectiveness of an 8-week group DBT-skills training program and a 16-week DBT-informed program including individual treatment and group-based skills training.

METHODS

This pragmatic trial employed a staggered, parallel-groups design. We recruited 104 participants, aged 16-25 years, with emotion dysregulation or emerging BPD symptoms. Participants were randomized to receive either program at a youth mental health service located in the Gold Coast, Australia. Data was collected via online surveys at baseline, 8-week, 16-week, and 24-week follow-up. Mixed effect linear models compared groups on the primary outcomes of emotion dysregulation and BPD symptoms, and secondary outcomes of suicidal ideation, coping skills, depression, anxiety, and stress.

RESULTS

Across groups there were significant and sustained improvements relating to emotion dysregulation, BPD symptoms, stress, depression, and emotion-focused coping; but not suicide risk, anxiety, or task-focused coping. There was no significant time by group differences between the 8-week and 16-week interventions on any primary or secondary outcome.

CONCLUSION

The more intensive mode of delivering DBT was not more effective than the brief group-based skills training. Both interventions resulted in significant improvements across both primary and most secondary outcomes. These results have implications for clinical practice regarding length and intensity of DBT treatment in young people.

Mindfulness-based Neurofeedback: A Systematic Review of EEG and fMRI studies

Neurofeedback concurrent with mindfulness meditation may reveal meditation effects on the brain and facilitate improved mental health outcomes. Here, we systematically reviewed EEG and fMRI studies of mindfulness meditation with neurofeedback (mbNF) and followed PRISMA guidelines. We identified 10 fMRI reports, consisting of 177 unique participants, and 9 EEG reports, consisting of 242 participants. Studies of fMRI focused primarily on downregulating the default-mode network (DMN). Although studies found decreases in DMN activations during neurofeedback, there is a lack of evidence for transfer effects, and the majority of studies did not employ adequate controls, e.g. sham neurofeedback. Accordingly, DMN decreases may have been confounded by general task-related deactivation. EEG studies typically examined alpha, gamma, and theta frequency bands, with the most robust evidence supporting the modulation of theta band activity. Both EEG and fMRI mbNF have been implemented with high fidelity in clinical populations. However, the mental health benefits of mbNF have not been established. In general, mbNF studies would benefit from sham-controlled RCTs, as well as clear reporting (e.g. CRED-NF).

Which Psychosocial Strengths Could Combat the Adolescent Suicide Spectrum? Dissecting the Covitality Model

Objective: Covitality is a meta-construct of positive intra/interpersonal self-schemas that organize and process life experiences. Its synergy favors psychosocial adjustment and prevents mental health problems during adolescence. At these ages, suicide is one of the leading causes of death worldwide. The purpose of this study was to determine which psychosocial strengths of the covitality model could combat adolescent suicide spectrum. Method: Participants were 5,528 Spanish adolescents aged 12-18 years, 50.74% females. The assessment protocol was completed in schools, under the supervision of the research staff. Statistical analyses were conducted using hurdle models, i.e., modeling zero-inflated count data. This process provided two sets of outcomes: the association - in probabilistic terms - between psychosocial strengths and the absence of suicide indicators (i.e., non-occurrence) and the association of these assets - via regression coefficients - with increased experimentation (i.e., duration/quantity). Results: All psychosocial strengths of the covitality model were related to the non-ocurrence of suicidal thoughts and behaviors, but not all to a shorter duration/quantity of their phenotypic manifestations. Covitality obtained greater association values on suicidal tendencies than its components analyzed independently. Belief in self and engaged living were the second-order factors with the higher estimating capacity. Specifically, emotional self-awareness, enthusiasm, gratitude, family support, and behavioral self-control were key first-order assets. Conclusions: These findings suggest that training adolescents in covitality assets could be an effective strategy for universal prevention against premature suicide. Moreover, this study provide evidence on which psychosocial strengths could counteract each phenotypic manifestation of suicide in order to customize selective and indicated preventive actions.

Systematic Review: The Measurement Properties of the Suicidal Ideation Questionnaire and Suicidal Ideation Questionnaire-Jr

OBJECTIVE

The Suicidal Ideation Questionnaire (SIQ) and the Suicidal Ideation Questionnaire-Junior (SIQ-Jr) were designed to capture suicidal ideation in adolescents and are often used in clinical trials. Our aim was to identify and appraise the published literature with respect to the validity, reliability, responsiveness, and interpretability of the SIQ and SIQ-Jr.

METHOD

We conducted a systematic review following COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines to identify, appraise, and synthesize published literature on measurement properties and interpretability of the SIQ and SIQ-Jr. We searched MEDLINE, Embase, APA PsycINFO, CINAHL, Web of Science, and Scopus from inception to May 16, 2023, to identify sources relevant to our aim.

RESULTS

We identified 15 sources meeting our eligibility criteria. The body of literature did not meet COSMIN standards to make recommendations for use with regard to these measurement instruments.

CONCLUSION

Further research is needed, with a focus on content validity and structural validity, prior to recommending the SIQ and SIQ-Jr for use in clinical practice and in clinical trials. No specific grant funding was used for this review.

PLAIN LANGUAGE SUMMARY

In this systematic review, authors analyzed 15 sources examining measurement properties of the Suicidal Ideation Questionnaire and Suicidal Ideation Questionnaire-Jr. Both measures are designed to capture suicidal ideation in adolescents and are used in clinical practice and clinical trials. The authors identified sufficient evidence for convergent validity for both measures. Authors concluded that further research is needed to support content validity, structural validity as a unidimensional scale (as they are often used) as well as their internal consistency, test-retest reliability, discriminative validity, predictive validity, and interpretability of these measures. The authors also emphasize the need to consider the limitations of these measures for researchers studying suicidal ideation and clinicians using these measures in their assessments of young people.

Global public concern of childhood and adolescence suicide: a new perspective and new strategies for suicide prevention in the post-pandemic era

BACKGROUND

Suicide is the second leading cause of death in young people worldwide and is responsible for about 52,000 deaths annually in children and adolescents aged 5-19 years. Familial, social, psychological, and behavioral factors play important roles in suicide risk. As traumatic events such as the COVID-19 pandemic may contribute to suicidal behaviors in young people, there is a need to understand the current status of suicide in adolescents, including its epidemiology, associated factors, the influence of the pandemic, and management initiatives.

DATA SOURCES

We investigated global and regional suicide mortality rates among children and adolescents aged 5-19 years using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. The suicide mortality rates from 1990 to 2019 were examined in 204 countries and territories across six World Health Organization (WHO) regions. Additionally, we utilized electronic databases, including PubMed/MEDLINE and Scopus, and employed various combinations of terms such as "suicide", "adolescents", "youth", "children", "risk factors", "COVID-19 pandemic", "prevention", and "intervention" to provide a narrative review on suicide within the pediatric population in the post-pandemic era.

RESULTS

Despite the decreasing trend in the global suicide mortality rate from 1990 to 2019, it remains high. The mortality rates from suicide by firearms or any other specified means were both greater in males. Additionally, Southeast Asia had the highest suicide rate among the six WHO regions. The COVID-19 pandemic seems to contribute to suicide risk in young people; thus, there is still a strong need to revisit appropriate management for suicidal children and adolescents during the pandemic.

CONCLUSIONS

The current narrative review integrates up-to-date knowledge on suicide epidemiology and the effects of the COVID-19 pandemic, risk factors, and intervention strategies. Although numerous studies have characterized trends in suicide among young people during the pre-pandemic era, further studies are required to investigate suicide during the pandemic and new strategies for suicide prevention in the post-pandemic era. It is necessary to identify effective prevention strategies targeting young people, particularly those at high risk, and successful treatment for individuals already manifesting suicidal behaviors. Care for suicidal children and adolescents should be improved with parental, school, community, and clinical involvement.

Remission, Recovery, Relapse, and Recurrence Rates for Suicide Attempts and Nonsuicidal Self-Injury for Suicidal Youth Treated With Dialectical Behavior Therapy or Supportive Therapy

OBJECTIVE

To evaluate rates of remission, recovery, relapse, and recurrence in suicidal youth who participated in a clinical trial comparing Dialectical Behavior Therapy (DBT) and Individual and Group Supportive Therapy (IGST).

METHOD

Participants were 173 youth, aged 12 to 18 years, with repetitive self-harm (including at least 1 prior suicide attempt [SA]) and elevated suicidal ideation (SI). Participants received 6 months of DBT or IGST and were followed for 6 months post-treatment. The sample was 95% female, 56.4% White, and 27.49% Latina. Remission was defined as absence of SA or nonsuicidal self-injury (NSSI) across one 3-month interval; recovery was defined across 2 or more consecutive intervals. Relapse and recurrence were defined as SA or NSSI following remission or recovery. Cross-tabulation with χ2 was used for between-group contrasts.

RESULTS

Over 70% of the sample reported remission of SA at each treatment and follow-up interval. There were significantly higher rates of remission and recovery and lower rates of relapse and recurrence for SA in DBT than for IGST. Across treatments and time points, SA had higher remission and recovery rates and lower relapse and recurrence rates than NSSI. There were no significant differences in NSSI remission between conditions; however, participants receiving DBT had significantly higher NSSI recovery rates than those receiving IGST for the 3- to 9-month, 3- to 12-month, and 6- to 12-month intervals.

CONCLUSION

Results showed higher percentages of SA remission and recovery for DBT as compared to IGST. NSSI was less likely to remit than SA.

PLAIN LANGUAGE SUMMARY

This study examined rates of remission, recovery, relapse, and recurrence of suicide attempts (SA) and nonsuicidal self-injury (NSSI) among the participants in the CARES Study, a randomized clinical trial of 6 months of Dialectical Behavior Therapy or Individual and Group Supportive Therapy. 173 youth aged 12 to 18 years participated in the study and were followed for 6 months post treatment. Over 70% of the sample reported remission of SA at each treatment and follow-up interval. There were significantly higher rates of remission and recovery and lower rates of relapse and recurrence for SA among participants who received Dialectical Behavioral Therapy. Across both treatments, remission and recovery rates were lower and relapse and recurrence rates were higher for NSSI than for SA. These results underscore the value of Dialectical Behavioral Therapy as a first line treatment for youth at high risk for suicide.

DIVERSITY & INCLUSION STATEMENT

We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants.

CLINICAL TRIAL REGISTRATION INFORMATION

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

CLINICALTRIALS

gov/; NCT01528020.

Suicide Risk Factors in High School Students

In Mexico, suicide has become an important public health problem, representing the third leading cause of death in the adolescent population. Suicidal behavior in adolescents is associated with the interaction of complex relationships between personal, interpersonal, and sociocultural factors. Through a quantitative, descriptive, and correlational cross-sectional study, the present study aimed to analyze the prevalence and risk factors associated with suicidal ideation among adolescents from different high schools of the high school system (SEMS) of the University of Guadalajara, in response to the psychosocial impact of the COVID-19 pandemic. A descriptive statistical analysis was carried out on the data obtained from the 3583 students surveyed, followed by a principal component analysis (PCA) to identify closely related social, emotional, and behavioral variables. The PCA yielded eight principal components, which together represent 75.42% of the variance across psychometric tests. A multiple linear regression analysis was used, with a regression value (R2) of 0.4811, indicating that the explanatory model can predict 48.1% of the variability in suicidal ideation, with a statistical significance level of 0.05. According to the studies conducted, 19% (688 students) showed indicators of high suicide risk and 26.8% (960 students) showed moderate risk. Depression, mental health, health-related quality of life, physical and psychological well-being, and mood and emotions are the most influential factors in suicidal ideation.

The Psychological Experiences of Adolescents Who Engage in Non-Suicidal Self-Injury: A Meta-Aggregative Synthesis of Qualitative Studies

Non-suicidal self-injury (NSSI) is an international public health problem. Qualitative synthesis of the psychological experiences associated with NSSI in adolescents remains limited. This study aimed to systematically review the factors, emotional experiences, coping strategies, and help-seeking experiences of adolescents who engage in NSSI. A comprehensive search of 10 databases was conducted. Two researchers independently conducted study screening, data extraction, and quality assessment. Eighteen articles were included and analyzed using a meta-aggregation approach. Four themes were identified: (1) factors contributing to NSSI, (2) emotions associated with engaging in NSSI, (3) coping strategies, and (4) potential barriers to seeking help. Our findings provide a comprehensive picture of the psychological experiences of adolescents who engage in NSSI. They primarily adopt negative coping strategies to deal with serious problems, and there are potential barriers to seeking help. Further research is needed to explore the true needs of adolescents, as well as how schools, families, and hospitals can play a collaborative role in improving adolescents' psychological issues.

The Impact of a One-Day Workshop on Good Psychiatric Management for Adolescent (GPM-A) Borderline Personality Disorder

OBJECTIVE

Despite evidence validating the diagnosis of borderline personality disorder (BPD) in youth, specifically showing persistence of BPD symptoms and morbidity similar to adults, there is reluctance to diagnose this in teens. Further, there is a belief among many trainees and academic child and adolescent psychiatrists (CAPs) that only specialty programs are effective, leading to treatment delays. This study charts the impact of a full-day workshop offered to an entire academic CAP department.

METHODS

A Good Psychiatric Management for Adolescent (GPM-A) Borderline Personality Disorder in-person workshop was offered to department members. Participants were asked to complete a pre-survey, an immediate post-training survey, and a survey at 6 months post-training. Utilizing a Qualtrics questionnaire, both linear mixed-effect models and paired t-tests were used to estimate the immediate and sustained effects of the training.

RESULTS

Thirty-two participants completed the workshop, with 31 answering the pre-survey, 27 the post-training survey, and 23 the 6-month follow-up survey. Immediately after the training and 6 months later, participants demonstrated statistically significant (p < .05) improvements in willingness to disclose the diagnosis of BPD, a reduced negative attitude around BPD, and an enhanced sense of confidence in addressing the needs of adolescents with BPD.

CONCLUSIONS

GPM-A training can make a positive impact on groups of clinicians who work with youth who meet criteria for BPD, specifically reducing stigma, encouraging trainees and faculty members to make the diagnosis more readily, and helping them feel more competent in addressing the treatment needs of adolescents with BPD.

An Umbrella Review of Cognitive Behavioural and Dialectical Behavioural Therapies to Treat Self-Harm and Suicidal Behaviour in Adolescents

BACKGROUND

The incidence of self-harm and suicidal behaviour in adolescents is increasing. Considering the great impact in this population, an actualization of the evidence of those psychological treatment's excellence for suicidal behaviour. Thus, the aim of this paper is to compile the available evidence on the effectiveness of cognitive behavioural therapy and dialectical behavioural therapy in preventing self-harm and suicidal behaviour in adolescents.

METHODS

A umbrella review was carried out, different databases (PubMed, CINAHL, Cochrane Library, Psyinfo, Embase, Web of Science, Scopus and Google Scholar) were consulted. The 16-item measurement tool to assess systematic reviews-2 (AMSTAR-2) were performed by two independent reviewers and any discrepancies were resolved by consensus. The Rayyan-Qatar Computing Research Institute was used for the screening process.

RESULTS

Nine systematic reviews were included. Cognitive Behavioural Therapy appears to reduce the incidence of suicide-related events compared with treatment as usual, compared to usual treatment (which usually consists of drugs and talk therapy) especially when combined with fluoxetine. Dialectical behavioural therapy seems to be associated with a reduction in suicidal ideation and self-harm.

CONCLUSIONS

Although the results found show results with high heterogeneity. The evidence on cognitive behavioural therapy and dialectical behavioural therapy for suicide prevention, self-harm and suicide ideation in adolescents seems to show positive results. Considering, the special population and great impact, further research is needed and comparable studies should be sought that allow to set up robust recommendations.

The use of CAMS and DBT to effectively treat patients who are suicidal

Around the world, suicide ideation, attempts, and deaths pose a major public and mental health challenge for patients (and their loved ones). Accordingly, there is a clear need for effective clinical treatments that reliably reduce suicidal thoughts and behaviors. In this article, we review the Collaborative Assessment and Management of Suicidality (CAMS) and Dialectical Behavior Therapy (DBT), two clinical treatments that rise to the highest levels of empirical rigor. Both CAMS and DBT are now supported by randomized controlled trials (RCTs), with independent replications, and meta-analyses. There are also supportive data related to training clinical providers to use CAMS and DBT with adherence. RCTs that investigate the use of both interventions within clinical trial research designs and the increasing use of these complementary approaches within routine clinical practice are discussed. Future directions for research and clinical use of CAMS and DBT are explored as means to effectively treat suicidal risk.

Dynamic Deconstructive Psychotherapy for Suicidal Adolescents: Effectiveness of Routine Care in an Outpatient Clinic

Suicidal behavior and demand for services have been increasing in adolescents. Many of the current treatments are focused on symptom mitigation, crisis management, and safety planning; however, few are aimed at remediating underlying vulnerabilities that may be contributing to suicide risk. Dynamic Deconstructive Psychotherapy (DDP) has been found to be effective for suicidal adults but has never been studied for adolescents. The present study examined real-world outcomes of 65 suicidal adolescents, aged 13-17 years, receiving weekly DDP in an outpatient clinic. The primary outcome was change in suicide ideation from baseline to 6 months of treatment as assessed by the Suicide Ideation Subscale of the Columbia Suicide Severity Rating Scale. In intent-to-treat analyses, suicide ideation significantly decreased over the 6 months with a large treatment effect (d = 1.19). Secondary measures, such as suicide attempts, self-harm, depression, anxiety, disability, self-compassion, and inpatient utilization, also improved significantly. Among the 42 adolescents (65%) who completed at least 6 months of treatment, suicide attempts decreased by 84%. DDP may be effective in reducing suicide ideation and other risk factors in suicidal adolescents and may be cost-effective given reduced inpatient utilization. These initial promising findings warrant further research and development.

Reducing self-harm in adolescents: the RISA-IPD individual patient data meta-analysis and systematic review

Background

Self-harm is common in adolescents and a major public health concern. Evidence for effective interventions is lacking. An individual patient data meta-analysis has the potential to provide more reliable estimates of the effects of therapeutic interventions for self-harm than conventional meta-analyses, to explore which treatments are best suited to certain groups.

Method

A systematic review and individual patient data meta-analysis of randomised controlled trials of therapeutic interventions to reduce repeat self-harm in adolescents who had a history of self-harm and presented to clinical services. Primary outcome was repetition of self-harm. The methods employed for searches, study screening and selection, and risk of bias assessment are described, with an overview of the outputs of the searching, selection and quality assessment processes. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance is followed.

Results

We identified a total 39 eligible studies, from 10 countries, where we sought Individual Patient Data (IPD), of which the full sample of participants were eligible in 18 studies and a partial sample of participants were eligible in 21 studies. We obtained IPD from 26 studies of 3448 eligible participants. For our primary outcome, repetition of self-harm, only 6 studies were rated as low risk of bias with 10 rated as high risk (although 2 of these were for secondary outcomes only).

Conclusions

Obtaining individual patient data for meta-analyses is possible but very time-consuming, despite clear guidance from funding bodies that researchers should share their data appropriately. More attention needs to be paid to seeking appropriate consent from study participants for (pseudo) anonymised data-sharing and institutions need to collaborate on agreeing template data-sharing agreements. Researchers and funders need to consider issues of research design more carefully. Our next step is to analyse all the data we have collected to see if it will tell us more about how we might prevent repetition of self-harm in young people.

Funding

This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 17/117/11. A plain language summary of this research article is available on the NIHR Journals Library Website https://doi.org/10.3310/GTNT6331.

Association between stress types and adolescent suicides: findings from the Korea Youth Risk Behavior Survey

Objective

This study aims to explore the association between types of stress and suicidal behaviors-ideation and attempts-among Korean adolescents in two distinct years: 2015 and 2020.

Methods

Data were acquired from the Korea Youth Risk Behavior Web-based Survey conducted in 2015 and 2020. Participants' desire for suicide was evaluated by asking questions about suicidal ideation and attempts, during the past year. Types of stress were divided into five categories: none, home, school, academic achievement, and appearance. Multiple logistic regression was used to investigate the association between variables of interest and dependent variables.

Results

Among the 77,363 adolescents included in this study, 8.8% male and 13.2% female participants had seriously thought about committing suicide, and the rate of male and female participants who tried committing suicide was 1.6% and 2.5%, respectively. While every type of stress was highly associated with suicidal ideation, family and home types of stress had the highest odds ratio (OR), that was statistically significant for both sexes (Male: OR 3.81, 95% Confidence Interval [CI] 2.81 to 5.15; Female: OR 3.64, 95% CI 2.42 to 5.50). Moreover, the OR increased in order of: appearance; academic achievement; school and friends; and family and home, compared to the group that perceived no stress. Suicidal attempts were statistically significant and higher in likelihood, only amongst the female group that experienced stress from family and home (OR 2.48, 95% CI 1.08 to 5.67). In comparison to year 2015, suicidal ideation and attempts decreased in year 2020, but participants experiencing stress from family and home had a higher tendency of attempting suicide, though not statistically significant, regardless of their sex (Male: OR 1.03, 95% CI 0.74 to 1.44; Female: OR 1.06, 95% CI 0.81 to 1.4).

Conclusion

Adolescents who experience stress from family and home, or school and friends, are more likely to think about suicide, or carry it out, as compared to those having different causes of stress.

Dialectical Behavioral Skills Group Therapy for Parents of Adolescents With Borderline Personality Disorder: A Pilot Study

Research has indicated the effectiveness of Dialectical behavior therapy in adolescents (DBT-A) with severe emotion dysregulation and other symptoms of Borderline Personality Disorder (BPD). The objective was to determine if DBT skills group with caregivers only could influence in potential mediators of DBT outcomes including rearing styles, emotion regulation and mindfulness skills, evaluated in both parents and adolescents. We implemented a 12-week group intervention based on DBT-A addressed to seven parents of adolescents with features of BPD. We tested differences after treatment using the non-parametric Wilcoxon test and calculated effect sizes. To understand individual changes, we reported clinical reliable change (CRC). The intervention was effective for improving rearing styles, emotion regulation and mindfulness skills in adolescents. Changes were stable after 6 months. The intervention showed good levels of satisfaction reported by parents. A short DBT group-only intervention with caregivers could modify relevant processes related with features of BPD in adolescents. Early interventions with adolescents with symptoms of BPD could prevent the development of BPD influencing in potential mediation mechanisms.