The association between motives, perceived problems and current thoughts of self-harm following an episode of self-harm. A network analysis

Evidence that implementation intentions reduce self-harm in the community

OBJECTIVES

Implementation intentions are 'IF-THEN' plans that encourage goal-intended behaviour. This study was designed to test whether an intervention encouraging the formation of implementation intentions can reduce self-harm in the community.

DESIGN

A randomized controlled design was used.

METHODS

At pre-intervention, outcome variables (self-harm in both specified and unspecified critical situations and suicidality) and potential moderators of implementation intentions (goal intention, mental imagery, and exposure to self-harm) were measured using self-report questionnaires. The participants (N = 469, aged 18-66 years, 86.4% female, 6.8% male and 6.7% other) were then randomized to either an experimental (implementation intention) or control task. At three-months post-intervention, self-report questionnaires were used again to measure the outcome variables.

RESULTS

There were no overall differences between the conditions at post-intervention. However, goal intention and mental imagery, but not exposure to self-harm, moderated the effects of condition on self-harm in specified critical situations. At high (mean + 1SD) levels of both goal intention and mental imagery, the experimental condition reported self-harming less frequently in the situations specified in their implementation intentions.

CONCLUSIONS

Implementation intentions therefore represent a useful intervention for reducing self-harm in specified critical situations for people in the community who wish to avoid self-harm and those who frequently experience self-harm and suicide related mental imagery.

Predictors of suicidal ideation severity among treatment-seeking young people with major depressive disorder: The role of state and trait anxiety

OBJECTIVE

Depression and suicidal ideation are closely intertwined. Yet, among young people with depression, the specific factors that contribute to changes in suicidal ideation over time are uncertain. Factors other than depressive symptom severity, such as comorbid psychopathology and personality traits, might be important contributors. Our aim was to identify contributors to fluctuations in suicidal ideation severity over a 12-week period in young people with major depressive disorder receiving cognitive behavioural therapy.

METHODS

Data were drawn from two 12-week randomised, placebo-controlled treatment trials. Participants (N = 283) were 15-25 years old, with moderate to severe major depressive disorder. The primary outcome measure was the Suicidal Ideation Questionnaire, administered at baseline and weeks 4, 8 and 12. A series of linear mixed models was conducted to examine the relationship between Suicidal Ideation Questionnaire score and demographic characteristics, comorbid psychopathology, personality traits and alcohol use.

RESULTS

Depression and anxiety symptom severity, and trait anxiety, independently predicted higher suicidal ideation, after adjusting for the effects of time, demographics, affective instability, non-suicidal self-injury and alcohol use.

CONCLUSIONS

Both state and trait anxiety are important longitudinal correlates of suicidal ideation in depressed young people receiving cognitive behavioural therapy, independent of depression severity. Reducing acute psychological distress, through reducing depression and anxiety symptom severity, is important, but interventions aimed at treating trait anxiety could also potentially be an effective intervention approach for suicidal ideation in young people with depression.

Coexisting service-related factors preceding suicide: a network analysis

OBJECTIVES

The overall objective was to analyse service-related factors involved in the complex processes that precede suicide in order to identify potential targets for intervention.

DESIGN AND SETTING

Explorative network analysis study of post-suicide root cause analysis data from Swedish primary and secondary healthcare.

PARTICIPANTS

217 suicide cases reported to the Swedish national root cause analysis database between 2012 and 2017.

PRIMARY AND SECONDARY OUTCOME MEASURES

A total of 961 reported incidents were included. Demographic data and frequencies of reported deficiencies were registered. Topology, centrality indices and communities were explored for three networks. All networks have been tested for robustness and accuracy.

RESULTS

Lack of follow-up, evaluations and insufficient documentation issues emerged as central in the network of major themes, as did the contributing factors representing organisational problems, failing procedures and miscommunication. When analysing the subthemes of deficiencies more closely, disrupted treatments and staffing issues emerged as prominent features. The network covering the subthemes of contributing factors also highlighted discontinuity, fragile work structures, inadequate routines, and lack of resources and relevant competence as potential triggers. However, as the correlation stability coefficients for this network were low, the results need further investigation. Four communities were detected covering nodes for follow-up, evaluation, cooperation, and procedures; communication, documentation and organisation; assessments of suicide risk and psychiatric status; and staffing, missed appointments and declined treatment.

CONCLUSION

The results of this study suggest that healthcare providers may improve patient safety in suicide preventive pathways by taking active measures to provide regular follow-ups to patients with elevated suicide risk. In some cases, declined or cancelled appointments could be a warning sign. Tentative results show organisational instability, in terms of work structure, resources and staffing, as a potential target for intervention, although this must be more extensively explored in the future.

First responder, clinician, and non‐clinical support staff knowledge, attitudes, and behaviours towards people presenting for emergency care following self‐harm: a mixed evidence synthesis

This is a protocol for a Cochrane Review (qualitative). The objectives are as follows:

The objectives of this review are threefold, as follows.

Firstly, to assess the content of knowledge, attitudes, and behaviours of first responders, clinicians, and non‐clinical support staff towards service users with SH presentations. 

Secondly, to understand how service user and staff characteristics (e.g. age, gender, sociodemographic background), type of SH presentation (e.g. method, repetition), and contextual factors (e.g. hospital environment, presence of bystanders) affect the knowledge, attitudes, and behaviours of first responders, clinicians, and non‐clinical support staff in providing acute care.

Thirdly, to assess whether clinicians' knowledge, attitudes, and behaviours have evolved over time.

Psychosocial interventions for self-harm in adults

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most counties, often repeated, and associated with suicide. There has been a substantial increase in both the number of trials and therapeutic approaches of psychosocial interventions for SH in adults. This review therefore updates a previous Cochrane Review (last published in 2016) on the role of psychosocial interventions in the treatment of SH in adults.

OBJECTIVES

To assess the effects of psychosocial interventions for self-harm (SH) compared to comparison types of care (e.g. treatment-as-usual, routine psychiatric care, enhanced usual care, active comparator) for adults (aged 18 years or older) who engage in SH.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020).

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing interventions of specific psychosocial treatments versus treatment-as-usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, or a combination of these, in the treatment of adults with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow-up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide.

DATA COLLECTION AND ANALYSIS

We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratio (ORs) and their 95% confidence intervals (CIs). For continuous outcomes, we calculated mean differences (MDs) or standardised mean differences (SMDs) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post-intervention) was appraised for each intervention using the GRADE approach.

MAIN RESULTS

We included data from 76 trials with a total of 21,414 participants. Participants in these trials were predominately female (61.9%) with a mean age of 31.8 years (standard deviation [SD] 11.7 years). On the basis of data from four trials, individual cognitive behavioural therapy (CBT)-based psychotherapy may reduce repetition of SH as compared to TAU or another comparator by the end of the intervention (OR 0.35, 95% CI 0.12 to 1.02; N = 238; k = 4; GRADE: low certainty evidence), although there was imprecision in the effect estimate. At longer follow-up time points (e.g., 6- and 12-months) there was some evidence that individual CBT-based psychotherapy may reduce SH repetition. Whilst there may be a slightly lower rate of SH repetition for dialectical behaviour therapy (DBT) (66.0%) as compared to TAU or alternative psychotherapy (68.2%), the evidence remains uncertain as to whether DBT reduces absolute repetition of SH by the post-intervention assessment. On the basis of data from a single trial, mentalisation-based therapy (MBT) reduces repetition of SH and frequency of SH by the post-intervention assessment (OR 0.35, 95% CI 0.17 to 0.73; N = 134; k = 1; GRADE: high-certainty evidence). A group-based emotion-regulation psychotherapy may also reduce repetition of SH by the post-intervention assessment based on evidence from two trials by the same author group (OR 0.34, 95% CI 0.13 to 0.88; N = 83; k = 2; moderate-certainty evidence). There is probably little to no effect for different variants of DBT on absolute repetition of SH, including DBT group-based skills training, DBT individual skills training, or an experimental form of DBT in which participants were given significantly longer cognitive exposure to stressful events. The evidence remains uncertain as to whether provision of information and support, based on the Suicide Trends in At-Risk Territories (START) and the SUicide-PREvention Multisite Intervention Study on Suicidal behaviors (SUPRE-MISS) models, have any effect on repetition of SH by the post-intervention assessment. There was no evidence of a difference for psychodynamic psychotherapy, case management, general practitioner (GP) management, remote contact interventions, and other multimodal interventions, or a variety of brief emergency department-based interventions.

AUTHORS' CONCLUSIONS

Overall, there were significant methodological limitations across the trials included in this review. Given the moderate or very low quality of the available evidence, there is only uncertain evidence regarding a number of psychosocial interventions for adults who engage in SH. Psychosocial therapy based on CBT approaches may result in fewer individuals repeating SH at longer follow-up time points, although no such effect was found at the post-intervention assessment and the quality of evidence, according to the GRADE criteria, was low. Given findings in single trials, or trials by the same author group, both MBT and group-based emotion regulation therapy should be further developed and evaluated in adults. DBT may also lead to a reduction in frequency of SH. Other interventions were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to the use of these interventions is inconclusive at present.

Association between depressive symptoms and suicidal risk: Based on self-reported and clinical-interview measurements from a network perspective

Suicide is commonly found in patients with major depressive disorder (MDD), while the associations among depressive symptoms and their relationships with suicidal risk remain unclear. This study identified the symptoms associated with suicidal risk and the most central symptoms in the MDD networks based on both self-reported and clinical-interview scales. A total of 446 outpatients with MDD were recruited. The Mini International Neuropsychiatric Interview (MINI) was used to assess the suicidal risk. The 13-item Beck Depression Inventory (BDI-13) and 17-item Hamilton Depression Rating Scale (HAMD-17) were used to measure the depressive symptoms. Network analysis was used to estimate the network models. Ten symptoms in the BDI-13 network were related to suicidal risk, among which sadness had the strongest association. Among the six symptoms in the HAMD-17 network that were associated with suicidal risk, guilty feeling was the strongest. Sense of failure was the most central symptom in the BDI-13 network, while depressed mood had the highest centrality in the HAMD-17 network. The depressive symptoms related to suicide risk and the clinical features of MDD showed different characteristics based on different assessment types. Combining self-reported and clinician-rated assessments in future studies and clinical practice might lead to some new findings.

[Clinic of suicidal crisis]

Nearly 5% of the general population experiences a suicidal crisis every year in France. It is essential for any caregiver to learn to recognize it and intervene appropriately. This crisis most often occurs in a context of stress combined with individual vulnerability factors that causes the individual to lose their balance. The clinical presentation for suicidal crisis vary from one subject to another. It is usually fluctuating and temporary. The subject does not want to die; he wants to stop suffering. The suicidal act is the dreaded but not systematic outcome of the suicidal crisis. Here we will set out the general principles of the assessment of the suicidal crisis.

Interventions for self-harm in children and adolescents

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most countries, often repeated, and associated with suicide. Evidence assessing the effectiveness of interventions in the treatment of SH in children and adolescents is lacking, especially when compared with the evidence for psychosocial interventions in adults. This review therefore updates a previous Cochrane Review (last published in 2015) on the role of interventions for SH in children and adolescents.

OBJECTIVES

To assess the effects of psychosocial interventions or pharmacological agents or natural products for SH compared to comparison types of care (e.g. treatment-as-usual, routine psychiatric care, enhanced usual care, active comparator, placebo, alternative pharmacological treatment, or a combination of these) for children and adolescents (up to 18 years of age) who engage in SH.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Specialized Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic Reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020).

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing specific psychosocial interventions or pharmacological agents or natural products with treatment-as-usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, placebo, alternative pharmacological treatment, or a combination of these, in children and adolescents with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow-up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide.

DATA COLLECTION AND ANALYSIS

We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence internals (CIs). For continuous outcomes, we calculated the mean difference (MD) or standardised mean difference (SMD) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post-intervention) was appraised for each intervention using the GRADE approach.

MAIN RESULTS

We included data from 17 trials with a total of 2280 participants. Participants in these trials were predominately female (87.6%) with a mean age of 14.7 years (standard deviation (SD) 1.5 years). The trials included in this review investigated the effectiveness of various forms of psychosocial interventions. None of the included trials evaluated the effectiveness of pharmacological agents in this clinical population. There was a lower rate of SH repetition for DBT-A (30%) as compared to TAU, EUC, or alternative psychotherapy (43%) on repetition of SH at post-intervention in four trials (OR 0.46, 95% CI 0.26 to 0.82; N = 270; k = 4; high-certainty evidence). There may be no evidence of a difference for individual cognitive behavioural therapy (CBT)-based psychotherapy and TAU for repetition of SH at post-intervention (OR 0.93, 95% CI 0.12 to 7.24; N = 51; k = 2; low-certainty evidence). We are uncertain whether mentalisation based therapy for adolescents (MBT-A) reduces repetition of SH at post-intervention as compared to TAU (OR 0.70, 95% CI 0.06 to 8.46; N = 85; k = 2; very low-certainty evidence). Heterogeneity for this outcome was substantial ( I² = 68%). There is probably no evidence of a difference between family therapy and either TAU or EUC on repetition of SH at post-intervention (OR 1.00, 95% CI 0.49 to 2.07; N = 191; k = 2; moderate-certainty evidence). However, there was no evidence of a difference for compliance enhancement approaches on repetition of SH by the six-month follow-up assessment, for group-based psychotherapy at the six- or 12-month follow-up assessments, for a remote contact intervention (emergency cards) at the 12-month assessment, or for therapeutic assessment at the 12- or 24-month follow-up assessments.

AUTHORS' CONCLUSIONS

Given the moderate or very low quality of the available evidence, and the small number of trials identified, there is only uncertain evidence regarding a number of psychosocial interventions in children and adolescents who engage in SH. Further evaluation of DBT-A is warranted. Given the evidence for its benefit in adults who engage in SH, individual CBT-based psychotherapy should also be further developed and evaluated in children and adolescents.

Pharmacological interventions for self-harm in adults

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most countries, often repeated, and associated with suicide. Evidence assessing the effectiveness of pharmacological agents and/or natural products in the treatment of SH is lacking, especially when compared with the evidence for psychosocial interventions. This review therefore updates a previous Cochrane Review (last published in 2015) on the role of pharmacological interventions for SH in adults.

OBJECTIVES

To assess the effects of pharmacological agents or natural products for SH compared to comparison types of treatment (e.g. placebo or alternative pharmacological treatment) for adults (aged 18 years or older) who engage in SH.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic Reviews [CDSR]), together with MEDLINE. Ovid Embase and PsycINFO (to 4 July 2020).

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing pharmacological agents or natural products with placebo/alternative pharmacological treatment in individuals with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow-up period of two years. Secondary outcomes included treatment acceptability, treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide.

DATA COLLECTION AND ANALYSIS

We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence internals (CIs). For continuous outcomes we calculated the mean difference (MD) or standardised mean difference (SMD) and 95% CI. The overall certainty of evidence for the primary outcome (i.e. repetition of SH at post-intervention) was appraised for each intervention using the GRADE approach.

MAIN RESULTS

We included data from seven trials with a total of 574 participants. Participants in these trials were predominately female (63.5%) with a mean age of 35.3 years (standard deviation (SD) 3.1 years). It is uncertain if newer generation antidepressants reduce repetition of SH compared to placebo (OR 0.59, 95% CI 0.29 to 1.19; N = 129; k = 2; very low-certainty evidence). There may be a lower rate of SH repetition for antipsychotics (21%) as compared to placebo (75%) (OR 0.09, 95% CI 0.02 to 0.50; N = 30; k = 1; low-certainty evidence). However, there was no evidence of a difference between antipsychotics compared to another comparator drug/dose for repetition of SH (OR 1.51, 95% CI 0.50 to 4.58; N = 53; k = 1; low-certainty evidence). There was also no evidence of a difference for mood stabilisers compared to placebo for repetition of SH (OR 0.99, 95% CI 0.33 to 2.95; N = 167; k = 1; very low-certainty evidence), or for natural products compared to placebo for repetition of SH (OR 1.33, 95% CI 0.38 to 4.62; N = 49; k = 1; lo- certainty) evidence.

AUTHORS' CONCLUSIONS

Given the low or very low quality of the available evidence, and the small number of trials identified, there is only uncertain evidence regarding pharmacological interventions in patients who engage in SH. More and larger trials of pharmacotherapy are required, preferably using newer agents. These might include evaluation of newer atypical antipsychotics. Further work should also include evaluation of adverse effects of pharmacological agents. Other research could include evaluation of combined pharmacotherapy and psychological treatment.

Development of a Self-Harm Monitoring System for Victoria

The prevention of suicide and suicide-related behaviour are key policy priorities in Australia and internationally. The World Health Organization has recommended that member states develop self-harm surveillance systems as part of their suicide prevention efforts. This is also a priority under Australia’s Fifth National Mental Health and Suicide Prevention Plan. The aim of this paper is to describe the development of a state-based self-harm monitoring system in Victoria, Australia. In this system, data on all self-harm presentations are collected from eight hospital emergency departments in Victoria. A natural language processing classifier that uses machine learning to identify episodes of self-harm is currently being developed. This uses the free-text triage case notes, together with certain structured data fields, contained within the metadata of the incoming records. Post-processing is undertaken to identify primary mechanism of injury, substances consumed (including alcohol, illicit drugs and pharmaceutical preparations) and presence of psychiatric disorders. This system will ultimately leverage routinely collected data in combination with advanced artificial intelligence methods to support robust community-wide monitoring of self-harm. Once fully operational, this system will provide accurate and timely information on all presentations to participating emergency departments for self-harm, thereby providing a useful indicator for Australia’s suicide prevention efforts.

Entrapment and suicide risk: The development of the 4-item Entrapment Scale Short-Form (E-SF)

Evidence suggests that suicidal behaviour arises from one's attempt to escape from unbearable situations or unbearable thoughts and feelings. These feelings of entrapment are usually assessed via the 16-item Entrapment Scale, but this is too long for routine use in clinical practice. The aim of this study was to develop a brief version of the full scale that reliably assesses entrapment. We used data collected from a clinical sample (n = 497) of patients following hospital-treated self-harm and a population-based sample (n = 3457) of young adults. Four items were selected that had both the highest factor loading and discriminatory parameters and that covered the theoretical constructs of internal and external entrapment. Correlations between the 4-item short-form and the 16-item full scale were nearly perfect (0.94 for the clinical sample, 0.97 for the population-based sample). When comparing the correlations between the short-form and the full scale with other clinical and psychological scales, the correlations were nearly identical. The 4-item Entrapment Scale Short-Form (E-SF) will provide very comparable information about entrapment for each respondent as the full scale will do. However, its brevity will increase the likelihood that the assessment of entrapment will be implemented into everyday clinical practice.

The Portrayal of Suicidal Behavior in Police Television Series

Fictional suicidal behavior can affect the public as a risk or a protective factor, and it may reflect how suicide is perceived in a society. However, surprisingly little is known of how suicidal behavior is portrayed in television series. The aim of this study was to investigate the characteristics of televised fatal and non-fatal suicidal behavior, preventative interventions, and the portrayal of people bereaved by suicide. All episodes (N = 475) of four Belgian police series were screened against inclusion and exclusion criteria, and 87 episodes with a total of 54 suicides, 13 attempted suicides, 13 suicide threats, and 20 characters bereaved by suicide were included in a quantitative and qualitative analysis. Televised suicidal behavior was primarily motivated by external motives, such as social/relational issues or the death of a significant other, and to a lesser extent, by internal motives, such as mental or physical health related issues. Interventions were likely to prevent suicide. People bereaved by suicide were mostly portrayed as individuals seeking justice. Shame, revenge, and escape were the major qualitative themes associated with suicidal behavior. Two prototypes emerged: a ruthless, "psychopath" type criminal, who kills him/herself before being arrested, and a suicidal individual struggling with devastating life events. The study provided unique insights in how suicidal behavior is televised in Belgian police series. Though some characteristics were portrayed adequately, mental health related issues were overlooked, spectacular suicide methods were overrepresented, and the bereaved characters were mostly unidimensional revengers. Strategies for improving the accuracy of televised suicidal behavior should be studied.

Modelling suicide ideation from beep to beep: Application of network analysis to ecological momentary assessment data

•EMA data were analyzed using network analysis (e.g., temporal networks).•Suicidal ideation at t was predicted by itself and perceived burdensomeness at t - 1.•Suicidal ideation at t - 1 predicted perceived burdensomeness, depression etc. at t.•At the same beep, suicidal ideation was related to all variables in the network.•Patients with higher average suicidal ideation had higher average hopelessness.