Is cognitive behavioural therapy effective in reducing suicidal ideation and behaviour when delivered face-to-face or via e-health? A systematic review and meta-analysis

Moderators and Mediators of Treatments for Suicidal Thoughts and Behaviors: A Review of More Than 50 Years of Randomized Controlled Trials

Psychosocial treatments for suicidal thoughts and behaviors (STBs) are in need of improvement, as suicide rates have substantially increased in the last 20 years and current interventions show limited efficacy. One way to potentially boost response rates is to personalize treatments by identifying what works how and for whom to maximize impact across different individuals. A scoping review of all suicide treatment randomized controlled trials was performed on PubMed, PsycInfo, and GoogleScholar through May 2024 to identify moderators and mediators of suicide treatment. Forty-six studies including moderators and 15 studies including mediators were identified and evaluated by at least two independent researchers. The most frequently tested moderators across both adults and adolescents include age, gender/sex, history of STBs, therapeutic alliance, comorbid depression, and comorbid borderline personality disorder diagnoses or symptoms, with the strongest support found for therapeutic alliance in adults. No mediator was tested in more than one trial or research group, but hopelessness, avoidance, mentalization, and number of treatment contacts in adolescents and resilience, anxiety sensitivity, acceptance, and therapeutic relationship in adults showed positive signals. Overall, additional work is needed as heterogeneity, lack of replication attempts, and concerns about moderator and mediator quality currently limit confidence in findings.

Acceptability and Feasibility of a Blended School-Based Intervention to Prevent Suicidal Ideation Among Adolescents in Chile: Results from a Randomized Control Pilot Study

Suicide prevention programs delivered in school settings have been shown to reduce suicide attempts and ideation among adolescents. School-based digital interventions targeting at-risk youth are a promising avenue for suicide prevention, and some evidence has shown that blending digital and face-to-face components may improve the effectiveness. However, further evidence on its acceptability, feasibility, and effectiveness is needed, especially in Latin America, where mental health support is limited. Reframe-IT is an internet-based Cognitive Behavioral Therapy (CBT) program to reduce youth suicidal ideation in school settings. We created four complementary face-to-face CBT sessions and, through a pilot study, tested the acceptability, feasibility, and effectiveness of a blended intervention (Reframe-IT +) in adolescents (N = 52) from 6 public schools in Chile, randomized into two groups: Reframe-IT + (N = 33) and Control (N = 19). We found that the intervention was acceptable and feasible, with high degrees of satisfaction and adherence. We also observed a significant reduction in suicidal ideation and depressive symptoms in the intervention group compared to the control group at post-intervention. Our results suggest that the Reframe-IT + could be delivered as a suitable, acceptable, and effective intervention to reduce suicide ideation in adolescents in school settings. Further research is needed to confirm these preliminary results.

Reframe-IT+, an indicated preventive school-based intervention, reduces suicidal ideation among adolescents in vulnerable contexts in Chile

BACKGROUND

Suicide prevention programs delivered in school settings have been shown to reduce suicide attempts and ideation among adolescents. School-based digital interventions targeting at-risk youth are a promising avenue for suicide prevention, and some evidence has shown that blending digital and face-to-face components may improve the effectiveness. However, further evidence is needed, especially in Latin America, where mental health support is limited. We tested the effectiveness of the Reframe-IT+, a blended cognitive behavioral indicated intervention to reduce suicidal ideation, designed to be delivered in school settings. It includes 13 sessions, combining eight internet-based sessions and five face-to-face sessions.

METHODS

We conducted a cluster RCT and delivered the Reframe-IT + among secondary students attending Years 9-11. We recruited 21 schools that were randomized into two groups: (1) Intervention Reframe-IT + Group (IG) (n = 863) and (2) Control Group (CG) (n = 683). All consented students completed online screening self-reported questionnaires at baseline. The primary outcome was suicidal ideation . Additionally, we tested the impact of the intervention on depressive and anxiety symptoms, hopelessness, and emotion regulatory strategies, including social solving-problems skills, behavioral activation, cognitive reappraisal, and emotion suppression. A total of 303 students (IG, n = 164; CG, n = 139) were identified as at risk and eligible for inclusion in the study. From those, 224 students (IG, n = 123; CG, n = 101) and their caregivers were interviewed to confirm inclusion and exclusion criteria. Finally, 48 and 47 students were allocated to control and intervention groups, respectively, and answered the online questionnaires at post-intervention. We performed an intention-to-treat analysis using repetitive measures and multilevel regression analyses.

RESULTS

We found a significant reduction in suicidal ideation (b=-6.7, p = 0.015, Cohen´s d = 0.49), depressive (b=-3.1, p = 0.002, Cohen´s d = 0.81) and anxiety (b=-2.60, p < 0.001, Cohen´s d = 0.72) symptoms, and hopelessness (b=-3.7, p < 0.001, Cohen´s d = 0.70) in the intervention group compared to the control group at post-intervention. We also found improvement in solving-problems skills (b=-1.6, p = 0.002, Cohen´s d = 0.58), behavioral activation (b = 2.8, p = 0.019, Cohen´s d = 0.47), and cognitive reappraisal (b = 2.2, p = 0.029, Cohen´s d = 0.53). In the exploration of the intervention mechanisms concerning suicidal ideation, the total indirect effect of the intervention (b = -5.727923; p = 0.008) was significant, whereas the direct effect (b = - 0.03195473, p = 0.903) was not significant (Suppl 2, Table 1). Problem-solving skill (b=-2.84, p = 0.016) was a significant mediator of intervention effects on suicidal ideation (Path a*b).

CONCLUSIONS

This is the first clustered RCT evaluation of the effectiveness of a blended indicated intervention to prevent suicidality in school settings in Latin America. This is the first step to informing policymakers to scale up an effective intervention for an important public health problem.

TRIAL REGISTRATION

Clinical Trials NCT05229302. Registered on January 27th, 2022.

Cognitive Behavioral Therapy Approaches for Chronic Suicidality

This review provides an overview of research evidence from the past 5 years concerning cognitive behavioral therapy for suicide prevention. The authors then discuss the clinical implementation of this approach in patients with chronic suicidal behavior.

Understanding suicidal transitions in Australian adults: protocol for the LifeTrack prospective longitudinal cohort study

BACKGROUND

The factors that influence transition from suicidal ideation to a suicide attempt or remission of suicidal thoughts are poorly understood. Despite an abundance of research on risk factors for suicidal ideation, no large-scale longitudinal population-based studies have specifically recruited people with suicidal ideation to examine the mechanisms underlying critical transitions to either suicide attempt or recovery from suicidal ideation. Without longitudinal data on the psychological, behavioural, and social determinants of suicide attempt and the remission of suicidal ideation, we are unlikely to see major gains in the prevention of suicide.

AIM

The LifeTrack Project is a population-based longitudinal cohort study that aims to identify key modifiable risk and protective factors that predict the transition from suicidal ideation to suicide attempt or remission of suicidal ideation. We will assess theory-informed risk and protective factors using validated and efficient measures to identify distinct trajectories reflecting changes in severity of suicidal ideation and transition to suicide attempt over three years.

METHODS

A three-year prospective population-based longitudinal cohort study will be conducted with adults from the general Australian population who initially report suicidal ideation (n = 842). Eligibility criteria include recent suicidal ideation (past 30 days), aged 18 years or older, living in Australia and fluent in English. Those with a suicide attempt in past 30 days or who are unable to participate in a long-term study will be excluded. Participants will be asked to complete online assessments related to psychopathology, cognition, psychological factors, social factors, mental health treatment use, and environmental exposures at baseline and every six months during this three-year period. One week of daily measurement bursts (ecological momentary assessments) at yearly intervals will also capture short-term fluctuations in suicidal ideation, perceived burdensomeness, thwarted belongingness, capability for suicide, and distress.

CONCLUSION

This study is intended to identify potential targets for novel and tailored therapies for people experiencing suicidal ideation and improve targeting of suicide prevention programs. Even modest improvements in current treatments may lead to important reductions in suicide attempts and deaths.

STUDY REGISTRATION

Australian New Zealand Clinical Trials Registry identifier: ACTRN12623000433606.

The Impact of Allied Health Brief Therapy Clinic Interventions in Consumers in Suicidal Crisis

Brief interventions increase access to and engagement with care for people who are discharged presentation to emergency departments or inpatient care due to suicidal behavior. This study was to investigate the effectiveness of the Allied Health Brief Therapies (AHBT) clinic interventions on suicide ideation, health service utilization, negative emotional states, and functioning and well-being in consumers in suicidal crisis. This research was designed as pre-post study. Three AHBT clinics were established to provide brief interventions in Queensland Australia. Repeated measures ANOVA and McNemar's test were used to measure the impact of the interventions. Sensitivity analysis was conducted to ensure the robustness and appropriate interpretation of the results. Among the 141 consumers who accepted the referral, 106 (75.2%) attended the AHBT sessions, and 35 (24.8%) did not start the interventions. The AHBT clinic interventions reduced consumers' presence and frequency of suicide ideation, emergency department presentations, and negative emotional states (depression, anxiety, and stress), and increased their functioning and well-being with large effect sizes. Change in the frequency of inpatient admission after the AHBT clinic interventions was statistically non-significant. This study provides evidence that the AHBT clinics can reduce suicidal risk factors, decrease health service utilization, and increase functioning and well-being in consumers in suicidal crisis. Future research should consider the use of a control group to increase confidence in the findings.

Developing a consensus of recovery from suicidal ideations and behaviours: A Delphi study with experts by experience

BACKGROUND

Understanding recovery in mental health has received significant attention and consequently, recovery has been incorporated into health policy across many countries in the Global North. In comparison, the concept of 'recovery' from suicidal thoughts and behaviours has received little attention. However, the few studies in this area appear to suggest that recovery is a complex and an idiosyncratic process with many contributing factors. This can present a challenge for clinicians and services seeking to become more recovery focused. Thus, it seems of importance to develop a consensus on how recovery from suicidal thoughts and behaviours is conceptualised.

AIM

The study aimed to use the Delphi design to establish a consensus of how recovery is defined by those with lived experience of suicidal thoughts and behaviours. The Delphi method draws on the expertise of a panel, often involving clinicians, researchers and lived experience experts to develop consensus over a topic by inviting them to rate the importance of, often a series of statements to a given topic area.

METHOD

Lived experience experts were asked to complete two rounds of questionnaires distributed online to capture their views on recovery.

RESULTS

A total of 196 individuals gave their views on the first round of the study and 97 gave their views on the second round. A final list of 110 statements was developed that 80% or more of participants defined as essential or important. Statements covered items that were important in defining, facilitation and hindering the process of recovery.

CONCLUSION

Findings are consistent with the wider literature that suggests that recovery is an idiosyncratic process, but with many commonly shared features. Here we also show that a comprehensive definition of recovery must include factors that hinder the process of recovery. Implications and recommendations for practice, policy development and future research are discussed.

What is important to service users and staff when implementing suicide-focused psychological therapies for people with psychosis into mental health services?

Introduction

Suicide is a leading cause of death globally. People with psychosis are at increased risk of suicide death and up to half experience suicidal thoughts and/or engage in suicidal behaviors in their lifetime. Talking therapies can be effective in alleviating suicidal experiences. However, research is yet to be translated into practice, demonstrating a gap in service provision. The barriers and facilitators in therapy implementation require a thorough investigation including the perspectives of different stakeholders such as service users and mental health professionals. This study aimed to investigate stakeholders' (health professionals and service users) perspectives of implementing a suicide-focused psychological therapy for people experiencing psychosis in mental health services.

Methods

Face-to-face, semi-structured interviews with 20 healthcare professionals and 18 service users were conducted. Interviews were audio recorded and transcribed verbatim. Data were analyzed and managed using reflexive thematic analysis and NVivo software.

Results

For suicide-focused therapy to be successfully implemented in services for people with psychosis, there are four key aspects that need to be considered: (i) Creating safe spaces to be understood; (ii) Gaining a voice; (iii) Accessing therapy at the right time; and (iv) Ensuring a straightforward pathway to accessing therapy.

Discussion

Whilst all stakeholders viewed a suicide-focused therapy as valuable for people experiencing psychosis, they also recognize that enabling successful implementation of such interventions will require additional training, flexibility, and resources to existing services.

Designing Clinical Trials to Assess the Impact of Pharmacological Treatment for Suicidal Ideation/Behavior: Issues and Potential Solutions

Suicide is a serious and growing public health concern yet randomized controlled trials (RCTs) that inform pharmacologic treatment remain limited. We emphasize the overall need for such trials and review the literature to highlight examples of trials that have aimed to study patients at elevated risk of suicide. We discuss key examples of existing psychotropic medication trials as well as psychotherapy intervention studies that can yield important design insights. Medications that have been studied in individuals at risk for suicide include lithium, clozapine, zolpidem, prazosin, ketamine, esketamine, and aripiprazole. While important design challenges should be considered-RCTs to study suicide are feasible and much needed. Issues such as overall trial design, patient-selection criteria, and the scales/tools used to assess suicidality are discussed.

Pharmacological and Somatic Treatment Effects on Suicide in Adults: A Systematic Review and Meta-Analysis

Background

Suicide is a public health crisis. We conducted a systematic review and meta-analysis of the effects of psychopharmacologic and somatic therapies on suicide risk.

Methods

A systematic search of MEDLINE for studies evaluating the effects of pharmacologic (excluding antidepressants) or somatic interventions on suicide risk was conducted. Studies were included if they used a comparison group, reported on suicide death, assessed a psychopharmacological or somatic intervention, and included adults. Study quality was assessed using the Newcastle-Ottawa scale. Fifty-seven studies were included from 2940 reviewed citations.

Results

In bipolar disorder, lithium was associated with a reduction in the odds of suicide compared to active controls (odds ratio [OR] = .58, p = .005; k = 12) and compared to placebo/no lithium (OR = .46, p = .009; k = 9). In mixed diagnostic samples, lithium was associated with a reduction in the odds of suicide compared to placebo/no lithium (OR = .27, p < .001; k = 12), but not compared to active controls (OR = .89, p = .468; k = 7). In psychotic disorders, clozapine was associated with a reduction in the odds of suicide (OR = .46, p = .007; k = 7). Associations between suicide death and electroconvulsive therapy (OR = .77, p = .053; k = 11), non-clozapine antipsychotics in bipolar disorder (OR = .73, p = .090; k = 6) and antipsychotics in psychotic disorders (OR = .39, p = .069; k = 6) were not significant. There was no consistent relationship between antiepileptic mood stabilizers and suicide. There were insufficient studies to meta-analyze associations of suicide risk with vagus nerve stimulation, transcranial magnetic stimulation, magnetic seizure therapy, or transcranial direct current stimulation.

Conclusion

Lithium and clozapine have consistent data supporting protective effects against suicide in certain clinical contexts.Reprinted from Depress Anxiety 2022; 39:100-112, with permission from John Wiley and Sons. Copyright © 2022.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Neural responsiveness to reward and suicidal ideation in social anxiety and major depression before and after psychotherapy

Suicidality is prevalent in Social Anxiety Disorder (SAD) and Major Depressive Disorder (MDD). Limited data indicate the reward positivity (RewP), a neurophysiological index of reward responsivity, and subjective capacity for pleasure may serve as brain and behavioral assays for suicide risk though this has yet to be examined in SAD or MDD in the context of psychotherapy. Therefore, the current study tested whether suicidal ideation (SI) relates to RewP and subjective capacity for anticipatory and consummatory pleasure at baseline and whether Cognitive Behavioral Therapy (CBT) impacts these measures. Participants with SAD (n = 55) or MDD (n = 54) completed a monetary reward task (gains vs. losses) during electroencephalogram (EEG) before being randomized to CBT or supportive therapy (ST), a comparator common factors arm. EEG and SI data were collected at baseline, mid-treatment, and post-treatment; capacity for pleasure was collected at baseline and post-treatment. Baseline results showed participants with SAD or MDD were comparable in SI, RewP, and capacity for pleasure. When controlling for symptom severity, SI negatively corresponded with RewP following gains and SI positively corresponded with RewP following losses at baseline. Yet, SI did not relate to subjective capacity for pleasure. Evidence of a distinct SI-RewP association suggests RewP may serve as a transdiagnositic brain-based marker of SI. Treatment outcome revealed that among participants with SI at baseline, SI significantly decreased regardless of treatment arm; also, consummatory, but not anticipatory, pleasure increased across participants regardless of treatment arm. RewP was stable following treatment, which has been reported in other clinical trial studies.

The significance of cognitive-behavioral therapy on suicide: An umbrella review

BACKGROUND

Suicide becomes a widespread public health concern. Cognitive-behavioral therapy (CBT) is used to correct negative thoughts and behaviors of patients at risk of suicide. The aim of this research is to summarize and evaluate the existing evidence to explore the impact of CBT on suicide.

METHOD

We conducted a systematic searched in PubMed, Web of Science, Cochrane database from the first available year to March 2021. The methodological quality was evaluated by AMSTAR-2 tool, and the evidence quality was evaluated by GRADE classification. We summarized all the comparative effects of CBT on suicide, and used forest plots to describe the impact of CBT on suicide related outcomes included suicidal ideation, suicide attempts. The random effects model was used to summarize data.

RESULTS

Nine systematic reviews and meta-analysis were included. Most of the systematic reviews and meta-analysis were of medium methodological and evidence quality. The impact of CBT on suicide outcomes could be divided into the following two categories: CBT reduced levels of suicidal ideation (SMD -0.28, 95 % CI -0.36 to -0.21), CBT relieved suicide attempts (RR 0.77, 95 % CI 0.69 to 0.87).

CONCLUSION

Based on the current evidence, CBT could relieve suicide, including suicide ideation, suicide attempts. CBT is scalable and cost-effective. It is helpful for health professionals to formulate personalized CBT programs, promote clinical and community applications and integrate them into comprehensive suicide interventions and prevention strategies.

Effectiveness of Digital Health Interventions on Unintentional Injury, Violence, and Suicide: Meta-Analysis

Digital technologies are increasingly used in health-care delivery and are being introduced into work to prevent unintentional injury, violence, and suicide to reduce mortality. To understand the potential of digital health interventions (DHIs) to prevent and reduce these problems, we conduct a meta-analysis and provide an overview of their effectiveness and characteristics related to the effects. We searched electronic databases and reference lists of relevant reviews to identify randomized controlled trials (RCTs) published in or before March 2020 evaluating DHIs on injury, violence, or suicide reduction. Based on the 34 RCT studies included in the meta-analysis, the overall random effect size was 0.21, and the effect sizes for reducing suicidal ideation, interpersonal violence, and unintentional injury were 0.17, 0.24, and 0.31, respectively, which can be regarded as comparable to the effect sizes of traditional face-to-face interventions. However, there was considerable heterogeneity between the studies. In conclusion, DHIs have great potential to reduce unintentional injury, violence, and suicide. Future research should explore DHIs' successful components to facilitate future implementation and wider access.

Testing the Effectiveness of a Blended Intervention to Reduce Suicidal Ideation among School Adolescents in Chile: A Protocol for a Cluster Randomized Controlled Trial

Suicidal ideation is prevalent in adolescents and is a marker for subsequent psychiatric vulnerability and symptom severity. Literature shows that blended care (integrating online and offline components in a treatment process) could improve the effectiveness and adherence of interventions targeting suicidal ideation in adolescents, but the evidence is inconclusive. Thus, we will test the effectiveness of a blended intervention to reduce suicidal ideation (primary outcome) in school settings using a single-blind two-armed cluster randomized controlled trial (cRCT). The internet-based component corresponds to the Reframe-IT, a program encompassing eight online sessions based on cognitive-behavioral therapy (CBT) principles. The face-to-face intervention will be delivered through four CBT sessions. Additionally, we will assess the effect of the intervention on the following secondary outcomes: suicidal attempts, depressive symptoms, hopelessness, emotional regulation, and problem-solving skills. Primary and secondary outcomes will be assessed at post-intervention, 3-month, 6-month, and 12-month follow-up. Finally, we will explore the mediation role of cognitive, emotional, and behavioral correlates of suicide on the effect of the intervention. Results will inform whether the intervention can reduce suicide among school adolescents and be implemented on a large scale in Chile.

Pharmacological and somatic treatment effects on suicide in adults: A systematic review and meta-analysis

BACKGROUND

Suicide is a public health crisis. We conducted a systematic review and meta-analysis of the effects of psychopharmacologic and somatic therapies on suicide risk.

METHODS

A systematic search of MEDLINE for studies evaluating the effects of pharmacologic (excluding antidepressants) or somatic interventions on suicide risk was conducted. Studies were included if they used a comparison group, reported on suicide death, assessed a psychopharmacological or somatic intervention, and included adults. Study quality was assessed using the Newcastle-Ottawa scale. Fifty-seven studies were included from 2940 reviewed citations.

RESULTS

In bipolar disorder, lithium was associated with a reduction in the odds of suicide compared to active controls (odds ratio [OR] = .58, p = .005; k = 12) and compared to placebo/no lithium (OR = .46, p = .009; k = 9). In mixed diagnostic samples, lithium was associated with a reduction in the odds of suicide compared to placebo/no lithium (OR = .27, p < .001; k = 12), but not compared to active controls (OR = .89, p = .468; k = 7). In psychotic disorders, clozapine was associated with a reduction in the odds of suicide (OR = .46, p = .007; k = 7). Associations between suicide death and electroconvulsive therapy (OR = .77, p = .053; k = 11), non-clozapine antipsychotics in bipolar disorder (OR = .73, p = .090; k = 6) and antipsychotics in psychotic disorders (OR = .39, p = .069; k = 6) were not significant. There was no consistent relationship between antiepileptic mood stabilizers and suicide. There were insufficient studies to meta-analyze associations of suicide risk with vagus nerve stimulation, transcranial magnetic stimulation, magnetic seizure therapy, or transcranial direct current stimulation.

CONCLUSION

Lithium and clozapine have consistent data supporting protective effects against suicide in certain clinical contexts.

Non-disclosing youth: a cross sectional study to understand why young people do not disclose suicidal thoughts to their mental health professional

BACKGROUND

Prevalence of suicidal ideation increases rapidly in adolescence, and many choose not to seek help and disclose their ideation. Young people who do disclose suicidal ideation, prefer to do so with peers and family compared to mental health professionals, who are best placed to provide evidence-based treatment. This study aimed to identify key factors associated with young people's decision to, or not to disclose suicidal thoughts to their mental health practitioner.

METHODS

A community-based sample of young Australians (16 - 25 years), who had experienced suicidal ideation and engaged with a mental health professional, completed an online questionnaire (N=513) which assessed demographic characteristics, severity of depression, anxiety, psychological distress, and suicidal ideation, lifetime suicide attempts, exposure to suicide loss, personal suicide stigma, prioritisation of mental health issues, and therapeutic alliance. Logistic regression analyses were used to identify factors associated with disclosure.

RESULTS

Though the full sample had engaged in therapy, 39% had never disclosed suicidal ideation to their clinician. Those who had disclosed were more likely to report greater therapeutic alliance (OR=1.04, 95% CI=1.02-1.06), personal suicide stigma (OR=1.04, 95% CI=1.01-1.06), prioritisation of suicidal ideation (OR=.24, 95% CI=0.14-0.42), and lifetime history of suicide attempt (OR=.32, 95% CI=0.18-0.57). The most common reason for not disclosing was concern that it would not remain confidential.

CONCLUSION

These findings provide new insights into why young people may not seek help by disclosing suicidal ideation, despite having access to a mental health professional, and establish evidence to inform practice decisions and the development of prevention strategies to support young people for suicide.

The Effectiveness of Self-Esteem-Related Interventions in Reducing Suicidal Behaviors: A Systematic Review and Meta-Analysis

Suicide is a serious social issue and is often treated using psychological interventions. The current systematic review and meta-analysis aimed to investigate the effectiveness of self-esteem-related interventions on suicidal behaviors. A systematic literature search for randomized controlled trials (RCTs) including a self-esteem component was conducted on 29 May 2021 and updated on 4 April 2022. In total, 12 studies were included in the systematic review and five studies were included in the meta-analysis. Small effect sizes were found for suicidal ideation at post intervention [g = -0.24, 95% CI (-0.48, 0.00)] and a 3-month follow-up [g = -0.36, 95% CI (-0.62, -0.11)]. However, these results should be interpreted cautiously due to the limited number of included studies and varied sample population. In conclusion, the current review suggests that future intervention studies should incorporate self-esteem enhancement in the treatment of suicidal behaviors, especially for suicidal ideation.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=250882.

[Psychotherapy after a suicide attempt-current evidence and evaluation]

Suizidversuche gelten als einer der wichtigsten Risikofaktoren für Suizide. Vor diesem Hintergrund wurden in den letzten Jahren diverse Psychotherapieangebote für Personen nach einem Suizidversuch entwickelt und untersucht. Im Rahmen dieses Artikels wird der aktuelle Stand der Effektivitätsforschung zusammengefasst, es werden Beispiele für erfolgreiche suizidfokussierte Psychotherapieprogramme gegeben und der gegenwärtige Forschungs- und Wissensstand wird kritisch reflektiert. Die Ergebnisse von 2 aktuellen Cochrane-Reviews zur Psychotherapie nach selbstverletzendem Verhalten im Kindes‑, Jugend- und Erwachsenenalter sowie Befunde aus 14 weiteren Metaanalysen zur psychologischen Suizidprävention, die in den vergangenen 5 Jahren publiziert wurden, werden überblicksartig dargestellt.

Die kognitive Verhaltenstherapie (KVT) und die dialektisch-behaviorale Therapie (DBT) haben sich als effektiv erwiesen. Insgesamt sind die gemittelten Effektstärken jedoch von geringer Größe und diverse methodische Probleme verunmöglichen weitreichende Schlussfolgerungen. Grundsätzlich kommt der suizidspezifischen Psychotherapie in der individuumszentrierten Suizidprävention besondere Bedeutung zu; die empirische Fundierung und Dissemination entsprechender Programme sind jedoch noch unzureichend.

Suicide prevention in psychiatric patients

An increased risk of suicide has been reported for psychiatric patients. In several world regions, an underlying psychiatric disorder is reported in up to 90% of people who die from suicide, though this rate seems to be considerably lower in low- and middle-income countries. Major psychiatric conditions associated with suicidality are mood disorders, alcohol and substance use disorders, borderline personality disorder, and schizophrenia. Comorbidity between different disorders is frequently associated with a higher suicide risk. A history of suicide attempts, feelings of hopelessness, impulsivity and aggression, adverse childhood experiences, severe psychopathology, and somatic disorders are common risk factors for suicide among psychiatric patients. Stressful life events and interpersonal problems, including interpersonal violence, are often triggers. A comprehensive and repeated suicide risk assessment represents the first step for effective suicide prevention. Particular attention should be paid during and after hospitalization, with the first days and weeks after discharge representing the most critical period. Pharmacological treatment of mood disorders and schizophrenia has been shown to have an anti-suicidal effect. A significant reduction of suicidal thoughts and behavior has been reported for cognitive behavioral therapy and dialectical behavior therapy. Brief interventions, including psychoeducation and follow-ups, are associated with a decrease in suicide deaths. Further development of suicide prevention in psychiatric patients will require a better understanding of additional risk and protective factors, such as the role of a person's decision-making capacity and social support, the role of spiritual and religious interventions, and the reduction of the treatment gap in mental health care.

Leite V, Porto DM, Robis KP, Fidalgo TM, Rocha GA, Diaz AP, Meleiro A, Correa H, Tung TC, Malloy-Diniz L, Quevedo J, da Silva AG. Brazilian Psychiatric Association guidelines for the management of suicidal behavior. Part 2. Screening, intervention, and prevention

This article continues our presentation of the Brazilian Psychiatric Association guidelines for the management of patients with suicidal behavior, with a focus on screening, intervention, postvention, prevention, and promotion. For the development of these guidelines, we conducted a systematic review of the MEDLINE (via PubMed), Cochrane Database of Systematic Reviews, Web of Science, and SciELO databases for research published from 1997 to 2020. Systematic reviews, clinical trials, and cohort/observational studies on screening, intervention, and prevention in suicidal behavior were included. This project involved 14 Brazilian psychiatry professionals and 1 psychologist selected by the Psychiatric Emergencies Committee of the Brazilian Psychiatric Association for their experience and knowledge in psychiatry and psychiatric emergencies. Publications were evaluated according to the 2011 Oxford Center for Evidence-Based Medicine (OCEBM) Levels of Evidence Classification. Eighty-five articles were reviewed (of 5,362 initially collected and 755 abstracts on the drug approach). Forms of screening, intervention, and prevention are presented. The intervention section presents evidence for psychotherapeutic and drug interventions. For the latter, it is important to remember that each medication is effective only for specific groups and should not replace treatment protocols. We maintain our recommendation for the use of universal screening plus intervention. Although the various studies differ in terms of the populations evaluated and several proposals are presented, there is already significant evidence for certain interventions. Suicidal behavior can be analyzed by evidence-based medicine protocols. Currently, the best strategy is to combine several techniques through the Safety Plan. Nevertheless, further research on the topic is needed to elucidate some approaches with particular potential for intervention and prevention. Systematic review registry number: CRD42020206517.

Effectiveness of internet-based cognitive behavioral therapy for suicide: a systematic review and meta-analysis of RCTs

Suicidal individuals rarely seek help and receive professional psychological intervention on their initiative. Internet-based cognitive behavioral therapy(iCBT) can increase availability and reduce stigma compared to face-to-face interventions for suicide.However, conclusions about the effectiveness of iCBT on suicide are controversial. The review aimed to determine the effectiveness of iCBT on reducing suicidal ideation (primary outcomes) and other outcomes related to suicide like suicide attempts(secondary outcomes). PubMed, the Cochrane Library, EMBASEwere searched up to March 2020 for RCTs of iCBT which aimed to reduce suicide.The potential bias was assessed by the Cochrane risk of bias tool. Data analyses wereperformed by RevMan5.3.Four studies meeting the eligibility criteria were included which reported data on a total of 1225 participants. We found iCBT was associated with reducing an individual's suicidal ideation, and first indications suggest that the treatment effect might be even more pronounced in the short term and in adults.Additionally, there was insufficient evidence to prove its effectiveness in reducing suicide attempts and suicide death.Overall, iCBT can overcome the disadvantages of traditional interventions and show promise on suicidal ideation. While ensuring safety and ethics, further studies are warranted, focusing on suicide specific behavior like suicide attempts.

Factors affecting suicidal ideation among premenopausal and postmenopausal women

WHAT IS KNOWN ON THE SUBJECT?: Pre- and postmenopausal women (PPW) experience changes in physical, psychological and social health. South-East Asia's female suicide rate is the highest compared with other countries, and the suicide rate of PPW in these countries continues to increase. The most influential factor in Asian women's suicidal ideation is family conflict; specifically, if PPW in South Korea cannot express their anger, it results in a culture-bound syndrome called "Hwa-Byung." However, there is a lack of research on Asian PPW. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study found differences in individual- and community-level factors affecting suicidal ideation between pre- and postmenopausal women. Individual factors that commonly affected suicidal ideation were experiencing violence, stress and depression. Individual factors that affected the suicidal ideation of premenopausal women more than postmenopausal women were religious beliefs, alcohol use and chronic disease. Community level factors affecting suicidal ideation were locational depression and locational counselling for stress in premenopausal women and locational counselling for depression in postmenopausal women. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses could help prevent suicide by developing and applying community-based programmes for PPW, considering the specific socio-economic and cultural context and characteristics of Asian women. Mental health nurses could help PPW participate in programmes by preparing various interventions such as case management, personal counselling, physical activity, home-based mental health services, cognitive behavioural therapy and digital interventions for self-management. Mental health nurses need to prepare various methods such as online, offline, individual and group methods to work effectively in any social situation. ABSTRACT: Introduction Pre- and postmenopausal women (PPW) experience physical and psychological changes with hormonal changes. Among Asian middle-aged women, family and culture affect suicidal ideation, and the suicide rate among this population is increasing. There are few existing research on suicidal ideation among Asian PPW. Aim We examined individual- and community-level factors that predict suicidal ideation among PPW. Method Large-scale panel data from 5,154 South Korean PPW aged 35-64 years were used in a series of multilevel logistic regression analyses to examine factors associated with suicidal ideation at individual and community levels. Results Among premenopausal women, religious beliefs, alcohol use, chronic disease, experience of violence, stress and depression were individual-level factors. Locational depression and locational counselling for stress were community-level factors. Among postmenopausal women, experience of violence, stress, depression and perceived health status were individual level factors, and locational counselling for depression was a community level factor. Discussion Suicidal ideation among PPW is affected by both individual and community level factors. Nurses must comprehensively determine what risk factors affect suicidal ideation through various intervention methods-including online, offline, individual and group methods-while considering socio-economic situations. Implications for Practice Mental health nurses should provide targeted biopsychosocial interventions targeting psychosocial and physical problems and promoting the use of community resources to reduce PPW's suicidal ideation.

Predictors of change in suicidal ideation across treatment phases of major depressive disorder: analysis of the STAR*D data

The effects of common antidepressants on suicidal ideation (SI) is unclear. In the landmark STAR*D trial antidepressants were effective for Major Depressive Disorder (MDD) in early treatment phases, but less effective in later phases. The effects of antidepressants on SI across the entire sample of the STAR*D trial has never been investigated. We performed a secondary analysis of the STAR*D data with the primary outcome of change in score on the suicide item (item three) of the Hamilton Rating Scale for Depression (HRSD₁₇) across all four study levels. We used descriptive statistics and logistic regression analyses. Pearson correlation was used for change in SI versus change in depression (HRSD₁₆). Reduction in mean (SD) SI was greater in levels one: 0.29 (±0.78) (p < 0.001) and two: 0.26 (±0.88) (p < 0.001) than in levels three: 0.16 (±0.92) (p = 0.005) and four: 0.18 (±0.93) (p = 0.094). A history of past suicide attempts (OR 1.72, p = 0.007), comorbid medical illness (OR 2.23, p = 0.005), and a family history of drug abuse (OR 1.69, p = 0.008) were correlated with worsening of SI across level one. Treatment with bupropion (OR 0.24, p < 0.001) or buspirone (OR 0.24, p = 0.001) were correlated with lowering of SI across level two. Improvement in SI was correlated with improvement in overall depression (HRSD₁₆) at level one: r(3756) = 0.48; level two: r(1027) = 0.38; level three: r(249) = 0.31; and level four: r(75) = 0.42 (p < 0.001 for all levels). Improvement in SI is limited with pharmacotherapy in patients with treatment-resistant depression. Treatments with known anti-suicidal effects in MDD, such as ECT, should be considered in these patients.

Adding cognitive therapy to antidepressant medications decreases suicidal ideation

BACKGROUND

Psychotherapy for depression and antidepressant medications have both been associated with decreases in suicidal ideation. Studies have not examined whether adding psychotherapy to antidepressant medications further reduces suicidal ideation relative to medications alone in adults.

METHODS

Participants (N = 452) were randomized to 7 months of treatment with antidepressant medications or combined treatment with both medications and cognitive therapy for depression. We examined change in the suicide items from the Beck Depression Inventory (BDI) and Hamilton Depression Rating Scale (HDRS) across treatment using Bayesian generalized linear mixed models for non-continuous outcomes.

RESULTS

Suicidal ideation decreased across treatment. When measured with the BDI, participants receiving both cognitive therapy and antidepressant medications showed 17% greater reductions in suicidal ideation relative to those receiving medications alone; this effect remained significant when controlling for depression severity. While the same pattern was observed when suicidal ideation was measured with the HDRS, the effect was smaller (7%) and not statistically significant. When BDI and HDRS scores were combined, participants receiving both therapy and medications showed 9% greater reductions in suicidal ideation relative to those receiving medications alone; this effect was marginally significant when controlling for depression severity.

LIMITATIONS

This is a secondary analysis of a randomized clinical trial designed to treat depression, in which suicidal ideation was assessed using single-item measures.

CONCLUSIONS

Adding cognitive therapy to antidepressant medications may reduce suicidal ideation to a greater extent than medications alone. Pending replication, combination treatment may be preferred for individuals with suicidal ideation.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00057577.

Rapid and sustained decreases in suicidality following a single dose of ayahuasca among individuals with recurrent major depressive disorder: results from an open-label trial

RATIONALE

Suicidality is a major public health concern with limited treatment options. Accordingly, there is a need for innovative interventions for suicidality. Preliminary evidence indicates that treatment with the psychedelic ayahuasca may lead to decreases in depressive symptoms among individuals with major depressive disorder (MDD). However, there remains limited understanding of whether ayahuasca also leads to reductions in suicidality.

OBJECTIVE

To examine the acute and post-acute effect of ayahuasca on suicidality among individuals with MDD.

METHODS

We conducted a secondary analysis of an open-label trial in which individuals with recurrent MDD received a single dose of ayahuasca (N = 17). Suicidality was assessed at baseline; during the intervention; and 1, 7, 14, and 21 days after the intervention.

RESULTS

Among individuals with suicidality at baseline (n = 15), there were significant acute (i.e., 40, 80, 140, and 180 min after administration) and post-acute (1, 7, 14, and 21 days after administration) decreases in suicidality following administration of ayahuasca. Post-acute effect sizes for decreases in suicidality were large (Hedges' g = 1.31-1.75), with the largest effect size 21 days after the intervention (g = 1.75).

CONCLUSIONS

When administered in the appropriate context, ayahuasca may lead to rapid and sustained reductions in suicidality among individuals with MDD. Randomized, double-blind studies with larger sample sizes are needed to confirm this early finding.

Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials.

OBJECTIVES

This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy.

DATA SOURCES

The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019.

REVIEW METHODS

Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality.

RESULTS

A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions.

LIMITATIONS

Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them.

CONCLUSION

Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes.

FUTURE WORK

Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017078690.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.

Adaptation of evidence-based suicide prevention strategies during and after the COVID-19 pandemic

Suicide is preventable. Nevertheless, each year 800,000 people die of suicide in the world. While there is evidence indicating that suicide rates de-crease during times of crises, they are expected to increase once the immediate crisis has passed. The COVID-19 pandemic affects risk and pro-tective factors for suicide at each level of the socio-ecological model. Economic downturn, augmented barriers to accessing health care, increased access to suicidal means, inappropriate media reporting at the societal level; deprioritization of mental health and preventive activities at the community level; interpersonal conflicts, neglect and violence at the relationship level; unemployment, poverty, loneliness and hopelessness at the individual level: all these variables contribute to an increase of depression, anxiety, post-traumatic stress disorder, harmful use of alcohol, substance abuse, and ultimately suicide risk. Suicide should be prevented by strengthening universal strategies directed to the entire population, including mitigation of unemployment, poverty and inequalities; prioritization of access to mental health care; responsible media reporting, with information about available support; prevention of increased alcohol intake; and restriction of access to lethal means of suicide. Selective interventions should continue to target known vulnerable groups who are socio-economically disadvantaged, but also new ones such as first responders and health care staff, and the bereaved by COVID-19 who have been deprived of the final contact with loved ones and funerals. Indicated preventive strategies targeting individuals who display suicidal behaviour should focus on available pharmacological and psychological treatments of mental disorders, ensuring proper follow-up and chain of care by increased use of telemedicine and other digital means. The scientific community, health care professionals, politicians and decision-makers will find in this paper a systematic description of the effects of the pandemic on suicide risk at the society, community, family and individual levels, and an overview of how evidence-based suicide preventive interventions should be adapted. Research is needed to investigate which adaptations are effective and in which con-texts.

Effectiveness of Internet- and Mobile-Based Cognitive Behavioral Therapy to Reduce Suicidal Ideation and Behaviors: Protocol for a Systematic Review and Meta-Analysis of Individual Participant Data

Internet- and mobile-based cognitive behavioral therapy (iCBT) might reduce suicidal ideation. However, recent meta-analyses found small effect sizes, and it remains unclear whether specific subgroups of participants experience beneficial or harmful effects. This is the study protocol for an individual participant meta-analysis (IPD-MA) aiming to determine the effectiveness of iCBT on suicidal ideation and identify moderators. We will systematically search CENTRAL, PsycINFO, Embase, and Pubmed for randomized controlled trials examining guided or self-guided iCBT for suicidality. All types of control conditions are eligible. Participants experiencing suicidal ideation will be included irrespective of age, diagnoses, or co-interventions. We will conduct a one-stage IPD-MA with suicidal ideation as the primary outcome, using a continuous measure, reliable improvement and deterioration, and response rate. Moderator analyses will be performed on participant-, study-, and intervention-level. Two independent reviewers will assess risk of bias and the quality of evidence using Cochrane's Risk of Bias Tool 2 and GRADE. This review was registered with OSF and is currently in progress. The IPD-MA will provide effect estimates while considering covariates and will offer novel insights into differential effects on a participant level. This will help to develop more effective, safe, and tailored digital treatment options for suicidal individuals.

Toward a unifying theory of dysregulated behaviors

Dysregulated behaviors, defined as active behaviors that have short-term benefits but cause serious recurrent long-term distress or impairment to the individual and/or those around them, include behaviors such as suicidal and nonsuicidal self-injury, aggression, and substance use. These behaviors are common and costly to the individual, their friends and family, and society. Despite similar etiological models and interventions, dysregulated behaviors have largely been studied in isolation from one another. The goals of this paper were to a) define dysregulated behaviors as a coherent class of behaviors, b) review the prevalence and consequences of dysregulated behaviors, c) outline how dysregulated behaviors fit into current models of psychopathology, and d) describe the key questions to be addressed by future research in this area. It is argued that integrating across theories of discrete dysregulated behaviors can help provide aid in the development of etiological models, which in turn can improve prevention and intervention for dysregulated behaviors.

Internet-Based Cognitive Behavioral Therapy to Reduce Suicidal Ideation: A Systematic Review and Meta-analysis

IMPORTANCE

Suicidal ideation is a widespread phenomenon. However, many individuals at risk for suicide do not seek treatment, which might be addressed by providing low-threshold, internet-based self-help interventions.

OBJECTIVE

To investigate whether internet-based self-help interventions directly targeting suicidal ideation or behavior are associated with reductions in suicidal ideation.

DATA SOURCES

A systematic search of PsycINFO, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and the Centre for Research Excellence of Suicide Prevention (CRESP) databases for trials from inception to April 6, 2019, was performed, supplemented by reference searches. Search strings consisted of various search terms related to the concepts of internet, suicide, and randomized clinical trials.

STUDY SELECTION

Two independent researchers reviewed titles, abstracts, and full texts. Randomized clinical trials evaluating the effectiveness of internet-based self-help interventions to reduce suicidal ideation were included. Interventions were eligible if they were based on psychotherapeutic elements. Trials had to report a quantitative measure of a suicide-specific outcome. Mobile-based and gatekeeper interventions were excluded; no further restrictions were placed on participant characteristics or date of publication.

DATA EXTRACTION AND SYNTHESIS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Risk of bias was evaluated using the Cochrane Risk of Bias Tool. Standardized mean differences were calculated using a random-effects model.

MAIN OUTCOMES AND MEASURES

Suicidal ideation was the a priori primary outcome.

RESULTS

Six unique eligible trials (1567 unique participants; 1046 [66.8%] female; pooled mean [SD] age, 36.2 [12.5] years) were included in the systematic review and meta-analysis. All identified interventions were internet-based cognitive behavioral therapy (iCBT). Participants assigned to the iCBT condition experienced a significantly reduced suicidal ideation compared with controls following intervention in all 6 trials (standardized mean difference, -0.29; 95% CI, -0.40 to -0.19; P < .001). Heterogeneity was low (I2 = 0%). The effect appeared to be maintained at follow-up in 4 trials (standardized mean difference, -0.18; 95% CI, -0.34 to -0.02; P = .03; I2 = 36%). Studies did not report sufficient data on completed suicides and suicide attempts to assess potential associations.

CONCLUSIONS AND RELEVANCE

These results show that iCBT interventions are associated with significant reductions in suicidal ideation compared with control conditions. Considering their high scalability, iCBT interventions have the potential to reduce suicide mortality. Future research should assess the effect of these digital health interventions on suicidal behavior and identify moderators and mediators to advance understanding of the mechanisms of effectiveness of these interventions.

Right care, first time: a highly personalised and measurement-based care model to manage youth mental health

Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change. Consequently, the effects of adolescent-onset mood and psychotic syndromes can have long term consequences. A key clinical challenge for youth mental health is to develop and test new systems that align with current evidence for comorbid presentations and underlying neurobiology, and are useful for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. Our highly personalised and measurement-based care model includes three core concepts: ▶ A multidimensional assessment and outcomes framework that includes: social and occupational function; self-harm, suicidal thoughts and behaviour; alcohol or other substance misuse; physical health; and illness trajectory. ▶ Clinical stage. ▶ Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on proposed pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). The model explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within this highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care as well as utilisation of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality, mental health care for young people. CHAPTER 1: MULTIDIMENSIONAL OUTCOMES IN YOUTH MENTAL HEALTH CARE: WHAT MATTERS AND WHY?: Mood and psychotic syndromes present one of the most serious public health challenges that we face in the 21st century. Factors including prevalence, age of onset, and chronicity contribute to substantial burden and secondary risks such as alcohol or other substance misuse. Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change; thus, effects can have long term consequences. We propose five key domains which make up a multidimensional outcomes framework that aims to address the specific needs of young people presenting to health services with emerging mental illness. These include social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Impairment and concurrent morbidity are well established in young people by the time they present for mental health care. Despite this, services and health professionals tend to focus on only one aspect of the presentation - illness type, stage and trajectory - and are often at odds with the preferences of young people and their families. There is a need to address the disconnect between mental health, physical health and social services and interventions, to ensure that youth mental health care focuses on the outcomes that matter to young people. CHAPTER 2: COMBINING CLINICAL STAGE AND PATHOPHYSIOLOGICAL MECHANISMS TO UNDERSTAND ILLNESS TRAJECTORIES IN YOUNG PEOPLE WITH EMERGING MOOD AND PSYCHOTIC SYNDROMES: Traditional diagnostic classification systems for mental disorders map poorly onto the early stages of illness experienced by young people, and purport categorical distinctions that are not readily supported by research into genetic, environmental and neurobiological risk factors. Consequently, a key clinical challenge in youth mental health is to develop and test new classification systems that align with current evidence on comorbid presentations, are consistent with current understanding of underlying neurobiology, and provide utility for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. This chapter outlines a transdiagnostic framework for classifying common adolescent-onset mood and psychotic syndromes, combining two independent but complementary dimensions: clinical staging, and three proposed pathophysiological mechanisms. Clinical staging reflects the progression of mental disorders and is in line with the concept used in general medicine, where more advanced stages are associated with a poorer prognosis and a need for more intensive interventions with a higher risk-to-benefit ratio. The three proposed pathophysiological mechanisms are neurodevelopmental abnormalities, hyperarousal and circadian dysfunction, which, over time, have illness trajectories (or pathways) to psychosis, anxious depression and bipolar spectrum disorders, respectively. The transdiagnostic framework has been evaluated in young people presenting to youth mental health clinics of the University of Sydney's Brain and Mind Centre, alongside a range of clinical and objective measures. Our research to date provides support for this framework, and we are now exploring its application to the development of more personalised models of care. CHAPTER 3: A COMPREHENSIVE ASSESSMENT FRAMEWORK FOR YOUTH MENTAL HEALTH: GUIDING HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE USING MULTIDIMENSIONAL AND OBJECTIVE MEASURES: There is an urgent need for improved care for young people with mental health problems, in particular those with subthreshold mental disorders that are not sufficiently severe to meet traditional diagnostic criteria. New comprehensive assessment frameworks are needed to capture the biopsychosocial profile of a young person to drive highly personalised and measurement-based mental health care. We present a range of multidimensional measures involving five key domains: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Objective measures include: neuropsychological function; sleep-wake behaviours and circadian rhythms; metabolic and immune markers; and brain structure and function. The recommended multidimensional measures facilitate the development of a comprehensive clinical picture. The objective measures help to further develop informative and novel insights into underlying pathophysiological mechanisms and illness trajectories to guide personalised care plans. A panel of specific multidimensional and objective measures are recommended as standard clinical practice, while others are recommended secondarily to provide deeper insights with the aim of revealing alternative clinical paths for targeted interventions and treatments matched to the clinical stage and proposed pathophysiological mechanisms of the young person. CHAPTER 4: PERSONALISING CARE OPTIONS IN YOUTH MENTAL HEALTH: USING MULTIDIMENSIONAL ASSESSMENT, CLINICAL STAGE, PATHOPHYSIOLOGICAL MECHANISMS, AND INDIVIDUAL ILLNESS TRAJECTORIES TO GUIDE TREATMENT SELECTION: New models of mental health care for young people require that interventions be matched to illness type, clinical stage, underlying pathophysiological mechanisms and individual illness trajectories. Narrow syndrome-focused classifications often direct clinical attention away from other key factors such as functional impairment, self-harm and suicidality, alcohol or other substance misuse, and poor physical health. By contrast, we outline a treatment selection guide for early intervention for adolescent-onset mood and psychotic syndromes (ie, active treatments and indicated and more specific secondary prevention strategies). This guide is based on experiences with the Brain and Mind Centre's highly personalised and measurement-based care model to manage youth mental health. The model incorporates three complementary core concepts: ▶A multidimensional assessment and outcomes framework including: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness trajectory. ▶Clinical stage. ▶Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on three underlying pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). These core concepts are not mutually exclusive and together may facilitate improved outcomes through a clinical stage-appropriate and transdiagnostic framework that helps guide decisions regarding the provision of appropriate and effective care options. Given its emphasis on adolescent-onset mood and psychotic syndromes, the Brain and Mind Centre's model of care also respects a fundamental developmental perspective - categorising childhood problems (eg, anxiety and neurodevelopmental difficulties) as risk factors and respecting the fact that young people are in a period of major biological and social transition. Based on these factors, a range of social, psychological and pharmacological interventions are recommended, with an emphasis on balancing the personal benefit-to-cost ratio. CHAPTER 5: A SERVICE DELIVERY MODEL TO SUPPORT HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE IN YOUTH MENTAL HEALTH: Over the past decade, we have seen a growing focus on creating mental health service delivery models that better meet the unique needs of young Australians. Recent policy directives from the Australian Government recommend the adoption of stepped-care services to improve the appropriateness of care, determined by severity of need. Here, we propose that a highly personalised approach enhances stepped-care models by incorporating clinical staging and a young person's current and multidimensional needs. It explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within a highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care and use of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality of, mental health care for young people.

Suicide prevention using self-guided digital interventions: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Digital interventions that deliver psychological self-help provide the opportunity to reach individuals at risk of suicide who do not access traditional health services. Our primary objective was to test whether direct (targeting suicidality) and indirect (targeting depression) digital interventions are effective in reducing suicidal ideation and behaviours, and our secondary analyses assessed whether direct interventions were more effective than indirect interventions.

METHODS

In this systematic review and meta-analysis, we searched online databases MEDLINE, PubMed, PsycINFO, and Cochrane CENTRAL for randomised controlled trials published between database inception to May 21, 2019. Superiority randomised controlled trials of self-guided digital interventions (app or web based, which delivered theory-based therapeutic content) were included if they reported suicidal ideation, suicidal plans, or suicide attempts as an outcome. Non-inferiority randomised controlled trials were excluded to ensure comparability of the effect. Data were extracted from published reports, and intention-to-treat data were used if available. The primary outcome was the difference in mean scores of validated suicidal ideation measures (Hedges'g) with the associated 95% CI for the analysis of digital intervention effectiveness on suicidal ideation. We also present funnel plots of the primary outcome measure (suicidal ideation) for direct and indirect interventions to assess for publication bias. We calculated I² (with I² CI) values to test heterogeneity. We used random-effects modelling for the meta-analyses to assess the primary and secondary outcomes. This study is registered with PROSPERO, CRD42018102084.

FINDINGS

The literature search yielded 739 articles (including manual searching) for suicidality and 8842 articles for depression. After screening, 14 papers reporting on 16 studies were included in the narrative review and meta-analysis. The 16 studies (ten on direct interventions and six on indirect interventions) provided baseline data for 4398 participants. The primary outcome of overall post-intervention effect for suicidal ideation was small but significant immediately following the active intervention phase (Hedges'g -0·18, 95% CI -0·27 to -0·10, p<0·0001; I²=0%, I² CI 0·0-47·9). The secondary objective, comparing direct and indirect interventions, showed that direct interventions (targeting suicidality) significantly reduced suicidal ideation at post-intervention (g -0·23, 95% CI -0·35 to -0·11, p<0·0001; I²=17·6%, I² CI 0·0-58·6), but indirect interventions (targeting depression) failed to reach significance (g -0·12, 95% CI -0·25 to 0·01, p=0·071; I²=0%, I² CI 0·0-30·7).

INTERPRETATION

Self-guided digital interventions directly targeting suicidal ideation are effective immediately post-intervention. Indirect interventions were not significant for reducing suicidal ideation. Our findings suggest that digital interventions should be promoted and disseminated widely, especially where there is a lack of, or minimal access to, health services.

FUNDING

Australian National Health and Medical Research Council.

Treatments for the Prevention and Management of Suicide: A Systematic Review

BACKGROUND

Suicide is a growing public health problem, with the national rate in the United States increasing by 30% from 2000 to 2016.

PURPOSE

To assess the benefits and harms of nonpharmacologic and pharmacologic interventions to prevent suicide and reduce suicide behaviors in at-risk adults.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, and other databases from November 2011 through May 2018.

STUDY SELECTION

Systematic reviews (SRs) and randomized controlled trials (RCTs) that assessed nonpharmacologic or pharmacologic therapies for adults at risk for suicide.

DATA EXTRACTION

One investigator abstracted data and assessed study quality, and a second investigator checked abstractions and assessments for accuracy.

DATA SYNTHESIS

Eight SRs and 15 RCTs were included. The evidence for psychological interventions suggests that cognitive behavioral therapy (CBT) reduces suicide attempts, suicidal ideation, and hopelessness compared with treatment as usual (TAU). Limited evidence suggests that dialectical behavior therapy (DBT) reduces suicidal ideation compared with wait-list control or crisis planning. The evidence for pharmacologic treatments suggests that ketamine reduces suicidal ideation with minimal adverse events compared with placebo or midazolam. Lithium reduces rates of suicide among patients with unipolar or bipolar mood disorders compared with placebo. However, no differences were observed between lithium and other medications in reducing suicide.

LIMITATION

Qualitative synthesis of new evidence with existing meta-analyses, methodological shortcomings of studies, heterogeneity of nonpharmacologic interventions, and limited evidence for pharmacologic treatments and harms.

CONCLUSION

Both CBT and DBT showed modest benefit in reducing suicidal ideation compared with TAU or wait-list control, and CBT also reduced suicide attempts compared with TAU. Ketamine and lithium reduced the rate of suicide compared with placebo, but there was limited information on harms. Limited data are available to support the efficacy of other nonpharmacologic or pharmacologic interventions.

PRIMARY FUNDING SOURCE

U.S. Department of Veterans Affairs Veterans Health Administration. (PROSPERO: CRD42018104978).

Assessment and Management of Patients at Risk for Suicide: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

DESCRIPTION

In May 2019, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved an update to the 2013 joint clinical practice guideline for assessing and managing patients who are at risk for suicide. This guideline provides health care providers with a framework by which to screen for, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients who may be at risk for suicide.

METHODS

In January 2018, the VA/DoD Evidence-Based Practice Work Group convened to develop a joint VA/DoD guideline including clinical stakeholders and conforming to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel drafted key questions, systematically searched and evaluated the literature through April 2018, created algorithms, and advanced 22 recommendations in accordance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

RECOMMENDATIONS

This synopsis, which includes 3 clinical practice algorithms, summarizes the key recommendations of the guideline related to screening and evaluation, risk management and treatment, and other management methods. Risk management and treatment recommendations address both pharmacologic and nonpharmacologic approaches for patients with suicidal ideation and behavior. Other management methods address lethal means safety (such as restricting access to firearms, poisons, and medications and installing barriers to prevent jumping from lethal heights) and population health strategies.

The Effectiveness of Internet-Based Self-Help Interventions to Reduce Suicidal Ideation: Protocol for a Systematic Review and Meta-Analysis

BACKGROUND

Suicidal ideation is a highly prevalent condition. There are several barriers for individuals to seek treatment that may be addressed by providing internet-based self-help interventions (ISIs). Current evidence suggests that ISIs for mental disorders may only be effective in reducing suicidal ideation if they specifically target suicidal thoughts or behaviors.

OBJECTIVE

The aim of this systematic review and meta-analysis is to investigate the effectiveness of ISIs that directly target suicidal thoughts or behaviors.

METHODS

We will conduct a sensitive systematic literature search in PsycINFO, MEDLINE, the Cochrane Central Register of Controlled Trials, and the Centre for Research Excellence of Suicide Prevention databases. Only randomized controlled trials evaluating the effectiveness of ISIs for suicide prevention will be included. Interventions must be delivered primarily in a Web-based setting; mobile-based interventions and interventions targeting gatekeepers will be excluded. Suicide ideation will be the primary outcome; secondary outcomes will be completed suicides, suicide attempts, depressiveness, anxiety, and hopelessness. Study quality will be assessed using the Cochrane Risk of Bias tool. We will provide a narrative synthesis of included studies. If studies are sufficiently homogenous, we will conduct a meta-analysis of the effectiveness on suicide ideation and, if possible, we will evaluate publication bias using funnel plots. We will evaluate the cumulative evidence in accordance with the Grading of Recommendations Assessment, Development and Evaluation framework.

RESULTS

This review is in progress, with findings expected by August 2019.

CONCLUSIONS

This systematic review and meta-analysis focuses on the effectiveness of ISIs for suicidal thoughts and behaviors. It will provide guidance to clinical practice and encourage further research by synthesizing the best available evidence.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) CRD42019130253; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=130253.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/14174.

Emerging trends in suicide prevention research

PURPOSE OF REVIEW

The purpose of this article is to present notable findings and developments in suicide prevention research and in particular, strategies to detect persons at risk for suicide as well as strategies to reduce suicide risk among the general population and specific risk groups.

RECENT FINDINGS

Popular strategies to detect persons at risk for suicide include scanning social media posts, prediction models using electronic health record data as well as the use of experienced sampling methodology to enhance our understanding of the suicidal process. Emerging approaches to reduce suicide risk include the development of media reporting recommendations, mass media campaigns to improve knowledge, attitudes and behaviour as well as technology-enhanced interventions.

SUMMARY

Recently, promising approaches to detect individuals at risk for suicide as well as effective strategies to reduce suicide risk emerged. Whether these new opportunities will translate into an effective reduction in suicide rates remains to be demonstrated.

The relationship between an electronic mental health stigma campaign and suicidal thoughts and behaviours: a two-arm randomized controlled trial in the Australian construction industry

Males employed in the construction industry are at greater risk of suicide than other employed males. It is plausible that a high level of stigma against mental health problems explains the elevated rates of suicide among this group. This study sought to test the effectiveness of an electronic mental health stigma intervention on suicide ideation, communication about suicide and attempts. Participants were randomly assigned to receive either a series of brief contact interventions over a 6-week period or a wait list control. Suicidal ideation, communication about suicide and suicide attempts were assessed using the Suicidal Behaviors Questionnaire-Revised at post-intervention. We used linear regression to assess effectiveness at post-intervention, adjusting for relevant covariates using both conventional methods and a propensity score approach. Results indicate that the intervention had no significant impact on suicidal thoughts, communication or suicide attempts. There was some indication that individuals in the intervention group reported a slight increase in attempts and communication about suicide. These observations underscore an urgent need for more research to understand the complex and nuanced relationship between stigma and suicide in non-clinical populations.

Effectiveness of Psychotherapy on Suicidal Risk: A Systematic Review of Observational Studies

Background: Suicidal behavior is a major public health concern worldwide, and the interest in the development of novel and more efficient treatment strategies and therapies to reduce suicidal risk is increasing. Some recent studies have summarized the results of randomized clinical trials (RCTs) assessing the efficacy of psychotherapeutic tools designed to treat patients at suicidal risk. However, observational studies, which reflect real-world effectiveness and may use original approaches, have not been reviewed. Method: The aim of this study is to systematically review the available scientific evidence issued from observational studies on the clinical effectiveness of psychotherapeutic tools designed to treat patients at suicide risk. We have thus performed a systematic search of PubMed and Web of Science databases. Results: Out of 1578 papers, 40 original observational studies fulfilled our selection criteria. The most used psychotherapeutic treatments were dialectical behavioral therapy (DBT, 27.5%) and cognitive behavioral therapy (CBT, 15.0%) in patients with a diagnosis of borderline personality disorder (32.5%) and depression (15.0%). Despite the between-study heterogeneity, interventions lead to a reduction in suicidal outcomes, i.e., suicidal ideation (55.0%) and suicide attempts (37.5%). The content and reporting quality varied considerably between the studies. Conclusion: DBT and CBT are the most widely used psychotherapeutic interventions and show promising results in existing observational studies. Some of the included studies provide innovative approaches. Group therapies and internet-based therapies, which are cost-effective methods, are promising treatments and would need further study.

Refining Suicide Prevention: a Narrative Review on Advances in Psychotherapeutic Tools

PURPOSE OF REVIEW

Since psychotherapies for suicide prevention are receiving increasing attention, our purpose was to evaluate the related literature [meta-analyses and reviews on their effect on suicidal outcomes (A), perspective reviews concerning specific socio-demographic and clinical features (B), original studies with particular interest (C)] published over the last 3 years.

RECENT FINDINGS

(A) Across different diagnoses, particularly, efficacious psychotherapies were cognitive behavioral therapy-based ones and interventions directly addressing suicidal thoughts and behaviors during the treatment. When the focus was restricted to specific diagnoses, results were different: for example, in borderline patients, dialectical behavior therapy and psychodynamic psychotherapies were the only efficacious interventions. (B) Family therapies for adolescents and treatments for elderly depressed patients with disability/cognitive impairment should be further developed. (C) General long-term effects seem to be present, but specific interventions and treatment duration should be considered. Results indicated the presence of a number of promising interventions.