Family-Based Crisis Intervention With Suicidal Adolescents: A Randomized Clinical Trial

What is the purpose of Psychiatric Emergency Care Centres? A qualitative study of health care staff

BACKGROUND

Psychiatric Emergency Care Centres do not have a clear treatment model or evidence base. An understanding of the patient population, clinical practice and approaches is needed to develop an evidence-based framework.

OBJECTIVES

Identify staff perceptions of the purpose of Psychiatric Emergency Care Centres, who should be treated and how.

METHODS

A multidisciplinary sample of clinicians and administrators currently working in, or with administrative oversight of, Psychiatric Emergency Care Centres were interviewed. All New South Wales Psychiatric Emergency Care Centres were approached and staff self-selected. A total of 36 people participated, including nurses, doctors, social workers and managers. A critical realist qualitative thematic analysis approach was used, with an inductive orientation.

RESULTS

Having an achievable admission goal was important. Although 'harm minimization' was often cited as important, this meant conflicting, superimposed notions to different people, including minimizing self-harm, reducing iatrogenic harm from unnecessary or coercive intervention and limiting harm to a resource-constrained system. Participants reported significant clinical practice variation and confidence in their practice.

CONCLUSION

The approach to the primary goal of 'harm minimization' reflects conflicting priorities in a complex system which are often not explicit. However, we identified a clinical practice framework upon which to base care pathways, training, intervention development and outcome assessment.

Suicide Risk and Social Connectedness in Cisgender and Transgender Lesbian, Gay, Bisexual, and Queer/Questioning Youth in the Emergency Department

PURPOSE

Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) youth are at high suicide risk. Family/peer connectedness may be protective factors; few studies assess social connectedness within cisgender lesbian, gay, bisexual, and queer (cis-LGBQ) and transgender and gender-diverse (TGD) samples. This study aims to identify associations between family/peer connectedness and suicidal thoughts/behaviors (STBs) among cisgender-LGBQ and TGD youth to better inform suicide prevention strategies.

METHODS

This study utilized data from LGBTQ youth aged 12-17 in the Emergency Department Screen for Teens at Risk for Suicide study. Youth completed measures for STBs (Ask Suicide-Screening Questions and Columbia Suicide Severity Rating Scale) and family/peer connectedness ("low," "moderate," and "high"). Logistic regression analyses examined associations between family/peer connectedness and STBs in cis-LGBQ and TGD youth.

RESULTS

53.2% (607/1,140) of cis-LGBQ and 69.7% (99/142) of TGD youth self-reported STBs. For cis-LGBQ youth, the odds of reporting STBs increased when comparing low/moderate versus high family connectedness (p < .001, adjOR = 9.8[6.8-14.2]; p < .001, adjOR = 3.5[2.7-4.7]) and low versus moderate (p < .001, adjOR = 2.8[1.9-4.0]). Regarding cis-LGBQ peer connectedness, the odds of reporting STBs increased when comparing low/moderate versus high (p < .01, adjOR = 1.8[1.2-2.7]; p < .05, adjOR = 1.5[1.1-2.1]), not low versus moderate (p = .4). For TGD youth, the odds of reporting STBs significantly increased when comparing low/moderate versus high family connectedness (p < .001, adjOR = 9.8[3.7-28.2]; p < .001, adjOR = 7.7[2.8-22.8]), not when comparing low versus moderate (p = .7). Peer connectedness levels had no significant associations with TGD youths' STB rates (p = .2, p = .3, p = .8).

DISCUSSION

LGBTQ, especially TGD youth, are at elevated suicide risk. High levels of family connectedness may especially help mitigate suicide risk in TGD youth. Future research should replicate findings in larger TGD samples and adapt LGBTQ-specific, family-based emergency department interventions.

Suicide Prevention and Telehealth in Children's Hospital Emergency Departments

OBJECTIVES

Suicide is a leading cause of death among adolescents. Emergency department (ED) visits for mental health concerns are rising, and telehealth is increasingly used to provide emergency mental health care. We conducted a national survey to describe suicide prevention practices and tele-mental health care in children's hospital EDs.

METHODS

We conducted a cross-sectional survey of leaders at all 52 US EDs affiliated with dedicated children's hospitals (ie, hospitals that provide care only to children) to describe use of tele-mental health care and suicide prevention practices.

RESULTS

Leaders from 41 EDs completed the survey (79% response rate). Tele-mental health care was used in 23 EDs (56%); there were no differences in ED structural characteristics between institutions with telehealth versus without telehealth. Among responding EDs, 40 (98%) reported they screen for suicide risk, and 29 (71%) reported they use a standardized approach to suicide prevention discharge planning. Risk reduction practices conducted at many but not all EDs included assessment of access to lethal means (n = 31, 86%), counseling on reduction of access to lethal means (n = 30, 73%) and providing patients with a list of professionals or agencies that they can contact in a crisis (n = 35, 85%). There were no differences in use of suicide prevention practices at EDs with versus without telehealth ( P > 0.1 for all).

CONCLUSIONS

Approximately half of children's hospital EDs use tele-mental health care, and hospitals with versus without tele-mental health care report similar rates of suicide prevention practice use. Opportunities exist to increase use of discharge safety practices.

Stabilizing Pediatric Patients During Psychiatric Boarding: A Quality Improvement Project

BACKGROUND AND OBJECTIVES

Psychiatric boarding has implications for youth, their families, and hospital systems. We undertook a quality improvement (QI) project to address boarding at our institution. We aimed to stabilize patients who were boarding in our emergency department (ED) observation unit and to decrease the percentage of patients admitted to psychiatric facilities.

METHODS

A multidisciplinary team created a stabilization protocol focused on enhancing coping strategies and family communication and providing psychoeducation and safety planning. This program was piloted in a group of patients experiencing boarding beginning in March 2021. Implementing the protocol involved additional staffing, plans for structured daily activities, and enhancements to the electronic health record.

RESULTS

During the baseline period (January 2019-February 2021), 65.7% (n = 498) of encounters in which patients boarded in the ED observation unit resulted in the patient being admitted to a psychiatric facility compared with 49.0% (n = 373) of encounters during the intervention period, reflecting a centerline shift on a statistical process control chart. From March 2021 to May 2022 (intervention period), 159 patients participated in the stabilization protocol across 164 encounters. Compared with similar nonpilot encounters (n = 446) occurring during the same period, pilot encounters (n = 164) were less likely to result in admission to a psychiatric facility (22.6% vs 58.2%) and were more likely to result in the patient being discharged home (75.0% vs 31.4%).

CONCLUSION

This QI project resulted in fewer patients being transferred to inpatient psychiatric care. This program illustrates that medical hospitals can creatively improve care for patients experiencing boarding.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prevention and Management of Risky Behaviors in Adolescents, Focusing on Suicide, Substance Use, and Risky Sexual Behaviors through Empowerment Programs: A Narrative Review

Background

Empowering adolescents to manage and reduce unhealthy behaviors and promote adaptive behaviors is a promising approach to promoting healthy behaviors. This review was an attempt to evaluate adolescent empowerment programs aimed at preventing and managing risky behaviors.

Materials and Methods

This narrative review was conducted in 2023. The texts were reviewed in two sections: (1) a review of articles and books in databases and (2) a review of international websites. The keywords used to search for studies and programs included substance-related disorders, risky behaviors, empowerment, program, adolescent, suicide, and risky sexual behaviors. These keywords were individually searched in international databases such as "PubMed, Scopus, and Web of Science." In the second section, a search was conducted on the websites of international organizations such as the World Health Organization (WHO). The inclusion criteria included having the full text of the original articles, articles in English, articles related to the development and evaluation of the effectiveness of empowerment programs, and the age range of adolescents. The texts that only had abstracts and were in non-English languages were excluded.

Results

The programs designed to empower adolescents were in three areas: (1) community-based and peer-based programs, (2) family-based programs, and (3) comprehensive programs. Most programs focused on peer group participation and skill interventions.

Conclusions

A powerful and effective empowering program for adolescents to prevent and control risky behaviors should be designed in the form of comprehensive programs in social, educational, economic, and health dimensions, and with the active engagement and participation of adolescents.

Urdu-Language Translation and Validation of the Ask Suicide-Screening Questions (ASQ) Tool: A Focus on Connotation and Context

Background Suicide is a significant cause of death in the world, and Pakistan, a low- and middle-income country, is no exception. Despite the increasing number of suicides, Pakistan does not have a validated suicide risk screening tool to identify suicide risk in the national language, Urdu, accurately. This study aims to translate and validate the Ask Suicide-Screening Questions (ASQ) tool into Urdu for suicide risk screening in Pakistan. Methodology We conducted this study at the Services Institute of Medical Sciences (SIMS), a large teaching hospital in Lahore, Pakistan, after receiving the approval of the SIMS Institutional Review Board. The study used a cross-sectional instrument validation study design. The inclusion criteria were youth and adults of both sexes aged 15-45 years, with an ability to understand, speak, read, and write in the Urdu language, who had no cognitive or intellectual limitation to consenting, and who were medically stable to participate. Exclusion criteria included any medical, physical, or cognitive unstable condition to consent or participate. We enrolled 300 participants in our convenience sample from the emergency department (ED), inpatient, and outpatient settings. The ASQ and the ASQ Brief Suicide Safety Assessment (BSSA) were translated and back-translated by Urdu language experts and modified to accommodate cultural and linguistic nuances. The clinician-administered BSSA Urdu version was used as a standard criterion to validate the ASQ by comparing the ASQ-Urdu responses vs. BSSA-Urdu responses. RStudio (version 2023.09.1+494) was used for statistical analyses Results The sample had an enrollment rate of 99.7% (300/301). The sample was 52% female (158/300); the mean age was 27.1 years (SD = 9.4), the overall screen-positive rate was 41.7% (125/300), and 9.3% (28/300) of the participants endorsed a past suicide attempt. In our sample, 35.9% (33/92) of outpatients, 32.2% (19/59) of inpatients, and 49.0% (73/149) of ED patients screened positive on the Urdu ASQ. The screen-positive rate was 16.9% (10/59) for participants aged 17 years and younger, 40.7% (35/86) for participants aged 18 to 25 years, and 51.6% (80/155) for participants aged 26 years and older. Compared to the criterion standard clinician-administered assessment, the Urdu ASQ had a sensitivity of 94.2% (95% confidence interval (CI) = 85.8%-98.4%), a specificity of 73.9% (95% CI = 67.7%-79.5%), a negative predictive value of 97.7% (95% CI = 94.2%-99.1%), and a positive predictive value of 52.0% (95% CI = 46.4%-57.6%). Conclusions The Urdu ASQ has strong psychometric properties, allowing healthcare professionals in Pakistan and worldwide with Urdu-speaking diaspora to identify individuals at risk for suicide efficiently. Utilizing cultural contexts in adapted screening tools improves the accuracy of suicide detection by ensuring that the tools are relevant, sensitive, and respectful to the cultural context of the individuals being assessed. High screen-positive rates in our pilot study underscore the need for early detection and intervention of suicide as a major global public health problem.

Brief Interventions for Suicidal Youths in Medical Settings: A Meta-Analysis

CONTEXT

Most youths who die by suicide have interfaced with a medical system in the year preceding their death, placing outpatient medical settings on the front lines for identification, assessment, and intervention.

OBJECTIVE

Review and consolidate the available literature on suicide risk screening and brief intervention with youths in outpatient medical settings and examine common outcomes.

DATA SOURCES

The literature search looked at PubMed, OVID, CINAHL, ERIC, and PsychInfo databases.

STUDY SELECTION

Interventions delivered in outpatient medical settings assessing and mitigating suicide risk for youths (ages 10-24). Designs included randomized controlled trials, prospective and retrospective cohort studies, and case studies.

DATA EXTRACTION

Authors extracted data on rates of referral to behavioral health services, initiation/adjustment of medication, follow-up in setting of assessment, suicidal ideation at follow-up, and suicide attempts and/or crisis services visited within 1 year of initial assessment.

RESULTS

There was no significant difference in subsequent suicide attempts between intervention and control groups. Analysis on subsequent crisis service could not be performed due to lack of qualifying data. Key secondary findings were decreased immediate psychiatric hospitalizations and increased mental health service use, along with mild improvement in subsequent depressive symptoms.

LIMITATIONS

The review was limited by the small number of studies meeting inclusion criteria, as well as a heterogeneity of study designs and risk of bias across studies.

CONCLUSIONS

Brief suicide interventions for youth in outpatient medical settings can increase identification of risk, increase access to behavioral health services, and for crisis interventions, can limit psychiatric hospitalizations.

The effectiveness of brief non-pharmacological interventions in emergency departments and psychiatric inpatient units for people in crisis: A systematic review and narrative synthesis

OBJECTIVE

Heterogeneous brief non-pharmacological interventions and guidelines exist to treat the burgeoning presentations to both emergency department and inpatient settings, for those in a crisis of mental ill-health. We systematically reviewed the literature to create a taxonomy of these brief non-pharmacological interventions, and review their evaluation methods and effectiveness.

METHOD

We conducted a systematic review across Cochrane, CINAHL, DARE, Embase, MEDLINE, PsycINFO databases. Studies meeting quality criteria, using Joanna Briggs Institute tools, were eligible. Interventions were categorised, and outcomes synthesised.

RESULTS

Thirty-nine studies were included: 8 randomised controlled trials, 17 quasi-experimental, 11 qualitative studies, and 3 file audits. Taxonomy produced six coherent intervention types: Skills-focussed, Environment-focussed, Special Observation, Psychoeducation, Multicomponent Group and Multicomponent Individual. Despite this, a broad and inconsistent range of outcome measures reflected different outcome priorities and prevented systematic comparison of different types of intervention or meta-analysis. Few brief non-pharmacological interventions had consistent evidential support: sensory modulation rooms consistently improved distress in inpatient settings. Short admissions may reduce suicide attempts and readmission, if accompanied by psychotherapy. Suicide-specific interventions in emergency departments may improve depressive symptoms, but not suicide attempt rates. There was evidence that brief non-pharmacological interventions did not reduce incidence of self-harm on inpatient wards. We found no evidence for frequently used interventions such as no-suicide contracting, special observation or inpatient self-harm interventions.

CONCLUSION

Categorising brief non-pharmacological interventions is feasible, but an evidence base for many is severely limited if not missing. Even when there is evidence, the inconsistency in outcomes often precludes clinicians from making inferences, although some interventions show promise.

Association between continuity of care and attendance of post-discharge follow-up after psychiatric emergency presentation

The number of accident and emergency (A&E) hospital attendances by young people aged 18 or under with a recorded diagnosis of a psychiatric condition more than tripled between 2010 and 2022. After discharge from the hospital, attendance at follow-up appointments in the community is critical to ensure the safety of young people and optimise the use of clinical resources. A retrospective cohort study was conducted to evaluate the association between follow-up attendance and the continuity of clinicians and clinical teams, using electronic clinical record data from East London NHS Foundation Trust (ELFT), between April 2019 and March 2022. Multi-level mixed effects logistic regression was performed to model the follow-up attendance odds based on whether the same or different clinician and clinical team offered the initial A&E and the community follow-up appointment or whether a crisis team was involved. 3134 A&E presentations by 2368 young people were identified within the study period. Following these presentations, 2091 follow-up appointments in the community were offered. The attendance rate increased by more than three times if the follow-up appointment was offered by the same clinician who saw the young person in A&E (odds ratio (OR) = 3.66; 95% CI 1.65-8.13). Whether the same clinical team provided the community follow-up appointment, or whether a crisis team was involved before discharge made no difference to the likelihood of follow-up attendance. The findings support the importance of the continuity of clinicians in the care of young people in crisis.

Review: Crisis responses for children and young people - a systematic review of effectiveness, experiences and service organisation (CAMH-Crisis)

BACKGROUND

In England, one in six children aged 5-19 has a probable diagnosable mental health disorder. This is a major public health problem, with multiple agencies adopting varying approaches to care delivery for children and young people (CYP) in crisis.

OBJECTIVES

To examine the organisation of crisis services across education, health, social care and voluntary sectors; the experiences and perceptions of CYP, families and staff; the effectiveness of current approaches to care and the goals of crisis intervention.

METHODS

A systematic review of all relevant English language evidence regarding the provision and receipt of crisis support for CYP aged 5-25 (PROSPERO-CRD42019160134). Seventeen databases were searched from 1995 to 2021 and relevant UK-only grey literature was identified. Critical appraisal was conducted using appropriate design specific appraisal tools. A narrative approach to synthesis was conducted.

RESULTS

In total, 138 reports (48 reports covering 42 primary research studies; 36 reports covering 39 descriptive accounts of the organisation services and 54 UK-only grey literature reports) were included. The evidence suggests that crisis services were organised as follows: triage/assessment-only, digitally mediated support approaches, and intervention approaches and models. When looking at experiences of crisis care, four themes were identified: (a) barriers and facilitators to seeking and accessing appropriate support; (b) what children and young people want from crisis services; (c) children's, young people's and families' experiences of crisis services; and (d) service provision. In determining effectiveness, the findings are summarised by type of service and were generated from single heterogenous studies. The goals of crisis services were identified.

DISCUSSION

Despite a lack of high-quality international studies, findings suggest that support prior to reaching crisis point is important. From this work, various aspects of crisis care have been identified that can be incorporated into existing services across education, health, social care and the voluntary sector.

Quantifying the Representation of Black Adolescents in Suicide Intervention Research

This systematic review aimed to quantify the representation of Black youth in U.S. suicide intervention research. Specifically, we sought to evaluate Black youth representation in terms of (a) equity of inclusion (i.e., the inclusion of Black youth in research study samples at a rate consistent with the overall national rate of Black adolescents in the US) and (b) equity of intervention efficacy (i.e., evaluating the presence of racial disparities in intervention efficacy/effect sizes). In addition, we aimed to evaluate whether an association existed between funding status of research and representation of Black youth in studies, and to provide recommendations for future research in this area. To this end, the present study extracted and analyzed demographic information of studies included in recent meta-analyses conducted by Robinson and colleagues (2018), which were not previously analyzed, in addition to new literature published between September 2017 and January 2021. Results showed that the prevalence of Black youth included in studies was representative (14.67%; ntotal = 4451, nBlack = 664), with a median inclusion rate of 13%; however, absolute sample and group sizes were so small that it precluded comparison of differential treatment outcomes for Black youth. Thus, out of 22 studies identified, only one was able to investigate treatment outcomes for suicide in Black youth specifically. This study points to the conclusion that without adequately powered studies, disparities in treatment efficacy for Black youth cannot be compared or addressed, and the existing disparity in suicidal outcomes for Black youth will grow even larger.

Suicide and Suicide Risk in Adolescents

Suicide is the second leading cause of death for 10- to 24-year-olds in the United States and is a global public health issue, with a recent declaration of a National State of Emergency in Children's Mental Health by the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children's Hospital Association. This clinical report is an update to the previous American Academy of Pediatrics clinical report, "Suicide and Suicide Attempts in Adolescents." Because pediatricians and pediatric health care providers are at the front line of care for adolescents amid a child and adolescent mental health crisis, and because of the chronic and severe shortage of mental health specialists, it is important that pediatric health care providers become facile with recognizing risk factors associated with suicidality and at-risk populations, screening and further assessment of suicidality as indicated, and evidence-based interventions for patients with suicidal ideation and associated behaviors. Suicide risk can be mitigated by appropriate screening, bolstering of protective factors, indicated treatment, community resources, and referrals to mental health providers when available.

Effectiveness of emergency department-based and initiated youth suicide prevention interventions: A systematic review

OBJECTIVE

This systematic review examined the effectiveness of Emergency Department-based and initiated youth suicide prevention interventions for suicide attempts, suicidal ideation, hospitalization, family system functioning, and other mental health symptoms.

METHODS

We searched five databases for randomized controlled trial (RCT) studies that examined Emergency Department-based and initiated suicide prevention interventions among youth aged 10 to 18 years old between May 2020 to June 2022. Using Cohen's d and 95% confidence interval as our standardised metrics, we followed the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) and Synthesis Without Meta-Analysis in Systematic Reviews (SWiM) guidelines when synthesizing, interpreting, and reporting the findings of this review.

RESULTS

Five studies were included in this review. Findings were first synthesized according to the targeted population of the study intervention and this review's outcomes. Two interventions were effective for decreasing depressive symptoms, hospitalization recidivism, and/or increasing family empowerment. There were no interventions that reduced subsequent suicide attempts. A meta-analysis was not conducted due to the heterogeneity of the data.

CONCLUSION

A need exists to develop and evaluate Emergency Department-based and initiated youth suicide prevention interventions that can be successfully and sustainably implemented in practice. Future research should focus on evaluating the components of interventions that effectively mitigate suicide risk among high-risk youth.

Risk of suicide in children and adolescents in the emergency department-is universal screening the answer?

OBJECTIVE

Suicide is a leading cause of death among children and adolescents. Suicide risk screening tools can detect the risk of suicide among patients presenting to healthcare settings. The aim of this review was to describe the effectiveness of universal suicide risk screening (all patients) compared with selective screening (behavioural health patients only) in children and adolescents in emergency departments (EDs).

METHOD

A literature search was conducted on PubMed for articles related to suicide risk screening in paediatric EDs between January 2016 and February 2022.

RESULTS

8 studies met the selection criteria. The review showed that 46%-93% of patients that screened positive for suicide risk had presented with a medical concern. These patients would have been missed without universal suicide risk screening. In both selective and universal screening scenarios, use of a suicide risk screening tool was better at detecting suicide risk compared with use of presenting problem alone. Suicide risk screening was found to be acceptable without increasing length of stay in the ED.

CONCLUSION

Based on this review, using a suicide screening tool can help detect patients at risk who would otherwise have been missed.

What Is Helpful and What Is Challenging for the Caregivers of Young People Receiving Interventions to Prevent Suicide? Caregivers' Perspectives-A Rapid Scoping Review

(1) Background: Suicide is a leading cause of death among young people. Preventing suicide in young people is a priority. Caregivers play a vital role in ensuring interventions for young people experiencing suicide ideation and/or attempts are implemented, and that they are maintained over time. Despite this, little is known about what caregivers find helpful and challenging in relation to suicide prevention interventions. This rapid scoping review is the first to address this gap. (2) Methods: Searches were completed on six electronic databases using keywords relating to 'suicide prevention, 'young people', and 'caregivers'. Ten studies-using both qualitative and quantitative methods, and involving >1400 carers from the United States and Europe-were selected for inclusion. (3) Results: The review shows that caregivers value interventions that are delivered by non-judgmental clinicians, that are suitable to the particular needs of their child, that are available when needed, and that support their confidence and communication. Caregivers experience difficulties with interventions that require their attendance at specific times, and that fail to recognize and/or address their own mental health needs. (4) Conclusions: The findings can be used to inform and improve the intervention design, with the aim of improving outcomes for caregivers and young people.

Suicide prevention: What does the evidence show for the effectiveness of safety planning for children and young people? - A systematic scoping review

WHAT IS KNOWN ON THE SUBJECT?: Suicide prevention is an international healthcare priority. There is an urgent need to use approaches that are helpful and follow research evidence. Safety planning is now widely used in suicide prevention; however, it was developed for use with adults, and little is known about its effectiveness for children/young people. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This systematic scoping review brings together all research evidence since 2008 that reported how effective safety planning is for children/young people. Findings highlight that when healthcare professionals help children/young people who are suicidal, they need to ensure that the safety plan is completed collaboratively with healthcare professionals and children/young people and that it is appropriate for their age and development. There is also need for healthcare professionals to better recognize and respond to the needs of parents/carers who are caring for a child/young person with suicidal ideations/behaviours. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: There is some research indicating that safety planning is effective for use with children/young people, but such evidence has primarily been obtained from females and there is need for more evidence from male study populations. Further research on its use is needed for certain groups of children/young people including those who are care experienced, or identify as lesbian, gay, bisexual and transgender. This review highlighted that healthcare professionals need specific training before they deliver safety planning for children/young people. It was identified that parents/carers have additional needs and should be involved in safety planning. An additional resource specifically for parents/carers should be developed.

ABSTRACT

INTRODUCTION: Suicide is a leading cause of death for children and young people and its prevention is a global priority. Many Mental Health Services employ safety planning as a brief intervention. There is some evidence of safety planning effectiveness for adults, but little is known about its effectiveness with young people.

AIM

To synthesize research reporting safety planning effectiveness for children/young people with suicidal ideation and identify good practice recommendations.

INCLUSION CRITERIA

The review relates to safety planning around suicide prevention for children/young people aged less than 18 years, even if it was within a wider intervention. The review was inclusive of all clinical areas (including mental health, primary care, etc), any geographical location or social economic status and inclusivity around the method of delivery.

METHODS

A systematic scoping review of literature reporting effectiveness data for the use of safety planning with children/young people with suicidal ideation. The systematic scoping review protocol (pre-registered with Open Science Framework) followed Joanna Briggs Institute conduct guidance and PRISMA-ScR checklist.

DATA ANALYSIS AND PRESENTATION

Fifteen studies were reported during 2008-2021. Overall, there is promising, but limited, evidence of effectiveness for safety planning for children/young people but with complete evidence gaps for some demographic sub-groups. Evidence determined that healthcare professionals should deliver a safety planning intervention that is completed collaboratively, developmentally appropriate, and recognizes parental/carer involvement.

DISCUSSION AND IMPLICATIONS FOR PRACTICE

Further research is needed but current evidence suggests safety planning should be a routine part of care packages for children/young people with suicidal ideation proportionate to their needs. Developing/implementing these plans needs bespoke health professional training and additional support and resources for parents/carers should be developed.

"Psychotherapy in the Pressure Cooker": A Systematic Review of Single Session Psychosocial Interventions in Emergency Departments for Suicide-related Thoughts or Behaviors

OBJECTIVES

Up to 20% of individuals who die by suicide have visited an emergency department (ED) within 4 weeks of their death. Limited guidance is available regarding the modification of clinical outcomes following a psychosocial intervention in the ED for pediatric and adult populations.

METHODS

A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted to identify studies focused on single-session psychosocial interventions for pediatric and adult patients experiencing suicide-related thoughts or behaviors (SRTB) in the ED. Two reviewers independently screened articles identified using the key terms suicide/self-harm, emergency department, and interview. Medline, PubMed, Embase, PsycINFO, CINAHL, and CENTRAL were searched from inception to August 2018.

RESULTS

After screening 3234 abstracts, 29 articles were selected for full-text review and 14 articles, representing 8 distinct studies (N=782), were included. A high level of heterogeneity was present in the included articles, with 7 randomized-controlled trials, 2 nonrandomized-controlled trials, 2 cohort studies, 2 observational studies, and 1 feasibility study. Most of the included studies focused on adolescents (6 articles) or military veterans (7 articles). Strong statistical evidence of ED interventions improving outpatient service linkage was supported (χ2: 81.80, P<0.0001, 7 studies).

CONCLUSIONS

The findings of this study suggested promising outcomes for patients presenting to the ED with SRTB who receive a single-session psychosocial intervention. All of the studies that measured such outcomes found significantly increased follow-up care in the intervention arm. Further research is needed to strengthen the evidence base, provide better patient representation, and improve our understanding of the mechanisms by which the psychosocial intervention for SRTB in the ED ameliorates patient outcomes (CRD42020156496).

Brief Interventions for Self-injurious Thoughts and Behaviors in Young People: A Systematic Review

Rates of self-injurious thoughts and behaviors (SITBs) increase sharply across adolescence and remain high in young adulthood. Across 50 years of research, existing interventions for SITBs remain ineffective and inaccessible for many young people in particular need of mental healthcare. Briefer intervention options may increase access to care. However, many traditional interventions for SITBs take 6 months or more to complete-making it difficult for providers to target SITBs under real-world time constraints. The present review (1) identifies and (2) summarizes evaluations of brief psychosocial interventions for SITBs in young people, ages 10-24 years. We conducted searches for randomized and quasi-experimental trials conducted in the past 50 years that evaluated effects of "brief interventions" (i.e., not exceeding 240 min, or four 60-min sessions in total length) on SITBs in young people. Twenty-six articles were identified for inclusion, yielding a total of 23 brief interventions. Across all trials, results are mixed; only six interventions reported any positive intervention effect on at least one SITB outcome, and only one intervention was identified as "probably efficacious" per standard criteria for evidence-based status. While brief interventions for SITBs exist, future research must determine if, how, and when these interventions should be disseminated.

Youth Suicide During the First Year of the COVID-19 Pandemic

OBJECTIVE

To identify potential differential changes in youth suicide deaths associated with the coronavirus disease (COVID-19) pandemic to better inform suicide prevention strategies.

METHODS

This cross-sectional study analyzed national suicide data for US youth aged 5 to 24 years from 2015 to 2020. Annual and monthly numbers of suicides were extracted overall and by sex, age, race and ethnicity, and method. Expected suicides were modeled from the trend in monthly deaths before COVID-19 (January 1, 2015-February 29, 2020), by using interrupted time-series analyses with quasi-Poisson regression. Rate ratios (RR) and corresponding 95% confidence intervals (CI) were used to compare expected and observed suicides during the first 10 months of COVID-19 (March 1, 2020-December 31, 2020).

RESULTS

Among 5568 identified youth suicides during the 2020 pandemic, 4408 (79.2%) were male, 1009 (18.1%) Hispanic, 170 (3.3%) non-Hispanic American Indian/Alaska Native, 262 (4.7%) Asian/Pacific Islander, 801 (14.4%) Black, and 3321 (59.6%) white. There was a significant increase in overall observed versus expected youth suicides during the COVID-19 pandemic (RR = 1.04, 95% CI = 1.01-1.07), equivalent to an estimated 212 excess deaths. Demographic subgroups including males (RR = 1.05, 95% CI = 1.02-1.08), youth aged 5 to 12 years (RR = 1.20, 95% CI = 1.03-1.41) and 18 to 24 years (RR =1.05, 95% CI = 1.02-1.08), non-Hispanic AI/AN youth (RR = 1.20, 95% CI = 1.03-1.39), Black youth (RR = 1.20, 95% CI = 1.12-1.29), and youth who died by firearms (RR = 1.14, 95% CI = 1.10-1.19) experienced significantly more suicides than expected.

CONCLUSIONS

Suicide deaths among US youth increased during COVID-19, with substantial variation by sex, age, race and ethnicity, and suicide method. Suicide prevention strategies must be tailored to better address disparities in youth suicide risk.

Family Treatments for Individuals at Risk for Suicide

Background: This PRISMA scoping review explored worldwide research on family-based treatments for suicide prevention. Research on this topic highlights the importance of facilitating familial understanding of a suicidal individual. Aim: The review sought evidence of outcomes of trials in which both the patient and family member in the intervention arm attended the same sessions at which suicide was openly discussed. Method: To explore this topic, the authors searched for randomized and nonrandomized controlled trials using Medline (Ovid), PsycINFO (Ovid), Social Services Abstracts (EBSCO), and Web of Science on July 8, 2020. Results: Ten different studies were included that spanned five treatment modalities. Specifically, of the interventions in these 10 articles, 40% employed some sort of cognitive-behavioral therapy, 20% examined attachment-based family therapy, 20% used family-based crisis intervention, and the remaining 20% were distinct interventions from one another. Additionally, several of these articles demonstrated rigorous study methodology and many of the articles reported significant improvements in suicidal ideation or behaviors. Conclusion: Several important research gaps were identified. While this approach has been largely understudied, and to date has been primarily researched in adolescent populations, family interventions have great potential for treatment and prevention of suicidality.

A Pilot Randomized Control Trial of a Dyadic Safety Planning Intervention: Safe Actions for Families to Encourage Recovery (SAFER)

A recent systematic review on family and suicide prevention efforts identified a lack of family-based safety planning interventions for adults. To address this gap, The Safe Actions for Families to Encourage Recovery (SAFER) intervention was created. SAFER is a novel, manualized, 4- session, family-based treatment intervention that provides the tools and structure to support family involvement in Safety Planning Intervention (SPI) for Veterans at moderate risk for suicide. The SAFER intervention includes the use of psychoeducation, communication skills training, and development of a Veteran, and a complementary supporting partner, SPI. This Stage II (2aii) randomized clinical trial (RCT) evaluated the preliminary efficacy of this innovative and much-needed approach. Thirty-nine Veterans and an associated supporting partner were randomized to receive either SAFER or currently mandated (i.e., standard) individual Safety Planning Intervention (I-SPI). Veterans in the SAFER condition as compared to I-SPI exhibited significant monthly decrements in suicide ideation as measured by the Columbia Suicide Severity Rating Scale (B=-0.37; p=.032). Moreover, a treatment-by-time interaction emerged when predicting improvements in Veteran suicide-related coping (B=0.08; p=.028) and supporting partner support of Veteran's coping efforts (B=0.17; p=.032). However, the treatment effect for Veteran coping was not significant in dyadic analyses (B=0.07; p=.151) after controlling for the partner's support (B=0.16; p=.009). Self-reported appraisals of relational factors and self-efficacy were not impacted by condition for either Veterans or supporting partners. This initial efficacy pilot trial suggests that a brief dyad-based SPI has the potential to improve Veteran suicide symptoms and help family members support the Veteran's coping efforts. However more intensive family work may be required for changes in self-perceptions of burdensomeness, belongingness, and caregiver perceptions of the Veteran as a burden. Nonetheless, SAFER's discussion and disclosure about suicide symptoms facilitated more robust development of SPI for the Veteran and their accompanying supporting partner.

Immediate and short-term efficacy of suicide-targeted interventions in suicidal individuals: A systematic review

OBJECTIVES

To address the extreme suicide risk period following a suicidal crisis, we aimed to assess the current evidence for specific healthcare system-based interventions on suicide-related outcomes within one-week or one-month in individuals with current suicidal ideation (SI) or a recent suicide attempt (SA).

METHODS

We performed a database (Medline, Academic Search Complete, PsycARTICLES, the Cochrane library, PubMed) and manual reference search for randomised controlled trials, published between March 2000 and March 2020. Antisuicidal efficacy was defined as SI, SA, or a closely related concept. Quality was assessed with the Cochrane Risk of Bias 2 tool for randomised trials.

RESULTS

Out of 34 trials, five reported ketamine or esketamine superiority over placebo in reducing SI in depressed subjects within one week, while five studies had negative findings. Single trials reported positive results for one-month antisuicidal efficacy of buprenorphine, paroxetine, a crisis response plan, and assertive case management. Most trials were underpowered and had moderate-to-high risk of bias.

CONCLUSIONS

Preliminary mixed evidence suggests the possible utility of several pharmacological (ketamine, esketamine paroxetine, and buprenorphine) and non-pharmacological (a crisis response plan, and assertive case management) interventions. Only the immediate efficacy of ketamine was supported by multiple studies, and replication is needed.

Positive Relationships with Adults and Resilience to Suicide Attempt among New Mexico Hispanic Adolescents

Suicide is a leading cause of adolescent death and has increased in recent years. The purpose of this study was to examine the effect that relationships with adults at home and in the community had on the probability of suicide attempts of Hispanic teenagers in New Mexico. Data from the 2019 New Mexico Youth Risk and Resiliency Survey were analyzed to identify the ways in which relationships with adults influenced suicide attempts among Hispanic adolescent students. The examined factors included: relationships with adults in the home and in the community and with same-age friends, and participation in hobbies or organizations outside of school. The resiliency factors were similar for male and female Hispanic students. As positive relationships with adults at home or in the community increased, the probability of suicide attempts decreased by 37-54%. Positive relationships with same-age friends were also associated with reduced suicide attempts. Community organization involvement and hobbies affected males and females differently. Adults at home and in the community can decrease the risk of suicide for Hispanic teenagers through supportive relationships. Hybrid programs focusing on adolescent health, positive communication, and academic support, which integrate adults from home and community environments, show promise in reducing suicidal thoughts and other risk behaviors.

Treatment compliance and risk and protective factors for suicide ideation to completed suicide in adolescents: a systematic review

OBJECTIVE

To review the literature regarding adolescent suicide risk and explore the associations between treatment compliance (expressed as a concept including measured adherence to treatment and/or mental health service utilization) and risk and protective factors for suicidal behavior (SB), as well as the association between treatment compliance and reattempts.

METHODS

PubMed, LILACS, and Google Scholar were searched using the following terms: (adolescent*) AND (suicide*) AND (risk factor OR protective factors) AND (treatment compliance OR treatment attrition OR treatment adherence OR treatment drop out OR treatment retention OR mental health utilization). We retrieved studies that focused on the relation of treatment compliance to risk and protective factors for SB and that had only adolescent samples.

RESULTS

Of 4,841 articles, 30 original articles were selected for review. Most studies indicated high mental health service (MHS) utilization and poor treatment adherence by SB patients. Social minority status and conduct disorder were associated with less treatment adherence, while female sex, parental perceived need for treatment, and major depression were associated with greater treatment adherence. Inpatient and intensive emergency care after SA and family interventions improved MHS utilization and treatment compliance. However, we found no substantial protective effect of treatment compliance against reattempts.

CONCLUSION

Effective treatment planning for compliance requires considering psychopathology, treatment planning, and social, familial, and individual factors.

Characteristics and Precipitating Circumstances of Suicide Among Children Aged 5 to 11 Years in the United States, 2013-2017

IMPORTANCE

Suicide is the eighth leading cause of death among children aged 5 to 11 years, with rates increasing during the past decade. A better understanding of factors associated with childhood suicide can inform developmentally appropriate prevention strategies.

OBJECTIVE

To examine characteristics and precipitating circumstances of childhood suicide.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study examined restricted-use data from the National Violent Death Reporting System (NVDRS) regarding child suicide decedents aged 5 to 11 years in the US from 2013 to 2017. The NVDRS is a state-based surveillance system that collects data on suicide and violent deaths in 50 states, with restricted-use data available from 37 states. Details and context related to suicide deaths were identified through a content analysis of case narratives from coroner or medical examiner and law enforcement reports associated with each incident.

EXPOSURES

Characteristics and precipitating circumstances associated with suicide cited in the coroner, medical examiner, and law enforcement case narratives.

MAIN OUTCOMES AND MEASURES

Suicide incidence and risk factors for suicide including mental health, prior suicidal behavior, trauma, and peer, school, or family-related problems.

RESULTS

Analyses included 134 child decedents (101 [75.4%] males; 79 [59.0%] White individuals; 109 [81.3%] non-Hispanic individuals; mean [SD] age, 10.6 [0.8] years). Most suicides occurred in the child's home (95.5% [n = 128]), and more specifically in the child's bedroom. Suicide by hanging or suffocation (78.4% [n = 105]) was the most frequent method, followed by firearms (18.7% [n = 25]). Details on gun access were noted in 88.0% (n = 22) of suicides by firearm, and in every case, the child obtained a firearm stored unsafely in the home. Findings revealed childhood suicide was associated with numerous risk factors accumulated over time, and suggest a progression toward suicidal behavior, especially for youth with a history of psychopathology and suicidal behavior. An argument between the child and a family member and/or disciplinary action was often a precipitating circumstance of the suicide.

CONCLUSIONS AND RELEVANCE

This qualitative study found that childhood suicide was associated with multiple risk factors and commonly preceded by a negative precipitating event. Potential prevention strategies include improvements in suicide risk assessment, family relations, and lethal means restriction, particularly safe firearm storage. Future research examining the myriad aspects of childhood suicide, including racial/ethnic and sex differences, is needed.

Clinical Characteristics, Outcomes, Disposition, and Acute Care of Children and Adolescents Treated for Acetaminophen Toxicity

OBJECTIVE

Acetaminophen is a common cause of intentional and inadvertent overdoses among children and adolescents worldwide. Little is known about characteristics and clinical outcomes of these youths. The primary goal of this naturalistic study was to describe the psychiatric characteristics, medical management, outcomes, and dispositions of children and adolescents evaluated for excessive acetaminophen exposure.

METHODS

The Rochester Epidemiology Project database was searched for all patients ages 0-18 treated for excessive acetaminophen exposure in Olmsted County, Minnesota, during a 7-year period (2004-2010). Demographic factors, overdose intentionality, medical and psychiatric treatment, mental health and addiction history, and disposition from the emergency department (ED) were documented.

RESULTS

Of 110 cases of acetaminophen overdose (89 female patients and 21 male patients), 97 (88%) were intentional and 13 (12%) were unintentional. Fifteen patients (14%) were discharged from the ED, and 69 (63%) required admission to a medical unit. Sixty-four (59%) received N-acetylcysteine. Ninety-eight (89%) were evaluated by psychiatry, and 80 (73%) were admitted for psychiatric hospitalization. Most had at least one psychiatric diagnosis, most commonly depression (55%); 22 (20%) had a prior suicide attempt. Substance use was common, notably alcohol dependence (N=16, 15%), alcohol abuse (N=18, 16%), and cannabis abuse (N=18, 16%). All survived and recovered without liver transplant.

CONCLUSIONS

Among pediatric patients with acetaminophen overdoses, psychiatric comorbidities and substance use were common. Most received both inpatient medical and psychiatric treatment. Interventions that restrict acetaminophen access are needed for this population, as are suicide risk reduction interventions for delivery in emergency settings.

Comparative Efficacy and Acceptability of Psychotherapies for Self-harm and Suicidal Behavior Among Children and Adolescents: A Systematic Review and Network Meta-analysis

IMPORTANCE

Self-harm and suicidal behavior are associated with substantial morbidity and mortality among children and adolescents. The comparative performance of psychotherapies for suicidality is unclear because few head-to-head clinical trials have been conducted.

OBJECTIVE

To compare the efficacy of psychotherapies for the treatment of self-harm and suicidality among children and adolescents.

DATA SOURCES

Four major bibliographic databases (PubMed, MEDLINE, PsycINFO, and Embase) were searched for clinical trials comparing psychotherapy with control conditions from inception to September 2020.

STUDY SELECTION

Randomized clinical trials comparing psychotherapies for suicidality and/or self-harm with control conditions among children and adolescents were included after a blinded review by 3 independent reviewers (A.B., M.P., and J.W.).

DATA EXTRACTION AND SYNTHESIS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed for data abstraction, and the Cochrane risk of bias tool was used to evaluate study-level risk of bias. Data abstraction was performed by 1 reviewer (A.B.) and confirmed by 2 independent blinded reviewers (J.W. and M.P.). Data were analyzed from October 15, 2020, to February 15, 2021.

MAIN OUTCOMES AND MEASURES

The primary outcomes were dichotomized self-harm and retention in treatment. The secondary outcomes were dichotomized all-cause treatment discontinuation and scores on instruments measuring suicidal ideation and depressive symptoms. Effect sizes were pooled using frequentist random-effects network meta-analysis models to generate summary odds ratios (ORs) and Cohen d standardized mean differences (SMDs). Negative Cohen d SMDs or ORs less than 1 indicated that the treatment reduced the parameter of interest relative to the control condition (eg, signifying a beneficial association with suicidal ideation).

RESULTS

The systematic search generated 1272 unique records. Of those, 44 randomized clinical trials (5406 total participants; 4109 female participants [76.0%]) from 49 articles were selected (5 follow-up studies were merged with their primary clinical trials to avoid publication bias). The selected clinical trials spanned January 1, 1995, to December 31, 2020. The median duration of treatment was 3 months (range, 0.25-12.00 months), and the median follow-up period was 12 months (range, 1-36 months). None of the investigated psychotherapies were associated with increases in study withdrawals or improvements in retention in treatment compared with treatment as usual. Dialectical behavioral therapies were associated with reductions in self-harm (OR, 0.28; 95% CI, 0.12-0.64) and suicidal ideation (Cohen d SMD, -0.71; 95% CI, -1.19 to -0.23) at the end of treatment, while mentalization-based therapies were associated with decreases in self-harm (OR, 0.38; 95% CI, 0.15-0.97) and suicidal ideation (Cohen d SMD, -1.22; 95% CI, -2.18 to -0.26) at the end of follow-up. The quality of evidence was downgraded because of high risk of bias overall, heterogeneity, publication bias, inconsistency, and imprecision.

CONCLUSIONS AND RELEVANCE

Although some psychotherapeutic modalities appear to be acceptable and efficacious for reducing self-harm and suicidality among children and adolescents, methodological issues and high risk of bias prevent a consistent estimate of their comparative performance.

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.

Recruitment of adolescents with suicidal ideation in the emergency department: lessons from a randomized controlled pilot trial of a youth suicide prevention intervention

BACKGROUND

Emergency Departments (EDs) are a first point-of-contact for many youth with mental health and suicidality concerns and can serve as an effective recruitment source for randomized controlled trials (RCTs) of mental health interventions. However, recruitment in acute care settings is impeded by several challenges. This pilot RCT of a youth suicide prevention intervention recruited adolescents aged 12 to 17 years presenting to a pediatric hospital ED with suicide related behaviors.

METHODS

Recruitment barriers were identified during the initial study recruitment period and included: the time of day of ED presentations, challenges inherent to study presentation, engagement and participation during an acute presentation, challenges approaching and enrolling acutely suicidal patients and families, ED environmental factors, and youth and parental concerns regarding the study. We calculated the average recruitment productivity for published trials of adolescent suicide prevention strategies which included the ED as a recruitment site in order to compare our recruitment productivity.

RESULTS

In response to identified barriers, an enhanced ED-centered recruitment strategy was developed to address low recruitment rate, specifically (i) engaging a wider network of ED and outpatient psychiatry staff (ii) dissemination of study pamphlets across multiple areas of the ED and relevant outpatient clinics. Following implementation of the enhanced recruitment strategy, the pre-post recruitment productivity, a ratio of patients screened to patients randomized, was computed. A total of 120 patients were approached for participation, 89 (74.2%) were screened and 45 (37.5%) were consented for the study from March 2018 to April 2019. The screening to randomization ratio for the study period prior to the introduction of the enhanced recruitment strategies was 3:1, which decreased to 1.8:1 following the implementation of enhanced recruitment strategies. The ratio for the total recruitment period was 2.1:1. This was lower than the average ratio of 3.2:1 for published trials.

CONCLUSIONS

EDs are feasible sites for participant recruitment in RCTs examining new interventions for acute mental health problems, including suicidality. Engaging multi-disciplinary ED staff to support recruitment for such studies, proactively addressing anticipated concerns, and creating a robust recruitment pathway that includes approach at outpatient appointments can optimize recruitment.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT03488602 , retrospectively registered April 4, 2018.

Primary and Secondary Prevention of Youth Suicide

Youth suicide is a national and global public health crisis. Pediatricians can use primary and secondary prevention strategies to intervene with youth before or after the onset of suicidal behaviors. Universal suicide risk screening programs can be used to identify youth in medical settings who may otherwise pass through the health care setting with undetected suicide risk. Pediatricians are uniquely positioned to help foster resilience in their young patients and equip families of at-risk youth with safety plans and lethal means safety counseling. Pediatricians on the frontlines of this critical public health crisis require education and training in detecting suicide risk, managing those who screen positive, and connecting their patients to much needed mental health interventions and treatments. Evidence-based suicide risk screening and assessment tools, paired with interventions, are feasible and potentially life-saving in the medical setting.

Meta-analysis of suicide rates among people discharged from non-psychiatric settings after presentation with suicidal thoughts or behaviours

OBJECTIVE

To quantify the suicide rate among people discharged from non-psychiatric settings after presentations with suicidal thoughts or behaviours.

METHOD

Meta-analysis of studies reporting suicide deaths among people with suicidal thoughts or behaviours after discharge from emergency departments or the medical or surgical wards of general hospitals.

RESULTS

A total of 115 studies reported 167 cohorts and 3747 suicide deaths among 248 005 patients during 1 263 727 person-years. The pooled suicide rate postdischarge was 483 suicide deaths per 100 000 person-years (95% confidence interval (CI) 445-520, prediction interval (PI) 200-770) with high between-sample heterogeneity (I²  = 92). The suicide rate was highest in the first year postdischarge (851 per 100 000 person-years) but remained elevated in the long term. Suicide rates were elevated among samples of men (716 per 100 000 person-years) and older people (799 per 100 000 person-years) but were lower in samples of younger people (107 per 100 000 person-years) and among studies published between 2010 and 2018 (329 per 100 000 person-years).

CONCLUSIONS

People with suicidal thoughts or behaviours who are discharged from non-psychiatric settings have highly elevated rates of suicide despite a clinically meaningful decline in these suicide rates in recent decades.

Treatment Engagement in Specific Psychological Treatment vs. Treatment as Usual for Adolescents With Self-Harm: Systematic Review and Meta-Analysis

Background: Self-harm is a major public health problem. It is one of the best predictors of suicide in adolescents. Despite recent advances in the understanding of self-harm, poor treatment engagement remains a significant clinical obstacle. Objectives: The purpose of this meta-analysis is to update and extend previous research investigating treatment engagement with specific psychological treatments (SPT) vs. treatment as usual (TAU) in adolescents who self-harm. Methods: Data sources were identified by searching the Medline, PsychINFO, EMBASE, and PubMed databases as of October 2017. Randomized Controlled Trials (RCTs) comparing SPT and TAU in adolescents (through age 18 years) with self-harm were included. Results: The results show that 12 RCTs investigating 1,255 young people were included in the meta-analysis. The proportion of adolescents not completing four or more sessions in SPT was significantly lower (28.4%, 179/630) than TAU (45.9%, 287/625), RR = 0.64 (95% CI:0.51 -0.79), p < 0.0001. There were significantly more adolescents engaged with SPT than TAU. Conclusions: Specific psychological treatments should be offered to adolescents with self-harm to maximize treatment engagement. Engaging adolescents with psychological treatment is necessary although not sufficient to achieve treatment goals.

A Further Look at Therapeutic Interventions for Suicide Attempts and Self-Harm in Adolescents: An Updated Systematic Review of Randomized Controlled Trials

Background: Suicide attempts (SA) and other types of self-harm (SH) are strong predictors of death by suicide in adolescents, emphasizing the need to investigate therapeutic interventions in reduction of these and other symptoms. We conducted an updated systematic review of randomized controlled trials (RCTs) from our previous study reporting therapeutic interventions that were effective in reducing SH including SA, while additionally exploring reduction of suicidal ideation (SI) and depressive symptoms (DS). Method: A systematic literature search was conducted across OVID Medline, psycINFO, PubMed, EMBASE, and Cochrane Library from the first available article to October 22nd, 2017, with a primary focus on RCTs evaluating therapeutic interventions in the reduction of self-harm. Search terms included self-injurious behavior; self-mutilation; suicide, attempted; suicide; drug overdose. Results: Our search identified 1,348 articles, of which 743 eligible for review, yielding a total of 21 studies which met predetermined inclusion criteria. Eighteen unique therapeutic interventions were identified among all studies, stratified by individual-driven, socially driven, and mixed interventions, of which 5 studies found a significant effect for primary outcomes of self-harm and suicide attempts (31.3%), and 5 studies found a significant effect for secondary outcomes of suicidal ideation and depressive symptoms (29.4%) for therapeutic intervention vs. treatment as usual. Collapsing across different variations of Cognitive Behavior Therapy (CBT), and classifying Dialectical Behavior Therapy for Adolescents (DBT-A) as a type of CBT, CBT is the only intervention with replicated positive impact on reducing self-harm in adolescents. Conclusion: While the majority of studies were not able to determine efficacy of therapeutic interventions for both primary and secondary outcomes, our systematic review suggests that individual self-driven and socially-driven processes appeared to show the greatest promise for reducing suicide attempts, with benefits of combined self-driven and systems-driven approaches for reducing overall self-harm. Further RCTs of all intervention categories are needed to address the clinical and etiological heterogeneity of suicidal behavior in adolescents, specifically suicidal ideation and depressive symptoms.

What Works in Youth Suicide Prevention? A Systematic Review and Meta-Analysis

BACKGROUND

Young people require specific attention when it comes to suicide prevention, however efforts need to be based on robust evidence.

METHODS

We conducted a systematic review and meta-analysis of all studies examining the impact of interventions that were specifically designed to reduce suicide-related behavior in young people.

FINDINGS

Ninety-nine studies were identified, of which 52 were conducted in clinical settings, 31 in educational or workplace settings, and 15 in community settings. Around half were randomized controlled trials. Large scale interventions delivered in both clinical and educational settings appear to reduce self-harm and suicidal ideation post-intervention, and to a lesser extent at follow-up. In community settings, multi-faceted, place-based approaches seem to have an impact. Study quality was limited.

INTERPRETATION

Overall whilst the number and range of studies is encouraging, gaps exist. Few studies were conducted in low-middle income countries or with demographic populations known to be at increased risk. Similarly, there was a lack of studies conducted in primary care, universities and workplaces. However, we identified that specific youth suicide-prevention interventions can reduce self-harm and suicidal ideation; these types of intervention need testing in high-quality studies.