A Randomized Controlled Trial of the Collaborative Assessment and Management of Suicidality (CAMS) Versus Treatment as Usual (TAU) for Suicidal College Students

Novel Telehealth Adaptations for Evidence-Based Outpatient Suicide Treatment: Feasibility and Effectiveness of the Crisis Care Program

Background: Suicide rates in the United States have escalated dramatically over the past 20 years and remain a leading cause of death. Access to evidenced-based care is limited, and telehealth is well-positioned to offer novel care solutions. The Crisis Care program is a suicide-specific treatment program delivered within a national outpatient telehealth setting using a digitally adapted version of the Collaborative Assessment and Management of Suicidality (CAMS) as the framework of care. This study investigates the feasibility and preliminary effectiveness of Crisis Care as scalable suicide-specific treatment model. Methods: Patient engagement, symptom reduction, and care outcomes were examined among a cohort of patients (n = 130) over 16 weeks. The feasibility of implementation was assessed through patient engagement. Clinical outcomes were measured with PHQ-9, GAD-7, and the CAMS SSF-4 rating scales. Results: Over 85% of enrolled patients were approved for Crisis Care at intake, and 83% went on to complete at least four sessions (the minimum required to graduate). All patient subgroups experienced declines in depressive symptoms, anxiety symptoms, suicidal ideation frequency, and suicide-specific risk factors. Conclusions: Results support the feasibility and preliminary effectiveness of Crisis Care as a suicide-specific care solution that can be delivered within a stepped-care model in an outpatient telehealth setting.

Advancing Suicide Intervention Strategies for Teens (ASSIST): study protocol for a multisite randomised controlled trial

INTRODUCTION

Brief interventions that reduce suicide risk following youth's experience with acute care due to suicidality are needed.

METHODS AND ANALYSIS

The study will use a three-arm randomised controlled trial designed to test the effectiveness of the Safety Planning Intervention with structured follow-up (SPI+) and the Collaborative Assessment and Management of Suicidality (CAMS) compared with enhanced usual care. The primary outcomes measure will be suicidal events, defined as death by suicide, attempted suicide, preparatory acts toward imminent suicidal behaviour or suicidal ideation resulting in a change in emergency evaluation or inpatient admission. Secondary measures will be the number of suicide attempts and severity of suicidal ideation. The experimental interventions, SPI+ and CAMS, consist of up to eight sessions over approximately 8 weeks that are designed to manage (SPI+) or treat (CAMS) patient-identified 'drivers' of suicidal thoughts and behaviours. Mechanisms and moderators of change will be evaluated to understand treatment impacts.

ETHICS AND DISSEMINATION

This study has been approved by the Seattle Children's Institutional Review Board and is monitored by external agencies including the University of Washington Institute for Translational Health Sciences, and a National Institute of Mental Health (NIMH)-appointed Data Safety and Monitoring Board. Trial results will help establish evidence towards safe and effective treatment strategies for youth transitioning from acute to outpatient care due to a suicidal crisis. The data will be shared with the NIMH Data Archives and disseminated through publications and conferences.

TRIAL REGISTRATION NUMBER

NCT05078970.

Reporting Ethical Procedures in Suicide Prevention Research: Current Status and Recommendations

OBJECTIVE

Ethical concerns frequently arise in suicide prevention research regarding participant safety and confidentiality. Despite a substantial literature on managing and navigating ethical concerns in suicide research, little attention has been paid to the reporting of ethical procedures. Furthermore, standard procedures for reporting ethical risk management procedures have not been developed.

METHOD

A review of the current literature was performed to examine the current state of reporting of ethical procedures within suicide research. Articles published in 2020 (N = 263) from three suicide-focused publications were screened and then coded (n = 131) to identify reporting of procedures for the ethical conduct of research and suicide risk management steps taken by the research teams.

RESULTS

The majority of articles reported ethical review or approval (84.7%) and reported the use of an informed consent process (77.9%). Only 28.2% included risk mitigation procedures. Of those 29.7% of those articles reported conducting risk evaluation, 66.7% reported resource dissemination, and 51.4% reported an intervention.

CONCLUSION

As empirical support for brief interventions accrues, suicide prevention researchers should consider establishing standards for the reporting of procedures to ensure the safety of participants with suicidal risk.HighlightsReporting suicide safety protocols helps ensure high ethical standards in research.Fewer than 1/3 of articles reviewed reported risk mitigation procedures in 2020.Standard procedures for reporting safety protocols in suicide research are needed.

Interventions for youth suicide and suicide-related behaviour: An update to a systematic review

OBJECTIVE

To update our 2018 review with the latest evidence from randomised controlled trials (RCTs) on the effectiveness of interventions to prevent youth suicide and suicide-related behaviour.

METHOD

In keeping with our 2018 review, Embase, PsycInfo, and Medline were searched using relevant key words. Included trials were RCTs evaluating the impact of an intervention or approach designed to prevent or reduce youth suicide and suicide-related behaviour. Key data were extracted, and results synthesised narratively.

RESULTS

Thirty RCTs were included across clinical (n = 13), educational (n = 8), and community settings (n = 9). No trials were conducted in workplace or primary care settings, or with indigenous populations, and few trials involved partnerships with young people. There were some concerns or a high risk of bias for most trials.

CONCLUSION

While a relatively large number of RCTs have been published in recent years, knowledge gaps remain. Further high-quality RCTs are needed, including those focussing on vulnerable population groups. Meaningful consumer involvement and a stronger emphasis on implementation are also recommended.

Depression and Suicide Risk Screening: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

Depression is common and associated with substantial burden. Suicide rates have increased over the past decade, and both suicide attempts and deaths have devastating effects on individuals and families.

Objective

To review the benefits and harms of screening and treatment for depression and suicide risk and the accuracy of instruments to detect these conditions among primary care patients.

Data Sources

MEDLINE, PsychINFO, Cochrane library through September 7, 2022; references of existing reviews; ongoing surveillance for relevant literature through November 25, 2022.

Study Selection

English-language studies of screening or treatment compared with control conditions, or test accuracy of screening instruments (for depression, instruments were selected a priori; for suicide risk, all were included). Existing systematic reviews were used for treatment and test accuracy for depression.

Data Extraction and Synthesis

One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality. Findings were synthesized qualitatively, including reporting of meta-analysis results from existing systematic reviews; meta-analyses were conducted on original research when evidence was sufficient.

Main Outcomes and Measures

Depression outcomes; suicidal ideation, attempts, and deaths; sensitivity and specificity of screening tools.

Results

For depression, 105 studies were included: 32 original studies (N=385 607) and 73 systematic reviews (including ≈2138 studies [N ≈ 9.8 million]). Depression screening interventions, many of which included additional components beyond screening, were associated with a lower prevalence of depression or clinically important depressive symptomatology after 6 to 12 months (pooled odds ratio, 0.60 [95% CI, 0.50-0.73]; reported in 8 randomized clinical trials [n=10 244]; I2 = 0%). Several instruments demonstrated adequate test accuracy (eg, for the 9-item Patient Health Questionnaire at a cutoff of 10 or greater, the pooled sensitivity was 0.85 [95% CI, 0.79-0.89] and specificity was 0.85 [95% CI, 0.82-0.88]; reported in 47 studies [n = 11 234]). A large body of evidence supported benefits of psychological and pharmacologic treatment of depression. A pooled estimate from trials used for US Food and Drug Administration approval suggested a very small increase in the absolute risk of a suicide attempt with second-generation antidepressants (odds ratio, 1.53 [95% CI, 1.09-2.15]; n = 40 857; 0.7% of antidepressant users had a suicide attempt vs 0.3% of placebo users; median follow-up, 8 weeks). Twenty-seven studies (n = 24 826) addressed suicide risk. One randomized clinical trial (n=443) of a suicide risk screening intervention found no difference in suicidal ideation after 2 weeks between primary care patients who were and were not screened for suicide risk. Three studies of suicide risk test accuracy were included; none included replication of any instrument. The included suicide prevention studies generally did not demonstrate an improvement over usual care, which typically included specialty mental health treatment.

Conclusions and Relevance

Evidence supported depression screening in primary care settings, including during pregnancy and postpartum. There are numerous important gaps in the evidence for suicide risk screening in primary care settings.

Brief and Ultra-Brief Suicide-Specific Interventions

The rising rates of suicide warrant effective treatments that can quickly help stabilize suicidal individuals and prevent future suicidal crises from occurring. Across the past few decades, there has been a rise in the development of ultra-brief (1-4 sessions) and brief suicide-specific interventions (6-12 sessions) to meet this need. This article reviews several prominent ultra-brief and brief interventions, including the Teachable Moment Brief Intervention, Attempted Suicide Short Intervention Program, Safety Planning Intervention, Crisis Response Planning, Cognitive Therapy for Suicide Prevention, Brief Cognitive-Behavioral Therapy for Suicide Prevention, Collaborative Assessment and Management of Suicidality, and the Coping Long-Term With Active Suicide Program. A brief review of each interventions' evidence base is also provided. Current challenges and directions for future research in testing the efficacy and effectiveness of suicide prevention initiatives are discussed.

The Collaborative Assessment and Management of Suicidality compared to enhanced treatment as usual for inpatients who are suicidal: A randomized controlled trial

Background

Although use of inpatient crisis hospital intervention for suicide risk is common, the evidence for inpatient treatments that reduce suicidal thoughts and behaviors is remarkably limited. To address this need, this novel feasibility pilot randomized controlled trial compared the use of the Collaborative Assessment and Management of Suicidality (CAMS) to enhanced treatment as usual (E-TAU) within a standard acute inpatient mental health care setting.

Objectives

We hypothesized that CAMS would be more effective than E-TAU in reducing suicidal thoughts and behaviors. As secondary outcomes we also investigated depressive symptoms, general symptom burden, reasons for living, and quality of the therapeutic relationship.

Methods

All patients were admitted due to acute suicidal thoughts or behaviors. They were randomly assigned to CAMS (n = 43) or E-TAU (n = 45) and assessed at four time points (admission, discharge, 1 month and 5 months after discharge). We used mixed-effects models, effect sizes, and reliable change analyses to compare improvements across and between treatment groups over time.

Results

Intent-to-treat analyses of 88 participants [mean age 32.1, SD = 13.5; n = 47 (53%) females] showed that both groups improved over time across all outcome measures with no significant between-group differences in terms of change in suicidal ideation, depression, reasons for living, and distress. However, CAMS showed larger effect sizes across all measures; for treatment completers CAMS patients showed significant improvement in suicidal ideation (p = 0.01) in comparison to control patients. CAMS patients rated the therapeutic relationship significantly better (p = 0.02) than E-TAU patients and were less likely to attempt suicide within 4 weeks after discharge (p = 0.05).

Conclusions

CAMS and E-TAU were both effective in reducing suicidal thoughts and symptom distress. Within this feasibility RCT the pattern of results was generally supportive of CAMS suggesting that inpatient use of CAMS is both feasible and promising. However, our preliminary results need further replication within well-powered multi-site randomized controlled trials.

Trial registration

DRKS-ID/ICTRP-ID: DRKS00013727. The trial was retrospectively registered in the German Clinical Trials Register, registration code/ DRKS-ID: DRKS00013727 on 12.01.2018 and also in the International Clinical Trials Registry Platform of the World Health Organization (identical registration code).

Nursing Students Facilitating the Transition from Suicidal Ideation to Action in the Rural: A Qualitative Study

OBJECTIVE

This study aims to increase understanding of the process of nursing students at risk of completing suicide attempts that facilitates the transition from suicidal ideation to action. And The Central Bureau of Statistics, there were 812 suicide cases throughout Indonesia.

METHODS

The qualitative research involved 15 nursing students who were selected purposively. data collection in rural East Java Data were collected through semi-structured interviews and analyzed using the Colaizzi phenomenological method.

RESULTS

We identified six main themes; 1 (the dimension of individual history). 2 (socio-cultural dimension) describes the problems experienced by nursing students on campus and off campus. 3 (interpersonal dimension). 4 (intrapersonal dimension); Factors of family conflict, peer conflict, and psychiatric and/or medical disorders. 5 (emotional dimension). 6. (be a good listener).

CONCLUSION

The intrapersonal element is the most influential catalyst in the progression from suicidal ideation to action. As prospective targets for preventive interventions and practices with nursing students at risk of suicide, our findings suggest the need for specific measures addressing freshman recruitment during selection for faculty, emotional dysregulation, and feelings of invalidity and entrapment. Nursing students need intrapersonal training. Being a good listener for all students, lecturers and staff is important to create a support system for suicide prevention in the nursing environment.

Perfectionistic Self-Presentation, Socially Prescribed Perfectionism, Self-Oriented Perfectionism, Interpersonal Hopelessness, and Suicidal Ideation in U.S. Adults: Reexamining the Social Disconnection Model

OBJECTIVE

Research has linked perfectionism to increased suicidal ideation (SI), although less is known regarding the mechanisms that explain this relation. The Perfectionism Social Disconnection Model (PSDM) posits that interpersonal aspects of perfectionism cause interpersonal problems (e.g., hostility, loneliness) which in turn increase a person's risk for experiencing SI. The present study aimed to replicate and extend previous findings related to the PSDM and SI using measures of interpersonal hopeless and general hopelessness.

METHOD

Tenets of the PSDM were tested in a sample of 313 U.S. adults with a history of SI, by determining whether experiences of general hopelessness and interpersonal hopelessness explained the relation between three types of perfectionism: perfectionistic self-presentation (PSP), socially prescribed perfectionism (SPP), and self-oriented perfectionism (SOP).

RESULTS

Results indicated that PSP, SPP, and SOP were positively associated with SI, general hopelessness, and interpersonal hopelessness.The relation between aspects of perfectionism and SI demonstrated an indirect effect through interpersonal hopelessness only.

CONCLUSIONS

These results lend support to the PSDM's assertion that interpersonal problems aid in explaining the relation between perfectionism and SI. The current study was limited by the cross-sectional nature of the study as well as the homogenous sample. Implications for research and clinical work are discussed.HIGHLIGHTSAspects of perfectionism are related to suicidal ideationAspects of perfectionism are related to interpersonal hopelessnessInterpersonal hopelessness explains why perfectionism and suicidal ideation are related.

Suicide Risk in Youth and Young Adults with Type 1 Diabetes: a Review of the Literature and Clinical Recommendations for Prevention

PURPOSE OF REVIEW

The manuscript reviews the extant literature on suicide-related thoughts and behaviors among youth and young adults with pediatric diabetes. This evidence is presented within the context of current theories of the etiology of suicidal behavior to highlight how diabetes may contribute to suicide risk, and to support providers in understanding the interplay between pediatric diabetes and suicide risk. The manuscript also reviews evidence-based approaches to suicide prevention suitable for use in pediatric healthcare settings, with suggestions for their application to this unique population.

RECENT FINDINGS

Several recent studies identify heightened rates of suicidal ideation, suicide attempts, and suicide among youth and young adults with pediatric diabetes, as compared with their peers without diabetes. Evidence-based suicide prevention approaches frequently emphasize the importance of reducing suicidal youths' access to potentially lethal means for suicidal behavior. This approach may require special considerations for youth with pediatric diabetes, due to their need to carry sufficient quantities of insulin and the dangers of inaccurate insulin dosing and/or overdose. Suggestions for suicide prevention for this population include risk screening as part of routine diabetes care, early prevention, education for youth and families, and provider awareness of risk factors, warning signs, and implications for diabetes care. Youth and young adults with diabetes reported elevated rates of suicide-related behaviors as compared with their peers without diabetes. Existing suicide prevention approaches may require substantial adaptation for use with youth and young adults with diabetes. Further research is needed to examine how to best prevent suicidal behaviors among this population.

Working with Young People at Risk of Suicidal Behaviour and Self-Harm: A Qualitative Study of Australian General Practitioners' Perspectives

General Practitioners (GPs) play a crucial role in the identification and support of young people at risk of suicidal behaviour and self-harm; however, no studies have explored GPs' perspectives, approaches, challenges, and resource needs when working with this cohort in an Australian setting. This was a qualitative study where fifteen GPs (Mage = 45.25 years) from multiple clinics in Western Australia took part in semi-structured interviews, and data were analysed thematically. Seven main themes were identified: (1) working with young people has its unique challenges; (2) screening and assessment tools can help to manage uncertainty and discomfort; (3) going beyond tools-the dialogue and relationship are most important; (4) there are limits to what we can offer in the time available; (5) the service access and referral pathways lack clarity and coordination; (6) the provision of mental health support should not fall on GPs alone; and (7) more comprehensive training in suicide and self-harm is needed. The findings highlight a number of opportunities to enhance care and better assist GPs working with young people who present with suicidal behaviour and self-harm, including considerations for conducting assessments, targeted resources such as training, and system and service improvements.

The effectiveness of the Collaborative Assessment and Management of Suicidality (CAMS) compared to alternative treatment conditions: A meta-analysis

INTRODUCTION

This meta-analysis aimed to test the efficacy of the Collaborative Assessment and Management of Suicidality (CAMS) intervention against other commonly used interventions for the treatment of suicide ideation and other suicide-related variables.

METHOD

Database, expert, and root and branch searches identified nine empirical studies that directly compared CAMS to other active interventions. A random effects model was used to calculate the effect size differences between the interventions; additionally, moderators of the effect sizes were tested for suicidal ideation.

RESULTS

In comparison to alternative interventions, CAMS resulted in significantly lower suicidal ideation (d = 0.25) and general distress (d = 0.29), significantly higher treatment acceptability (d = 0.42), and significantly higher hope/lower hopelessness (d = 0.88). No significant differences for suicide attempts, self-harm, other suicide-related correlates, or cost effectiveness were observed. The effect size differences for suicidal ideation were consistent across study types and quality, timing of outcome measurement, and the age and ethnicity of participants; however, the effect sizes favoring CAMS were significantly smaller with active duty military/veteran samples and with male participants.

CONCLUSIONS

The existing research supports CAMS as a Well Supported intervention for suicidal ideation per Center of Disease Control and Prevention criteria. Limitations and future directions are discussed.

Effectiveness of a Continuity-of-Care Model to Reduce Youth Suicidality

Background: Suicidal ideation and recent suicide attempts greatly increase the risk of suicide among youth. Many youth experiencing suicidality are not adequately connected to in-person treatment. Aims: This study aimed to determine the efficacy of a continuity-of-care approach in reducing suicide attempts, ideation, and related hospital and emergency department (ED) visits among youth at high risk for suicide. Method: Data on suicidal ideation, attempts, and related hospital and ED visits were collected over a 6-month period for youth under age 25 (n = 376). One-way repeated measures ANOVA and Cochran's Q tests assessed change from intake at the 3- and 6-month follow-up. Results: Youth had significantly fewer suicide attempts and related hospital and ED visits at both 3- and 6-month timepoints. Suicidal ideation decreased to 52% from intake to 6-month follow-up. Limitations: This study lacked a comparison population to examine continuity-of-care versus treatment-as-usual. Furthermore, the study did not extend beyond 6 months, limiting the ability to assess the intervention's long-term effectiveness. Conclusion: This youth-focused continuity-of-care model reduced suicidal ideation and related behaviors. Further studies should utilize control groups to confirm the validity of these results.

Collaborative Assessment and Management of Suicidality for Teens: A Promising Frontline Intervention for Addressing Adolescent Suicidality

This pilot open trial examined the feasibility, acceptability, and preliminary outcomes of the Collaborative Assessment and Management of Suicidality for teens (CAMS-4Teens) who presented to outpatient care with suicidal thoughts and behaviors. Participants were 22 adolescents (13-17; 59% identified as female) with clinical elevations (≥7) on the Suicidal Behaviors Questionnaire-Revised (SBQ-R). Primary outcomes were feasibility and acceptability. We also explored outcomes of suicidal thoughts and behaviors, as well as mixed effects modeling for weekly assessments of the Suicide Status Form (SSF) Core Assessment constructs. Our main implementation outcomes suggest that the intervention is acceptable, appropriate, and feasible to deliver. Clinicians were adherent to the model with high ratings of adherence. In addition, preliminary evaluation of suicidal thoughts and behaviors found a large effect size for reduction in suicidal thoughts. Benchmarking to other adolescent suicide specific interventions and the Collaborative Assessment of Management of Suicidality with adult populations provide promise that suicidal adolescent responses may be on par with established interventions. Findings from the study are preliminary in nature and intended to inform if CAMS with adolescents is a promising approach to engage and treat patient-defined "drivers" of suicide. The results suggest that a future investigation with power to detect significant change over another active intervention is warranted.

Psychosocial interventions for self-harm in adults

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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