Acne excoriée: Diagnostic overview and management

Acne excoriée (AE) is a skin picking disorder (SPD) within the group of obsessive compulsive (OCD) and related disorders characterized by the compulsive manipulation of acne lesions. AE typically appears in females during adolescence or young adulthood and can cause significant disfigurement and psychosocial impairment. This disorder is under-recognized due to patient discomfort to disclose excoriation habits or lack of behavior awareness. It is imperative that dermatologists accurately diagnose and treat this disorder to minimize long-term damage to the skin. This review aims to provide an overview of the diagnosis and treatment options for AE.

Pretreatment cognitive performance is associated with differential self-harm outcomes in 6 v. 12-months of dialectical behavior therapy for borderline personality disorder

BACKGROUND

Recent findings suggest that brief dialectical behavior therapy (DBT) for borderline personality disorder is effective for reducing self-harm, but it remains unknown which patients are likely to improve in brief v. 12 months of DBT. Research is needed to identify patient characteristics that moderate outcomes. Here, we characterized changes in cognition across brief DBT (DBT-6) v. a standard 12-month course (DBT-12) and examined whether cognition predicted self-harm outcomes in each arm.

METHODS

In this secondary analysis of 240 participants in the FASTER study (NCT02387736), cognitive measures were administered at pre-treatment, after 6 months, and at 12 months. Self-harm was assessed from pre-treatment to 2-year follow-up. Multilevel models characterized changes in cognition across treatment. Generalized estimating equations examined whether pre-treatment cognitive performance predicted self-harm outcomes in each arm.

RESULTS

Cognitive performance improved in both arms after 6 months of treatment, with no between-arm differences at 12-months. Pre-treatment inhibitory control was associated with different self-harm outcomes in DBT-6 v. DBT-12. For participants with average inhibitory control, self-harm outcomes were significantly better when assigned to DBT-12, relative to DBT-6, at 9-18 months after initiating treatment. In contrast, participants with poor inhibitory control showed better self-harm outcomes when assigned to brief DBT-6 v. DBT-12, at 12-24 months after initiating treatment.

CONCLUSIONS

This work represents an initial step toward an improved understanding of patient profiles that are best suited to briefer v. standard 12 months of DBT, but observed effects should be replicated in a waitlist-controlled study to confirm that they were treatment-specific.

Accounting for diversity in the treatment of suicide and self-injury: A systematic review of the past 50 years of randomized controlled trials

PURPOSE

Patients receiving treatment for self-injurious thoughts and behaviors (SITBs) have diverse backgrounds, yet it remains unclear exactly who is represented in the current SITB treatment literature.

METHODS

We conducted a systematic review of the past 50 years of randomized controlled trials (RCTs) testing SITB treatments to evaluate sampling practices and reporting of sample characteristics, as well as inclusion of global populations across the included 525 papers. We also assessed changes over the past five decades in these three domains.

RESULTS

SITB RCTs frequently reported age and sex (98.6%-95.1%), less frequently reported race (83.4%-38.6%), socioeconomic status (48.1%-46.1%) and ethnicity (41.9%-8.1%), and rarely reported LGBTQ+ status (3.7%-1.6%). U.S.-based RCTs featured predominantly White, non-Hispanic, and non-LGBTQ+ samples. Most RCTs were conducted in high-income North American or European countries. Sample reporting practices, sample representativeness, and inclusion of global populations modestly and inconsistently improved over time.

CONCLUSIONS

There has not been substantial improvement in reporting practices, sample representativeness, or inclusion of global populations in SITB RCTs over the past 50 years. Acknowledging who is being studied and representing diverse populations in SITB treatment research is key to connecting research advances with those who may need it most.

Variation in the clinical management of self-harm by area-level socio-economic deprivation: findings from the multicenter study of self-harm in England

BACKGROUND

We investigated disparities in the clinical management of self-harm following hospital presentation with self-harm according to level of socio-economic deprivation (SED) in England.

METHODS

108 092 presentations to hospitals (by 57 306 individuals) after self-harm in the Multicenter Study of Self-harm spanning 17 years. Area-level SED was based on the English Index of Multiple Deprivation. Information about indicators of clinical care was obtained from each hospital's self-harm monitoring systems. We assessed the associations of SED with indicators of care using mixed effect models.

RESULTS

Controlling for confounders, psychosocial assessment and admission to a general medical ward were less likely for presentations by patients living in more deprived areas relative to presentations by patients from the least deprived areas. Referral for outpatient mental health care was less likely for presentations by patients from the two most deprived localities (most deprived: adjusted odd ratio [aOR] 0.77, 95% CI 0.71-0.83, p < 0.0001; 2nd most deprived: aOR 0.80, 95% CI 0.74-0.87, p < 0.0001). Referral to substance use services and 'other' services increased with increased SED. Overall, referral for aftercare was less likely following presentations by patients living in the two most deprived areas (most deprived: aOR 0.85, 95% CI 0.78-0.92, p < 0.0001; 2nd most deprived: aOR 0.86, 95% CI 0.79-0.94, p = 0.001).

CONCLUSIONS

SED is associated with differential care for patients who self-harm in England. Inequalities in care may exacerbate the risk of adverse outcomes in this disadvantaged population. Further work is needed to understand the reasons for these differences and ways of providing more equitable care.

Self-Hatred: The Unaddressed Symptom of Borderline Personality Disorder

Individuals with borderline personality disorder (BPD) often report chronic, severe self-hatred. It is frequently experienced as immutable, seen as a barrier to recovery, and is associated with risk for self-injury and suicide attempts. Yet self-hatred remains a poorly understood, underdiagnosed, and undertreated presentation of BPD. In this concept article and review, we describe the nature of self-hatred in BPD and related disorders, propose a theory as to the development of self-hatred in BPD, review the assessments of and interventions for self-hatred, and consider next steps in the research, assessment, and treatment of self-hatred in BPD. Through increased awareness, understanding, and measures of self-hatred in BPD, new treatment paradigms can be developed to ensure more comprehensive recovery.

Efficacy of mentalization-based therapy in treating self-harm: A systematic review and meta-analysis

INTRODUCTION

Mentalization-based therapy (MBT) and its adapted version for adolescents (MBT-A) are repeatedly highlighted as promising treatments for reducing self-harm, particularly in borderline personality disorder (BPD). Despite the availability of publications providing evidence of their efficacy in reducing self-harm, recent meta-analyses have yielded mixed results. To inform best-practice clinical decision-making, we conducted a systematic review and meta-analysis. We aimed to disentangle findings for both adolescents and adults on the efficacy of MBT(-A) in reducing self-harm (primary outcome) and symptoms of BPD and depression (secondary outcomes).

METHODS

Web of Science, Scopus, Embase, PubMed/Medline, and Cochrane Review Database were searched for eligible studies published until September 2022. In total, 14 studies were identified, comprising 612 participants from nine MBT studies (six pre-post, three RCTs) and five MBT-A studies (two pre-post, three RCTs). Aggregated effect sizes were estimated using random-effects models. Meta-regressions were conducted to assess the effect of moderator variables (treatment duration, drop-out rates, and age) on effect sizes.

RESULTS

Overall, both MBT and MBT-A demonstrated promising effects in reducing self-harm (g = -0.82, 95% CI -1.15 to -0.50), borderline personality disorder (g = -1.08, 95% CI -1.38 to -0.77), and depression (g = -1.1, 95% CI -1.52 to -0.68) symptoms. However, when compared to control interventions (TAU, SCM), MBT(-A) did not prove to be more efficacious, with the exception of MBT showing superior effects on BPD symptoms in adults (g = -0.56, 95% CI -0.88 to -0.24).

CONCLUSION

Although the pre-post evaluations seem promising, this analysis, including RCTs, showed no superiority of MBT(-A) to control conditions, so that prioritizing the application of MBT (-A) for the treatment of self-harm is not supported. Possible explanations and further implications are discussed.

Shame, suicidal ideation, and urges for non-suicidal self-injury among individuals with borderline personality disorder receiving dialectical behavior therapy: The mediating role of anger

INTRODUCTION

Borderline personality disorder (BPD) is a disorder of pervasive emotion dysregulation associated with high rates of self-injurious thoughts and behaviors (SITB). Understanding specific emotion states in relation to SITB is important for effective intervention.

METHODS

The current study examined whether, and how, the specific emotion of shame contributes to suicide ideation and urges to engage in non-suicidal self-injury (NSSI) both directly, and indirectly via anger, among individuals with BPD. Participants (N = 100) were enrolled in a 6-month comprehensive dialectical behavior therapy (DBT) program and provided daily ratings of shame, anger, suicide ideation, and urges for NSSI.

RESULTS

We found that higher daily ratings of shame and anger were directly associated with higher same-day ratings of both suicidal ideation and urges for NSSI. Furthermore, anger partially mediated the relationships between shame and both suicidal ideation and urges for NSSI.

CONCLUSION

These findings highlight shame and anger as potential antecedents of SITB among individuals with BPD. Clinical approaches, such as DBT, that include personalized, ongoing, clinical assessment of these specific affective states may be particularly important for treatment of SITB.

A case report of an atypical severe case of skin picking disorder managed by a multidisciplinary team

BACKGROUND

While skin picking disorder remains relatively common, it often does not present to psychiatry until significant morbidity or comorbidities are reached. It is described as recurrent picking of skin leading to skin lesions, with repeated attempts to decrease or stop skin picking. It is also often associated with significant distress or functional impairment. There has been limited research in this specific disorder and treatment efficacy has often been poor in severe cases. For various reasons, only a small amount of patients with this disorder present to care, and often to a multidisciplinary team prior to psychiatry.

CASE PRESENTATION

This is a case presentation of a 44 year old male with a complex past psychiatric history, ultimately untreated for an underlying skin picking disorder. He presented for urgent medical care following a self-inflicted wound through the central frontal bone and dura over the course of 2 years. He was treated with current psychiatric evidence based medicine, including an SSRI, antipsychotic augmentation and NAC, along with habit reversal techniques during the admission. He was concurrently managed with the neurosurgery team, initially with a poor prognosis due to the severity of his presentation. He required debriding of the devitalized bone within the adjacent brain to cover the dural defect, IV antibiotics for 6 weeks, and an initial skin graft on his initial admission.

CONCLUSIONS

This case in particular highlighted the importance of urgent treatment via a multidisciplinary approach to avoid mortality. It highlights the importance of increasing awareness about the disorder and that treatment with SSRI's, along with antipsychotic and NAC adjuncts remains the mainstay of acute treatment.

Depression and comorbid obstructive sleep apnea: Association between positive airway pressure adherence, occurrence of self-harm events, healthcare resource utilization, and costs

OBJECTIVE

Previous studies have shown that treatment of obstructive sleep apnea (OSA) with positive airway pressure (PAP) therapy in patients with depression may improve depression symptoms and response to antidepressant therapy. We investigated the association between PAP therapy adherence, self-harm events, healthcare resource utilization (HCRU), and costs over 2 years in a national sample of patients with pre-existing depression and newly diagnosed comorbid OSA.

METHODS

Administrative claims data were linked to objective PAP therapy usage. Inverse probability treatment weighting was used to compare outcomes over 2 years across PAP adherence levels. The predicted numbers of emergency room (ER) visits and hospitalizations by adherence level were assessed using risk-adjusted generalized linear models.

RESULTS

37,459 patients were included. Relative to non-adherent patients, consistently adherent patients had fewer self-harm events (0.04 vs 0.05, p < 0.001) after 1 year, and significantly (all p < 0.001) fewer ER visits (0.66 vs 0.86) and all-cause hospitalizations (0.13 vs 0.17), and lower total ($11,847 vs $11,955), inpatient hospitalization ($1634 vs $2274), and ER visit ($760 vs $1006) costs per patient in the second year of PAP therapy. Consistently adherent patients showed lower risk for hospitalizations and ER visits.

LIMITATIONS

Using observational claims data, we were unable to assess clinical characteristics including sleep, sleepiness, and daytime symptoms, or important social determinants of health. We were limited in assessing care received outside of the included health plans.

CONCLUSION

Consistent adherence to PAP therapy over 2 years was associated with improved HCRU outcomes for patients with pre-existing depression newly diagnosed with comorbid OSA.

The Cost-Effectiveness of Psychosocial Interventions Following Self-Harm in Australia

Background: Psychosocial interventions following self-harm in adults, in particular cognitive behavioral therapy (CBT), can be effective in lowering the risk of repeated self-harm. Aims: To evaluate the cost-effectiveness of CBT for reducing repeated self-harm in the Australian context. Method: The current study adopted the accessing cost-effectiveness (ACE) approach using return-on-investment (ROI) analysis. Uncertainty and sensitivity analyses (Sas) tested the robustness of the model outputs to changes in three assumptions: general practitioner referral pathway (SA1), private setting intervention delivery (SA2), and training costs (SA3). Results: The intervention produced cost savings of A$ 46M (95% UI -223.7 to 73.3) and A$ 18.3M (95% UI -86.2 to 24.6), subject to the effect of intervention lasting 2- or 1-year follow-up. The ROI ratio reduced to 5.22 in SA1 (95% UI -10.1 to 27.9), 2.5 in SA2 (95% UI -4.8 to 13.3), and 5.1 in SA3 (95% UI -9.8 to 27.8). Limitations: We assumed that the effectiveness would reduce 50% within 5 years in the base case, and we used Australian data and a partial social perspective. Conclusions: The current study demonstrated cost-effectiveness of CBT for adults who have self-harmed with the return-on-investment ratio of A$ 2.3 to $6.0 for every A$ 1 invested.

Disclosures of self-injurious thoughts and behaviors to parents in the context of adolescent therapy: A qualitative investigation

Self-injurious thoughts and behaviors (SITBs), including suicidal thoughts, suicide attempts, and nonsuicidal self-injury, are highly prevalent among adolescents. Identifying adolescents at risk for SITBs relies on their disclosure, and these disclosures commonly occur in therapy context. Moreover, therapists often breach confidentiality to inform adolescents' parent or guardian when they disclose SITBs. Research has explored rates of and barriers to disclosure among adolescents, yet no studies have examined adolescents' experiences of disclosure in the therapy context. Further, no studies have examined adolescents' experiences when their parents are then informed. In this study, we examined qualitative responses from 1495 adolescents who had experienced a SITB disclosure in the therapy context. Qualitative questions included asking adolescents to describe how the SITB disclosure occurred, how their parents were informed, and their parents' reactions. Using open and axial coding, several themes emerged. Adolescents described therapist breaches of confidentiality as collaborative, noncollaborative, or unclear. Adolescents described their parents' affective responses, communication about SITBs, validating and invalidating responses, treatment-oriented responses, and ways that parents restricted their access to people, places, and activities. Findings have implications for the development of clinical guidelines when adolescents disclose SITBs in therapy and highlight areas for future research in adolescent SITB disclosure.

A Meta-Analysis of Treatment for Self-Injurious Behavior in Children and Adolescents With Intellectual and Developmental Disabilities

Self-injurious behavior (SIB) among children and youth with developmental disabilities has not diminished in prevalence despite the availability of effective interventions, and the impact on quality of life for people and their families is devastating. The current meta-analysis reviews SIB intervention research between 2011 and 2021 using single-case experimental designs with children and youth up to 21 years old and provides a quantitative synthesis of data from high-quality studies including moderator analyses to determine effects of participant and study characteristics on intervention outcomes. Encouraging findings include a high level of effectiveness across studies in the decrease of SIB (Tau-U = -0.90) and increase of positive behavior (Tau-U = 0.73), as well as an increase in studies (relative to prior reviews) reporting intervention fidelity, generalization, maintenance, and social validity. However, our findings shed limited light on potential moderating variables in the development of interventions for children and youth who exhibit SIB. Of the potential moderators of intervention effects, only implementer (researcher/therapist vs. parent/caregiver) and setting (clinic vs. home) were significantly associated with improved outcomes. We discuss the need for more robust involvement of natural communities of implementers in SIB intervention research to better equip them to effectively and sustainably meet the needs of people they care for. We also discuss the importance of creating systems enabling broad access for children with SIB to effective interventions in service of reducing burden for people, families, and society over time.

Staff perceptions of barriers to self-harm care in the emergency department: A cross-sectional survey study

BACKGROUND

Emergency departments (EDs) are often the first point of contact for people with self-harm; however, they do not always receive optimal care. The study objective was to examine the perspectives of ED staff who respond to self-harm presentations, perceived barriers to providing optimal, guideline-concordant care, and staff's familiarity with existing guidelines.

METHODS

An online cross-sectional survey comprising purpose-designed questions concerning self-harm in the ED was completed by 131 staff (83.2% nurses) from two hospitals in Victoria, Australia. Survey results were analysed using Stata version 16 and frequencies and percentages were calculated.

RESULTS

Respondents reported knowledge of how to appropriately manage a person presenting with self-harm. However, lack of space (62.3%) and time (78.7%) to conduct the appropriate assessments, lack of self-harm training (71.8%), and limited awareness of or access to guidelines and recommendations for self-harm management within the ED (63.6%), were identified as primary barriers to their ability to appropriately manage these presenters.

CONCLUSIONS

Improvements to the ED environment and processes, as well as the provision of regular self-harm specific education and training for all ED staff are needed. Implementation of best-practice standards should prioritise guideline-concordant care, with a particular focus on the education needs of nursing staff.

Evaluation and management of suicidal ideation and self-harm in children in the emergency department

Suicide is a leading cause of death among youth, and the emergency department (ED) serves as the primary point of healthcare contact for many with suicidal ideation. As suicide-related presentations to the ED continue to rise, the implementation of time- and cost-effective care pathways becomes ever more critical. Evidence-based tools for the identification and stratification of suicide risk can aid in clinical decision-making and care linkage. This issue reviews best practices for suicide risk assessment of youth to guide evaluation, management, and disposition planning within the ED setting.

Further evidence of renewal in automatically maintained behavior

Renewal is a relapse phenomenon that refers to the recurrence of a previously reduced behavior following a change in stimulus conditions. Muething et al. (2022) examined the phenomenology of renewal among individuals with automatically maintained challenging behavior treated at an outpatient clinic. We replicated their findings by retrospectively examining renewal across various topographies of automatically maintained behavior treated at an inpatient hospital, and we extended their work by also examining differences across subtypes of automatically maintained self-injurious behavior. The prevalence of renewal was comparable to that observed by Muething et al., supporting the notion that automatically maintained challenging behavior is susceptible to relapse phenomena. Furthermore, renewal was twice as likely to occur for individuals with Subtype 2 versus Subtype 1 self-injurious behavior, providing additional evidence of behavioral differentiation between subtypes. Our findings suggest that even after apparent stability in treatment, practitioners should remain vigilant for the recurrence of automatically maintained behavior during generalization.

[Intervention effect of narrative therapy on non-suicidal self-injury in adolescents with depressive disorder: a prospective randomized controlled study]

OBJECTIVES

To study the intervention effect of narrative therapy on non-suicidal self-injury (NSSI), as well as anxiety and depression symptoms in adolescents with depressive disorder.

METHODS

Sixty adolescents with depressive disorder and NSSI were randomly assigned to either the intervention group or the control group using coin flipping. The control group received conventional psychological support, while the intervention group received individual narrative therapy in addition to the conventional psychological support (twice a week, 60 minutes per session, for a total of 3 weeks). Assessment of treatment efficacy was conducted using the Adolescent Self-Harm Questionnaire, Children's Depression Inventory, and Children's Anxiety and Mood Scale before the intervention, at the end of the intervention, and one month after the intervention for both groups.

RESULTS

A total of 26 adolescents in the intervention group and 29 adolescents in the control group completed the entire study. At the end of the intervention and one month after the intervention, the intervention group showed a significant reduction in the NSSI frequency score, NSSI level, anxiety score, and depression score compared to before the intervention (P<0.017). Moreover, at the end of the intervention and one month after the intervention, the intervention group exhibited significantly lower NSSI frequency score, NSSI severity score, NSSI level, anxiety score and depression score compared to the control group (P<0.05).

CONCLUSIONS

Narrative therapy is effective in reducing NSSI frequency and alleviating NSSI severity, as well as anxiety and depression symptoms in adolescents with depressive disorder.

Outcomes for university students following emergency care presentation for deliberate self-harm: a retrospective observational study of emergency departments in England for 2017/2018

OBJECTIVES

Identify university-aged students and contrast their healthcare provision and outcomes with other patients in the same age group attending emergency departments for deliberate self-harm.

DESIGN

Retrospective cross-sectional observational study.

SETTING

Patients visiting 129 public hospital emergency departments across England between April 2017 and March 2018.

PARTICIPANTS

14 074 patients aged 18-23 visiting emergency departments for conditions linked to deliberate self-harm, 1016 of which were identified as university-aged students.

OUTCOME MEASURES

We study various outcomes across the entire patient pathway in the emergency department: waiting time to initial assessment on arrival at the emergency department, count of investigations delivered, discharge destination (patients refusing treatment or leave before being seen, referred to another provider or admitted to inpatient care, discharged with no follow-up) and unplanned follow-up visit within 7 days.

RESULTS

We find a statistically significant difference of 0.262 (-0.491 to -0.0327) less investigations delivered to students compared with non-students (about 8% compared with the baseline number of investigations for non-students). Stratified analyses reveal that this difference is concentrated among students visiting the emergency department outside of regular working hours (-0.485 (-0.850 to -0.120)) and students visiting for repeated deliberate self-harm episodes (-0.881 (-1.510 to -0.252)). Unplanned reattendance within 7 days is lower among students visiting emergency departments during out of hours (-0.0306 (-0.0576 to -0.00363)), while students arriving by ambulance are less likely to be referred to another provider (-0.0708 (-0.140 to -0.00182)) compared with non-students.

CONCLUSIONS

We find evidence of less-intense investigations being delivered to patients aged 18-23 identified as students compared with non-students visiting emergency departments after an episode of deliberate self-harm. Given the high risk of suicide attempts after episodes of deliberate self-harm among students, our findings may highlight the need for more focused interventions on this group of patients.

Systematic Review: Patient Outcomes in Transdiagnostic Adolescent Partial Hospitalization Programs

OBJECTIVE

Partial hospitalization programs (PHPs) are designed to help stabilize patients with acute mental health problems and are considered more cost-effective than inpatient care for patients who do not require 24-hour monitoring. Many PHPs treat transdiagnostic adolescents to reduce suicidality, self-harm, and other high-risk behaviors; however, the effectiveness of such programs is unknown. We aimed to review the existing evidence for the effects of PHPs on adolescent mental health symptoms and functioning.

METHOD

We retrieved peer-reviewed evaluations of PHPs treating adolescents with a range of disorders that reported quantitative clinical outcomes. We followed PRISMA guidelines for systematic reviews and included studies published since 2000.

RESULTS

Fifteen studies of 10 PHPs in North America, Europe, Asia, and Australia met inclusion criteria, 5 of which used comparison groups. Most participants were White and female with depressive disorders. All studies found improvements in adolescents' functioning and mental health from admission to discharge; however, only 1 study tested PHP relative to other levels of care, and only 1 study included follow-up data. Dialectical behavior therapy (DBT) may be an effective theoretical orientation for PHP settings, but evidence is limited.

CONCLUSION

Evidence for effectiveness of PHPs relative to other models is limited. Currently available research suggests that many high-risk transdiagnostic adolescents tend to improve during PHP treatment; however, controlled studies with follow-up data are needed to determine whether partial hospitalization is effective and, if so, how effective, and whether treatment gains persist after discharge.

Pilot Evaluation of a Remote Psychotherapy Service for Students Who Self-Harm: University-Community Outpatient Psychotherapy Engagement (U-COPE)

Self-harm is becoming increasingly common in student populations. Brief psychological therapies might be helpful for those who have recently self-harmed. The current paper reports on an evaluation of a brief psychotherapy service delivered via remote means, namely University-Community Outpatient Psychotherapy Engagement (U-COPE). The service combines elements of psychodynamic interpersonal and cognitive analytic therapy to help students who present with self-harm related difficulties. The primary aim was to understand students' and practitioners' experiences of a remote psychotherapy service. Semi-structured interviews were conducted with a total of nine participants (seven students and two practitioners). Interview data were analysed using thematic analysis. Analyses of the interviews across the stakeholders revealed three overarching themes: 'Accessibility'; 'Therapeutic experiences'; and 'Spaces and places of therapy'. Students appreciated the rapid access to intervention, especially as student services are typically characterised by long waiting lists. Despite the brief nature of the intervention, many students reported feeling a sense of control over the direction and pace of the therapeutic sessions, which is an important consideration for those who self-harm. The findings suggest that U-COPE may be helpful to students with difficulties related to self-harm. Further investigation of this brief intervention is warranted in order to ascertain whether U-COPE has a long-term impact on difficulties and distress-related behaviours.

Needs for mobile and internet-based psychological intervention in patients with self-injury and suicide-related behaviors: a qualitative systematic review

BACKGROUND

In recent years, mobile psychological interventions have proven effective in reducing self-injury and suicide-related behaviors. Therefore, it is essential to continually enhance the user experience and address patients' needs to facilitate the development of mobile mental health interventions. Identifying patients with mobile mental health needs can be challenging for mental health professionals. To address this, we conducted a systematic review of qualitative research to synthesize the needs of patients engaged in self-injury and suicide-related behaviors for mobile and internet-based psychological interventions.

METHODS

This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA) and the Enhancing Transparency in Reporting the Synthesis of Qualitative Research statement (ENTREQ). We explored 11 databases and synthesized the results using thematic analysis.

RESULTS

Sixteen qualitative and mixed-method studies were included. The study found that the needs of patients with self-injury and suicide-related behaviors for mobile psychological intervention included therapy, technology, culture, privacy, communication, emotional support, personalization, and self-management. Consistent with the Technology Acceptance Model (TAM), the needs of patients with self-injury and suicide-related behaviors are influenced by the perceived ease of use and perceived usefulness of the mobile intervention. However, the findings also highlight the importance and unmet needs of peer support, communication, self-management, and empowerment in using mobile psychological interventions for patients with self-injury and suicide-related behaviors.

CONCLUSIONS

Studies in this area have shown that the needs of patients with self-harm and suicide-related behaviors cover multiple stages, including basic therapeutic and technical needs and advanced emotional needs. This complexity makes it challenging to address the needs of patients engaged in self-injury and suicide-related behaviors through digital interventions. In the future, mental health professionals should be encouraged to participate in multidisciplinary collaborations to expand the use of digital interventions, enhancing remote self-management for patients and providing new strategies for the ongoing care of psychiatric patients. We registered the review protocol on PROSPERO (CRD42022324958).

How do people conceptualize self-harm recovery and what helps in adolescence, young and middle adulthood? A qualitative meta-synthesis

OBJECTIVE

Self-harm can be understood as any behavior individuals use to harm themselves, irrespective of motive. Evidence has extensively examined the epidemiology and function of self-harm to the individual, but less is known about the subjective processes underpinning recovery. Such insights could inform therapeutic interventions to better support individuals. The present aim was to synthesize qualitative themes from eligible literature to identify how adolescents, young adults, and those in middle adulthood conceptualize self-harm recovery and the factors impacting this process.

METHODS

Eleven studies were identified from a systematic search of five electronic research databases: PsycINFO, Embase, Medline, Global Health, and CINAHL. Studies were critically appraised using an adapted Critical Appraisal Skills Program tool for qualitative research. A meta-synthesis was conducted using reflexive thematic analysis to generate themes across the included studies.

RESULTS

Themes depicted recovery as a multidimensional, nonlinear, and subjective process, characterized by a "push and pull" between states of (re-)engagement and cessation/reduction. Transition between these states was influenced by intrapersonal and interpersonal factors which were embedded in a wider milieu of the meaning of self-harm to the individual.

CONCLUSION

Contemporary ideas of symptom eradication as the only marker of complete recovery may hinder individuals in the long-term, presenting an obstacle both to quality of life and therapeutic progress. Movement away from self-harm recovery as a uniform or singular phenomenon could enhance person-centered care.

Physical and Pharmacologic Restraint in Hospitalized Children With Autism Spectrum Disorder

OBJECTIVES

Children with autism spectrum disorder (ASD) have high rates of cooccurring conditions and are hospitalized longer and more frequently than children without ASD. Little is known about use of involuntary physical or pharmacologic restraint in hospitalized children with ASD. This study compares use of restraint because of violent or self-injurious behavior during inpatient pediatric hospitalization in children with ASD compared with typical peers.

METHODS

This retrospective cohort study examines electronic health records of all children aged 5 to 21 years admitted to a pediatric medical unit at a large urban hospital between October 2016 and October 2021. Billing diagnoses from inpatient encounters identified ASD and cooccurring diagnoses. Clinical orders identified physical and pharmacologic restraint. Propensity score matching ensured equivalency between ASD and matched non-ASD groups on demographic factors. Logistic regression determined the odds of restraint in children with ASD compared with children without ASD, controlling for hospitalization factors and cooccurring diagnoses.

RESULTS

Of 21 275 hospitalized children, 367 (1.7%) experienced restraint and 1187 (5.6%) had ASD. After adjusting for reason for admission, length of stay, and cooccurring mental health, developmental, and behavioral disorders, children with ASD were significantly more likely to be restrained than children without ASD (odds ratio 2.3, 95% confidence interval 1.6-3.4; P < .001).

CONCLUSIONS

Hospitalized children with ASD have significantly higher odds of restraint for violent or self-injurious behavior compared with children without ASD after accounting for reason for admission, length of hospitalization and cooccurring diagnoses. Work is needed to modify the hospital environment for children with ASD to reduce behavioral dysregulation and restraint.

Psychosocial interventions for suicidal and self-injurious-related behaviors among adolescents: a systematic review and meta-analysis of Chinese practices

Background

Suicidal and self-injurious-related behaviors (SSIRBs) are a serious public health challenge in China. However, a comprehensive systematic review of psychosocial interventions for SSIRBs among Chinese adolescents has not been performed. To fill this gap, this systematic review and meta-analysis aimed to examine psychosocial interventions for SSIRBs among Chinese adolescents.

Methods

Eight international (PubMed, EMBASE, Cochrane Library, ScienceDirect, Clinical Trial, CINAHL, PsycINFO, and Web of Science) and four Chinese (Wanfang, SinoMed, CEPS, and CNKI) databases were searched from inception to 31 January 2023. Data extraction and quality assessment were independently conducted by two groups of researchers. Qualitative synthesis and meta-analysis were both used.

Results

The initial search yielded 16,872 titles. Of the 649 full texts reviewed, 19 intervention articles focusing on SSIRBs met the inclusion criteria. Thirteen out of the 19 included studies involved cognitive-behavioral therapy (CBT). Seven non-suicidal self-injury (NSSI) studies assessing self-injurious behaviors were included (six short-term studies and three long-term studies). Compared with long-term interventions [-1.30 (95% CI: -1.84, -0.76)], short-term psychosocial interventions had a higher standardized mean difference (SMD) value [1.86 (95% CI: -2.72, -0.99)]. Meta-regression showed an inverse relationship between the treatment response and sample size (slope = 0.068, Z = 2.914, p = 0.004) and proportion of females (slope = 1.096, Z = 5.848, p < 0.001). Subgroup analyses showed that compared with the "less than 1 month" group [-0.494 (-0.783, -0.205)], in the "immediate postintervention" group, the pooled estimate was significantly lower [-2.800 (-4.050, -1.550), p < 0.001].

Conclusion

Our review systematically summarized the key characteristics and effectiveness of existing psychosocial interventions for SSIRBs among Chinese adolescents. Short-term psychosocial interventions for NSSI were significantly effective in reducing self-injurious behavior scores, especially in the immediate postintervention period. More favorable treatment responses could be observed in both male and small samples.

Adolescent self-harm: Parents' experiences of supporting their child and help-seeking

Self-harm in children and adolescents is a growing public health issue. Parents are forefront in identifying, responding to and supporting their child to seek help. A sequential mixed-method study which included an online survey (N = 37) and a semi-structured interview (n = 10) was conducted to understand parents' experiences of supporting and accessing help for their child. Parents (M = 45.70 years, SD = 6.18) with a child who has engaged in self-harm behaviours (M = 16.89 years, SD = 3.91) participated. Parents sought help from a range of services and perceived psychiatrists, private psychologists and friends as the most helpful and school psychologists, paediatricians, Emergency Department (ED) and the national youth mental health organisation as the least helpful. Two themes were interpreted from the qualitative data: (1) An emotional journey into the dark unknown, and (2) The promise of psychological help. A series of recommendations for other parents in similar situations, as well as health professionals were made. Parents want health professionals to provide appropriate referrals, work collaboratively with families, meaningfully connect with and validate parents, provide practical and psychological support for families and establish parent support groups. There remains a need for widely available evidence-informed resources, information and support for parents.

Frequency and predictors of individual treatment outcomes (response, remission, exacerbation, and relapse) in clinical adolescents with nonsuicidal self-injury

BACKGROUND

Nonsuicidal self-injury (NSSI) is prevalent in adolescent clinical samples. There is evidence that NSSI can be treated effectively but data on individual treatment outcomes is limited. The goal of this study was to examine response, remission, exacerbation, and relapse rates over one and two years, respectively, among a clinical sample of adolescents with NSSI. Furthermore, we aimed to identify clinically relevant predictors of NSSI trajectories.

METHODS

The sample consists of n = 203 adolescents (12-17 y., 94% female) from a specialized outpatient clinic for risk-taking and self-harming behavior with NSSI on at least five days in the six months before first assessment. Assessments were completed at baseline and one (FU1) and two (FU2) years later using structured clinical interviews and self-report questionnaires.

RESULTS

At FU1, 75% reported a reduction in NSSI frequency by at least 50% (treatment response); among those, one third (25% of the entire sample) achieved a remission (0 NSSI); an exacerbation (⩾50% more NSSI) was observed in 11% of patients. Of those in remission, 41% relapsed one year later. Predictors of non-response or non-remission were inpatient treatment and depressive symptoms. Adolescents with lower NSSI frequency at baseline had a higher risk of exacerbation. Due to limited sample size at FU2 no prediction model for relapse was established.

CONCLUSIONS

While most adolescents presenting with NSSI achieved significant improvement, more attention should be paid to the rather low rates of full remission. Prediction and early detection of individuals who deteriorate during or relapse after treatment is critical.

Fluctuations in anger, depressive symptoms, and self-injurious thoughts and behaviors throughout partial hospitalization treatment

Self-injurious thoughts and behavior (SITB), including passive and active suicidal ideation (SI) and self-harm (SH) urges and behavior, are critical phenomena to predict and target during treatment. Partial hospital programs (PHP) provide unique opportunities to understand how negative affect (e.g., depression and anger) and SITB fluctuate daily. The current study aimed to explore associations between aspects of negative affect (depression and anger) and types of SITB throughout PHP treatment. PHP patients (N = 1625) who attend at least five days of treatment were included in the current sample. Anger-related symptoms, depressive symptoms, SH urges, SH occurrence, passive SI, and active SI were measured daily. A series of generalized linear mixed models were conducted to examine whether depressive and anger-related symptoms predicted SITB across patients (between-person) and throughout PHP treatment (within-person). At the between-person level, higher average depressive symptoms predicted greater severity of all forms of SITB, whereas higher average anger-related symptoms predicted greater severity SH urges and occurrence. At the within-person level, increases in depressive symptoms were associated with increases in all aspects of SITB, whereas increases in anger-related symptoms predicted increases in passive and active SI. The current study suggests that monitoring changes in negative affect throughout treatment can provide possible targets to reduce SITB.

Life experienced as worth living and beyond: a qualitative study of the pathways to recovery and flourishing amongst individuals treated for borderline personality disorder

BACKGROUND

Dialectical Behaviour Therapy (DBT) is recognized as a leading evidence-based treatment, effective in reducing symptoms of borderline personality disorder (BPD), as well as co-occurring clinical syndromes. However, symptom remission may not be the same as a life experienced as worth living. The purpose of the study was to understand, from the perspective of individuals with lived experience, the concepts of recovery, life experienced as worth living and flourishing after treatment for BPD, and to describe the pathways to wellness after symptom remission.

METHODS

Semi-structured interviews were conducted with nine adult women previously diagnosed with BPD, co-occurring clinical syndromes and severe self-harm behaviour who self-identified as recovered for a minimum of two years, recruited from a network for individuals with lived experience. The average duration of recovery was 5.7 years with a range from 2 to 10 + years. Data were analysed using thematic analysis.

RESULTS

Four main themes and 14 subthemes were generated from our analyses. Main themes indicated that loved ones helped recovery and to create a life worth living, that participants identified as recovered and as healthy and beyond, and that becoming well is a long process associated in part with reclaiming a healthy identity. Participants defined recovery as separate but related to a life worth living, which in turn was separate but related to being healthy and having lives they described as being beyond health and well-being. The wellness process was described as lengthy and non-linear, including setbacks that with time no longer derailed daily life. A proposed theoretical model depicting the wellness process over time from symptom remission to the experience of a life beyond health and wellness is presented.

CONCLUSIONS

This qualitative study contributes knowledge of what a life experienced as worth living means, as well as how wellness progressed into flourishing for some participants within a sample of individuals with lived experience. Our findings may inform treatment development that targets more than symptom reduction, which in turn may shorten trajectories from symptom remission to health, wellness, and flourishing.

A smartphone-based intervention for young people who self-harm ('PRIMARY'): study protocol for a multicenter randomized controlled trial

BACKGROUND

Self-harm in young people is a public health concern connected with severe mental health problems, such as personality pathology. Currently, there are no specific evidence-based interventions available for young people who self-harm. Therefore, we developed PRe-Intervention Monitoring of Affect and Relationships in Youth (PRIMARY), a smartphone-based intervention, co-designed by clinicians and young people with lived experience of mental ill-health. PRIMARY combines the Experience Sampling Method (ESM) with weekly report sessions. The study aims to examine the effectiveness of PRIMARY with regard to reducing self-harm, and improving emotion regulation and quality of relationships.

METHODS

This study is a multicenter, parallel groups, randomized controlled trial (RCT) comparing the PRIMARY intervention to a waiting list control group. PRIMARY comprises 28 consecutive days of questionnaires five times each day (i.e., ESM) and four weekly report sessions. Participants will comprise 180 young people referred for treatment to the participating Dutch mental healthcare institutions and (1) are aged 12 to 25 years, and (2) engaged in ≥ 1 act of self-harm in the past year. Participants are randomly allocated to a study group after screening in a 1:1 ratio by an independent researcher using computer-generated randomization sequences with stratified block randomization by age (12 to 15 years / 16 to 25 years). Staff will conduct assessments with all participants at baseline (Wave 1), after 28 days (Wave 2), and in a subsample after 10 weeks of subsequent specialized treatment (Wave 3). The primary outcomes are self-harm, emotion regulation, and quality of relationships. Secondary outcomes include patient and clinician satisfaction. Exploratory analyses of ESM data will examine the relationship between emotions, social relationships, and self-harm.

DISCUSSION

The results of this trial will clarify whether an innovative smartphone-based intervention is effective for reducing self harm and improving emotion regulation and the quality of social relationships. It has the potential to fill a treatment gap of interventions specifically targeting self-harm. If proven effective, it would provide an accessible, easy-to-implement, low-cost intervention for young people. Furthermore, the ESM-data will allow detailed analyses into the processes underlying self-harm, which will contribute to theoretical knowledge regarding the behavior.

TRIAL REGISTRATION

ISRCTN42088538 ( https://doi.org/10.1186/ISRCTN42088538 ), retrospectively registered on the 26th of October 2022.

New guidance for self-harm: an opportunity not to be missed

In this editorial we, as members of the 2022 NICE Guideline Committee, highlight and discuss what, in our view, are the key guideline recommendations (generated through evidence synthesis and consensus) for mental health professionals when caring for people after self-harm, and we consider some of the implementation challenges.

How, when and where to intervene in self-harm in youth in low- and middle-income countries: Thinking beyond healthcare systems

BACKGROUND

Low- and middle-income countries (LMICs) account for 78% of global suicides. Self-harm is the clearest antecedent of suicide. The health and social systems have struggled to provide adequate evidence based help to young people with self-harm. In addition, the negative attitudes towards those who self-harm in these settings interfere with help-seeking behaviour.

AIMS AND METHOD

In our submission of a comment, we discuss the reasons for thinking beyond healthcare systems in LMICs to address self-harm in youth and the possible ways to achieve it.

RESULTS AND CONCLUSION

We truly believe that harnessing the potential of social systems such as schools is important for addressing self-harm in LMICs. We present our arguments in favour of feasible measures that can be implemented to achieve this.

Left with a Sisyphean task - the experiences of nurse practitioners with treating non-suicidal self-injury in the emergency department: a descriptive qualitative study

BACKGROUND

Non-suicidal self-injury (NSSI) is a prevalent phenomenon in somatic emergency departments, where nurses are the most consistent group of healthcare professionals who treat people with NSSI, which means they may affect the NSSI trajectory and help-seeking in the future. The objective of this study was to describe the experiences of nurse practitioners with treatment of people presenting with NSSI in the emergency department.

METHODS

Individual, semi-structured telephone interviews were conducted with seventeen purposefully recruited nurse practitioners from three emergency departments in the Capital Region of Denmark. Interview transcripts were analysed using inductive content analysis, as described by Graneheim and Lundman.

RESULTS

The analysis resulted in the formulation of three categories and 10 subcategories describing how nurse practitioners feel confident and competent in treating physical injuries due to NSSI but at the same time insecure about how to provide adequate care and engage in conversations about NSSI and mental wellbeing with people with NSSI. An overarching theme, 'Left with a Sisyphean task', reflects the nurses' feeling of being handed the responsibility for performing a laborious, never-ending, and futile task.

CONCLUSION

The findings indicate that nurse practitioners feel confident and competent in treating physical injuries due to NSSI but insecure about how to provide adequate care. Therefore, there is a need for training and guidelines.

An Ideal-Type Analysis of People's Perspectives on Care Plans Received from the Emergency Department following a Self-Harm or Suicidal Crisis

People presenting to Emergency Departments (EDs) in a self-harm/suicidal crisis in England receive a psychosocial assessment and care plan. We aimed to construct a typology of peoples' perspectives on crisis care plans to explore the range of experiences of care plans. Thirty-two semi-structured interviews with people who presented to EDs following a self-harm/suicidal crisis in England were analysed using an ideal-type analysis. Cases were systematically compared to form clusters of cases with similar experiences of care plans. People's perspectives on care plans fitted into three types: (1) personalised care plans (n = 13), consisting of advice or referrals perceived as helpful; (2) generic care plans (n = 13), consisting of generic advice that the person already knew about or had already tried; and (3) did not receive a care plan (n = 6) for those who reported not receiving a care plan, or who were only provided with emergency contacts. Care planning in the ED following a suicidal/self-harm crisis was perceived as supportive if it provided realistic and personalised advice, based on what had/had not worked previously. However, many people reported not receiving a helpful care plan, as it was ill-fitted to their needs or was not considered sufficient to keep them safe, which may mean that these patients are at increased risk of repeat self-harm.

The Effectiveness of a Mindfulness Induction as a Buffer Against Stress Among University Students With and Without a History of Self-Injury

Stressful experiences are abundant in university and students with a history of nonsuicidal self-injury (NSSI) may be hyper-reactive to stress. While brief mindfulness inductions have been proposed as a buffer against acute stress, whether they function differently in students with a history of NSSI remains in question. This study sought to explore the impact of an online mindfulness induction on (a) two facets of state mindfulness (i.e., mind and body) and (b) state stress, following a stress induction task, in university students with versus without a history of NSSI. Participants were Canadian university students with (n = 82; Mage = 21.30 years, SD = 2.92; 87.8% female) and without (n = 82; Mage = 21.71 years, SD = 3.18; 87.8% female) a history of NSSI, matched on gender, age, and faculty, who completed baseline (T1) measures of state stress and state mindfulness. Participants were randomly assigned to complete a mindfulness induction or an active control task. All participants then underwent a stress induction, and again completed measures of state stress and state mindfulness (T2). Results from three-way mixed ANOVAs revealed that state stress increased from T1 to T2 for all participants, regardless of group or condition. Among those assigned to the control condition, state mindfulness of the body was lower at T2 for participants with a history of NSSI compared to those without such a history. However, participants with a history of NSSI who completed the mindfulness induction reported greater state mindfulness of the body at T2 than students with a history of NSSI who completed an active control task. Findings highlight the unique response of university students with a history of NSSI to a brief mindfulness induction. Implications are discussed in the context of future research and clinical applications.

Using electronic health record data to predict future self-harm or suicidal ideation in young people treated by child and youth mental health services

INTRODUCTION

Identifying young people who are at risk of self-harm or suicidal ideation (SHoSI) is a priority for mental health clinicians. We explore the utility of routinely collected data in developing a tool to aid early identification of those at risk.

METHOD

We used electronic health records of 4610 young people aged 5-19 years who were treated by Child and Youth Mental Health Services (CYMHS) in greater Brisbane, Australia. Two Lasso models were trained to predict the risk of future SHoSI in young people currently rated SHoSI; and those who were not.

RESULTS

For currently non-SHoSI children, an Area Under the Receiver Operating Characteristics (AUC) of 0.78 was achieved. Those with the highest risk were 4.97 (CI 4.35-5.66) times more likely to be categorized as SHoSI in the future. For current SHoSI children, the AUC was 0.62.

CONCLUSION

A prediction model with fair overall predictive power for currently non-SHoSI children was generated. Predicting persistence for SHoSI was more difficult. The electronic health records alone were not sufficient to discriminate at acceptable levels and may require adding unstructured data such as clinical notes. To optimally predict SHoSI models need to be tested and validated separately for those young people with varying degrees of risk.

Finding Voices: a survey of young people's experiences of the ED

BACKGROUND

Mental health presentations in young people are increasing. Recurrence of self-harm (SH) presentations is common and of great concern since self-harm is known to be a risk factor for suicide. Previous reports suggest that the ED experience for this group is poor. A study was carried out at the Royal Berkshire NHS Foundation Trust. The objective was to pilot new and existing measures to capture the perceived needs and expectations of young people attending ED following SH compared with those attending with suspected fractures (SFs).

METHODS

Young people were approached to complete a questionnaire as they arrived in ED and again before they left. Questionnaires were a combination of pre-existing tools as well as piloting novel questions specific to the ED where no suitable tool previously existed. Satisfaction with the ED treatment was measured along with reattendance up to one year later.

RESULTS

The survey was started in 2019 and suspended in March 2020 at the outset of the COVID-19 pandemic and subsequently closed, having screened 917 and recruited 104 adolescents. All the measures showed satisfactory psychometric properties with internal consistencies (alpha) of over 0.75. The two patient groups differed at baseline: it was found that the SH group had lower mood on the Short Mood and Feelings Questionnaire (p<0.001) and scored more highly on the Borderline Personality Features Scale for Children than the SF group (p<0.001) but the expectations of care across both groups was similar. Using the experience measures, the SH group was less satisfied with treatment than the SF group (p=0.0263).

CONCLUSION

Our findings underline the similarities between the two groups in terms of their expectations of care. Terminating the study early at the outset of the COVID-19 pandemic has precluded any further firm conclusions to be drawn. Further research is needed.

Self-harm among youth during the first 28 months of the COVID-19 pandemic in Ontario, Canada: a population-based study

BACKGROUND

Youth have reported worsening mental health during the COVID-19 pandemic. We sought to evaluate rates of pediatric acute care visits for self-harm during the pandemic according to age, sex and mental health service use.

METHODS

We conducted a population-based, repeated cross-sectional study using linked health administrative data sets to measure monthly rates of emergency department visits and hospital admissions for self-harm among youth aged 10-17 years between Jan. 1, 2017, and June 30, 2022, in Ontario, Canada. We modelled expected rates of acute care visits for self-harm after the pandemic onset based on prepandemic rates. We reported relative differences between observed and expected monthly rates overall and by age group (10-13 yr and 14-17 yr), sex and mental health service use (new and continuing).

RESULTS

In this population of about 1.3 million children and adolescents, rates of acute care visits for self-harm during the pandemic were higher than expected for emergency department visits (0.27/1000 population v. 0.21/1000 population; adjusted rate ratio [RR] 1.29, 95% confidence interval [CI] 1.19-1.39) and hospital admissions (0.74/10 000 population v. 0.43/10 000 population, adjusted RR 1.72, 95% CI 1.46-2.03). This increase was primarily observed among females. Rates of emergency department visits and hospital admissions for self-harm were higher than expected for both those aged 10-13 years and those aged 14-17 years, as well as for both those new to the mental health system and those already engaged in care.

INTERPRETATION

Rates of acute care visits for self-harm among children and adolescents were higher than expected during the first 2 and a half years of the COVID-19 pandemic, particularly among females. These findings support the need for accessible and intensive prevention efforts and mental health supports in this population.

Impact of Treatment Initiation and Engagement on Deliberate Self-Harm Among Individuals With First-Episode Psychosis

OBJECTIVE

Individuals with psychosis are at increased risk for suicide, with the greatest risk being present during the first few months after diagnosis. The authors aimed to examine whether treatment initiation within 14 days of diagnosis and treatment engagement within 90 days of initiation reduce the risk for deliberate self-harm (DSH) among individuals with first-episode psychosis (FEP).

METHODS

A retrospective longitudinal cohort design was adopted by using Ohio Medicaid claims for 6,349 adolescents and young adults ages 15-24 years with FEP. Logistic regression was used to examine factors associated with treatment initiation and engagement. Cox proportional hazard models were used to estimate the impact of treatment initiation and engagement on DSH. Propensity score weighting was used to control for sociodemographic and clinical covariates.

RESULTS

Approximately 70% of the sample initiated treatment, 55% of whom engaged in treatment. Treatment initiation and engagement were associated with both demographic and clinical variables. Treatment initiation significantly reduced the hazard of DSH (average treatment effect in the entire population: hazard ratio [HR]=0.62, 95% CI=0.47-0.81; average treatment effect among those treated: HR=0.64, 95% CI=0.52-0.80). In contrast, treatment engagement was not significantly associated with DSH.

CONCLUSIONS

These results suggest that the initial treatment contact is essential for reducing DSH among adolescents and young adults with FEP. Additionally, the finding that treatment engagement did not reduce DSH suggests that standard clinical care may not be sufficient for reducing DSH in this population. These findings highlight the need for suicide-specific interventions for individuals with FEP.

Self-Help Habit Replacement in Individuals With Body-Focused Repetitive Behaviors: A Proof-of-Concept Randomized Clinical Trial

Importance

Body-focused repetitive behaviors (BFRBs; eg, skin picking) encompass a set of conditions at the interface of dermatology and psychiatry/psychology. The disorder is prevalent but currently underdiagnosed and undertreated.

Objective

To compare a new self-help intervention, habit replacement, against a wait-list control condition for the treatment of BFRBs.

Design, Setting, and Participants

This randomized clinical trial was conducted online in 2022. Participants were a population-based nonclinical sample with BFRBs and were recruited via social media. Initially, 481 individuals entered the assessment; 213 were excluded blind to results. A final sample of 268 participants were randomized. The intervention period was 6 weeks.

Interventions

Participants were randomized to a self-help intervention, habit replacement, or a wait-list control condition (each n = 134).

Main Outcomes and Measures

The Generic BFRB Scale-45 (GBS-45, self-report) represented the primary outcome.

Results

Individuals in the 2 conditions (n = 268; 241 [89.9%] women; mean [SD] age, 36.8 [11.1] years; skin picking, 68.3%; trichotillomania, 28.4%; nail biting, 36.6%; lip-cheek biting, 26.1%; other, 20.1%) did not differ on any baseline characteristics. The experimental group significantly improved on the primary outcome (GBS-45) for both the per-protocol (technique was used at least once weekly, ηp2 = 0.068, P = .001) and the intention-to-treat analyses relative to the wait-list control group (expectation-maximization algorithm; ηp2 = 0.019, P = .02). The interaction of group and time yielded statistical trends in favor of the experimental condition only on the Patient Health Questionnaire-9 and quality of life. For the Clinical Global Impressions scale, more individuals in the habit replacement group reported improvement (52.8% vs 19.6%; P < .001). User satisfaction in the habit replacement group was high. Moderation analyses that included all baseline variables showed that those who exhibited nail biting particularly benefited from the new technique.

Conclusions and Relevance

The present proof-of-concept randomized clinical trial tentatively demonstrates that habit replacement is a feasible and effective self-help strategy against BFRBs, especially for nail biting. Study limitations include the lack of external assessment and verified diagnoses. In addition, the study is missing follow-up data. Self-help habit replacement shows promise in reducing BFRBs but not concomitant symptoms.

Trial Registration

German Clinical Trials Register Identifier: DRKS00030511.

Editorial: Global Widening of the Inequitable Child and Adolescent Mental Health Care Chasm During COVID-19

The long-standing and inequitable chasm between clinical need and child and adolescent mental health care has likely widened during the COVID-19 pandemic, especially for children and adolescents in developing low- and middle-income countries (LMICs). Internationally, the risk for suicidal behaviors among young people rose, while timely access to care worsened.1 People in LMICs are envisioned to be precariously positioned within a perfect storm characterized by greater exposure to life-threatening COVID-19-related social determinants of health that also pose higher risk of new and recurrent mental disorders.2 In this issue of the Journal, the study by Wong et al.3 is the first international study to report a substantial rise in emergency department (ED) visits for any psychiatric disorder and self-harm among children and adolescents after the onset of the COVID-19 pandemic. Using a retrospective cohort study design, ED visits for any psychiatric disorder and self-harm were compared between March-April of 2019 (prepandemic), 2020 (early pandemic), and 2021 (later pandemic), with the most recent time interval corresponding to the "third wave of the pandemic worldwide." The total sample included 8,174 psychiatric ED visits to 62 emergency units in 25 countries, including developing countries with lower-middle, upper-middle, and high incomes as well as developed countries with upper-middle and high incomes. Of these, 3,865 psychiatric ED visits in 13 countries had data for all time intervals. Using the complete data, compared with March-April 2019, the rate of ED visits for any psychiatric disorder was lower in March-April 2020, consistent with the abrupt drop reported in the United States that broadly aligns with statewide school closures and shelter in place orders.4,5 However, when comparing early pandemic with later pandemic time intervals matched by months, the rates for any psychiatric and self-harm ED visits were twice as high. Despite the sharp drop following the onset of the pandemic, when compared with the prepandemic time interval, the overall rates of ED visits for any psychiatric diagnosis and self-harm during the later pandemic were 50% and 70% higher, respectively. Girls were also at greater risk for self-harm ED visits following the onset of the COVID-19 pandemic. Compared with the prepandemic time interval matched by months, girls had almost twice the odds of a self-harm ED visit in March-April 2021. The international rise in self-harm ED visits likely driven by the increases among girls is also consistent with prior US studies.4,5.

Factors Associated With Utilization of Electroconvulsive Therapy During Psychiatric Hospitalization Among Children and Adolescents in China

PURPOSE

Based on a nationally representative sample in China, we examined the demographic and clinical correlates of utilization of electroconvulsive therapy (ECT) in child and adolescent (C/A) patients younger than 18 years during psychiatric hospitalization.

METHODS

As part of a national survey, 41 provincial tertiary psychiatric hospitals in mainland China were selected. Data from 196 C/A patients who were discharged from these psychiatric hospitals from March 19 to 31, 2019, were retrieved and analyzed.

RESULTS

(1) The overall rate of ECT among C/A patients during psychiatric hospitalization was 15.6% (n = 30). (2) Between ECT and non-ECT groups, significant differences were found in sex, age, length of stay, Global Assessment of Functioning at admission, treatment outcome, and self-injurious behavior during hospitalization, and the ratio of marked improvement on discharge. (3) Multiple logistic regression analysis revealed that ECT use was independently and positively associated with an older age, male sex, lower Global Assessment of Functioning, and self-injurious behavior during hospitalization.

CONCLUSIONS

The frequency of ECT use was relatively frequent in C/A patients during psychiatric hospitalization in our nationally representative sample in China. Developing more specific and operational criteria for the use of ECT for C/A patients is needed to provide guidance for the optimal use of ECT in this patient population.

Is equipoise a useful concept to justify randomised controlled trials in the cultural context of Pakistan? A survey of clinicians in relation to a trial of talking therapy for young people who self-harm

BACKGROUND

Clinical equipoise, also defined as the uncertainty principle, is considered essential when recruiting subjects to a clinical trial. However, equipoise is threatened when clinicians are influenced by their own preferences. Little research has investigated equipoise in the context of trial recruitment.

METHODS

This cross-sectional survey sought clinicians' views (operationalised as 11 statements relating to treatments offered in a trial of a psychological intervention for young people) about equipoise and individual treatment preferences in the context of moral justification for recruiting young people at risk of self-harm or suicide to a randomised controlled trial (RCT) to evaluate the Youth Culturally Adapted Manual Assisted Psychological Intervention (Y-CMAP) in Pakistan. We compared the views of clinicians involved in Y-CMAP RCT recruitment to those of a sample of clinicians not involved in trial recruitment but treating similar patients, comparing their sociodemographic characteristics and the proportions of those in each group agreeing with each statement.

RESULTS

There was a response rate of 96% (75/78). Findings showed that, during trial recruitment and before the RCT results were known, the majority of all responding clinicians (73.3%) considered Y-CMAP to be an effective treatment for young people at risk of self-harm or suicide. Although there was an acknowledgement of individual preferences for the intervention, there was near consensus (90%) on the need to conduct an RCT for reaching an evidence-based decision. However, there were no significant differences in the proportion of recruiting clinicians reporting a treatment preference for Y-CMAP than non-recruiting clinicians (31 (88.6%) versus 36 (90%), p = 0.566). A significantly higher proportion of non-recruiting clinicians (87.5%) as compared to (48.5%) in the trial (p = 0.000) stated that there may be other treatments that may be equally good for the patients, seemingly undermining a preference for the intervention. Those reporting a treatment preference also acknowledged that there was nothing on which this preference was based, however confident they felt about them, thus accepting clinical equipoise as ethical justification for conducting the RCT. There was a significant group difference in views that treatment overall is better as a result of young patients' participation in the Y-CMAP trial (p = 0.015) (i.e. more clinicians not involved in the trial agreed with this statement). Similarly, more clinicians not involved in the trial agreed on the perceived availability of other treatment options that were good for young people at risk of self-harm (p < 0.05).

CONCLUSIONS

The paper highlights that clinicians in Pakistan accept the notion of clinical equipoise as an ethical justification for patient participation in RCTs. The need for conducting RCTs to generate evidence base and to reduce bias was considered important by the clinical community.

Adolescents' attitudes toward non-suicidal self-injury (NSSI) and their perspectives of barriers to seeking professional treatment for NSSI

PURPOSE

This study aimed to investigate the attitudes of adolescents toward NSSI, and to explore their perspectives on barriers to seeking professional treatment for NSSI.

METHODS

A qualitative phenomenological design was used to conduct in-depth interviews with 17 adolescents with NSSI in a psychiatric hospital in Beijing, China. Data from the 17 adolescents were analyzed using Colaizzi's 7-step analysis.

RESULTS

Two themes were extracted: (1) attitudes toward NSSI (normal, effective, ignorant, disgraceful); (2) subjective/objective barriers to seeking professional treatment (negative attitudes toward NSSI, fear of being regarded as an attention getter, fear of interfering with personal relationships, fear of aggravating the family burden, fear of being criticized by parents, fear of ongoing hospitalization, fear of the side effects of medication, etc.).

CONCLUSIONS

It is suggested to strengthen the knowledge of NSSI among adolescents, families and society, formulate interventions suitable for Chinese sociocultural backgrounds, and cultivate the specialty literacy of mental health nurses and their abilities to identify the barriers, which are required for eliminating barriers to seeking professional treatment and establishing a system for seeking full coverage of professional treatment.

A proposed clinical pathway for the patients with Borderline Personality Disorder presenting to Emergency Departments

OBJECTIVE

Emergency Department (ED) care of repeated self-injury, intensive affective lability, and interpersonal dysfunction associated with borderline personality disorder (BPD) is challenging. We propose an evidence-based acute clinical pathway for people with BPD.

CONCLUSION

Our standardised evidence-based short-term acute hospital treatment pathway includes structured ED assessment, structured short-term hospital admission when clinically indicated, and immediate short-term (4-sessions) clinical follow-up. This approach could be adopted nationally to reduce iatrogenic harm, acute service overdependence and negative healthcare system impacts of BPD.

Brief Psychotherapeutic Intervention Compared with Treatment as Usual for Adolescents with Nonsuicidal Self-Injury: Outcomes over a 2-4-Year Follow-Up

INTRODUCTION

The "Cutting Down Programme" (CDP), a brief psychotherapeutic intervention for treating nonsuicidal self-injury (NSSI) in adolescents, was comparable to high-quality treatment as usual (TAU) in a previous randomized controlled trial (RCT).

OBJECTIVE

The aim of the study was to evaluate the long-term outcomes of the CDP over up to 4 years.

METHODS

Assessments of NSSI, suicide attempts, borderline personality disorder (BPD), depression, and quality of life took place 2 to 4 years (T3) after enrollment in a RCT. The evolution of NSSI, suicide attempts, depression, and quality of life was analyzed using (generalized) linear mixed-effects models. Ordered logistic regression was used for analyzing BPD diagnoses. Data from T0, T2, and T3 are reported.

RESULTS

Out of 74 patients, 70 (95%) were included in the T3 assessment. The frequency of NSSI events alongside with suicide attempts and depression further decreased between T2 and T3 and BPD between T0 and T3 in both groups. Quality of life remained stable in both groups between T2 and T3. Both groups received substantial but comparable additional treatment between T2 and T3. More treatment sessions during the follow-up period were linked to larger improvements of NSSI.

CONCLUSIONS

The CDP was found to be as effective as TAU in promoting recovery from NSSI and comorbid symptoms in the long term. Results suggest that treatment effects from a brief psychotherapeutic intervention may endure and even further improve after completion of the program. However, additional treatment seems to improve chances for recovery independent from CDP versus TAU.

Effects of Group Psychotherapy for Nonsuicidal Self-Injury: A Meta-Analysis

Nonsuicidal self-injury (NSSI) is prevalent and concerning among adolescents and adults. Although prior meta-analytic work has considered the efficacy of individual psychotherapy for reducing NSSI, the efficacy of group psychotherapy remains unclear. We conducted a systematic meta-analysis of group psychotherapy studies with NSSI measures. We identified a total of eight studies, including published articles (n = 6) or dissertations (n = 2) with 10 total effect sizes for group interventions. Overall, random-effects meta-analysis suggests that group psychotherapies have a significant small effect on NSSI. However, when corrected for publication bias, the effect is no longer significant. This meta-analysis cautiously suggests that group psychotherapies, which are cost-effective and efficient, hold promise for attenuating NSSI. The field would benefit from further study and treatment refinement, including consideration of what works for whom.