Systematic Review and Individual Participant Data Meta-Analysis: Reducing Self-Harm in Adolescents: Pooled Treatment Effects, Study, Treatment, and Participant Moderators - 27/08/25
Doi : 10.1016/j.jaac.2025.01.017
Alex Wright-Hughes, MSc a, ⁎ 
, Amanda J. Farrin, MSc a, Peter Fonagy, CBE, FMedSci b, Dennis Ougrin, PhD c, Daniel Stahl, PhD d, Judy Wright, MSc a, Donna Irving, BA e, Faraz Mughal, FRCGP f, Alex Truscott, BA b, Emma Diggins, MA a, Andrew Chanen, PhD g, Emily Cooney, PhD h, Greg Carter, FRANZCP i, Kerrie Clover, PhD i, Mark Dadds, PhD j, Guy Diamond, PhD k, Christianne Esposito-Smythers, PhD l, Jonathan Green, FRCPsych, FMedSc m, Helen Griffiths, DClinPsychol n, Hossein Hassanian-Moghaddam, MD, FACMT o, Simon Hatcher, MD p, Philip Hazell, PhD q, Nusrat Husain, MD m, Michael Kaess, MD r, s, Cheryl King, PhD t, Britt Morthorst, PhD u, Rory C. O’Connor, PhD v, Pilar Santamarina-Perez, PhD w, Peter Tyrer, FMedSci x, Rebecca Walwyn, PhD a, #, David Cottrell, FRCPsych a, #
, Amanda J. Farrin, MSc a, Peter Fonagy, CBE, FMedSci b, Dennis Ougrin, PhD c, Daniel Stahl, PhD d, Judy Wright, MSc a, Donna Irving, BA e, Faraz Mughal, FRCGP f, Alex Truscott, BA b, Emma Diggins, MA a, Andrew Chanen, PhD g, Emily Cooney, PhD h, Greg Carter, FRANZCP i, Kerrie Clover, PhD i, Mark Dadds, PhD j, Guy Diamond, PhD k, Christianne Esposito-Smythers, PhD l, Jonathan Green, FRCPsych, FMedSc m, Helen Griffiths, DClinPsychol n, Hossein Hassanian-Moghaddam, MD, FACMT o, Simon Hatcher, MD p, Philip Hazell, PhD q, Nusrat Husain, MD m, Michael Kaess, MD r, s, Cheryl King, PhD t, Britt Morthorst, PhD u, Rory C. O’Connor, PhD v, Pilar Santamarina-Perez, PhD w, Peter Tyrer, FMedSci x, Rebecca Walwyn, PhD a, #, David Cottrell, FRCPsych a, # a University of Leeds, Leeds, United Kingdom
b University College London, London, United Kingdom
c Queen Mary University of London, London, United Kingdom
d King’s College London, London, United Kingdom
e Leeds Trinity University, Leeds, United Kingdom
f Keele University, Keele, United Kingdom
g University of Melbourne, Melbourne, Australia
h University of Otago, Wellington, New Zealand
i University of Newcastle, New South Wales, Australia
j University of Sydney, Sydney, Australia
k ABFT International Training Institute, Plantation, Florida
l George Mason University, Fairfax, Virginia
m University of Manchester, Manchester, United Kingdom
n University of Edinburgh, Edinburgh, United Kingdom
o Shahid Beheshti University of Medical Sciences, Tehran, Iran
p University of Ottawa, Ottawa, Ontario, Canada
q University of Sydney School of Medicine, Sydney, Australia
r University of Bern, Bern, Switzerland
s University of Heidelberg, Heidelberg, Germany
t University of Michigan, Ann Arbor, Michigan
u University of Copenhagen, Copenhagen, Denmark
v University of Glasgow, Glasgow, United Kingdom
w Hospital Clinic de Barcelona, Barcelona, Spain
x Imperial College London, London, United Kingdom
∗Correspondence to Alex Wright-Hughes, MSc, Complex Interventions Division, Clinical Trial Research Unit, Leeds Institute of Clinical Trials Research, School of Medicine, University of Leeds, UKComplex Interventions DivisionClinical Trial Research UnitLeeds Institute of Clinical Trials ResearchSchool of MedicineUniversity of LeedsUK
Abstract |
Objective |
Self-harm is common in adolescents and a major public health concern. Evidence for effective interventions that stop repetition is lacking. This individual participant data (IPD) meta-analysis of randomized controlled trials (RCTs) aimed to provide robust estimates of therapeutic intervention effects and explore which treatments are best suited to different subgroups.
Method |
Databases and trial registers to January 2022 were searched. RCTs compared therapeutic intervention to control, targeted adolescents ages 11 to 18 with a history of self-harm and receiving clinical care, and reported on outcomes related to self-harm or suicide attempt. Primary outcome was repetition of self-harm 12 months after randomization. Two-stage random-effects IPD meta-analyses were conducted overall and by intervention. Secondary analyses incorporated aggregate data from RCTs without IPD.
Results |
The search identified 39 eligible studies; 26 provided IPD (3,448 participants), and 7 provided aggregate data (698 participants). There was no evidence that interventions were more or less effective than controls at preventing repeat self-harm by 12 months in IPD (odds ratio 1.06 [95% CI 0.86, 1.31], 20 studies, 2,949 participants) or IPD and aggregate data (odds ratio 1.02 [95% CI 0.82, 1.27], 22 studies, 3,117 participants) meta-analyses and no evidence of heterogeneity of treatment effects on study and treatment factors. Across all interventions, participants with multiple prior self-harm episodes showed evidence of improved treatment effect on self-harm repetition 6 to 12 months after randomization (odds ratio 0.33 [95% CI 0.12, 0.94], 9 studies, 1,771 participants).
Conclusion |
This large-scale meta-analysis of RCTs provided no evidence that therapeutic intervention was more, or less, effective than control for reducing repeat self-harm. Evidence indicating more effective interventions in youth with 2 or more self-harm incidents was observed. Funders and researchers need to agree on a core set of outcome measures to include in subsequent studies.
Plain language summary |
Self-harm is common in adolescents and linked to higher risks of repeated self-harm and suicide. This meta-analysis of 33 randomized controlled trials involving 4,146 adolescents found that therapeutic interventions were no more effective than standard care at preventing repeat self-harm at 12 months. However, interventions were more effective in youth with 2 or more self-harm incidents. The authors discuss limitations posed by the lack of uniform outcome measures for self-harm.
Clinical guidance |
• | No single, specific intervention can be conclusively recommended for preventing repetition of self-harm in youth. |
• | Young people with multiple prior episodes of self-harm are at heightened risk and may be more likely to benefit from treatment. |
Study preregistration information |
Reducing Self-harm in Adolescents: An Individual Participant Data Meta-analysis; display_record.php?RecordID=152119.
Le texte complet de cet article est disponible en PDF.Key words : adolescents, IPD meta-analysis, self-harm, suicide, systematic review
Plan
| This research was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment (HTA) Programme (project number 17/117/11). The funder commissioned research to answer the question: “Is it possible to identify subgroups of adolescents in whom a therapeutic intervention for self-harm shows some evidence of benefit in order to guide future primary research?” using an IPD meta-analysis. Having commissioned the research, the funder had no further role in the conduct or writing up of the research. The views expressed in this publication are those of the author(s) and do not necessarily reflect those of the HTA Programme, the NIHR, the UK National Health Service (NHS), or the Department of Health and Social Care. The project was sponsored by the University of Leeds (grant number RG.PSRY.116370). An independent Study Steering Group including independent clinical and statistical experts with relevant expertise and a patient and public involvement (PPI) representative provided independent oversight of the project. |
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| Formal ethical approval for the project was provided by the University of Leeds, Faculty of Medicine & Health Ethics Committee (MREC 18-098). |
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| Data Sharing: Data sharing is subject to original study author permissions. |
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| Professor Richard Riley served as the statistical expert for this research and reviewed the statistical analysis plan. The project was peer reviewed as part of the grant application and protocol publication. |
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| The authors would like to thank all the chief investigators of the studies identified in the search and their colleagues, including organizational legal departments for their help in clarifying issues of eligibility and data sharing agreements. We would also like to thank the members of our Independent Steering Committee and the PPI representatives who assisted us throughout. |
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| Disclosure: Alex Wright-Hughes has received funding to her institution from the National Institute for Health Research (NIHR) and Yorkshire Cancer Research UK. She is a Trials Protocol Editor (payments to institution). She receives personal payments for travel expenses only as a Trial Steering Committee and Data Monitoring and Ethics Committee member on NIHR- and Medical Research Council (MRC)–funded studies and as a member of the NIHR Research for Patient Benefit Yorkshire and North-East Regional Advisory Committee. Amanda J. Farrin was a member of the NIHR funding committee Health Technology Assessment Clinical Trials & Evaluation (until November 2018) and the NIHR CTU Standing Advisory Committee and is an NIHR Senior Investigator. She has received funding to her institution from the NIHR and MRC. Peter Fonagy receives personal payments for book royalties from Guilford Press, American Psychiatric Publishing, and Oxford University Press. Payments for speaking/presenting are paid to his institution. He has leadership roles as an International Panel Member of Academic Health Solutions Ltd, Clinical Professor of Psychiatry at Yale University School of Medicine, Honorary Treasurer, Board of Directors, Psychoanalytic Electronic Publishing, Board of Directors, member and Co-chair of the Quality of Care Subcommittee, Silver Hill Hospital, Connecticut, Chair of the Silver Hill Academic Advisory Board, Member of the National Collaborating Centre for Mental Health Management, the NSPCC Research Advisory Group, and the Royal Foundation Steering Group for Her Royal Highness The Duchess of Cambridge Early Years, trustee of Mental Health Innovations UK, board member for London Mental Health Transformation Board of the Health London Partnership, Chair of the National Health Service (NHS) Parent Infant Perinatal Pathway, and of the Prudence Trust Mental Health Advisory Panel, member of the Remote Working in Mental Health Core Group, Health Innovation Network, and member of the Higher London Mental Health and Wellbeing network. He is Chief Executive of the Anna Freud National Centre for Children and Families, Executive Clinical Director, UCLPartners Mental Health and Wellbeing Programme and National Senior Clinical Advisor, Children and Young People’s mental health at NHS England. Dennis Ougrin has received funding to his institution from NIHR, South London and Maudsley NHS Trust, MRC, and the Guy’s & St Thomas’ Charity. He received personal payments for book royalties from Hodder Arnold and Cambridge Scholars. He is a Board Member of Association for Child and Adolescent Mental Health, and a Trustee of the Ukrainian Institute, London. Daniel Stahl received support by the NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London. Faraz Mughal is in receipt of an NIHR Doctoral Fellowship (payments to institution) and was a member of the 2022 National Institute for Health Care Excellence self-harm guideline development committee, is funded by the NIHR (300957), and is supported by the Greater Manchester NIHR Patient Safety Research Collaboration. Emma Diggins is in receipt of an NIHR Doctoral Fellowship (payments to institution). Andrew Chanen has received funding to his institution from the National Health and Medical Research Council, Australia, Medical Research Future Fund, Australia, and the Australian Research Council. He is a Non-Executive Board Member of the National Education Alliance for Borderline Personality Disorder. Emily Cooney has received funding to her institution from HRC. She holds grants on dialectical behavior therapy (DBT)–related research, is a director and shareholder of a DBT training company Dialectical Behavior Therapy New Zealand (DBTNZ). She receives reimbursement for teaching DBT and has received personal payments for consulting from DBTNZ and Behavioral Tech, for support for meeting attendance from DBTNZ and Otago University Wellington, and for speaking. She is Chair of the DBT treatment integrity committee of the World Dialectical Behavior Therapy Association. Greg Carter has received funding to his institution from the Australian Government Department of Health, Medical Research Future Fund Million Minds Mission Suicide Prevention, National Suicide Prevention Leadership, and Support Program Grant. He has received personal payments for speaking at, chairing, and support for attending meetings from Otsuka and Janssen Australia and New Zealand (Janssen-Cilag Pty Ltd). He is a member of the Data and Safety Monitoring Board of Quitlink and the Data Monitoring Committee of AFFINITY. He is Chair of the Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines for Deliberate Self-harm. Kerrie Clover has reported no biomedical, financial interests or potential conflicts of interest. She holds an honorary position as Convenor of the Australian Psychological Society special interest group for Psychologists in Oncology. Nusrat Husein has received funding to his institution from Global Challenges Research Fund Research Council UK, NIHR, MRC Global Challenges Research Fund, MRC, Department for International Development, and NIHR. He is a member of the MRC Faculty of Global Health Experts, an NIHR Senior Investigator, President of the Manchester Medical Society, and a member of the executive committee for the Faculty of Academic Psychiatry. He is a former Trustee of Pakistan Institute of Living and Learning (PILL), Abaseen Foundation, and Lancashire Mind and a past Chair of the Board of Trustees at the Manchester Global Foundation. Michael Kaess has received funding to his institution from the Swiss National Science Foundation, the German Federal Ministry for Education and Research, the Baden-Württemberg Foundation (Germany), and the Dietmar Hopp Foundation (Germany). He has received personal payments for speaking on attention-deficit/hyperactivity disorder from Takeda Swiss. He is a member of the executive board of the ReconWell GmbH, a company owned by the University Hospital Bern, which develops mental health blended-intervention apps. This position is unpaid as it is part of his employment in Bern. Cheryl King has received funding to her institution from the National Institute of Mental Health. She has received personal payments for consulting from Oui Therapeutics, LLC, and speaker fees for invited lectures at the New York State Suicide Prevention Conference, the Nevada Psychiatric Association, and numerous universities. She is a member of the Scientific Advisory Council of the American Foundation for Suicide Prevention. She is a stockholder in Oui Therapeutics, LLC and Vytyl Health Management, Inc. Britt Morthorst has received funding from the Novo Nordisk Foundation for a current school project on suicide prevention in the primary sector (independent of the present study, grant number NNF23SA0083854). Rory C. O’Connor has received funding to his institution from the Medical Research Foundation, the Mindstep Foundation, the Chief Scientist’s Office, MRC, Public Health Scotland, the Scottish Government, NIHR, Shout 85258, the Scottish Association for Mental Health, the Zoetis Foundation, Jonathan’s Voice, Attention Deficit Hyperactivity Disorder UK, and the Barfil Charitable Trust. He has received personal payments for book royalties and for workshops and invited addresses. He is a trustee and Science Council member of MQ Mental Health Research, President of the International Association for Suicide Prevention, and co-chair of the Academic Advisory Group to the Scottish Government’s National Suicide Prevention Advisory Group. He is also a board member of the International Academy of Suicide Research and was a member of the National Institute of Health and Care Excellence guideline group for the management of self-harm. Jonathan Green is an NIHR Senior Investigator and a Fellow of the Academy of Medical Sciences, UK. Rebecca Walwyn is in receipt of an NIHR Advanced Fellowship and has received grants from NIHR, MRC, and Engineering and Physical Sciences Research Council. David Cottrell is Trial Steering Committee chair of the NIHR-funded Best Services Trial (BeST?) and Data Monitoring and Ethics Committee chair of the NIHR-funded Comparison of Effectiveness and Cost-Effectiveness of Intensive Community Care Services versus Usual Inpatient Care for Young People with Psychiatric Emergencies (IVY). He is a member of the DMEC of the NIHR-funded Mentalization for Offending Adult Males (MOAM). He is chair of the Independent Advisory Group of the NIHR Children and Families Policy Research Unit, University College London. He was chair of the NIHR Advanced Fellowship Panel. He has received personal payments for travel expenses in all of these roles. Judy Wright has received funding to her institution from NIHR UK, Arthritis Research UK, Nuffield Foundation and Cancer Research UK (CRUK). She has received personal payments for book royalties and for teaching on the Nottingham Systematic Review Course. Donna Irving, Alex Truscott, Mark Dadds, Guy Diamond, Christianne Esposito-Smythers, Helen Griffiths, Hossein Hassanian-Moghaddam, Simon Hatcher, Philip Hazell, Pilar Santamarina-Perez, and Peter Tyrer have reported no biomedical financial interests or potential conflicts of interest. |
© 2025
American Academy of Child and Adolescent Psychiatry. Publié par Elsevier Masson SAS. Tous droits réservés.
Vol 64 - N° 9
P. 997-1029 - septembre 2025 Retour au numéro
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