Therapeutic Interventions for Suicide Attempts and Self-Harm in Adolescents: Systematic Review and Meta-Analysis - 24/12/14

Doi : 10.1016/j.jaac.2014.10.009

Dennis Ougrin, MBBS, MRCPsych, PGDip(Oxon), PhD ^a,^⁎ , Troy Tranah, BSc, MSc, PhD ^b, Daniel Stahl, PhD ^c, Paul Moran, MBBS, BSc, MSc, DLSHTM, MD, MRCPsych ^c, Joan Rosenbaum Asarnow, PhD ^d
^a Institute of Psychiatry, King’s College London and South London and Maudsley National Health Service (NHS) Foundation Trust
^b South London and Maudsley NHS Foundation Trust
^c King’s College London
^d University of California, Los Angeles

^∗Correspondence to Dennis Ougrin, MBBS, MRCPsych, PGDip(Oxon), PhD, King’s College London, Child and Adolescent Psychiatry, Institute of Psychiatry, PO85, De Crespigny Park, London SE5 8AF, UK

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Wednesday 24 December 2014

Abstract

Objective

Suicidal behavior and self-harm are common in adolescents and are associated with elevated psychopathology, risk of suicide, and demand for clinical services. Despite recent advances in the understanding and treatment of self-harm and links between self-harm and suicide and risk of suicide attempt, progress in reducing suicide death rates has been elusive, with no substantive reduction in suicide death rates over the past 60 years. Extending prior reviews of the literature on treatments for suicidal behavior and repetitive self-harm in youth, this article provides a meta-analysis of randomized controlled trials (RCTs) reporting efficacy of specific pharmacological, social, or psychological therapeutic interventions (TIs) in reducing both suicidal and nonsuicidal self-harm in adolescents.

Method

Data sources were identified by searching the Cochrane, Medline, PsychINFO, EMBASE, and PubMed databases as of May 2014. RCTs comparing specific therapeutic interventions versus treatment as usual (TAU) or placebo in adolescents (through age 18 years) with self-harm were included.

Results

Nineteen RCTs including 2,176 youth were analyzed. TIs included psychological and social interventions and no pharmacological interventions. The proportion of the adolescents who self-harmed over the follow-up period was lower in the intervention groups (28%) than in controls (33%) (test for overall effect z = 2.31; p = .02). TIs with the largest effect sizes were dialectical behavior therapy (DBT), cognitive-behavioral therapy (CBT), and mentalization-based therapy (MBT). There were no independent replications of efficacy of any TI. The pooled risk difference between TIs and TAU for suicide attempts and nonsuicidal self-harm considered separately was not statistically significant.

Conclusion

TIs to prevent self-harm appear to be effective. Independent replication of the results achieved by DBT, MBT, and CBT is a research priority.

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Key Words : self-harm, randomized controlled trials, meta-analysis

Plan

Method

Inclusion Criteria

Exclusion Criteria

Identification and Selection of Studies

Statistical Analysis

Results

Included Studies

Effects of TIs Versus TAU on Self-Harm

Meta-Regression

Funnel Plots and Risk of Bias

Discussion

	Clinical guidance is available at the end of this article.
	Supplemental material cited in this article is available online.
	The authors’ time was paid for by the following institutions: King’s College London (D.O., D.S., P.M.), South London and Maudsley NHS Foundation Trust (T.T.), and University of California, Los Angeles (J.R.A.). Drs. Stahl and Moran were also supported in part by the National Institute for Health Research (NIHR) Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and King’s College London. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health.
	Dr. Stahl served as the statistical expert for this research.
	The authors thank Emily Simonoff, PhD, Bruce Clark, PhD, and Jo Fletcher, of King’s College London and South London and Maudsley NHS Foundation Trust, for facilitating this work.
	Disclosure: Dr. Ougrin has received royalties for the book entitled Self-Harm in Young People: A Therapeutic Assessment Manual from Hodder Arnold Publishing. Dr. Moran has received research grant funding from Guys and St. Thomas' Charity for developing and testing decisional support for young people who self-harm. Dr. Asarnow has received research grant funding from the National Institute of Mental Health and American Foundation of Suicide Prevention. She has also consulted on quality improvement and interventions for depression and suicidal/self-harm behavior. Drs. Tranan and Stahl report no biomedical financial interests or potential conflicts of interest.