Comparative efficacy of psychotherapies for reducing self-harm and suicidality in young individuals shows inconsistent and low-quality evidence

1. Although some psychotherapeutic modalities are well-tolerated and efficacious in reducing self-harm and suicidality in children and adolescents, methodological concerns and high risk of bias prevent a consistent and objective assessment of their comparative performance.

2. This lack of consistent evidence precludes a definitive hierarchy of psychotherapeutic treatments during clinical decision-making, indicating the need for further high-quality randomized clinical trials (RCTs).

Evidence Rating Level: 1 (Excellent)

Study Rundown: Self-harm and suicidal behavior are associated with substantial morbidity and mortality and known to peak in incidence and prevalence during adolescent years. These behaviors cause substantial burdens for patients, families, communities, and health systems, thus, evidence-based prevention strategies and therapeutic efforts aimed at young people are needed. Despite this, the comparative performance of various psychotherapeutic modalities for reducing self-harm and suicidality in young individuals is unclear due to a lack of precise head-to-head clinical trials. This systematic review and network meta-analysis (NMA) sought to investigate the comparative efficacy and acceptability of psychosocial interventions for the treatment of self-harm and suicidality among children and adolescents. The primary outcomes of the review were dichotomized self-harm frequency and retention in treatment while secondary outcomes included dichotomized all-cause treatment discontinuation and scores on instruments measuring suicidal ideation and depressive symptoms. From 1,272 unique records generated from four major bibliographic databases, the review included 44 RCTs (5,406 total participants; 4,109 female [76.0%]) from a total of 49 selected articles (including 5 follow-up studies). The selected RCTs spanned from 1995 to 2020 with a median duration of treatment of 3 months (range, 0.25-12.00 months) and a median follow-up period of 12 months (range, 1-36 months). None of the investigated psychotherapies were associated with more study withdrawals when compared with treatment as usual. However, efficacy was inconsistent across outcomes and psychotherapies. Therefore, although the NMA found that most psychotherapies were well tolerated and efficacious for particular measures of self-harm or suicidality, caution is recommended when interpreting these findings due to low RCT quality, lack of consistency across outcome measures and treatment periods, and publication bias. A limitation of this study was the reliance on indirect treatment observations as evidence when comparing psychotherapeutic modalities head-to-head. Indirect observations are more susceptible to bias and when interpreted from a few RCTs with small samples, has the potential to create imprecise and underpowered estimates.

Click to read the study in JAMA

Relevant Reading: A further look at therapeutic interventions for suicide attempts and self-harm in adolescents: an updated systematic review of randomized controlled trials

In-Depth [systematic review and meta-analysis]: This systematic review and NMA pooled data from eligible RCTs comparing psychotherapies for suicidality and/or self-harm with control conditions among children and adolescents after a blinded review by three independent reviewers. The systematic search was conducted from four major bibliographic databases (PubMed, MEDLINE, PsycINFO, and Embase) in September 2020 and generated 1,272 original studies. From these, 44 eligible RCTs (5,406 total participants; 4,109 female [76.0%]) from 49 articles were selected, spanning from 1995 to 2020 (5 follow-up studies were merged with their primary RCTs to avoid publication bias). The median duration of psychotherapy was 3 months (range, 0.25-12.00 months) while the median duration of follow-up was 12 months (range, 1-36 months). None of the investigated psychotherapies were associated with increases in study withdrawals or improvements in retention in treatment when compared with control conditions. However, efficacy was inconsistent across outcomes and psychotherapies in the selected studies due to low-quality evidence, heterogeneity, and a high risk of bias overall. Dialectical behavioral therapies (DBT) were associated with reductions in self-harm (OR, 0.28; 95%CI, 0.12-0.64) and suicidal ideation (Cohen d SMD, −0.71; 95%CI, −1.19 to −0.23) at the end of the treatment period, while mentalization-based therapies (MBT) were associated with decreases in self-harm (OR, 0.38; 95%CI, 0.15-0.97) and suicidal ideation (Cohen d SMD, −1.22; 95%CI, −2.18 to −0.26) at the end of the follow-up period. These findings indicate that although certain psychotherapeutic modalities appeared to be acceptable and efficacious for reducing self-harm and suicidality among young people, intrinsic methodological issues and high risk of publication bias suggests the need for additional high-quality RCTs.

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