Comparative Efficacy and Acceptability of Psychotherapies for Self-harm and Suicidal Behavior Among Children and Adolescents: A Systematic Review and Network Meta-analysis | Adolescent Medicine | JAMA Network Open | JAMA Network
[Skip to Navigation]
Sign In
Figure 1.  Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Flowchart of Study Selection Process
Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Flowchart of Study Selection Process
Figure 2.  Network Plot of Eligible Psychotherapy Comparisons for Retention in Treatment
Network Plot of Eligible Psychotherapy Comparisons for Retention in Treatment

Line width corresponds with the number of clinical trials comparing psychotherapy pairs. BI indicates brief intervention; CAT, cognitive analytic therapy; CBT, cognitive behavioral therapy; DBT, dialectical behavioral therapy; ET, eclectic therapy; FT, family-based therapy; IPT, interpersonal therapy; MBT, mentalization-based therapy; MDT, mode deactivation therapy; ST, supportive therapy; STPP, short-term psychoanalytic psychotherapy; TAU, treatment as usual; and WLC, wait-list control group.

Figure 3.  Forest Plots of Treatment Acceptability Across All Clinical Trials in Network Meta-analysis
Forest Plots of Treatment Acceptability Across All Clinical Trials in Network Meta-analysis

All psychotherapies were compared with treatment as usual (TAU) using a random-effects model. For treatment ranking score, treatments at the top of the plots have higher ranking. OR indicates odds ratio; SMD, Cohen d standardized mean difference. All other definitions appear in the Figure 2 caption.

Table 1.  Characteristics of Randomized Clinical Trials Included in Network Meta-analysis
Characteristics of Randomized Clinical Trials Included in Network Meta-analysis
Table 2.  Network Meta-analysis Indices
Network Meta-analysis Indices
1.
Klonsky  ED, Victor  SE, Saffer  BY.  Nonsuicidal self-injury: what we know, and what we need to know.   Can J Psychiatry. 2014;59(11):565-568. doi:10.1177/070674371405901101 PubMedGoogle ScholarCrossref
2.
Kothgassner  OD, Robinson  K, Goreis  A, Ougrin  D, Plener  PL.  Does treatment method matter? a meta-analysis of the past 20 years of research on therapeutic interventions for self-harm and suicidal ideation in adolescents.   Borderline Personal Disord Emot Dysregul. 2020;7(1):9. doi:10.1186/s40479-020-00123-9 PubMedGoogle ScholarCrossref
3.
Campisi  SC, Carducci  B, Akseer  N, Zasowski  C, Szatmari  P, Bhutta  ZA.  Suicidal behaviours among adolescents from 90 countries: a pooled analysis of the global school-based student health survey.   BMC Public Health. 2020;20(1):1102. doi:10.1186/s12889-020-09209-z PubMedGoogle ScholarCrossref
4.
McLoughlin  AB, Gould  MS, Malone  KM.  Global trends in teenage suicide: 2003-2014.   QJM. 2015;108(10):765-780. doi:10.1093/qjmed/hcv026 PubMedGoogle ScholarCrossref
5.
Hawton  K, Saunders  KEA, O’Connor  RC.  Self-harm and suicide in adolescents.   Lancet. 2012;379(9834):2373-2382. doi:10.1016/S0140-6736(12)60322-5 PubMedGoogle ScholarCrossref
6.
Fontanella  CA, Steelesmith  DL, Brock  G, Bridge  JA, Campo  JV, Fristad  MA.  Association of cannabis use with self-harm and mortality risk among youths with mood disorders.   JAMA Pediatr. Published online January 19, 2021. PubMedGoogle Scholar
7.
Gobbi  G, Atkin  T, Zytynski  T,  et al.  Association of cannabis use in adolescence and risk of depression, anxiety, and suicidality in young adulthood: a systematic review and meta-analysis.   JAMA Psychiatry. 2019;76(4):426-434. doi:10.1001/jamapsychiatry.2018.4500 PubMedGoogle ScholarCrossref
8.
Ougrin  D, Tranah  T, Stahl  D, Moran  P, Asarnow  JR.  Therapeutic interventions for suicide attempts and self-harm in adolescents: systematic review and meta-analysis.   J Am Acad Child Adolesc Psychiatry. 2015;54(2):97-107. doi:10.1016/j.jaac.2014.10.009 PubMedGoogle ScholarCrossref
9.
Iyengar  U, Snowden  N, Asarnow  JR, Moran  P, Tranah  T, Ougrin  D.  A further look at therapeutic interventions for suicide attempts and self-harm in adolescents: an updated systematic review of randomized controlled trials.   Front Psychiatry. 2018;9:583. doi:10.3389/fpsyt.2018.00583 PubMedGoogle ScholarCrossref
10.
MHASEF Research Team. The Mental Health of Children and Youth in Ontario: A Baseline Scorecard. Institute for Clinical Evaluative Sciences; 2015. Accessed April 3, 2020. https://www.ices.on.ca/flip-publication/MHASEF_Report_2015/files/assets/basic-html/index.html#4
11.
MHASEF Research Team. The Mental Health of Children and Youth in Ontario: 2017 Scorecard. Institute for Clinical Evaluative Sciences; 2017. Accessed April 3, 2020. https://www.ices.on.ca/Publications/Atlases-and-Reports/2017/MHASEF
12.
Centre for Suicide Prevention. Self-harm and suicide. Centre for Suicide Prevention; 2020. Accessed April 4, 2020. https://www.suicideinfo.ca/resource/self-harm-and-suicide/
13.
Klonsky  ED, Glenn  CR.  Resisting urges to self-injure.   Behav Cogn Psychother. 2008;36(2):211-220. doi:10.1017/S1352465808004128 PubMedGoogle ScholarCrossref
14.
Renaud  J, Berlim  MT, Séguin  M, McGirr  A, Tousignant  M, Turecki  G.  Recent and lifetime utilization of health care services by children and adolescent suicide victims: a case-control study.   J Affect Disord. 2009;117(3):168-173. doi:10.1016/j.jad.2009.01.004 PubMedGoogle ScholarCrossref
15.
Hawton  K, Witt  KG, Taylor Salisbury  TL,  et al.  Interventions for self-harm in children and adolescents.   Cochrane Database Syst Rev. 2015;(12):CD012013. doi:10.1002/14651858.CD012013 PubMedGoogle Scholar
16.
Robinson  J, Hetrick  SE, Martin  C.  Preventing suicide in young people: systematic review.   Aust N Z J Psychiatry. 2011;45(1):3-26. doi:10.3109/00048674.2010.511147 PubMedGoogle ScholarCrossref
17.
Storebø  OJ, Stoffers-Winterling  JM, Völlm  BA,  et al.  Psychological therapies for people with borderline personality disorder.   Cochrane Database Syst Rev. 2020;5(5):CD012955. doi:10.1002/14651858.CD012955.pub2PubMedGoogle Scholar
18.
Jørgensen  MS, Storebø  OJ, Stoffers-Winterling  JM, Faltinsen  E, Todorovac  A, Simonsen  E.  Psychological therapies for adolescents with borderline personality disorder (BPD) or BPD features—a systematic review of randomized clinical trials with meta-analysis and trial sequential analysis.   PLoS One. 2021;16(1):e0245331. doi:10.1371/journal.pone.0245331 PubMedGoogle Scholar
19.
Miura  T, Noma  H, Furukawa  TA,  et al.  Comparative efficacy and tolerability of pharmacological treatments in the maintenance treatment of bipolar disorder: a systematic review and network meta-analysis.   Lancet Psychiatry. 2014;1(5):351-359. doi:10.1016/S2215-0366(14)70314-1 PubMedGoogle ScholarCrossref
20.
Yildiz  A, Vieta  E, Correll  CU, Nikodem  M, Baldessarini  RJ.  Critical issues on the use of network meta-analysis in psychiatry.   Harv Rev Psychiatry. 2014;22(6):367-372. doi:10.1097/HRP.0000000000000025 PubMedGoogle ScholarCrossref
21.
Cipriani  A, Furukawa  TA, Salanti  G,  et al.  Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis.   Lancet. 2018;391(10128):1357-1366. doi:10.1016/S0140-6736(17)32802-7PubMedGoogle ScholarCrossref
22.
Jansen  JP, Naci  H.  Is network meta-analysis as valid as standard pairwise meta-analysis? it all depends on the distribution of effect modifiers.   BMC Med. 2013;11(1):159. doi:10.1186/1741-7015-11-159 PubMedGoogle ScholarCrossref
23.
Hutton  B, Salanti  G, Caldwell  DM,  et al.  The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations.   Ann Intern Med. 2015;162(11):777-784. doi:10.7326/M14-2385 PubMedGoogle ScholarCrossref
24.
Liberati  A, Altman  DG, Tetzlaff  J,  et al.  The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.   PLoS Med. 2009;6(7):e1000100. doi:10.1371/journal.pmed.1000100 PubMedGoogle Scholar
25.
Roy Rosenzweig Center for History and New Media website. 2018. Accessed July 19, 2019. https://rrchnm.org/
26.
Covidence systematic review software. Veritas Health Innovation; 2019. Accessed July 19, 2019. https://www.covidence.org/
27.
Higgins  JPT, Altman  DG, Gøtzsche  PC,  et al; Cochrane Bias Methods Group; Cochrane Statistical Methods Group.  The Cochrane Collaboration's tool for assessing risk of bias in randomised trials.   BMJ. 2011;343:d5928. doi:10.1136/bmj.d5928 PubMedGoogle ScholarCrossref
28.
Sedgwick  P, Marston  L.  How to read a funnel plot in a meta-analysis.   BMJ. 2015;351:h4718. doi:10.1136/bmj.h4718 PubMedGoogle ScholarCrossref
29.
Egger  M, Davey Smith  G, Schneider  M, Minder  C.  Bias in meta-analysis detected by a simple, graphical test.   BMJ. 1997;315(7109):629-634. doi:10.1136/bmj.315.7109.629 PubMedGoogle ScholarCrossref
30.
Guyatt  GH, Oxman  AD, Vist  GE,  et al; GRADE Working Group.  GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.   BMJ. 2008;336(7650):924-926. doi:10.1136/bmj.39489.470347.AD PubMedGoogle ScholarCrossref
31.
Cohen  J.  Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Lawrence Erlbaum Associates; 1988.
32.
Lipsey  MW, Wilson  DB.  Practical Meta-analysis. Sage Publications; 2001. Hedrick TE, Bickman L, Rog DJ, eds. Applied Social Research Methods Series; vol 49.
33.
Bahji  A, Ermacora  D, Stephenson  C, Hawken  ER, Vazquez  G.  Comparative efficacy and tolerability of pharmacological treatments for the treatment of acute bipolar depression: A systematic review and network meta-analysis.   J Affect Disord. 2020;269:154-184. doi:10.1016/j.jad.2020.03.030 PubMedGoogle ScholarCrossref
34.
Bahji  A, Ermacora  D, Stephenson  C, Hawken  ER, Vazquez  G.  Comparative efficacy and tolerability of adjunctive pharmacotherapies for acute bipolar depression: a systematic review and network meta-analysis.   Can J Psychiatry. 2021;66(3):274-288. Published online November 11, 2020. doi:10.1177/0706743720970857PubMedGoogle ScholarCrossref
35.
Bahji  A, Meyyappan  AC, Hawken  ER.  Efficacy and acceptability of cannabinoids for anxiety disorders in adults: a systematic review & meta-analysis.   J Psychiatr Res. 2020;129:257-264. doi:10.1016/j.jpsychires.2020.07.030 PubMedGoogle ScholarCrossref
36.
Bahji  A, Stephenson  C, Tyo  R, Hawken  ER, Seitz  DP.  Prevalence of cannabis withdrawal symptoms among people with regular or dependent use of cannabinoids: a systematic review and meta-analysis.   JAMA Netw Open. 2020;3(4):e202370. doi:10.1001/jamanetworkopen.2020.2370 PubMedGoogle Scholar
37.
Bahji  A, Vazquez  GH, Zarate  CA  Jr.  Comparative efficacy of racemic ketamine and esketamine for depression: a systematic review and meta-analysis.   J Affect Disord. 2021;278:542-555. doi:10.1016/j.jad.2020.09.071 PubMedGoogle ScholarCrossref
38.
Wong  J, Bahji  A, Khalid-Khan  S.  Systematic review and meta-analyses of psychotherapies for adolescents with subclinical and borderline personality disorder: a reply to the commentary by Jørgensen, Storebø, and Simonsen.   Can J Psychiatry. 2020;65(5):356-357. doi:10.1177/0706743719898328 PubMedGoogle ScholarCrossref
39.
RStudio: integrated development for R. RStudio; 2020. Accessed October 15, 2020. https://www.rstudio.com/
40.
Rücker  G, Krahn  U, König  J, Efthimiou  O, Schwarzer  G. Netmeta: network meta-analysis using frequentist methods. Version 1.3-0. CRAN.R Project; 2019. Accessed October 8, 2019. https://cran.r-project.org/web/packages/netmeta/index.html
41.
Salanti  G.  Indirect and mixed-treatment comparison, network, or multiple-treatments meta-analysis: many names, many benefits, many concerns for the next generation evidence synthesis tool.   Res Synth Methods. 2012;3(2):80-97. doi:10.1002/jrsm.1037 PubMedGoogle ScholarCrossref
42.
Salanti  G, Higgins  JPT, Ades  AE, Ioannidis  JPA.  Evaluation of networks of randomized trials.   Stat Methods Med Res. 2008;17(3):279-301. doi:10.1177/0962280207080643 PubMedGoogle ScholarCrossref
43.
Huhn  M, Nikolakopoulou  A, Schneider-Thoma  J,  et al.  Comparative efficacy and tolerability of 32 oral antipsychotics for the acute treatment of adults with multi-episode schizophrenia: a systematic review and network meta-analysis.   Lancet. 2019;394(10202):939-951. doi:10.1016/S0140-6736(19)31135-3 PubMedGoogle ScholarCrossref
44.
Rouse  B, Chaimani  A, Li  T.  Network meta-analysis: an introduction for clinicians.   Intern Emerg Med. 2017;12(1):103-111. doi:10.1007/s11739-016-1583-7 PubMedGoogle ScholarCrossref
45.
Higgins  JPT, Thompson  SG, Deeks  JJ, Altman  DG.  Measuring inconsistency in meta-analyses.   BMJ. 2003;327(7414):557-560. doi:10.1136/bmj.327.7414.557 PubMedGoogle ScholarCrossref
46.
Borenstein  M, Hedges  LV, Higgins  JPT, Rothstein  HR.  A basic introduction to fixed-effect and random-effects models for meta-analysis.   Res Synth Methods. 2010;1(2):97-111. doi:10.1002/jrsm.12 PubMedGoogle ScholarCrossref
47.
Jørgensen  MS, Storebø  OJ, Bo  S,  et al.  Mentalization-based treatment in groups for adolescents with borderline personality disorder: 3- and 12-month follow-up of a randomized controlled trial.   Eur Child Adolesc Psychiatry. Published online May 9, 2020. doi:10.1007/s00787-020-01551-2 PubMedGoogle Scholar
48.
Mehlum  L, Ramberg  M, Tørmoen  AJ,  et al.  Dialectical behavior therapy compared with enhanced usual care for adolescents with repeated suicidal and self-harming behavior: outcomes over a one-year follow-up.   J Am Acad Child Adolesc Psychiatry. 2016;55(4):295-300. doi:10.1016/j.jaac.2016.01.005 PubMedGoogle ScholarCrossref
49.
Mehlum  L, Ramleth  RK, Tørmoen  AJ,  et al.  Long term effectiveness of dialectical behavior therapy versus enhanced usual care for adolescents with self-harming and suicidal behavior.   J Child Psychol Psychiatry. 2019;60(10):1112-1122. doi:10.1111/jcpp.13077 PubMedGoogle ScholarCrossref
50.
Ougrin  D, Boege  I, Stahl  D, Banarsee  R, Taylor  E.  Randomised controlled trial of therapeutic assessment versus usual assessment in adolescents with self-harm: 2-year follow-up.   Arch Dis Child. 2013;98(10):772-776. doi:10.1136/archdischild-2012-303200 PubMedGoogle ScholarCrossref
51.
Cottrell  DJ, Wright-Hughes  A, Eisler  I,  et al.  Longer-term effectiveness of systemic family therapy compared with treatment as usual for young people after self-harm: an extended follow up of pragmatic randomised controlled trial.   EClinicalMedicine. 2020;18:100246. doi:10.1016/j.eclinm.2019.100246 PubMedGoogle Scholar
52.
Beck  E, Bo  S, Jørgensen  MS,  et al.  Mentalization-based treatment in groups for adolescents with borderline personality disorder: a randomized controlled trial.   J Child Psychol Psychiatry. 2020;61(5):594-604. doi:10.1111/jcpp.13152 PubMedGoogle ScholarCrossref
53.
Cottrell  DJ, Wright-Hughes  A, Collinson  M,  et al.  Effectiveness of systemic family therapy versus treatment as usual for young people after self-harm: a pragmatic, phase 3, multicentre, randomised controlled trial.   Lancet Psychiatry. 2018;5(3):203-216. doi:10.1016/S2215-0366(18)30058-0 PubMedGoogle ScholarCrossref
54.
Mehlum  L, Tørmoen  AJ, Ramberg  M,  et al.  Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial.   J Am Acad Child Adolesc Psychiatry. 2014;53(10):1082-1091. doi:10.1016/j.jaac.2014.07.003 PubMedGoogle ScholarCrossref
55.
Ougrin  D, Zundel  T, Ng  A, Banarsee  R, Bottle  A, Taylor  E.  Trial of therapeutic assessment in London: randomised controlled trial of therapeutic assessment versus standard psychosocial assessment in adolescents presenting with self-harm.   Arch Dis Child. 2011;96(2):148-153. doi:10.1136/adc.2010.188755 PubMedGoogle ScholarCrossref
56.
Alavi  A, Sharifi  B, Ghanizadeh  A, Dehbozorgi  G.  Effectiveness of cognitive-behavioral therapy in decreasing suicidal ideation and hopelessness of the adolescents with previous suicidal attempts.   Iran J Pediatr. 2013;23(4):467-472.PubMedGoogle Scholar
57.
Apsche  JA, Bass  CK, Houston  MA.  A one year study of adolescent males with aggression and problems of conduct and personality: a comparison of MDT and DBT.   Int J Behav Consult Ther. 2006;2(4):544-552. doi:10.1037/h0101006Google ScholarCrossref
58.
Asarnow  JR, Baraff  LJ, Berk  M,  et al.  An emergency department intervention for linking pediatric suicidal patients to follow-up mental health treatment.   Psychiatr Serv. 2011;62(11):1303-1309. doi:10.1176/ps.62.11.pss6211_1303 PubMedGoogle ScholarCrossref
59.
Asarnow  JR, Hughes  JL, Babeva  KN, Sugar  CA.  Cognitive-behavioral family treatment for suicide attempt prevention: a randomized controlled trial.   J Am Acad Child Adolesc Psychiatry. 2017;56(6):506-514. doi:10.1016/j.jaac.2017.03.015 PubMedGoogle ScholarCrossref
60.
Britton  WB, Lepp  NE, Niles  HF, Rocha  T, Fisher  NE, Gold  JS.  A randomized controlled pilot trial of classroom-based mindfulness meditation compared to an active control condition in sixth-grade children.   J Sch Psychol. 2014;52(3):263-278. doi:10.1016/j.jsp.2014.03.002 PubMedGoogle ScholarCrossref
61.
Chanen  AM, Jackson  HJ, McCutcheon  LK,  et al.  Early intervention for adolescents with borderline personality disorder using cognitive analytic therapy: randomised controlled trial.   Br J Psychiatry. 2008;193(6):477-484. doi:10.1192/bjp.bp.107.048934 PubMedGoogle ScholarCrossref
62.
Cooney  E; New Zealand Ministry of Health; Wise Group (N.Z.), Te Pou o te Whakaaro Nui. Feasibility of Evaluating DBT for Self-harming Adolescents: A Small Randomised Controlled Trial. Te Pou o Te Whakaaro Nui–The National Centre of Mental Health Research and Workforce Development; 2010. Accessed September 12, 2020. https://www.worldcat.org/title/feasibility-of-evaluating-dbt-for-self-harming-adolescents-a-small-randomised-controlled-trial/oclc/679320661
63.
Cotgrove  A, Zirinsky  L, Black  D, Weston  D.  Secondary prevention of attempted suicide in adolescence.   J Adolesc. 1995;18(5):569-577. doi:10.1006/jado.1995.1039Google ScholarCrossref
64.
Diamond  GS, Wintersteen  MB, Brown  GK,  et al.  Attachment-based family therapy for adolescents with suicidal ideation: a randomized controlled trial.   J Am Acad Child Adolesc Psychiatry. 2010;49(2):122-131. doi:10.1016/j.jaac.2009.11.002PubMedGoogle Scholar
65.
Diamond  GS, Kobak  RR, Krauthamer Ewing  ES,  et al.  A randomized controlled trial: attachment-based family and nondirective supportive treatments for youth who are suicidal.   J Am Acad Child Adolesc Psychiatry. 2019;58(7):721-731. doi:10.1016/j.jaac.2018.10.006 PubMedGoogle ScholarCrossref
66.
Donaldson  D, Spirito  A, Esposito-Smythers  C.  Treatment for adolescents following a suicide attempt: results of a pilot trial.   J Am Acad Child Adolesc Psychiatry. 2005;44(2):113-120. doi:10.1097/00004583-200502000-00003 PubMedGoogle ScholarCrossref
67.
Esposito-Smythers  C, Spirito  A, Kahler  CW, Hunt  J, Monti  P.  Treatment of co-occurring substance abuse and suicidality among adolescents: a randomized trial.   J Consult Clin Psychol. 2011;79(6):728-739. doi:10.1037/a0026074 PubMedGoogle ScholarCrossref
68.
Esposito-Smythers  C, Hadley  W, Curby  TW, Brown  LK.  Randomized pilot trial of a cognitive-behavioral alcohol, self-harm, and HIV prevention program for teens in mental health treatment.   Behav Res Ther. 2017;89:49-56. doi:10.1016/j.brat.2016.11.005 PubMedGoogle ScholarCrossref
69.
Gleeson  JFM, Chanen  A, Cotton  SM, Pearce  T, Newman  B, McCutcheon  L.  Treating co-occurring first-episode psychosis and borderline personality: a pilot randomized controlled trial.   Early Interv Psychiatry. 2012;6(1):21-29. doi:10.1111/j.1751-7893.2011.00306.x PubMedGoogle ScholarCrossref
70.
Goodyer  IM, Reynolds  S, Barrett  B,  et al.  Cognitive behavioural therapy and short-term psychoanalytical psychotherapy versus a brief psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled superiority trial.   Lancet Psychiatry. 2017;4(2):109-119. doi:10.1016/S2215-0366(16)30378-9 PubMedGoogle ScholarCrossref
71.
Green  JM, Wood  AJ, Kerfoot  MJ,  et al.  Group therapy for adolescents with repeated self harm: randomised controlled trial with economic evaluation.   BMJ. 2011;342:d682. doi:10.1136/bmj.d682 PubMedGoogle ScholarCrossref
72.
Griffiths  H, Duffy  F, Duffy  L,  et al.  Efficacy of mentalization-based group therapy for adolescents: the results of a pilot randomised controlled trial.   BMC Psychiatry. 2019;19(1):167. doi:10.1186/s12888-019-2158-8 PubMedGoogle ScholarCrossref
73.
Harrington  R, Kerfoot  M, Dyer  E,  et al.  Randomized trial of a home-based family intervention for children who have deliberately poisoned themselves.   J Am Acad Child Adolesc Psychiatry. 1998;37(5):512-518. doi:10.1016/S0890-8567(14)60001-0 PubMedGoogle ScholarCrossref
74.
Hazell  PL, Martin  G, Mcgill  K,  et al.  Group therapy for repeated deliberate self-harm in adolescents: failure of replication of a randomized trial.   J Am Acad Child Adolesc Psychiatry. 2009;48(6):662-670. doi:10.1097/CHI.0b013e3181a0acec PubMedGoogle Scholar
75.
Hetrick  SE, Yuen  HP, Bailey  E,  et al.  Internet-based cognitive behavioural therapy for young people with suicide-related behaviour (Reframe-IT): a randomised controlled trial.   Evid Based Ment Health. 2017;20(3):76-82. doi:10.1136/eb-2017-102719 PubMedGoogle ScholarCrossref
76.
Hill  RM, Pettit  JW.  Pilot randomized controlled trial of LEAP: a selective preventive intervention to reduce adolescents’ perceived burdensomeness.   J Clin Child Adolesc Psychol. 2019;48(sup1)(suppl 1):S45-S56. doi:10.1080/15374416.2016.1188705PubMedGoogle ScholarCrossref
77.
Kaess  M, Edinger  A, Fischer-Waldschmidt  G, Parzer  P, Brunner  R, Resch  F.  Effectiveness of a brief psychotherapeutic intervention compared with treatment as usual for adolescent nonsuicidal self-injury: a single-centre, randomised controlled trial.   Eur Child Adolesc Psychiatry. 2020;29(6):881-891. doi:10.1007/s00787-019-01399-1 PubMedGoogle ScholarCrossref
78.
Kennard  BD, Goldstein  T, Foxwell  AA,  et al.  As Safe As Possible (ASAP): a brief app-supported inpatient intervention to prevent postdischarge suicidal behavior in hospitalized, suicidal adolescents.   Am J Psychiatry. 2018;175(9):864-872. doi:10.1176/appi.ajp.2018.17101151 PubMedGoogle ScholarCrossref
79.
King  CA, Kramer  A, Preuss  L, Kerr  DCR, Weisse  L, Venkataraman  S.  Youth-Nominated Support Team for suicidal adolescents (version 1): a randomized controlled trial.   J Consult Clin Psychol. 2006;74(1):199-206. doi:10.1037/0022-006X.74.1.199 PubMedGoogle ScholarCrossref
80.
King  CA, Klaus  N, Kramer  A, Venkataraman  S, Quinlan  P, Gillespie  B.  The Youth-Nominated Support Team–Version II for suicidal adolescents: a randomized controlled intervention trial.   J Consult Clin Psychol. 2009;77(5):880-893. doi:10.1037/a0016552 PubMedGoogle ScholarCrossref
81.
King  CA, Gipson  PY, Horwitz  AG, Opperman  KJ.  Teen options for change: an intervention for young emergency patients who screen positive for suicide risk.   Psychiatr Serv. 2015;66(1):97-100. doi:10.1176/appi.ps.201300347 PubMedGoogle ScholarCrossref
82.
McCauley  E, Berk  MS, Asarnow  JR,  et al.  Efficacy of dialectical behavior therapy for adolescents at high risk for suicide: a randomized clinical trial.   JAMA Psychiatry. 2018;75(8):777-785. doi:10.1001/jamapsychiatry.2018.1109 PubMedGoogle ScholarCrossref
83.
Ougrin  D, Corrigall  R, Poole  J,  et al.  Comparison of effectiveness and cost-effectiveness of an intensive community supported discharge service versus treatment as usual for adolescents with psychiatric emergencies: a randomised controlled trial.   Lancet Psychiatry. 2018;5(6):477-485. doi:10.1016/S2215-0366(18)30129-9 PubMedGoogle ScholarCrossref
84.
Pineda  J, Dadds  MR.  Family intervention for adolescents with suicidal behavior: a randomized controlled trial and mediation analysis.   J Am Acad Child Adolesc Psychiatry. 2013;52(8):851-862. doi:10.1016/j.jaac.2013.05.015 PubMedGoogle ScholarCrossref
85.
Robinson  J, Yuen  HP, Gook  S,  et al.  Can receipt of a regular postcard reduce suicide-related behaviour in young help seekers? a randomized controlled trial.   Early Interv Psychiatry. 2012;6(2):145-152. doi:10.1111/j.1751-7893.2011.00334.x PubMedGoogle ScholarCrossref
86.
Rossouw  TI, Fonagy  P.  Mentalization-based treatment for self-harm in adolescents: a randomized controlled trial.   J Am Acad Child Adolesc Psychiatry. 2012;51(12):1304-1313. doi:10.1016/j.jaac.2012.09.018 PubMedGoogle ScholarCrossref
87.
Santamarina-Perez  P, Mendez  I, Singh  MK,  et al.  Adapted dialectical behavior therapy for adolescents with a high risk of suicide in a community clinic: a pragmatic randomized controlled trial.   Suicide Life Threat Behav. 2020;50(3):652-667. doi:10.1111/sltb.12612 PubMedGoogle ScholarCrossref
88.
Schuppert  HM, Giesen-Bloo  J, van Gemert  TG,  et al.  Effectiveness of an emotion regulation group training for adolescents—a randomized controlled pilot study.   Clin Psychol Psychother. 2009;16(6):467-478. doi:10.1002/cpp.637 PubMedGoogle ScholarCrossref
89.
Schuppert  HM, Timmerman  ME, Bloo  J,  et al.  Emotion regulation training for adolescents with borderline personality disorder traits: a randomized controlled trial.   J Am Acad Child Adolesc Psychiatry. 2012;51(12):1314-1323. doi:10.1016/j.jaac.2012.09.002 PubMedGoogle ScholarCrossref
90.
Sinyor  M, Williams  M, Mitchell  R,  et al.  Cognitive behavioral therapy for suicide prevention in youth admitted to hospital following an episode of self-harm: a pilot randomized controlled trial.   J Affect Disord. 2020;266:686-694. doi:10.1016/j.jad.2020.01.178 PubMedGoogle ScholarCrossref
91.
Tang  TC, Jou  SH, Ko  CH, Huang  SY, Yen  CF.  Randomized study of school-based intensive interpersonal psychotherapy for depressed adolescents with suicidal risk and parasuicide behaviors.   Psychiatry Clin Neurosci. 2009;63(4):463-470. doi:10.1111/j.1440-1819.2009.01991.x PubMedGoogle ScholarCrossref
92.
Van Voorhees  BW, Fogel  J, Reinecke  MA,  et al.  Randomized clinical trial of an internet-based depression prevention program for adolescents (Project CATCH-IT) in primary care: 12-week outcomes.   J Dev Behav Pediatr. 2009;30(1):23-37. doi:10.1097/DBP.0b013e3181966c2a PubMedGoogle ScholarCrossref
93.
Wharff  EA, Ginnis  KB, Ross  AM, White  EM, White  MT, Forbes  PW.  Family-based crisis intervention with suicidal adolescents: a randomized clinical trial.   Pediatr Emerg Care. 2019;35(3):170-175. doi:10.1097/PEC.0000000000001076 PubMedGoogle ScholarCrossref
94.
Wood  A, Trainor  G, Rothwell  J, Moore  A, Harrington  R.  Randomized trial of group therapy for repeated deliberate self-harm in adolescents.   J Am Acad Child Adolesc Psychiatry. 2001;40(11):1246-1253. doi:10.1097/00004583-200111000-00003 PubMedGoogle ScholarCrossref
95.
Yen  S, Spirito  A, Weinstock  LM, Tezanos  K, Kolobaric  A, Miller  I.  Coping long term with active suicide in adolescents: results from a pilot randomized controlled trial.   Clin Child Psychol Psychiatry. 2019;24(4):847-859. doi:10.1177/1359104519843956 PubMedGoogle ScholarCrossref
96.
Robinson  J, Bailey  E, Witt  K,  et al.  What works in youth suicide prevention? a systematic review and meta-analysis.   EClinicalMedicine. 2018;4-5:52-91. doi:10.1016/j.eclinm.2018.10.004 PubMedGoogle ScholarCrossref
97.
Dray  J, Bowman  J, Campbell  E,  et al.  Systematic review of universal resilience-focused interventions targeting child and adolescent mental health in the school setting.   J Am Acad Child Adolesc Psychiatry. 2017;56(10):813-824. doi:10.1016/j.jaac.2017.07.780 PubMedGoogle ScholarCrossref
98.
Fonagy  P, Target  M, Cottrell  D,  et al.  What Works for Whom? A Critical Review of Treatments for Children and Adolescents. 1st ed. Guilford Press; 2005.
99.
Glenn  CR, Franklin  JC, Nock  MK.  Evidence-based psychosocial treatments for self-injurious thoughts and behaviors in youth.   J Clin Child Adolesc Psychol. 2015;44(1):1-29. doi:10.1080/15374416.2014.945211PubMedGoogle ScholarCrossref
100.
Merz  J, Schwarzer  G, Gerger  H.  Comparative efficacy and acceptability of pharmacological, psychotherapeutic, and combination treatments in adults with posttraumatic stress disorder: a network meta-analysis.   JAMA Psychiatry. 2019;76(9):904-913. doi:10.1001/jamapsychiatry.2019.0951 PubMedGoogle ScholarCrossref
101.
Milner  A, Spittal  MJ, Kapur  N, Witt  K, Pirkis  J, Carter  G.  Mechanisms of brief contact interventions in clinical populations: a systematic review.   BMC Psychiatry. 2016;16(1):194. doi:10.1186/s12888-016-0896-4 PubMedGoogle ScholarCrossref
102.
Weisz  JR, Kuppens  S, Ng  MY,  et al.  What five decades of research tells us about the effects of youth psychological therapy: a multilevel meta-analysis and implications for science and practice.   Am Psychol. 2017;72(2):79-117. doi:10.1037/a0040360 PubMedGoogle ScholarCrossref
103.
Werner-Seidler  A, Perry  Y, Calear  AL, Newby  JM, Christensen  H.  School-based depression and anxiety prevention programs for young people: a systematic review and meta-analysis.   Clin Psychol Rev. 2017;51:30-47. doi:10.1016/j.cpr.2016.10.005 PubMedGoogle ScholarCrossref
104.
Wong  J, Bahji  A, Khalid-Khan  S.  Psychotherapies for adolescents with subclinical and borderline personality disorder: a systematic review and meta-analysis.   Can J Psychiatry. 2020;65(1):5-15. doi:10.1177/0706743719878975PubMedGoogle ScholarCrossref
105.
Cesana  BM, Biganzoli  EM.  Phase IV studies: some insights, clarifications, and issues.   Curr Clin Pharmacol. 2018;13(1):14-20. doi:10.2174/1574884713666180412152949 PubMedGoogle ScholarCrossref
106.
Eccleston  C, Fisher  E, Craig  L, Duggan  GB, Rosser  BA, Keogh  E.  Psychological therapies (internet-delivered) for the management of chronic pain in adults.   Cochrane Database Syst Rev. 2014;2014(2):CD010152. doi:10.1002/14651858.CD010152.pub2 PubMedGoogle Scholar
107.
Haugh  S, O’Connor  L, Slattery  B,  et al.  The relative effectiveness of psychotherapeutic techniques and delivery modalities for chronic pain: a protocol for a systematic review and network meta-analysis.   HRB Open Res. 2020;2:25. doi:10.12688/hrbopenres.12953.2PubMedGoogle ScholarCrossref
108.
Willis  BH, Riley  RD.  Measuring the statistical validity of summary meta-analysis and meta-regression results for use in clinical practice.   Stat Med. 2017;36(21):3283-3301. doi:10.1002/sim.7372 PubMedGoogle ScholarCrossref
109.
Riley  RD, Jackson  D, Salanti  G,  et al.  Multivariate and network meta-analysis of multiple outcomes and multiple treatments: rationale, concepts, and examples.   BMJ. 2017;358:j3932. doi:10.1136/bmj.j3932 PubMedGoogle ScholarCrossref
110.
Thorlund  K, Mills  EJ.  Sample size and power considerations in network meta-analysis.   Syst Rev. 2012;1(1):41. doi:10.1186/2046-4053-1-41 PubMedGoogle ScholarCrossref
111.
Shean  G.  Limitations of randomized control designs in psychotherapy research.   Adv Psychiatry. 2014;2014:561452. doi:10.1155/2014/561452Google Scholar
112.
Munder  T, Flückiger  C, Gerger  H, Wampold  BE, Barth  J.  Is the allegiance effect an epiphenomenon of true efficacy differences between treatments? a meta-analysis.   J Couns Psychol. 2012;59(4):631-637. doi:10.1037/a0029571 PubMedGoogle ScholarCrossref
113.
Rosenman  R, Tennekoon  V, Hill  LG.  Measuring bias in self-reported data.   Int J Behav Healthc Res. 2011;2(4):320-332. doi:10.1504/IJBHR.2011.043414 PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Views 4,612
    Citations 0
    Original Investigation
    Psychiatry
    April 16, 2021

    Comparative Efficacy and Acceptability of Psychotherapies for Self-harm and Suicidal Behavior Among Children and Adolescents: A Systematic Review and Network Meta-analysis

    Author Affiliations
    • 1Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
    • 2Department of Psychiatry, Queen’s University, Kingston, Ontario, Canada
    • 3Division of Child and Youth Mental Health, Queen’s University, Kingston, Ontario, Canada
    • 4Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
    JAMA Netw Open. 2021;4(4):e216614. doi:10.1001/jamanetworkopen.2021.6614
    Key Points

    Question  What are the comparative efficacies and acceptability of psychosocial interventions for the treatment of self-harm and suicidality among children and adolescents?

    Findings  In this systematic review and network meta-analysis of pooled data from 44 randomized clinical trials of psychotherapies for children and adolescents that involved 5406 total participants, the investigated psychotherapies were found to be acceptable to patients, but the evidence was inconsistent with regard to self-harm and suicidality measures across therapeutic modalities.

    Meaning  The findings indicate that, although some psychotherapeutic modalities appeared to be acceptable and efficacious for reducing self-harm and suicidality among children and adolescents, methodological issues and high risk of bias suggest a need for additional randomized clinical trials.

    Abstract

    Importance  Self-harm and suicidal behavior are associated with substantial morbidity and mortality among children and adolescents. The comparative performance of psychotherapies for suicidality is unclear because few head-to-head clinical trials have been conducted.

    Objective  To compare the efficacy of psychotherapies for the treatment of self-harm and suicidality among children and adolescents.

    Data Sources  Four major bibliographic databases (PubMed, MEDLINE, PsycINFO, and Embase) were searched for clinical trials comparing psychotherapy with control conditions from inception to September 2020.

    Study Selection  Randomized clinical trials comparing psychotherapies for suicidality and/or self-harm with control conditions among children and adolescents were included after a blinded review by 3 independent reviewers (A.B., M.P., and J.W.).

    Data Extraction and Synthesis  The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed for data abstraction, and the Cochrane risk of bias tool was used to evaluate study-level risk of bias. Data abstraction was performed by 1 reviewer (A.B.) and confirmed by 2 independent blinded reviewers (J.W. and M.P.). Data were analyzed from October 15, 2020, to February 15, 2021.

    Main Outcomes and Measures  The primary outcomes were dichotomized self-harm and retention in treatment. The secondary outcomes were dichotomized all-cause treatment discontinuation and scores on instruments measuring suicidal ideation and depressive symptoms. Effect sizes were pooled using frequentist random-effects network meta-analysis models to generate summary odds ratios (ORs) and Cohen d standardized mean differences (SMDs). Negative Cohen d SMDs or ORs less than 1 indicated that the treatment reduced the parameter of interest relative to the control condition (eg, signifying a beneficial association with suicidal ideation).

    Results  The systematic search generated 1272 unique records. Of those, 44 randomized clinical trials (5406 total participants; 4109 female participants [76.0%]) from 49 articles were selected (5 follow-up studies were merged with their primary clinical trials to avoid publication bias). The selected clinical trials spanned January 1, 1995, to December 31, 2020. The median duration of treatment was 3 months (range, 0.25-12.00 months), and the median follow-up period 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 compared with treatment as usual. Dialectical behavioral therapies 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 treatment, while mentalization-based therapies 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 follow-up. The quality of evidence was downgraded because of high risk of bias overall, heterogeneity, publication bias, inconsistency, and imprecision.

    Conclusions and Relevance  Although some psychotherapeutic modalities appear to be acceptable and efficacious for reducing self-harm and suicidality among children and adolescents, methodological issues and high risk of bias prevent a consistent estimate of their comparative performance.

    Introduction

    Over the past 2 decades, there has been an increase in research exploring diverse aspects of self-harm and suicidal behavior among youths.1 Self-harm appears to peak in adolescence,2 with recent global surveys indicating that between 10% and 20% of adolescents reported past-year suicidal ideation and suicide attempts.3 In addition to sex and gender considerations,4 genetic vulnerability and several psychiatric, psychosocial, familial, and cultural factors may mediate suicide risk.5 Substance use, particularly cannabis, has also been implicated as a risk factor for self-harm and mortality risk among young adults.6,7

    Despite the advances in research on the prevalence, correlates, classification, and function of self-harm and suicidal behaviors, there has been limited progress in reducing suicide rates for almost 60 years.8,9 Self-harm and suicidality among youths continue to be substantial burdens for patients, families, communities, and health systems.1,10-14 Evidence-based self-harm and suicide prevention efforts aimed at young people are needed.5,15

    At present, there are insufficient data from randomized clinical trials (RCTs) to recommend targeted pharmacological treatments for self-harm or suicidal behavior in youths. However, some nonpharmacological interventions, including psychotherapies, appear to improve some aspects of suicidal behavior. Several meta-analyses have synthesized data from RCTs examining psychotherapies for self-harm and suicidality in youth populations. Ougrin et al8 found the largest effect sizes with dialectical behavioral therapy (DBT), cognitive behavioral therapy (CBT), and mentalization-based therapy (MBT). Nonetheless, they noted a lack of independent replications of efficacy for any intervention.

    Hawton et al15 reported preliminary data indicating that MBT may be associated with reductions in self-harm and recommended further evaluation of therapeutic assessment and DBT. However, no evidence was found to indicate that group-based therapies, compliance enhancement, CBT, family-based therapy, or provision of an emergency card was associated with decreases in suicidal behaviors. Robinson et al16 reported no differences between treatment and control groups across 15 RCTs, with the exception of 1 study that compared CBT with treatment as usual. Storebø et al17 found that DBT and MBT had some beneficial consequences for reducing self-harm among individuals with borderline personality disorder (BPD) but noted that these conclusions were based on low-quality evidence. Jørgensen et al18 reported a significant association between DBT and self-harm at the end of treatment compared with control interventions but no association between cognitive analytic therapy or MBT and reductions in self-harm among adolescents with BPD or BPD features compared with treatment as usual, emphasizing the need for more high-quality clinical trials with larger samples.

    Kothgassner et al2 found that the pooling of psychological treatments was associated with improvements in self-harm, suicidal ideation, and depressive symptoms compared with active control conditions, with subgroup analyses indicating that DBT and family-based therapy may be associated with decreases in self-harm and suicidal ideation. Previous authors of systematic reviews have cited the small number of RCTs, limited direct comparisons between treatments, low quality of evidence, and lack of independent replication of individual RCT findings as key limitations.2,8 Given the inconsistency across previous reviews, the most appropriate type of psychotherapy for the treatment of adolescents who present with self-harm or suicidality remains unclear.

    An alternative approach, termed network meta-analysis (NMA), might alleviate some of these previous challenges, particularly the shortage of head-to-head studies.19-21 An NMA is a meta-analysis of multiple treatments that simultaneously compares treatments across direct and indirect evidence sources in a single network.22 Network meta-analysis can be used to pool the samples across many small RCTs to increase the power for detecting differences across outcomes. Network meta-analyses may be preferable to standard meta-analyses in some situations, as the network's indirect comparisons can mitigate study-specific biases that are not identifiable in head-to-head RCTs.22 A network meta-analysis can also incorporate more data into the analysis, allowing researchers to tackle the bigger picture, while a traditional meta-analysis often provides a fragmented view.22 However, the valid application of NMA depends on the satisfaction of several statistical requirements, such as a similar distribution of effect modifiers across clinical trials and comparisons.20 The present NMA aimed to reexamine the comparative efficacy and safety of psychotherapies for the treatment of self-harm and suicidal behaviors among children and adolescents.

    Methods

    This review was registered with the Open Science Framework (https://osf.io/zcwvk) and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline and its extension for NMAs.23,24

    Eligibility Criteria

    We used the populations-interventions-comparators-outcomes-study design framework to define review eligibility. We considered RCTs that measured self-harm or suicidal behavior among children or adolescents aged 10 to 19 years. We defined self-harm as any intentional injury to oneself, regardless of suicidal motivation.2 To categorize interventions, we coded therapy protocols using the following groups: brief intervention, cognitive analytic therapy, CBT, DBT, family-based therapy, interpersonal therapy, MBT, mode deactivation therapy, supportive therapy, and short-term psychoanalytic psychotherapy (eTable 1 in the Supplement). Clinical trials blending 3 or more modalities were categorized as eclectic therapies.

    To facilitate our analyses, we collapsed some interventions into larger categories. For example, brief motivational interviewing sessions, hospital admission tokens, brief app-based interventions, and youth-nominated support teams were categorized as brief interventions. Subcomponents of established psychotherapy were collapsed into the parent modality (eg, emotion regulation training and mindfulness interventions into DBT), and variants of an established modality were collapsed into the main classification (eg, MBT for adolescents into MBT). We defined nondirective nonspecific interventions as supportive therapy. Therapies were categorized as either individual or group rather than considering group therapy as a separate modality. We considered treatment as usual, enhanced usual care, waitlist control, and active comparators; however, we collapsed enhanced usual care into treatment as usual.

    The primary outcomes were self-harm frequency (participants with ≥1 deliberate episodes of self-harm, including suicide attempts and nonsuicidal self-injury) and retention in treatment (participants who completed the primary treatment protocol). Secondary outcomes were study withdrawals (the number of participants who withdrew from the clinical trial for any reason) and suicidal ideation and depression severity, measured using clinician- or self-rated instruments. We excluded nonrandomized designs, crossover RCTs, and studies with missing or unobtainable data.

    Search Strategy, Selection, and Data Collection

    We developed a comprehensive search strategy in PubMed, MEDLINE, Embase, and PsycINFO from the date of their inception to September 15, 2021 (eTable 2 in the Supplement). Search terms included self-harm, self-injury, suicidal ideation, or suicidal behavior and therapy or intervention. We reviewed the bibliographies of included records and previous reviews to supplement the electronic search.

    Our review relied on Covidence, a web-based systematic review manager,25,26 to facilitate study selection by 2 investigators (A.B. and M.P.) who independently screened all records for the eligibility criteria by title and/or abstract and full text. Discrepancies were resolved through consensus.

    Three reviewers (A.B., M.P., and J.W.) independently abstracted data and performed quality assessments using a spreadsheet (Microsoft Excel; Microsoft Corp). Extracted variables included sample size, demographic characteristics, intervention characteristics (modality and number of sessions), outcome measures, study name and authors, study location, and treatment duration and follow-up.

    Risk of Bias

    To evaluate risk of bias within studies, 3 reviewers (A.B., M.P., and J.W.) independently appraised RCT quality using the Cochrane risk of bias tool,27 which assigns a low, high, or unclear rating to 6 domains: randomization, allocation concealment, blinding of participants, blinding of evaluators, incomplete outcome reporting, and selective reporting. We also considered allegiance, adherence, and attention biases.18 Allegiance bias occurs when the developer of a treatment is also an RCT investigator. Adherence bias concerns the fidelity of a treatment to protocol. Attention bias is produced by discrepant therapy doses (ie, sessions) between RCT arms. Overall study-level bias was considered high if any individual domain received a high score or had 2 or more unclear fields.

    To assess the risk of bias across studies, we evaluated publication bias by graphing funnel plots28 and applying the Egger test.29 We used Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines,30 and we downgraded the quality of evidence if we detected a high risk of bias, imprecision in outcomes, or heterogeneity.

    Summary Measures and Statistical Analysis

    We used Cohen d standardized mean differences (SMDs) and odds ratios (ORs) to summarize effect sizes for continuous and dichotomous variables. Standardized mean differences of 0.2, 0.5, and 0.8 corresponded to small, medium, and large effect sizes.31 Negative Cohen d SMDs or ORs less than 1 indicated that the treatment reduced the parameter of interest relative to the control condition (eg, signifying a beneficial effect for suicidal ideation).31,32

    We followed the same analytic approaches used in previous NMAs of studies examining psychiatric disorders (eMethods in the Supplement).33-38 We used the RStudio netmeta package, version 3.5.1 (RStudio).39,40 Forest plots were graphed for each outcome measure (self-harm, retention in treatment, study withdrawals, suicidality, and depression), and treatment rankings were created to represent each therapy’s effect size compared with treatment as usual. To preserve randomization, we used frequentist random-effects models, which accommodate different measures for the same outcome (eg, alternative instruments measuring suicidal ideation).41 To maximize available data, outcomes presented as dichotomous were pooled with continuous data using an inverse variance method. We assumed a jointly randomizable network, in which participants were equally likely to be randomized to any of the treatments.21,41-43 To determine NMA goodness of fit, transitivity (the extent of network heterogeneity) and consistency (the extent of agreement between direct and indirect comparisons)44 were assessed. To quantify transitivity, τ2 (total variation) and I2 (percentage of τ2 not caused by random error) were measured, with higher values indicating more heterogeneity.45,46 The Cochrane Q statistic was used to evaluate consistency, with the assumption of a full design-by-treatment interaction random-effects model; P > .05 indicated that the model was consistent. Dual analyses were conducted by distinguishing outcomes at the end of treatment from outcomes at the end of follow-up.

    Network-level subgroup or meta-regression analyses could not be performed owing to limitations in the currently available RStudio packages. Data were analyzed from October 15, 2020, to February 15, 2021.

    Results
    Study Selection and Characteristics

    The systematic search identified 1272 unique records (Figure 1). After exclusion of 1101 records for ineligible study population, design, intervention, and/or outcomes, 171 full-text articles were assessed for eligibility. Of those, 44 RCTs (5406 total participants; 4109 female participants [76.0%]) from 49 articles were selected. To avoid publication bias, we merged 5 follow-up RCTs47-51 with their primary clinical trials.52-55

    The RCTs included in our review47,48,50-95 spanned 1995 to 2020, with most studies conducted in the US (Table 1). With regard to clinical samples, 31 RCTs examined any patient who presented with self-harm behaviors, and 8 RCTs involved adolescents with BPD. The median duration of treatment and follow-up was 3 months (range, 0.25-12.00 months) and 12 months (range, 1-36 months), respectively. Among the 44 RCTs included, 33 studies offered individual psychotherapy, and the most common modalities were brief intervention, family-based therapy, and DBT (Figure 2).

    Risk of Bias

    With regard to risk of bias within studies, most of the 44 RCTs reported adequate randomization (39 studies), adequate allocation concealment (33 studies), and blinded outcome assessors (36 studies). Only 27 RCTs were preregistered, and only 13 RCTs provided published protocols; 31 studies therefore had a high risk of bias for selective reporting. The risk of incomplete outcome reporting was increased in 11 RCTs because of insufficient details on attrition. Most RCTs reported information on funding (41 studies) and therapist adherence or fidelity (28 studies). However, a high risk of allegiance bias was found in 38 RCTs, and a high risk of attention bias was found in at least 10 RCTs (the risk of attention bias was unclear in an additional 27 studies). As a consequence, a high overall risk of bias was present in all 44 RCTs (eTable 3 in the Supplement).

    To evaluate risk of bias across studies, we downgraded the quality of evidence for all outcomes owing to the high risk of bias in all included RCTs. We also downgraded the overall quality of evidence because of high heterogeneity in suicidal ideation and mood symptoms and imprecision for psychotherapies that had few representative RCTs (eg, mode deactivation therapy and short-term psychoanalytic psychotherapy had only 1 representative RCT each). Although inconsistency was low, publication bias was found for self-harm frequency at the end of treatment (Table 2).

    Synthesis of Findings

    None of the investigated psychotherapies were associated with more study withdrawals compared with treatment as usual (Figure 3A and Figure 3B). However, efficacy was inconsistent across outcomes and psychotherapies. For example, eclectic therapy and DBT were associated with reductions in self-harm at the end of treatment (OR, 0.14 [95% CI, 0.03-0.78] for eclectic therapy and 0.28 [95% CI, 0.12-0.64] for DBT) (Figure 3C), while DBT and family-based therapy were associated with reductions in suicidal ideation at the end of treatment (Cohen d SMD, −0.71 [95% CI, −1.19 to −0.23] for DBT and −0.65 [95% CI, −1.06 to −0.23] for family-based therapy) compared with treatment as usual (Figure 3E). For depressive symptoms, only family-based therapy was associated with reductions in symptom severity at the end of treatment (Cohen d SMD, −0.60; 95% CI, −1.12 to −0.08) (Figure 3G).

    In extended follow-up, only MBT and brief intervention plus treatment as usual were associated with decreases in self-harm (OR, 0.38 [95% CI, 0.15-0.97] for MBT and 0.70 [95% CI, 0.50-0.96] for brief intervention plus treatment as usual) (Figure 3D), and only MBT and family-based therapy were associated with reductions in suicidal ideation (Cohen d SMD, −1.22 [95% CI, −2.18 to −0.26] for MBT and −1.14 [95% CI, −1.96 to −0.32] for family-based therapy) compared with treatment as usual (Figure 3F). None of the investigated therapies were associated with improvements in depressive symptoms over longer follow-up periods (Figure 3H). Participants in the wait-list control groups experienced worsening conditions, with increases in self-harm, mood symptoms, and suicidal ideation compared with participants receiving treatment as usual.

    Discussion

    Although the present NMA found that most psychotherapies were reasonably well tolerated and some psychotherapies indicated efficacy for particular measures of self-harm or suicidality, caution is recommended to avoid overinterpretation of these findings owing to low RCT quality, lack of consistency across outcome measures and treatment periods, and publication bias. When significant, most psychotherapies had small to medium effects compared with treatment as usual. Substantial reductions in self-harm and suicidal behavior were often observed in both the treatment and control groups, and group differences were subsequently small and nonsignificant for many RCTs.

    The present NMA is not the first, and is unlikely to be the last, study to review psychotherapeutic efficacy for self-harm and suicidality among children and adolescents.8,9,15,16,96-103 Although the present review did not focus on a specific clinical sample, relevant insights can be drawn from studies of adolescents with particular diagnoses, such as BPD. For example, Wong et al104 reported that a range of psychotherapies, including DBT and MBT, were associated with short-term, but not long-term, reductions in BPD symptomatology. However, as in previous reviews, Wong et al104 observed diminishing therapeutic efficacy over time, as psychotherapy effect sizes decreased during follow-up relative to the end of treatment. In addition, the clinical trials included in the review by Wong et al104 were of varying lengths and reported variable outcome measures for different dimensions of BPD symptomatology and functioning, which introduced several limitations in the formulation of firmer conclusions about the relative benefits of other therapies. In the present NMA, decreasing efficacy during follow-up compared with the end of treatment was also observed. Although it was more challenging to directly assess this pattern in the present NMA because of the varying numbers of studies reporting data on end of treatment and follow-up for particular psychotherapies, this challenge is not unique to our review.

    Most previous meta-analyses of psychotherapies for children and adolescents with suicidal behaviors have identified similar limitations, highlighting the need for additional research and large-scale RCTs.2 Conducting research on self-harm and suicidal behavior among adolescents is intrinsically challenging because of the distinct trajectory of self-harm, the transient nature of some suicidal behaviors, and the nature of control interventions, which can often confer therapeutic benefits.2 Despite these challenges, the present review does not intend to downgrade the overall utility of psychotherapies, which remain useful for the treatment of a range of mental disorders, often as first-line interventions. However, the diverse array of psychotherapies and their evaluation in individual RCTs produced methodological challenges in creating a clear hierarchy of treatment rankings, which was the intended aim of this review. In part, the most challenging aspect of this review was synthesizing the data across a range of diverse RCTs that explored different psychotherapeutic modalities. Thus, the high risk of bias in the individual RCTs of psychotherapies for self-harm and suicidality among children and adolescents may have had implications for the findings.

    Several approaches have emerged in studies of child and adolescent psychiatry that may support future comparative effectiveness research involving psychotherapies for self-harm. For example, a 2021 review by Jørgensen et al18 extended previous meta-analyses of BPD studies by conducting a trial sequential analysis, which aids the interpretation of meta-analyses involving sparse data and helps to address type 1 and type 2 errors. An alternative approach involves individual participant-level analyses and comprises pooling individual-level data to arrive at a single estimate of a treatment’s efficacy rather than a summary of aggregate RCT-level estimates. As a consequence, using data from large longer-term observational studies, such as phase 4 clinical trials, could be another option, which may also provide more real-world estimates of treatment effectiveness rather than efficacy.105

    Strengths and Limitations

    This study has strengths. To our knowledge, this review is the first to apply NMA to evaluate psychotherapies for the treatment of self-harm and suicidality among children and adolescents. Given the abundance of single-treatment RCTs and the shortage of head-to-head RCTs, the use of NMAs can provide a novel approach to synthesizing knowledge with the data available.106,107

    This study also has several limitations. Although NMA is a powerful tool for comparative effectiveness research, it can produce misleading results when misapplied or misinterpreted. Most of our evidence relied on indirect treatment comparisons; when using head-to-head comparisons, indirect observations are more susceptible to bias. For a subset of psychotherapies (eg, mode deactivation therapy, short-term psychoanalytic psychotherapy, and supportive therapy), the availability of few RCTs and the use of small samples creates imprecise and potentially underpowered estimates. Although we pooled studies regardless of diagnostic classification to maximize statistical power, the findings of this review are less generalizable to specific clinical populations, such as adolescents with BPD.108,109 As a consequence, high heterogeneity was observed in some outcomes; however, given the lack of standardized protocols for RCTs investigating psychotherapy, this heterogeneity was, to a certain extent, unavoidable and not a specific limitation of this review.110 Although the RCTs examining family-based therapy were similar, the number of sessions ranged from 1 to 12; this difference may have produced additional heterogeneity. The duration of psychotherapy is another possible source of heterogeneity. We used the random-effects model to estimate effect sizes across different instruments measuring suicidality or depression, and we assumed that these instruments measured the same construct. However, this assumption was not definitively assessed and could have increased heterogeneity.

    In addition to the challenges inherent in blinded clinical trials of psychotherapies,111 the risk of bias in individual RCTs was high because of other factors, particularly allegiance,112 selective reporting, and incomplete outcome reporting biases. Response and social desirability biases could have produced biased self-reported subjective measures, to which self-harm and suicidal ideation are particularly susceptible.113 Despite an extensive search, we may have missed relevant RCTs, given the publication bias in one of our primary outcomes. Although we did not detect network-level publication bias for most other outcomes, individual psychotherapies may have been subject to publication bias, as only 1 study was conducted for some interventions (eg, mode deactivation therapy and short-term psychoanalytic psychotherapy). Therapy-comparator differences could have been diminished by the active therapeutic nature of some comparator conditions, such as treatment as usual and enhanced usual care, which often provide unstructured psychotherapy sessions independent of a particular psychological modality.2

    Conclusions

    Although the findings of this review suggest that some psychotherapies are well tolerated and have some efficacy for specific measures of self-harm or suicidality, the estimates indicated that the evidence quality was low to very low for most psychotherapies. A lack of consistent evidence precludes a definitive hierarchy of treatments and suggests a need for additional high-quality RCTs.

    Back to top
    Article Information

    Accepted for Publication: February 26, 2021.

    Published: April 16, 2021. doi:10.1001/jamanetworkopen.2021.6614

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Bahji A et al. JAMA Network Open.

    Corresponding Author: Anees Bahji, MD, CISAM, Department of Psychiatry, University of Calgary, 2500 University Dr NW, Calgary, AB T2N 1N4, Canada (anees.bahji1@ucalgary.ca).

    Author Contributions: Dr Bahji had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Bahji, Roberge, Ortega.

    Acquisition, analysis, or interpretation of data: Bahji, Pierce, Wong, Patten.

    Drafting of the manuscript: Bahji, Pierce, Ortega.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Bahji, Patten.

    Administrative, technical, or material support: Pierce, Ortega.

    Supervision: Roberge.

    Conflict of Interest Disclosures: Dr Bahji reported receiving grants from the 2020 Friends of Matt Newell Endowment in Substance Use and the American Psychiatric Association COVID-19 Impact on Psychiatry Research Initiative outside the submitted work. No other disclosures were reported.

    Funding/Support: This work was supported by the Cuthbertson and Fischer Chair in Pediatric Mental Health at the University of Calgary (Dr Patten).

    Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    References
    1.
    Klonsky  ED, Victor  SE, Saffer  BY.  Nonsuicidal self-injury: what we know, and what we need to know.   Can J Psychiatry. 2014;59(11):565-568. doi:10.1177/070674371405901101 PubMedGoogle ScholarCrossref
    2.
    Kothgassner  OD, Robinson  K, Goreis  A, Ougrin  D, Plener  PL.  Does treatment method matter? a meta-analysis of the past 20 years of research on therapeutic interventions for self-harm and suicidal ideation in adolescents.   Borderline Personal Disord Emot Dysregul. 2020;7(1):9. doi:10.1186/s40479-020-00123-9 PubMedGoogle ScholarCrossref
    3.
    Campisi  SC, Carducci  B, Akseer  N, Zasowski  C, Szatmari  P, Bhutta  ZA.  Suicidal behaviours among adolescents from 90 countries: a pooled analysis of the global school-based student health survey.   BMC Public Health. 2020;20(1):1102. doi:10.1186/s12889-020-09209-z PubMedGoogle ScholarCrossref
    4.
    McLoughlin  AB, Gould  MS, Malone  KM.  Global trends in teenage suicide: 2003-2014.   QJM. 2015;108(10):765-780. doi:10.1093/qjmed/hcv026 PubMedGoogle ScholarCrossref
    5.
    Hawton  K, Saunders  KEA, O’Connor  RC.  Self-harm and suicide in adolescents.   Lancet. 2012;379(9834):2373-2382. doi:10.1016/S0140-6736(12)60322-5 PubMedGoogle ScholarCrossref
    6.
    Fontanella  CA, Steelesmith  DL, Brock  G, Bridge  JA, Campo  JV, Fristad  MA.  Association of cannabis use with self-harm and mortality risk among youths with mood disorders.   JAMA Pediatr. Published online January 19, 2021. PubMedGoogle Scholar
    7.
    Gobbi  G, Atkin  T, Zytynski  T,  et al.  Association of cannabis use in adolescence and risk of depression, anxiety, and suicidality in young adulthood: a systematic review and meta-analysis.   JAMA Psychiatry. 2019;76(4):426-434. doi:10.1001/jamapsychiatry.2018.4500 PubMedGoogle ScholarCrossref
    8.
    Ougrin  D, Tranah  T, Stahl  D, Moran  P, Asarnow  JR.  Therapeutic interventions for suicide attempts and self-harm in adolescents: systematic review and meta-analysis.   J Am Acad Child Adolesc Psychiatry. 2015;54(2):97-107. doi:10.1016/j.jaac.2014.10.009 PubMedGoogle ScholarCrossref
    9.
    Iyengar  U, Snowden  N, Asarnow  JR, Moran  P, Tranah  T, Ougrin  D.  A further look at therapeutic interventions for suicide attempts and self-harm in adolescents: an updated systematic review of randomized controlled trials.   Front Psychiatry. 2018;9:583. doi:10.3389/fpsyt.2018.00583 PubMedGoogle ScholarCrossref
    10.
    MHASEF Research Team. The Mental Health of Children and Youth in Ontario: A Baseline Scorecard. Institute for Clinical Evaluative Sciences; 2015. Accessed April 3, 2020. https://www.ices.on.ca/flip-publication/MHASEF_Report_2015/files/assets/basic-html/index.html#4
    11.
    MHASEF Research Team. The Mental Health of Children and Youth in Ontario: 2017 Scorecard. Institute for Clinical Evaluative Sciences; 2017. Accessed April 3, 2020. https://www.ices.on.ca/Publications/Atlases-and-Reports/2017/MHASEF
    12.
    Centre for Suicide Prevention. Self-harm and suicide. Centre for Suicide Prevention; 2020. Accessed April 4, 2020. https://www.suicideinfo.ca/resource/self-harm-and-suicide/
    13.
    Klonsky  ED, Glenn  CR.  Resisting urges to self-injure.   Behav Cogn Psychother. 2008;36(2):211-220. doi:10.1017/S1352465808004128 PubMedGoogle ScholarCrossref
    14.
    Renaud  J, Berlim  MT, Séguin  M, McGirr  A, Tousignant  M, Turecki  G.  Recent and lifetime utilization of health care services by children and adolescent suicide victims: a case-control study.   J Affect Disord. 2009;117(3):168-173. doi:10.1016/j.jad.2009.01.004 PubMedGoogle ScholarCrossref
    15.
    Hawton  K, Witt  KG, Taylor Salisbury  TL,  et al.  Interventions for self-harm in children and adolescents.   Cochrane Database Syst Rev. 2015;(12):CD012013. doi:10.1002/14651858.CD012013 PubMedGoogle Scholar
    16.
    Robinson  J, Hetrick  SE, Martin  C.  Preventing suicide in young people: systematic review.   Aust N Z J Psychiatry. 2011;45(1):3-26. doi:10.3109/00048674.2010.511147 PubMedGoogle ScholarCrossref
    17.
    Storebø  OJ, Stoffers-Winterling  JM, Völlm  BA,  et al.  Psychological therapies for people with borderline personality disorder.   Cochrane Database Syst Rev. 2020;5(5):CD012955. doi:10.1002/14651858.CD012955.pub2PubMedGoogle Scholar
    18.
    Jørgensen  MS, Storebø  OJ, Stoffers-Winterling  JM, Faltinsen  E, Todorovac  A, Simonsen  E.  Psychological therapies for adolescents with borderline personality disorder (BPD) or BPD features—a systematic review of randomized clinical trials with meta-analysis and trial sequential analysis.   PLoS One. 2021;16(1):e0245331. doi:10.1371/journal.pone.0245331 PubMedGoogle Scholar
    19.
    Miura  T, Noma  H, Furukawa  TA,  et al.  Comparative efficacy and tolerability of pharmacological treatments in the maintenance treatment of bipolar disorder: a systematic review and network meta-analysis.   Lancet Psychiatry. 2014;1(5):351-359. doi:10.1016/S2215-0366(14)70314-1 PubMedGoogle ScholarCrossref
    20.
    Yildiz  A, Vieta  E, Correll  CU, Nikodem  M, Baldessarini  RJ.  Critical issues on the use of network meta-analysis in psychiatry.   Harv Rev Psychiatry. 2014;22(6):367-372. doi:10.1097/HRP.0000000000000025 PubMedGoogle ScholarCrossref
    21.
    Cipriani  A, Furukawa  TA, Salanti  G,  et al.  Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis.   Lancet. 2018;391(10128):1357-1366. doi:10.1016/S0140-6736(17)32802-7PubMedGoogle ScholarCrossref
    22.
    Jansen  JP, Naci  H.  Is network meta-analysis as valid as standard pairwise meta-analysis? it all depends on the distribution of effect modifiers.   BMC Med. 2013;11(1):159. doi:10.1186/1741-7015-11-159 PubMedGoogle ScholarCrossref
    23.
    Hutton  B, Salanti  G, Caldwell  DM,  et al.  The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations.   Ann Intern Med. 2015;162(11):777-784. doi:10.7326/M14-2385 PubMedGoogle ScholarCrossref
    24.
    Liberati  A, Altman  DG, Tetzlaff  J,  et al.  The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.   PLoS Med. 2009;6(7):e1000100. doi:10.1371/journal.pmed.1000100 PubMedGoogle Scholar
    25.
    Roy Rosenzweig Center for History and New Media website. 2018. Accessed July 19, 2019. https://rrchnm.org/
    26.
    Covidence systematic review software. Veritas Health Innovation; 2019. Accessed July 19, 2019. https://www.covidence.org/
    27.
    Higgins  JPT, Altman  DG, Gøtzsche  PC,  et al; Cochrane Bias Methods Group; Cochrane Statistical Methods Group.  The Cochrane Collaboration's tool for assessing risk of bias in randomised trials.   BMJ. 2011;343:d5928. doi:10.1136/bmj.d5928 PubMedGoogle ScholarCrossref
    28.
    Sedgwick  P, Marston  L.  How to read a funnel plot in a meta-analysis.   BMJ. 2015;351:h4718. doi:10.1136/bmj.h4718 PubMedGoogle ScholarCrossref
    29.
    Egger  M, Davey Smith  G, Schneider  M, Minder  C.  Bias in meta-analysis detected by a simple, graphical test.   BMJ. 1997;315(7109):629-634. doi:10.1136/bmj.315.7109.629 PubMedGoogle ScholarCrossref
    30.
    Guyatt  GH, Oxman  AD, Vist  GE,  et al; GRADE Working Group.  GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.   BMJ. 2008;336(7650):924-926. doi:10.1136/bmj.39489.470347.AD PubMedGoogle ScholarCrossref
    31.
    Cohen  J.  Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Lawrence Erlbaum Associates; 1988.
    32.
    Lipsey  MW, Wilson  DB.  Practical Meta-analysis. Sage Publications; 2001. Hedrick TE, Bickman L, Rog DJ, eds. Applied Social Research Methods Series; vol 49.
    33.
    Bahji  A, Ermacora  D, Stephenson  C, Hawken  ER, Vazquez  G.  Comparative efficacy and tolerability of pharmacological treatments for the treatment of acute bipolar depression: A systematic review and network meta-analysis.   J Affect Disord. 2020;269:154-184. doi:10.1016/j.jad.2020.03.030 PubMedGoogle ScholarCrossref
    34.
    Bahji  A, Ermacora  D, Stephenson  C, Hawken  ER, Vazquez  G.  Comparative efficacy and tolerability of adjunctive pharmacotherapies for acute bipolar depression: a systematic review and network meta-analysis.   Can J Psychiatry. 2021;66(3):274-288. Published online November 11, 2020. doi:10.1177/0706743720970857PubMedGoogle ScholarCrossref
    35.
    Bahji  A, Meyyappan  AC, Hawken  ER.  Efficacy and acceptability of cannabinoids for anxiety disorders in adults: a systematic review & meta-analysis.   J Psychiatr Res. 2020;129:257-264. doi:10.1016/j.jpsychires.2020.07.030 PubMedGoogle ScholarCrossref
    36.
    Bahji  A, Stephenson  C, Tyo  R, Hawken  ER, Seitz  DP.  Prevalence of cannabis withdrawal symptoms among people with regular or dependent use of cannabinoids: a systematic review and meta-analysis.   JAMA Netw Open. 2020;3(4):e202370. doi:10.1001/jamanetworkopen.2020.2370 PubMedGoogle Scholar
    37.
    Bahji  A, Vazquez  GH, Zarate  CA  Jr.  Comparative efficacy of racemic ketamine and esketamine for depression: a systematic review and meta-analysis.   J Affect Disord. 2021;278:542-555. doi:10.1016/j.jad.2020.09.071 PubMedGoogle ScholarCrossref
    38.
    Wong  J, Bahji  A, Khalid-Khan  S.  Systematic review and meta-analyses of psychotherapies for adolescents with subclinical and borderline personality disorder: a reply to the commentary by Jørgensen, Storebø, and Simonsen.   Can J Psychiatry. 2020;65(5):356-357. doi:10.1177/0706743719898328 PubMedGoogle ScholarCrossref
    39.
    RStudio: integrated development for R. RStudio; 2020. Accessed October 15, 2020. https://www.rstudio.com/
    40.
    Rücker  G, Krahn  U, König  J, Efthimiou  O, Schwarzer  G. Netmeta: network meta-analysis using frequentist methods. Version 1.3-0. CRAN.R Project; 2019. Accessed October 8, 2019. https://cran.r-project.org/web/packages/netmeta/index.html
    41.
    Salanti  G.  Indirect and mixed-treatment comparison, network, or multiple-treatments meta-analysis: many names, many benefits, many concerns for the next generation evidence synthesis tool.   Res Synth Methods. 2012;3(2):80-97. doi:10.1002/jrsm.1037 PubMedGoogle ScholarCrossref
    42.
    Salanti  G, Higgins  JPT, Ades  AE, Ioannidis  JPA.  Evaluation of networks of randomized trials.   Stat Methods Med Res. 2008;17(3):279-301. doi:10.1177/0962280207080643 PubMedGoogle ScholarCrossref
    43.
    Huhn  M, Nikolakopoulou  A, Schneider-Thoma  J,  et al.  Comparative efficacy and tolerability of 32 oral antipsychotics for the acute treatment of adults with multi-episode schizophrenia: a systematic review and network meta-analysis.   Lancet. 2019;394(10202):939-951. doi:10.1016/S0140-6736(19)31135-3 PubMedGoogle ScholarCrossref
    44.
    Rouse  B, Chaimani  A, Li  T.  Network meta-analysis: an introduction for clinicians.   Intern Emerg Med. 2017;12(1):103-111. doi:10.1007/s11739-016-1583-7 PubMedGoogle ScholarCrossref
    45.
    Higgins  JPT, Thompson  SG, Deeks  JJ, Altman  DG.  Measuring inconsistency in meta-analyses.   BMJ. 2003;327(7414):557-560. doi:10.1136/bmj.327.7414.557 PubMedGoogle ScholarCrossref
    46.
    Borenstein  M, Hedges  LV, Higgins  JPT, Rothstein  HR.  A basic introduction to fixed-effect and random-effects models for meta-analysis.   Res Synth Methods. 2010;1(2):97-111. doi:10.1002/jrsm.12 PubMedGoogle ScholarCrossref
    47.
    Jørgensen  MS, Storebø  OJ, Bo  S,  et al.  Mentalization-based treatment in groups for adolescents with borderline personality disorder: 3- and 12-month follow-up of a randomized controlled trial.   Eur Child Adolesc Psychiatry. Published online May 9, 2020. doi:10.1007/s00787-020-01551-2 PubMedGoogle Scholar
    48.
    Mehlum  L, Ramberg  M, Tørmoen  AJ,  et al.  Dialectical behavior therapy compared with enhanced usual care for adolescents with repeated suicidal and self-harming behavior: outcomes over a one-year follow-up.   J Am Acad Child Adolesc Psychiatry. 2016;55(4):295-300. doi:10.1016/j.jaac.2016.01.005 PubMedGoogle ScholarCrossref
    49.
    Mehlum  L, Ramleth  RK, Tørmoen  AJ,  et al.  Long term effectiveness of dialectical behavior therapy versus enhanced usual care for adolescents with self-harming and suicidal behavior.   J Child Psychol Psychiatry. 2019;60(10):1112-1122. doi:10.1111/jcpp.13077 PubMedGoogle ScholarCrossref
    50.
    Ougrin  D, Boege  I, Stahl  D, Banarsee  R, Taylor  E.  Randomised controlled trial of therapeutic assessment versus usual assessment in adolescents with self-harm: 2-year follow-up.   Arch Dis Child. 2013;98(10):772-776. doi:10.1136/archdischild-2012-303200 PubMedGoogle ScholarCrossref
    51.
    Cottrell  DJ, Wright-Hughes  A, Eisler  I,  et al.  Longer-term effectiveness of systemic family therapy compared with treatment as usual for young people after self-harm: an extended follow up of pragmatic randomised controlled trial.   EClinicalMedicine. 2020;18:100246. doi:10.1016/j.eclinm.2019.100246 PubMedGoogle Scholar
    52.
    Beck  E, Bo  S, Jørgensen  MS,  et al.  Mentalization-based treatment in groups for adolescents with borderline personality disorder: a randomized controlled trial.   J Child Psychol Psychiatry. 2020;61(5):594-604. doi:10.1111/jcpp.13152 PubMedGoogle ScholarCrossref
    53.
    Cottrell  DJ, Wright-Hughes  A, Collinson  M,  et al.  Effectiveness of systemic family therapy versus treatment as usual for young people after self-harm: a pragmatic, phase 3, multicentre, randomised controlled trial.   Lancet Psychiatry. 2018;5(3):203-216. doi:10.1016/S2215-0366(18)30058-0 PubMedGoogle ScholarCrossref
    54.
    Mehlum  L, Tørmoen  AJ, Ramberg  M,  et al.  Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial.   J Am Acad Child Adolesc Psychiatry. 2014;53(10):1082-1091. doi:10.1016/j.jaac.2014.07.003 PubMedGoogle ScholarCrossref
    55.
    Ougrin  D, Zundel  T, Ng  A, Banarsee  R, Bottle  A, Taylor  E.  Trial of therapeutic assessment in London: randomised controlled trial of therapeutic assessment versus standard psychosocial assessment in adolescents presenting with self-harm.   Arch Dis Child. 2011;96(2):148-153. doi:10.1136/adc.2010.188755 PubMedGoogle ScholarCrossref
    56.
    Alavi  A, Sharifi  B, Ghanizadeh  A, Dehbozorgi  G.  Effectiveness of cognitive-behavioral therapy in decreasing suicidal ideation and hopelessness of the adolescents with previous suicidal attempts.   Iran J Pediatr. 2013;23(4):467-472.PubMedGoogle Scholar
    57.
    Apsche  JA, Bass  CK, Houston  MA.  A one year study of adolescent males with aggression and problems of conduct and personality: a comparison of MDT and DBT.   Int J Behav Consult Ther. 2006;2(4):544-552. doi:10.1037/h0101006Google ScholarCrossref
    58.
    Asarnow  JR, Baraff  LJ, Berk  M,  et al.  An emergency department intervention for linking pediatric suicidal patients to follow-up mental health treatment.   Psychiatr Serv. 2011;62(11):1303-1309. doi:10.1176/ps.62.11.pss6211_1303 PubMedGoogle ScholarCrossref
    59.
    Asarnow  JR, Hughes  JL, Babeva  KN, Sugar  CA.  Cognitive-behavioral family treatment for suicide attempt prevention: a randomized controlled trial.   J Am Acad Child Adolesc Psychiatry. 2017;56(6):506-514. doi:10.1016/j.jaac.2017.03.015 PubMedGoogle ScholarCrossref
    60.
    Britton  WB, Lepp  NE, Niles  HF, Rocha  T, Fisher  NE, Gold  JS.  A randomized controlled pilot trial of classroom-based mindfulness meditation compared to an active control condition in sixth-grade children.   J Sch Psychol. 2014;52(3):263-278. doi:10.1016/j.jsp.2014.03.002 PubMedGoogle ScholarCrossref
    61.
    Chanen  AM, Jackson  HJ, McCutcheon  LK,  et al.  Early intervention for adolescents with borderline personality disorder using cognitive analytic therapy: randomised controlled trial.   Br J Psychiatry. 2008;193(6):477-484. doi:10.1192/bjp.bp.107.048934 PubMedGoogle ScholarCrossref
    62.
    Cooney  E; New Zealand Ministry of Health; Wise Group (N.Z.), Te Pou o te Whakaaro Nui. Feasibility of Evaluating DBT for Self-harming Adolescents: A Small Randomised Controlled Trial. Te Pou o Te Whakaaro Nui–The National Centre of Mental Health Research and Workforce Development; 2010. Accessed September 12, 2020. https://www.worldcat.org/title/feasibility-of-evaluating-dbt-for-self-harming-adolescents-a-small-randomised-controlled-trial/oclc/679320661
    63.
    Cotgrove  A, Zirinsky  L, Black  D, Weston  D.  Secondary prevention of attempted suicide in adolescence.   J Adolesc. 1995;18(5):569-577. doi:10.1006/jado.1995.1039Google ScholarCrossref
    64.
    Diamond  GS, Wintersteen  MB, Brown  GK,  et al.  Attachment-based family therapy for adolescents with suicidal ideation: a randomized controlled trial.   J Am Acad Child Adolesc Psychiatry. 2010;49(2):122-131. doi:10.1016/j.jaac.2009.11.002PubMedGoogle Scholar
    65.
    Diamond  GS, Kobak  RR, Krauthamer Ewing  ES,  et al.  A randomized controlled trial: attachment-based family and nondirective supportive treatments for youth who are suicidal.   J Am Acad Child Adolesc Psychiatry. 2019;58(7):721-731. doi:10.1016/j.jaac.2018.10.006 PubMedGoogle ScholarCrossref
    66.
    Donaldson  D, Spirito  A, Esposito-Smythers  C.  Treatment for adolescents following a suicide attempt: results of a pilot trial.   J Am Acad Child Adolesc Psychiatry. 2005;44(2):113-120. doi:10.1097/00004583-200502000-00003 PubMedGoogle ScholarCrossref
    67.
    Esposito-Smythers  C, Spirito  A, Kahler  CW, Hunt  J, Monti  P.  Treatment of co-occurring substance abuse and suicidality among adolescents: a randomized trial.   J Consult Clin Psychol. 2011;79(6):728-739. doi:10.1037/a0026074 PubMedGoogle ScholarCrossref
    68.
    Esposito-Smythers  C, Hadley  W, Curby  TW, Brown  LK.  Randomized pilot trial of a cognitive-behavioral alcohol, self-harm, and HIV prevention program for teens in mental health treatment.   Behav Res Ther. 2017;89:49-56. doi:10.1016/j.brat.2016.11.005 PubMedGoogle ScholarCrossref
    69.
    Gleeson  JFM, Chanen  A, Cotton  SM, Pearce  T, Newman  B, McCutcheon  L.  Treating co-occurring first-episode psychosis and borderline personality: a pilot randomized controlled trial.   Early Interv Psychiatry. 2012;6(1):21-29. doi:10.1111/j.1751-7893.2011.00306.x PubMedGoogle ScholarCrossref
    70.
    Goodyer  IM, Reynolds  S, Barrett  B,  et al.  Cognitive behavioural therapy and short-term psychoanalytical psychotherapy versus a brief psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled superiority trial.   Lancet Psychiatry. 2017;4(2):109-119. doi:10.1016/S2215-0366(16)30378-9 PubMedGoogle ScholarCrossref
    71.
    Green  JM, Wood  AJ, Kerfoot  MJ,  et al.  Group therapy for adolescents with repeated self harm: randomised controlled trial with economic evaluation.   BMJ. 2011;342:d682. doi:10.1136/bmj.d682 PubMedGoogle ScholarCrossref
    72.
    Griffiths  H, Duffy  F, Duffy  L,  et al.  Efficacy of mentalization-based group therapy for adolescents: the results of a pilot randomised controlled trial.   BMC Psychiatry. 2019;19(1):167. doi:10.1186/s12888-019-2158-8 PubMedGoogle ScholarCrossref
    73.
    Harrington  R, Kerfoot  M, Dyer  E,  et al.  Randomized trial of a home-based family intervention for children who have deliberately poisoned themselves.   J Am Acad Child Adolesc Psychiatry. 1998;37(5):512-518. doi:10.1016/S0890-8567(14)60001-0 PubMedGoogle ScholarCrossref
    74.
    Hazell  PL, Martin  G, Mcgill  K,  et al.  Group therapy for repeated deliberate self-harm in adolescents: failure of replication of a randomized trial.   J Am Acad Child Adolesc Psychiatry. 2009;48(6):662-670. doi:10.1097/CHI.0b013e3181a0acec PubMedGoogle Scholar
    75.
    Hetrick  SE, Yuen  HP, Bailey  E,  et al.  Internet-based cognitive behavioural therapy for young people with suicide-related behaviour (Reframe-IT): a randomised controlled trial.   Evid Based Ment Health. 2017;20(3):76-82. doi:10.1136/eb-2017-102719 PubMedGoogle ScholarCrossref
    76.
    Hill  RM, Pettit  JW.  Pilot randomized controlled trial of LEAP: a selective preventive intervention to reduce adolescents’ perceived burdensomeness.   J Clin Child Adolesc Psychol. 2019;48(sup1)(suppl 1):S45-S56. doi:10.1080/15374416.2016.1188705PubMedGoogle ScholarCrossref
    77.
    Kaess  M, Edinger  A, Fischer-Waldschmidt  G, Parzer  P, Brunner  R, Resch  F.  Effectiveness of a brief psychotherapeutic intervention compared with treatment as usual for adolescent nonsuicidal self-injury: a single-centre, randomised controlled trial.   Eur Child Adolesc Psychiatry. 2020;29(6):881-891. doi:10.1007/s00787-019-01399-1 PubMedGoogle ScholarCrossref
    78.
    Kennard  BD, Goldstein  T, Foxwell  AA,  et al.  As Safe As Possible (ASAP): a brief app-supported inpatient intervention to prevent postdischarge suicidal behavior in hospitalized, suicidal adolescents.   Am J Psychiatry. 2018;175(9):864-872. doi:10.1176/appi.ajp.2018.17101151 PubMedGoogle ScholarCrossref
    79.
    King  CA, Kramer  A, Preuss  L, Kerr  DCR, Weisse  L, Venkataraman  S.  Youth-Nominated Support Team for suicidal adolescents (version 1): a randomized controlled trial.   J Consult Clin Psychol. 2006;74(1):199-206. doi:10.1037/0022-006X.74.1.199 PubMedGoogle ScholarCrossref
    80.
    King  CA, Klaus  N, Kramer  A, Venkataraman  S, Quinlan  P, Gillespie  B.  The Youth-Nominated Support Team–Version II for suicidal adolescents: a randomized controlled intervention trial.   J Consult Clin Psychol. 2009;77(5):880-893. doi:10.1037/a0016552 PubMedGoogle ScholarCrossref
    81.
    King  CA, Gipson  PY, Horwitz  AG, Opperman  KJ.  Teen options for change: an intervention for young emergency patients who screen positive for suicide risk.   Psychiatr Serv. 2015;66(1):97-100. doi:10.1176/appi.ps.201300347 PubMedGoogle ScholarCrossref
    82.
    McCauley  E, Berk  MS, Asarnow  JR,  et al.  Efficacy of dialectical behavior therapy for adolescents at high risk for suicide: a randomized clinical trial.   JAMA Psychiatry. 2018;75(8):777-785. doi:10.1001/jamapsychiatry.2018.1109 PubMedGoogle ScholarCrossref
    83.
    Ougrin  D, Corrigall  R, Poole  J,  et al.  Comparison of effectiveness and cost-effectiveness of an intensive community supported discharge service versus treatment as usual for adolescents with psychiatric emergencies: a randomised controlled trial.   Lancet Psychiatry. 2018;5(6):477-485. doi:10.1016/S2215-0366(18)30129-9 PubMedGoogle ScholarCrossref
    84.
    Pineda  J, Dadds  MR.  Family intervention for adolescents with suicidal behavior: a randomized controlled trial and mediation analysis.   J Am Acad Child Adolesc Psychiatry. 2013;52(8):851-862. doi:10.1016/j.jaac.2013.05.015 PubMedGoogle ScholarCrossref
    85.
    Robinson  J, Yuen  HP, Gook  S,  et al.  Can receipt of a regular postcard reduce suicide-related behaviour in young help seekers? a randomized controlled trial.   Early Interv Psychiatry. 2012;6(2):145-152. doi:10.1111/j.1751-7893.2011.00334.x PubMedGoogle ScholarCrossref
    86.
    Rossouw  TI, Fonagy  P.  Mentalization-based treatment for self-harm in adolescents: a randomized controlled trial.   J Am Acad Child Adolesc Psychiatry. 2012;51(12):1304-1313. doi:10.1016/j.jaac.2012.09.018 PubMedGoogle ScholarCrossref
    87.
    Santamarina-Perez  P, Mendez  I, Singh  MK,  et al.  Adapted dialectical behavior therapy for adolescents with a high risk of suicide in a community clinic: a pragmatic randomized controlled trial.   Suicide Life Threat Behav. 2020;50(3):652-667. doi:10.1111/sltb.12612 PubMedGoogle ScholarCrossref
    88.
    Schuppert  HM, Giesen-Bloo  J, van Gemert  TG,  et al.  Effectiveness of an emotion regulation group training for adolescents—a randomized controlled pilot study.   Clin Psychol Psychother. 2009;16(6):467-478. doi:10.1002/cpp.637 PubMedGoogle ScholarCrossref
    89.
    Schuppert  HM, Timmerman  ME, Bloo  J,  et al.  Emotion regulation training for adolescents with borderline personality disorder traits: a randomized controlled trial.   J Am Acad Child Adolesc Psychiatry. 2012;51(12):1314-1323. doi:10.1016/j.jaac.2012.09.002 PubMedGoogle ScholarCrossref
    90.
    Sinyor  M, Williams  M, Mitchell  R,  et al.  Cognitive behavioral therapy for suicide prevention in youth admitted to hospital following an episode of self-harm: a pilot randomized controlled trial.   J Affect Disord. 2020;266:686-694. doi:10.1016/j.jad.2020.01.178 PubMedGoogle ScholarCrossref
    91.
    Tang  TC, Jou  SH, Ko  CH, Huang  SY, Yen  CF.  Randomized study of school-based intensive interpersonal psychotherapy for depressed adolescents with suicidal risk and parasuicide behaviors.   Psychiatry Clin Neurosci. 2009;63(4):463-470. doi:10.1111/j.1440-1819.2009.01991.x PubMedGoogle ScholarCrossref
    92.
    Van Voorhees  BW, Fogel  J, Reinecke  MA,  et al.  Randomized clinical trial of an internet-based depression prevention program for adolescents (Project CATCH-IT) in primary care: 12-week outcomes.   J Dev Behav Pediatr. 2009;30(1):23-37. doi:10.1097/DBP.0b013e3181966c2a PubMedGoogle ScholarCrossref
    93.
    Wharff  EA, Ginnis  KB, Ross  AM, White  EM, White  MT, Forbes  PW.  Family-based crisis intervention with suicidal adolescents: a randomized clinical trial.   Pediatr Emerg Care. 2019;35(3):170-175. doi:10.1097/PEC.0000000000001076 PubMedGoogle ScholarCrossref
    94.
    Wood  A, Trainor  G, Rothwell  J, Moore  A, Harrington  R.  Randomized trial of group therapy for repeated deliberate self-harm in adolescents.   J Am Acad Child Adolesc Psychiatry. 2001;40(11):1246-1253. doi:10.1097/00004583-200111000-00003 PubMedGoogle ScholarCrossref
    95.
    Yen  S, Spirito  A, Weinstock  LM, Tezanos  K, Kolobaric  A, Miller  I.  Coping long term with active suicide in adolescents: results from a pilot randomized controlled trial.   Clin Child Psychol Psychiatry. 2019;24(4):847-859. doi:10.1177/1359104519843956 PubMedGoogle ScholarCrossref
    96.
    Robinson  J, Bailey  E, Witt  K,  et al.  What works in youth suicide prevention? a systematic review and meta-analysis.   EClinicalMedicine. 2018;4-5:52-91. doi:10.1016/j.eclinm.2018.10.004 PubMedGoogle ScholarCrossref
    97.
    Dray  J, Bowman  J, Campbell  E,  et al.  Systematic review of universal resilience-focused interventions targeting child and adolescent mental health in the school setting.   J Am Acad Child Adolesc Psychiatry. 2017;56(10):813-824. doi:10.1016/j.jaac.2017.07.780 PubMedGoogle ScholarCrossref
    98.
    Fonagy  P, Target  M, Cottrell  D,  et al.  What Works for Whom? A Critical Review of Treatments for Children and Adolescents. 1st ed. Guilford Press; 2005.
    99.
    Glenn  CR, Franklin  JC, Nock  MK.  Evidence-based psychosocial treatments for self-injurious thoughts and behaviors in youth.   J Clin Child Adolesc Psychol. 2015;44(1):1-29. doi:10.1080/15374416.2014.945211PubMedGoogle ScholarCrossref
    100.
    Merz  J, Schwarzer  G, Gerger  H.  Comparative efficacy and acceptability of pharmacological, psychotherapeutic, and combination treatments in adults with posttraumatic stress disorder: a network meta-analysis.   JAMA Psychiatry. 2019;76(9):904-913. doi:10.1001/jamapsychiatry.2019.0951 PubMedGoogle ScholarCrossref
    101.
    Milner  A, Spittal  MJ, Kapur  N, Witt  K, Pirkis  J, Carter  G.  Mechanisms of brief contact interventions in clinical populations: a systematic review.   BMC Psychiatry. 2016;16(1):194. doi:10.1186/s12888-016-0896-4 PubMedGoogle ScholarCrossref
    102.
    Weisz  JR, Kuppens  S, Ng  MY,  et al.  What five decades of research tells us about the effects of youth psychological therapy: a multilevel meta-analysis and implications for science and practice.   Am Psychol. 2017;72(2):79-117. doi:10.1037/a0040360 PubMedGoogle ScholarCrossref
    103.
    Werner-Seidler  A, Perry  Y, Calear  AL, Newby  JM, Christensen  H.  School-based depression and anxiety prevention programs for young people: a systematic review and meta-analysis.   Clin Psychol Rev. 2017;51:30-47. doi:10.1016/j.cpr.2016.10.005 PubMedGoogle ScholarCrossref
    104.
    Wong  J, Bahji  A, Khalid-Khan  S.  Psychotherapies for adolescents with subclinical and borderline personality disorder: a systematic review and meta-analysis.   Can J Psychiatry. 2020;65(1):5-15. doi:10.1177/0706743719878975PubMedGoogle ScholarCrossref
    105.
    Cesana  BM, Biganzoli  EM.  Phase IV studies: some insights, clarifications, and issues.   Curr Clin Pharmacol. 2018;13(1):14-20. doi:10.2174/1574884713666180412152949 PubMedGoogle ScholarCrossref
    106.
    Eccleston  C, Fisher  E, Craig  L, Duggan  GB, Rosser  BA, Keogh  E.  Psychological therapies (internet-delivered) for the management of chronic pain in adults.   Cochrane Database Syst Rev. 2014;2014(2):CD010152. doi:10.1002/14651858.CD010152.pub2 PubMedGoogle Scholar
    107.
    Haugh  S, O’Connor  L, Slattery  B,  et al.  The relative effectiveness of psychotherapeutic techniques and delivery modalities for chronic pain: a protocol for a systematic review and network meta-analysis.   HRB Open Res. 2020;2:25. doi:10.12688/hrbopenres.12953.2PubMedGoogle ScholarCrossref
    108.
    Willis  BH, Riley  RD.  Measuring the statistical validity of summary meta-analysis and meta-regression results for use in clinical practice.   Stat Med. 2017;36(21):3283-3301. doi:10.1002/sim.7372 PubMedGoogle ScholarCrossref
    109.
    Riley  RD, Jackson  D, Salanti  G,  et al.  Multivariate and network meta-analysis of multiple outcomes and multiple treatments: rationale, concepts, and examples.   BMJ. 2017;358:j3932. doi:10.1136/bmj.j3932 PubMedGoogle ScholarCrossref
    110.
    Thorlund  K, Mills  EJ.  Sample size and power considerations in network meta-analysis.   Syst Rev. 2012;1(1):41. doi:10.1186/2046-4053-1-41 PubMedGoogle ScholarCrossref
    111.
    Shean  G.  Limitations of randomized control designs in psychotherapy research.   Adv Psychiatry. 2014;2014:561452. doi:10.1155/2014/561452Google Scholar
    112.
    Munder  T, Flückiger  C, Gerger  H, Wampold  BE, Barth  J.  Is the allegiance effect an epiphenomenon of true efficacy differences between treatments? a meta-analysis.   J Couns Psychol. 2012;59(4):631-637. doi:10.1037/a0029571 PubMedGoogle ScholarCrossref
    113.
    Rosenman  R, Tennekoon  V, Hill  LG.  Measuring bias in self-reported data.   Int J Behav Healthc Res. 2011;2(4):320-332. doi:10.1504/IJBHR.2011.043414 PubMedGoogle ScholarCrossref
    ×