Hogberg, G., Hallstrom, T.

Mood regulation focused CBT based on memory reconsolidation, reduced suicidal ideation and depression in youth in a randomised controlled study

Suicide attempts and suicidal ideation in adolescence are considered to be related to suicide and psychiatric adversity later in life. Secondary prevention by improving the treatment of suicidal youth is a distinct possibility. In this study, treatment with a systematised mood-regulation focused cognitive behavioural therapy (MR-CBT) (n = 15) was compared with treatment as usual (TAU) (n = 12) in a group of depressed adolescents in a clinical setting. MR-CBT focuses on mood regulation by means of counter conditioning with memory reconsolidation being the proposed mechanism of change. Subjects practice keeping emotionally positive memories to diminish the emotional impact of negative memories. Symptoms of depression were tested with a short version of the Mood and Feelings Questionnaire (SMFQ), and wellbeing with the World Health Organization 5 Wellbeing Index (WHO-5). Suicidal events were rated according to the clinical interview Columbia Suicide Severity Rating Scale (C-SSRS). Suicidal events at the end of treatment were significantly reduced in the MR-CBT group, but not in the TAU group. Depression and wellbeing improved significantly in both treatment groups. While far from conclusive, the results are encouraging enough to suggest that further studies should be undertaken to examine whether psychotherapy focusing on mood regulation for young individuals at risk might enhance secondary prevention of suicide. Copyright © 2018 by the authors. Licensee MDPI, Basel, Switzerland.

International Journal of Environmental Research and Public Health, 15 (5) (no pagination)(921) :

McCauley, E., Berk, M. S., Asarnow, J. R., Adrian, M., Cohen, J., Korslund, K., Avina, C., Hughes, J., Harned, M., Gallop, R., Linehan, M. M.

Efficacy of Dialectical Behavior Therapy for Adolescents at High Risk for Suicide: A Randomized Clinical Trial

Importance: Suicide is a leading cause of death among 10- to 24-year-old individuals in the United States; evidence on effective treatment for adolescents who engage in suicidal and self-harm behaviors is limited.\rObjective: To evaluate the efficacy of dialectical behavior therapy (DBT) compared with individual and group supportive therapy (IGST) for reducing suicide attempts, nonsuicidal self-injury, and overall self-harm among high-risk youths. \rDesign, Setting, and Participants: This randomized clinical trial was conducted from January 1, 2012, through August 31, 2014, at 4 academic medical centers. A total of 173 participants (pool of 195; 22 withdrew or were excluded) 12 to 18 years of age with a prior lifetime suicide attempt (>=3 prior self-harm episodes, suicidal ideation, or emotional dysregulation) were studied. Adaptive randomization balanced participants across conditions within sites based on age, number of prior suicide attempts, and psychotropic medication use. Participants were followed up for 1 year. \rInterventions: Study participants were randomly assigned to DBT or IGST. Treatment duration was 6 months. Both groups had weekly individual and group psychotherapy, therapist consultation meetings, and parent contact as needed.\rMain Outcomes and Measures: A priori planned outcomes were suicide attempts, nonsuicidal self-injury, and total self-harm assessed using the Suicide Attempt Self-Injury Interview.\rResults: A total of 173 adolescents (163 [94.8%] female and 97 [56.4%] white; mean [SD] age, 14.89 [1.47] years) were studied. Significant advantages were found for DBT on all primary outcomes after treatment: suicide attempts (65 [90.3%] of 72 receiving DBT vs 51 [78.9%] of 65 receiving IGST with no suicide attempts; odds ratio [OR], 0.30; 95% CI, 0.10-0.91), nonsuicidal self-injury (41 [56.9%] of 72 receiving DBT vs 26 [40.0%] of 65 receiving IGST with no self- injury; OR, 0.32; 95% CI, 0.13-0.70), and self-harm (39 [54.2%] of 72 receiving DBT vs 24 [36.9%] of 65 receiving IGST with no self-harm; OR, 0.33; 95% CI, 0.14-0.78). Rates of self-harm decreased through 1-year follow-up. The advantage of DBT decreased, with no statistically significant between-group differences from 6 to 12 months (OR, 0.65; 95% CI, 0.12-3.36; P = .61). Treatment completion rates were higher for DBT (75.6%) than for IGST (55.2%), but pattern-mixture models indicated that this difference did not informatively affect outcomes.\rConclusions and Relevance: The results of this trial support the efficacy of DBT for reducing self-harm and suicide attempts in highly suicidal self-harming adolescents. On the basis of the criteria of 2 independent trials supporting efficacy, results support DBT as the first well-established, empirically supported treatment for decreasing repeated suicide attempts and self-harm in youths.\rTrial Registration: ClinicalTrials.gov Identifier: NCT01528020.

JAMA Psychiatry, 75(8) : 777-785

Ougrin, D., Corrigall, R., Poole, J., Zundel, T., Sarhane, M., Slater, V., Stahl, D., Reavey, P., Byford, S., Heslin, M., Ivens, J., Crommelin, M., Abdulla, Z., Hayes, D., Middleton, K., Nnadi, B., Taylor, E.

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

Background: Intensive community treatment to reduce dependency on adolescent psychiatric inpatient care is recommended in guidelines but has not been assessed in a randomised controlled trial in the UK. We designed a supported discharge service (SDS) provided by an intensive community treatment team and compared outcomes with usual care. Methods: Eligible patients for this randomised controlled trial were younger than 18 years and had been admitted for psychiatric inpatient care in the South London and Maudsley NHS Foundation Trust. Patients were assigned 1:1 to either the SDS or to usual care by use of a computer-generated pseudorandom code with random permuted blocks of varying sizes. The primary outcome was number of inpatient bed-days, change in Strengths and Difficulties Questionnaire (SDQ) scores, and change in Children's Global Assessment Scale (CGAS) scores at 6 months, assessed by intention to treat. Cost-effectiveness was explored with acceptability curves based on CGAS scores and quality-adjusted life-years (QALYs) calculated from the three-level EuroQol measure of health-related quality of life (EQ-5D-3L), taking a health and social care perspective. This study is registered with the ISRCTN Registry, number ISRCTN82129964. Findings: Hospital use at 6 months was significantly lower in the SDS group than in the usual care group (unadjusted median 34 IQR 17-63 vs 50 days, 19-125, p=0.04). The ratio of mean total inpatient days for usual care to SDS was 1.67 (95% CI 1.02-2.81, p=0.04), which decreased to 1.65 (0.99-2.77, p=0.057) when adjusted for differences in hospital use before randomisation. Scores for SDQ and CGAS did not differ between groups. The cost-effectiveness acceptability curve based on QALYs showed that the probability of SDS being cost-effective compared with usual care was around 60% with a willingness-to-pay threshold of 20 000-30 000 per QALY, and that based on CGAS showed at least 58% probability of SDS being cost-effective compared with usual care irrespective of willingness to pay. We recorded no adverse events attributable to SDS or usual care. Interpretation: SDS provided by an intensive community treatment team reduced bed usage at 6 months' follow-up but had no effect on functional status and symptoms of mental health disorders compared with usual care. The possibility of preventing admissions, particularly through features such as reduced self-harm and improved reintegration into school, with intensive community treatment should be investigated in future studies. Funding: South London and Maudsley NHS Trust. Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND 4.0 license

The Lancet Psychiatry, 5(6) : 477- 485

Plener, P. L., Kaess, M., Schmahl, C., Pollak, S., Fegert, J. M., Brown, R. C.

Non-suicidal self-injury in adolescents

Deutsches Arzteblatt International, 115(3) : 23-30

Robinson, J., Calear, A. L., Bailey, E.

Suicide prevention in educational settings: a review

Objectives: Youth suicide rates are unacceptably high. Schools have long been accepted as an appropriate setting for suicide prevention activities. This review aims to synthesise the evidence for all types of suicide prevention interventions across educational settings. Methods: The review draws on two previous reviews conducted by the authors. In order to be included, studies had to test a specific suicide prevention intervention in an educational setting, have a suicide-related outcome and target young people. Results: A totally of 21 studies were included: 17 were conducted in school settings and four in universities. Seven of the school-based studies (41%) and one of the university studies (25%) were randomised controlled trials. Overall, the trials conducted in schools reported positive effects, as did four of the non- randomised controlled trials. Two of the university-based studies reported positive effects. Both universal and indicated interventions showed positive results; no iatrogenic effects were reported. Conclusions: School-based studies can have a positive impact on suicide- related behaviour and, overall, do not appear to cause harm. Study quality is variable, and the number of studies conducted in school settings far exceed those conducted in universities. These gaps need to be addressed by future research. Copyright © 2018, © The Royal Australian and New Zealand College of Psychiatrists 2018.

Australasian Psychiatry, 26(2) : 132-140

Weinstein, S. M., Cruz, R. A., Isaia, A. R., Peters, A. T., West, A. E.

Child- and Family-Focused Cognitive Behavioral Therapy for Pediatric Bipolar Disorder: Applications for Suicide Prevention

Despite high rates of suicide ideation (SI) and behavior in youth with pediatric bipolar disorder (PBD), little work has examined how psychosocial interventions impact suicidality among this high-risk group. The current study examined SI outcomes in a randomized clinical trial comparing Child- and Family-Focused Cognitive Behavioral Therapy (CFF-CBT) for PBD versus psychotherapy treatment-as-usual (TAU). Although not designed for suicide prevention, CFF-CBT addresses child and family factors related to suicide risk and thus was hypothesized to generalize to the treatment of suicidality.

Suicide & Life-Threatening Behavior, 48(6) : 797- 811

Hooley, J. M., Fox, K. R., Wang, S. B., Kwashie, A. N. D.

Novel online daily diary interventions for nonsuicidal self-injury: A randomized controlled trial

Background: Nonsuicidal self-injury (NSSI), which involves self-damaging behavior (e.g., cutting) causes tissue damage and places people at elevated risk for future suicidal behaviors. Yet few specific treatments for NSSI currently exist. Extreme self-criticism is implicated in the development and maintenance of NSSI. We conducted a randomized controlled trial to evaluate Autobiographical Self-Enhancement Training (ASET), a novel, cognitive intervention for NSSI focused on reducing self-criticism and enhancing positive self-worth. We also examined whether Expressive Writing (EW) was a helpful treatment for NSSI. Method(s): Participants (N = 144) who had engaged in NSSI at least twice in the past month were recruited online and then randomly assigned via Qualtrics to receive the ASET intervention (N = 49), the EW intervention (N = 49), or Daily Journaling [JNL; N = 46]), an active comparison condition. Treatments were designed as month-long daily diaries. Participants in ASET wrote about something that made them feel good about themselves that day, participants in EW described something that had been on their mind that day, and participants in JNL reported on the events of the day in a factually descriptive manner without emotional content. Result(s): Intent-to-treat analyses revealed that, regardless of treatment group, participants showed significant reductions in self- criticism, NSSI episodes, depression, and suicide ideation from baseline to the end of active treatment. Relative to the JNL group, the ASET group reported significantly less self-criticism at post-treatment; this was not maintained at follow-up. There was also a trend toward ASET being associated with less suicide ideation at the end of treatment compared to EW. This difference was significant at the 3-month follow-up. Unexpectedly, the JNL group reported significantly less suicide ideation than the EW group at post-treatment; this was maintained at 3-month follow-up. No significant treatment effects were detected for suicide plans, suicidal behaviors, desire to discontinue NSSI, or likelihood of future NSSI. Conclusion(s): Self-criticism is an important treatment target in NSSI, but changing self-criticism in people with an established history of NSSI presents challenges. Nonetheless, all approaches provided benefits. This study also established the feasibility of inexpensive and easily disseminated treatments for NSSI. Copyright © 2018 The Author(s).

BMC Psychiatry, 18 (1) (no pagination)(264) :

King, C. A., Gipson, P. Y., Arango, A., Foster, C. E., Clark, M., Ghaziuddin, N., Stone, D.

LET's CONNECT community mentorship program for youths with peer social problems: Preliminary findings from a randomized effectiveness trial

This study examined the effectiveness of LET's CONNECT (LC), a community mentorship program for youths who report peer social problems, which is based on a positive youth development framework. Participants were 218 youths (66.5% girls), aged 12 to 15 years, who were recruited from an urban medical emergency department and screened positive for bullying victimization, bullying perpetration, and/or low social connectedness. Youths were randomized to LC (n = 106) or the control condition (n = 112). Six-month outcomes were assessed with self-report measures of youth social connectedness, community connectedness, thwarted belongingness, depression, self-esteem, and suicidal ideation. LC was associated with a significant increase in only one of these outcomes, social connectedness (effect size = 0.4). It was associated consistently with trend-level positive changes for thwarted belongingness (decreased), depression (decreased), community connectedness, and self-esteem (effect sizes = 0.2). There was no effect on suicidal ideation (effect size = 0.0), and although not a primary outcome, eight youths in the LC condition and seven youths in the control condition engaged in suicidal behavior between baseline and follow-up. Although LC effect sizes are consistent with those from previous studies of community mentorship, there were multiple challenges to LC implementation that affected dosage and intervention fidelity, and that may account for the lack of stronger positive effects. Copyright © 2018 Wiley Periodicals, Inc.

Journal of Community Psychology, 46(7) : 885- 902

Brent, D. A., Kennard, B. D.

Impact of a Brief Inpatient Intervention and Suicide Safety Planning App to Decrease Suicidal Behavior After Hospital Discharge [conference abstract]

Objectives: This presentation will describe and evaluate the impact of a brief inpatient intervention, As Safe As Possible (ASAP), supported by an emotion-regulation and safety-planning smartphone application (app) called BRITE on postdischarge suicide attempts. Method(s): A total of 66 suicidal adolescent inpatients were randomized to either ASAP/BRITE + treatment as usual (TAU) versus TAU alone. ASAP was a 2.7-hour inpatient intervention that emphasized safety planning, emotion regulation, and distress tolerance. The app was personalized to each participant to provide reminders for reasons for living, distraction, and interventions for distress tolerance and emotion regulation, as well as providing access to a safety plan with emergency contact numbers. Result(s): Within 6 months, 16% of those assigned to ASAP/BRITE had made suicide attempts versus 31% of those in TAU. Perceived social support increased in the ASAP/BRITE arm, and the more participants used the app, the greater their increase in reasons for living (rho = 0.37, p = 0.08). Three participants made suicide attempts while still in the hospital. Excluding these individuals and adjusting for the baseline variable associated with the time to suicide attempt, participants assigned to ASAP/BRITE had a significantly lower hazard ratio (HR) for suicide attempt [HR = 0.22 (95% CI 0.05-0.99)]. ASAP/BRITE showed a stronger effect in those with a history of a suicide attempts (N = 53) [test for moderation, HR = 0.07 (95% CI 0.01-0.79), p = 0.03]. Conclusion(s): In this pilot study, ASAP/BRITE shows promise as a brief inpatient intervention to decrease postdischarge suicide attempts. SIB, S, PRE Copyright © 2018

Journal of the American Academy of Child and Adolescent Psychiatry, 57 (10 Supplement) : S33

Iyengar, U., Snowden, N., Asarnow, J. R., 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

Background: Suicide attempts (SA) and other types of self-harm (SH) are strong predictors of death by suicide in adolescents, emphasizing the need to investigate therapeutic interventions in reduction of these and other symptoms. We conducted an updated systematic review of randomized controlled trials (RCTs) from our previous study reporting therapeutic interventions that were effective in reducing SH including SA, while additionally exploring reduction of suicidal ideation (SI) and depressive symptoms (DS). Method: A systematic literature search was conducted across OVID Medline, psycINFO, PubMed, EMBASE, and Cochrane Library from the first available article to October 22nd, 2017, with a primary focus on RCTs evaluating therapeutic interventions in the reduction of self-harm. Search terms included self-injurious behavior; self-mutilation; suicide, attempted; suicide; drug overdose. Results: Our search identified 1,348 articles, of which 743 eligible for review, yielding a total of 21 studies which met predetermined inclusion criteria. Eighteen unique therapeutic interventions were identified among all studies, stratified by individual-driven, socially driven, and mixed interventions, of which 5 studies found a significant effect for primary outcomes of self-harm and suicide attempts (31.3%), and 5 studies found a significant effect for secondary outcomes of suicidal ideation and depressive symptoms (29.4%) for therapeutic intervention vs. treatment as usual. Collapsing across different variations of Cognitive Behavior Therapy (CBT), and classifying Dialectical Behavior Therapy for Adolescents (DBT-A) as a type of CBT, CBT is the only intervention with replicated positive impact on reducing self-harm in adolescents. Conclusion: While the majority of studies were not able to determine efficacy of therapeutic interventions for both primary and secondary outcomes, our systematic review suggests that individual self-driven and socially-driven processes appeared to show the greatest promise for reducing suicide attempts, with benefits of combined self-driven and systems-driven approaches for reducing overall self-harm. Further RCTs of all intervention categories are needed to address the clinical and etiological heterogeneity of suicidal behavior in adolescents, specifically suicidal ideation and depressive symptoms.

Frontiers in psychiatry Frontiers Research Foundation, 9 : 583

McManama-O'Brien, K. H., Sellers, C. M., Battalen, A. W., Ryan, C. A., Maneta, E. K., Aguinaldo, L. D., White, E., Spirito, A.

Feasibility, acceptability, and preliminary effects of a brief alcohol intervention for suicidal adolescents in inpatient psychiatric treatment

Alcohol use, both short-term intoxication and longer-term use, is a notable risk factor for suicide. Despite the strong relationship between alcohol use and suicidal thoughts and behaviors, providers typically treat these two problems independently. In particular, acute psychiatric care hospitalizations for adolescents are typically brief, and many only cursorily address alcohol use. Integrating a brief motivational enhancement intervention for alcohol use into an inpatient psychiatric hospitalization treatment protocol has the potential to enhance motivation to stop or reduce drinking if adolescents can more fully understand how it increases risk for suicidal behavior. This study tested the feasibility, acceptability, and preliminary effects of the Alcohol and Suicide Intervention for Suicidal Teens (ASIST), a brief motivational enhancement intervention targeting alcohol use and suicidal thoughts and behaviors for suicidal adolescents receiving inpatient psychiatric treatment. Results from a randomized pilot trial of ASIST (N = 50) revealed that the intervention was both feasible and acceptable, with 92% of those in the ASIST condition reporting that the intervention helped them to understand how their alcohol use is related to their suicidal thoughts and behaviors. Study findings suggest a larger randomized controlled trial may be warranted to test the effectiveness of ASIST with psychiatrically hospitalized adolescents. Copyright © 2018

Journal of Substance Abuse Treatment, 94 : 105-112

Kennard, B. D., Goldstein, T., Foxwell, A. A., McMakin, D. L., Wolfe, K., Biernesser, C., Moorehead, A., Douaihy, A., Zullo, L., Wentroble, E., Owen, V., Zelazny, J., Iyengar, S., Porta, G., Brent, D.

As safe as possible (ASAP): A brief app- supported inpatient intervention to prevent postdischarge suicidal behavior in Hospitalized, Suicidal Adolescents

Objective: The authors report on a pilot study of an inpatient intervention for suicidal adolescents, As Safe as Possible (ASAP), supported by a smartphone app (BRITE) to reduce suicide attempts following hospital discharge. Method(s): Across two sites, 66 adolescents hospitalized for suicidal ideation (N=26) or a recent suicide attempt (N=40) were randomly assigned to the ASAP intervention program plus treatment as usual or to treatment as usual alone. ASAP, which focuses on emotion regulation and safety planning, is a 3-hour intervention delivered on the inpatient unit. The BRITE app prompted participants to rate their level of emotional distress on a daily basis and provided personalized strategies for emotion regulation and safety planning. A blind, independent evaluator assessed suicide attempts following hospital discharge and suicidal ideation at 4, 12, and 24 weeks after discharge. Result(s): The ASAP intervention did not have a statistically significant effect on suicide attempt, although findings were in the hypothesized direction for occurrence of an attempt (16% compared with 31%; x²=1.86, df=1, g=20.36) and time to an attempt (hazard ratio=0.49, 95% CI=0.16, 1.47). Past history of a suicide attempt was a significant moderator of treatment outcome, with a stronger, albeit nonsignificant, effect of the ASAP intervention among participants with a history of suicide attempt (hazard ratio=0.23, 95% CI=0.05, 1.09). There were no treatment effects on suicidal ideation. The majority of participants (70%) used the BRITE app (median usage, 19 times). Participants reported high satisfaction with both the intervention and the app. Conclusion(s): The ASAP intervention program shows promise in reducing the incidence of postdischarge suicide attempts among adolescents hospitalized for suicidality and merits further study. Copyright © 2018 American Psychiatric Association. All rights reserved.

American Journal of Psychiatry, 175(9) : 864-872