Zero Suicide Quality Improvement: Developmental and Pandemic-Related Patterns in Youth at Risk for Suicide Attempts.

The Zero Suicide (ZS) approach to health system quality improvement (QI) aspires to reduce/eliminate suicides through enhancing risk detection and suicide-prevention services. This first report from our randomized trial evaluating a stepped care for suicide prevention intervention within a health system conducting ZS-QI describes 1) our screening and case identification process, 2) variation among adolescents versus young adults; and 3) pandemic-related patterns during the first COVID-19 pandemic year. Between April 2017 and January 2021, youths aged 12-24 with elevated suicide risk were identified through an electronic health record (EHR) case-finding algorithm followed by direct assessment screening to confirm risk. Eligible/enrolled youth were evaluated for suicidality, self-harm, and risk/protective factors. Case finding, screening, and enrollment yielded 301 participants showing suicide risk-indicators: 97% past-year suicidal ideation, 83% past suicidal behavior; 90% past non-suicidal self-injury (NSSI). Compared to young adults, adolescents reported: more past-year suicide attempts (47% vs 21%, p<.001) and NSSI (past 6-months, 64% vs 39%, p<.001); less depression, anxiety, posttraumatic stress, and substance use; and greater social connectedness. Pandemic-onset was associated with lower participation of racial-ethnic minority youths (18% vs 33%, p<.015) and lower past-month suicidal ideation and behavior. Results support the value of EHR case-finding algorithms for identifying youths with potentially elevated risk who could benefit from suicide-prevention services, which merit adaptation for adolescents versus young adults. Lower racial-ethnic minority participation after the COVID-19 pandemic-onset underscores challenges for services to enhance health equity during a period with restricted in-person health care, social distancing, school closures, and diverse stresses.

IL-6 predicts non-suicidal self-injury over 3 months in high-risk adolescents.

BACKGROUND: Suicide is the second leading cause of death in 12- to 17-year-old adolescents in the USA. Research on biological mechanisms contributing to self-harm risk that could be targeted in treatment could help to prevent suicide and self-harm episodes. AIMS: We aimed to evaluate whether markers of inflammation, interleukin-6 (IL-6) and C-reactive protein (CRP), predict self-harm over 3 months within a sample selected for elevated suicide/self-harm risk at project entry. METHOD: Fifty-one adolescents aged 12-19 years selected for elevated suicide/self-harm risk completed three clinical interviews about suicide attempts and non-suicidal self-injury, 3 months apart. At baseline and 3 months, youth also provided blood samples, from which we assayed levels of IL-6 and CRP. RESULTS: Using generalised mixed models, we found that greater levels of IL-6 predicted more self-harm episodes (odds ratio [OR] = 3.3, 95% CI: 1.1, 10.0) and specifically, non-suicidal self-injury (OR = 3.5, 95% CI: 1.1, 11.2), over 3 months. CONCLUSIONS: The study findings increase our understanding of whether and how inflammation may be implicated in risk of self-harm. IL-6 may be a viable biological marker of short-term risk for self-harm.

Remission, Recovery, Relapse, and Recurrence Rates for Suicide Attempts and Nonsuicidal Self-Injury for Suicidal Youth Treated With Dialectical Behavior Therapy or Supportive Therapy.

OBJECTIVE: To evaluate rates of remission, recovery, relapse, and recurrence in suicidal youth who participated in a clinical trial comparing Dialectical Behavior Therapy (DBT) and Individual and Group Supportive Therapy (IGST). METHOD: Participants were 173 youth, aged 12 to 18 years, with repetitive self-harm (including at least 1 prior suicide attempt [SA]) and elevated suicidal ideation (SI). Participants received 6 months of DBT or IGST and were followed for 6 months post-treatment. The sample was 95% female, 56.4% White, and 27.49% Latina. Remission was defined as absence of SA or nonsuicidal self-injury (NSSI) across one 3-month interval; recovery was defined across 2 or more consecutive intervals. Relapse and recurrence were defined as SA or NSSI following remission or recovery. Cross-tabulation with χ2 was used for between-group contrasts. RESULTS: Over 70% of the sample reported remission of SA at each treatment and follow-up interval. There were significantly higher rates of remission and recovery and lower rates of relapse and recurrence for SA in DBT than for IGST. Across treatments and time points, SA had higher remission and recovery rates and lower relapse and recurrence rates than NSSI. There were no significant differences in NSSI remission between conditions; however, participants receiving DBT had significantly higher NSSI recovery rates than those receiving IGST for the 3- to 9-month, 3- to 12-month, and 6- to 12-month intervals. CONCLUSION: Results showed higher percentages of SA remission and recovery for DBT as compared to IGST. NSSI was less likely to remit than SA. DIVERSITY & INCLUSION STATEMENT: We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. CLINICAL TRIAL REGISTRATION INFORMATION: Collaborative Adolescent Research on Emotions and Suicide (CARES); https://www. CLINICALTRIALS: gov/; NCT01528020.

Leader and Provider Perspectives on Implementing Safe Alternatives for Teens and Youth - Acute (SAFETY-A) in Public School Districts Serving Racial/ethnic Minoritized Youth.

Racial/ethnic minoritized (REM) youth represent a high-risk group for suicide, yet there are striking disparities in their use of mental health services (MHS) even after risk is identified in schools. Prior research suggests that school-based risk assessments and hospitalization encounters can be negatively experienced by REM youth and families, thus deterring likelihood of seeking follow-up care. The Safe Alternatives for Teens and Youth-Acute (SAFETY-A) is a brief, strengths-based, cognitive-behavioral family intervention demonstrated to increase linkage to MHS when implemented in emergency departments. With its focus on strengths and family engagement, SAFETY-A may cultivate a positive therapeutic encounter suited to addressing disparities in MHS by enhancing trust and family collaboration, if appropriately adapted for schools. Thirty-seven school district leaders and frontline school MHS providers from districts serving primarily socioeconomically disadvantaged REM communities participated in key informant interviews and focus groups. First, interviews were conducted to understand usual care processes for responding to students with suicidal thoughts and behaviors, and perspectives on the strengths and disadvantages of current practices. An as-is process analysis was used to describe current practices spanning risk assessment, crisis intervention, and follow-up. Second, focus groups were conducted to solicit perceptions of the fit of SAFETY-A for these school contexts. Thematic analysis of the interviews and focus groups was used to identify multilevel facilitators and barriers to SAFETY-A implementation, and potential tailoring variables for implementation strategies across school districts.

Practitioner Review: Common elements in treatments for youth suicide attempts and self-harm - a practitioner review based on review of treatment elements associated with intervention benefits.

BACKGROUND: Adopting a common elements approach, this practitioner review aims to highlight specific treatment elements that are common to interventions with demonstrated benefits in randomized controlled trials (RCTs) for reducing suicide attempts and self-harm in youth. Identification of common treatment elements among effective interventions offers a key strategy for clarifying the most robust features of effective interventions and improving our ability to implement effective treatment and decrease the lag between scientific advances and clinical care. METHODS: A systematic search of RCTs evaluating interventions targeting suicide/self-harm in youth (ages 12-18) yielded a total of 18 RCTs assessing 16 different manualized interventions. An open coding process was used to identify common elements present within each intervention trial. Twenty-seven common elements were identified and classified into format, process, and content categories. All trials were coded for the inclusion of these common elements by two independent raters. RCTs were also classified into those where trial results supported improvements in suicide/self-harm behavior (n = 11 supported trials) and those without supported evidence (n = 7 unsupported trials). RESULTS: Compared with unsupported trials, the 11 supported trials shared the following elements: (a) inclusion of therapy for both the youth and family/caregivers; (b) an emphasis on relationship-building and the therapeutic alliance; (c) utilization of an individualized case conceptualization to guide treatment; (d) provided skills training (e.g. emotion regulation skills) to both youth and their parents/caregivers; and (e) lethal means restriction counseling as part of self-harm monitoring and safety planning. CONCLUSIONS: This review highlights key treatment elements associated with efficacy that community practitioners can incorporate in their treatments for youth presenting with suicide/self-harm behaviors.

Youth Mental Health Screening and Linkage to Care.

One Mind, in partnership with Meadows Mental Health Policy Institute, convened several virtual meetings of mental health researchers, clinicians, and other stakeholders in 2020 to identify first steps toward creating an initiative for early screening and linkage to care for youths (individuals in early adolescence through early adulthood, ages 10-24 years) with mental health difficulties, including serious mental illness, in the United States. This article synthesizes and builds on discussions from those meetings by outlining and recommending potential steps and considerations for the development and integration of a novel measurement-based screening process in youth-facing school and medical settings to increase early identification of mental health needs and linkage to evidence-based care. Meeting attendees agreed on an initiative incorporating a staged assessment process that includes a first-stage brief screener for several domains of psychopathology. Individuals who meet threshold criteria on the first-stage screener would then complete an interview, a second-stage in-depth screening, or both. Screening must be followed by recommendations and linkage to an appropriate level of evidence-based care based on acuity of symptoms endorsed during the staged assessment. Meeting attendees proposed steps and discussed additional considerations for creating the first nationwide initiative for screening and linkage to care, an initiative that could transform access of youths to mental health screening and care.

Improving Care Linkage for Racial-Ethnic Minority Youths Receiving Emergency Department Treatment for Suicidality: SAFETY-A.

OBJECTIVE: This study evaluated the effects of Safe Alternatives for Teens and Youths-Acute (SAFETY-A), a brief strengths-based, cognitive-behavioral family intervention, on racial-ethnic minority youths receiving emergency department (ED) treatment for suicidal episodes. METHODS: Participants were 105 racial-ethnic minority youths enrolled in a randomized controlled trial evaluating SAFETY-A versus enhanced usual care for youths receiving ED treatment for suicidal episodes. Analyses examined group effects on care linkage after discharge and adequate treatment dose. A sample of 55 White youths was included for comparison. RESULTS: Racial-ethnic minority youths who received SAFETY-A had higher treatment linkage rates than those receiving usual care. Adequate treatment dose rates did not differ by group. CONCLUSIONS: Racial-ethnic minority youths receiving SAFETY-A had higher treatment linkage rates after discharge than those receiving usual care. SAFETY-A is a promising approach to enhance care continuity and mental health equity for racial-ethnic minority youths at risk for suicide.

Stepped care for suicide prevention in teens and young adults: Design and methods of a randomized controlled trial.

BACKGROUND: Suicide is the second­leading cause of death among adolescents and young adults in the United States, with rates rising over much of the last decade. The design, testing, and implementation of interventions to prevent suicide in this population is a public health priority. This manuscript outlines the design and methods for a research study that compares two interventions aimed at reducing suicide and suicide attempts in youth. METHODS: We will enroll 300 youth aged 12-24 at high risk for suicide in this randomized controlled parallel group superiority trial. Participants will be randomly assigned to one of two study arms: (1) Zero Suicide Quality Improvement (ZSQI) implemented within the Kaiser Permanente Northwest (KPNW) health system, or (2) ZSQI plus a stepped care intervention for suicide prevention (SC-SP), where the services offered (including care management and dialectical behavior therapy [DBT]) increase based on risk level. Outcomes will be assessed at baseline, as well as 3-, 6-, and 12-months post randomization. The study was conceptualized and designed collaboratively by investigators at UCLA and KPNW. RESULTS: To be reported in future manuscripts. CONCLUSION: The main objective of the study is to determine whether the SC-SP intervention is superior to ZSQI with regard to lowering rates of fatal and nonfatal suicide attempts. Interventions that incorporate the latest research need to be designed and tested under controlled conditions to make progress toward the goal of achieving zero suicide. The results from this trial will directly inform those efforts. CLINICALTRIALS: gov, NCT03092271, https://clinicaltrials.gov/ct2/show/NCT03092271https://clinicaltrials.gov/ct2/show/NCT01379027.

Trajectories of Treatment Response and Nonresponse in Youth at High Risk for Suicide.

OBJECTIVE: To examine trajectories of treatment response in suicidal youth who participated in a randomized controlled trial comparing dialectical behavior therapy (DBT) and individual and group supportive therapy. METHOD: Using latent class analysis across both treatment conditions, secondary analyses were conducted of data from a multisite randomized controlled trial comprising 173 youths ages 12-18 with repetitive self-harm (SH) (including ≥1 lifetime suicide attempts) and elevated suicidal ideation (SI). The sample was 95% female, 56.4% White, and 27.49% Latina. Participants received 6 months of DBT or individual and group supportive therapy and 6 months of follow-up. Primary outcomes were SH and SI. RESULTS: Of the sample, 63% and 74% were members of latent classes that showed improvement in SI and SH, respectively; 13% were total nonresponders, with no improvement in SI or SH. SH nonresponse emerged at the midpoint of treatment (3 months), with nonresponders showing a sharp increase in SH over the remainder of treatment and follow-up. Youth receiving DBT were significantly more likely to be an SH responder vs nonresponder than youths in individual and group supportive therapy (ꭓ21 = 6.53, p = .01). An optimal threshold cut point using multivariate predictors of total nonresponse (White, externalizing symptoms, total SH, and SI) predicted total nonresponders to DBT with 100% accuracy. CONCLUSION: This is the first study to identify trajectories of both SI and SH response to treatment in a sample of adolescents at risk of suicide. Results may inform personalized treatment approaches. CLINICAL TRIAL REGISTRATION INFORMATION: Collaborative Adolescent Research on Emotions and Suicide (CARES); https://www. CLINICALTRIALS: gov/; NCT01528020.

"Lock and Protect": Development of a Digital Decision Aid to Support Lethal Means Counseling in Parents of Suicidal Youth.

Objective: Reducing access to lethal methods is an effective suicide prevention strategy that is often neglected in routine care. Digital interventions have shown promise for addressing such gaps in care; and decision aids have proven useful for supporting complicated health-related decisions, like those involving lethal means restriction. This article describes a parent/caregiver-facing web-based decision aid, the development process, and user testing. Method: A user-centered, participatory, mixed methods development design was employed. Beginning with an adult-focused decision aid developed by members of our team, we assessed ten iterations of the parent/caregiver decision aid with stakeholders (N = 85) using qualitative interviews and quantitative surveys. Stakeholders included: parents/caregivers whose children had histories of suicidal episodes before age 25, young adults with histories of suicidal thoughts/behaviors, firearm owners/representatives from firearm stores/ranges/groups, mental and medical health care providers, and emergency responders. Results: The final "Lock and Protect" decision aid was viewed as "useful for changing access to lethal means" by 100% of participants. Ninety-four percent of participants rated the information on reducing access to lethal means as good to excellent, and 91% rated the information on storage options as good to excellent. Qualitative feedback underscored a preference for offering this digital tool with a "human touch," as part of safety and discharge planning. Conclusions: "Lock and Protect" is a user-friendly web-based tool with potential for improving rates of lethal means counseling for parents/caregivers of suicidal youth and ultimately reducing pre-mature deaths by suicide.

Editorial: COVID-19: lessons learned for suicide prevention.

This editorial discusses lessons learned from the COVID-19 public health emergency as they relate to the prevention of suicide, the second leading cause of death in adolescents and young adults globally. Recognizing that COVID-19 impact and response varied across nations, we offer a US perspective, addressing two questions: (a) what have we learned from this pandemic and mitigation strategies used to reduce cases of COVID-19 illness and deaths; and (b) how can our research advance knowledge and be advanced by work aimed at understanding the impact of this 'unusual' period? Provisional data indicate that during the pandemic and lockdown period, there were some declines in suicide rates for the total US population and no change in youth. However, data also indicate increases in reported suicidal ideation and behavior, mental health-related ED visits, and ED visits for suicidal ideation and behavior in youth. Heterogeneity of pandemic effects is noteworthy, with ethnic and racial minority populations suffering the most from COVID-19, COVID-19-related risk factors, and possibly suicide deaths. As vaccinations can prevent severe COVID-19 cases and deaths, we also have demonstrations of effective 'psychological inoculations' such as community-based interventions for reducing suicide attempts and deaths. During COVID-19, we mobilized to provide clinical care through telehealth and digital interventions. The challenge now is to continue to put our science to work to mitigate the adverse impacts of the pandemic on suicide and suicide risk factors, our children's mental health, and enhance mental health and well-being in our communities.

Parent and Youth Preferences in the Treatment of Youth Depression.

Patient-centered care requires providing care that is responsive to patient preferences, needs, and values, yet data on parent and youth treatment preferences remains sparse. The present study (1) identifies variations in parent and youth preferences for depression treatment, and (2) explores relationships between parent and youth demographics and psychosocial functioning, and the preferences that parents and youth endorse. Participants were 64 youth and 63 parents awaiting randomization in a clinical trial evaluating psychosocial youth depression treatments. Parents preferred treatments that emphasize learning skills and strategies (82.5%) and include the parent in treatment at least some of the time (96.8%). Youth preferred that the therapist meet mostly with the youth alone (67.2%) but share at least some information with parents (78.1%). Youth (43.8%) tended to respond "don't know" to questions about their preferred therapeutic approach. Understanding parent and youth preferences, especially psychosocial treatment preferences, is needed to provide high-quality, patient-centered care.

Incorporating family factors into treatment planning for adolescent depression: Perceived parental criticism predicts longitudinal symptom trajectory in the Youth Partners in Care trial.

BACKGROUND: This study aimed to clarify the predictive significance of youth perceptions of parental criticism assessed using a brief measure designed to enhance clinical utility. We hypothesized that high perceived parental criticism would be associated with more severe depression over 18-months of follow-up. METHODS: The study involved secondary analyses from the Youth Partners in Care trial, which demonstrated that a quality improvement intervention aimed at increasing access to evidence-based depression treatment in primary care led to improved depression outcomes at post-treatment compared to usual care enhanced by provider education regarding depression evaluation/management. Patients (N = 418; ages 13-21) were assessed at four time points: baseline; post-treatment (six-month follow-up); 12- and 18-month follow-ups. The primary analysis estimated the effect of perceived parental criticism on likelihood of severe depression (i.e., Center for Epidemiological Studies-Depression Scale ≥ 24) over post-intervention follow-ups using a repeated-measures logistic regression model. Secondarily, a linear mixed-effects growth model examined symptom trajectories from baseline through 18-months using the Mental Health Index-5, a measure of emotional distress available at all time-points. RESULTS: High perceived parental criticism emerged as a robust predictor of clinically-elevated depression (OR=1.66, p=.02) and a more pernicious symptom trajectory over 18-months (ß =-1.89, p<.0001). LIMITATIONS: The association between the self-report perceived criticism and traditional expressed emotion measures derived from verbal and nonverbal parental behaviors was not evaluated. CONCLUSIONS: Results support perceived parental criticism as a predictor of youth depression outcomes over 18-months. This brief measure can be feasibly integrated within clinical assessment to assist clinicians in optimizing treatment benefits.

Future Directions for Optimizing Clinical Science & Safety: Ecological Momentary Assessments in Suicide/Self-Harm Research.

OBJECTIVE: Mobile technology has facilitated rapid growth in the use of intensive longitudinal methods (ILM), such as ecological momentary assessments (EMA), that help identify proximal indicators of risk in real-time and real-world settings. To realize the potential of ILM for advancing knowledge regarding suicidal and self-injurious thoughts and behaviors (SITB), this article aims to provide a systematic review of safety protocols in published ILM studies of youth SITB, highlight considerations for maximizing safety, and offer an agenda for future research. METHOD: We conducted a systematic review of risk management strategies in published studies applying ILM to assess SITB in youth. RESULTS: The review indicated diverse safety strategies, with near-universal use of preventive strategies before beginning ILM surveys. Strategies for participant protection during the survey period included automated protective messages to seek support when elevated risk was detected; and staff-led strategies, some of which included active outreach to parents/caregivers when youth responses suggested elevated risk. Studies assessing suicidality all provided staff-led follow-up. There was minimal information on youth reactivity to intensive longitudinal assessments of SITB. Available evidence did not suggest increased suicidal ideation, suicide attempts, self-injurious behavior, or deaths with ILM. CONCLUSIONS: Based on the review, we propose a research agenda to inform safety procedures in ILM research and a model for managing risk in future ILM studies of youth SITB. This model begins with a needs assessment and proposes a "goodness of fit" approach for matching safety procedures to the specific needs of each ILM study.

Development and efficacy of a family-focused treatment for depression in childhood.

BACKGROUND: Depression in childhood frequently involves significant impairment, comorbidity, stress, and mental health problems within the family. Family-Focused Treatment for Childhood Depression (FFT-CD) is a 15-session developmentally-informed, evidence-based intervention targeting family interactions to enhance resiliency within the family system to improve and manage childhood depression. METHODS: We present the conceptual framework underlying FFT-CD, the treatment development process, the intervention strategies, a case illustration, and efficacy data from a recent 2-site randomized clinical trial (N = 134) of 7-14 year old children randomly assigned to FFT-CD or individual supportive psychotherapy (IP) conditions. RESULTS: Compared to children randomized to IP, those randomized to FFT-CD showed higher rates of depression response (≥50% Children's Depression Rating Scale-Revised reduction) across the course of acute treatment (77.7% vs. 59.9%, t = 1.97, p = .0498). The rate of improvement overall leveled off following treatment with a high rate of recovery from index depressive episodes in both groups (estimated 76% FFT-CD, 77% IP), and there was an attenuation of observed group differences. By final follow-up (9 months post-treatment), one FFT-CD child and six IP children had suffered depressive recurrences, and four IP children attempted suicide. LIMITATIONS: Without a no treatment control group it is not possible to disentangle the impact of the interventions from time alone. CONCLUSIONS: While seldom evaluated, family interventions may be particularly appropriate for childhood depression. FFT-CD has demonstrated efficacy compared to individual supportive therapy. However, findings underscore the need for an extended/chronic disease model to enhance outcomes and reduce risk over time.

Adolescent Suicide Attempt Prevention: Predictors of Response to a Cognitive-Behavioral Family and Youth Centered Intervention.

OBJECTIVE: Suicide is a leading cause of adolescent death. Recent data support the efficacy of cognitive-behavioral treatments with strong family components for reducing suicide risk; however, not all youth benefit from current interventions. Identifying predictors of treatment response can inform treatment selection and optimize benefits. METHOD: This study examines predictors of response to a DBT-informed cognitive-behavioral family treatment (SAFETY), among 50 youth with recent suicide attempts/self-harm. Youth and parents were assessed at baseline and post-treatment. RESULTS: Results indicated medium-to-large effect sizes for SAFETY on youth suicidal behavior (SB; defined as suicide attempts, aborted attempts, and planning), depression, hopelessness, social adjustment, and parental depression. Classification tree analysis, with a correct classification rate of 93.3%, and follow-up logistic analyses indicated that 35% of youths reporting active SB at baseline reported active SB at post-treatment, whereas post-treatment SB was rare among youths whose active suicidality had resolved by the baseline assessment (5%). Among youths reporting baseline SB, those endorsing sleep problems were more likely to report post-treatment SB (53%) versus those without sleep problems (0%). CONCLUSIONS: These findings highlight the potential value of personalized treatment approaches based on pretreatment characteristics and the significance of baseline SB and sleep problems for predicting treatment response.

Correction.

This corrects the article DOI: 10.4088/JCP.09m05885blu.​​.

Predictors and moderators of recurring self-harm in adolescents participating in a comparative treatment trial of psychological interventions.

BACKGROUND: In primary analyses, dialectical behavior therapy (DBT) was associated with greater reduction in self-harm during treatment than individual/group supportive therapy (IGST). The objective of this paper was to examine predictors and moderators of treatment outcomes for suicidal adolescents who participated in a randomized controlled trial evaluating DBT and IGST. METHODS: Adolescents (N = 173) were included in the intent-to-treat sample and randomized to receive 6 months of DBT or IGST. Potential baseline predictors and moderators were identified within four categories: demographics, severity markers, parental psychopathology, and psychosocial variables. Primary outcomes were suicide attempts (SA) and nonsuicidal self-injury evaluated at baseline, midtreatment (3 months), and end of treatment (6 months) via the Suicide Attempt and Self-Injury Interview (Psychological Assessment, 18, 2006, 303). For each moderator or predictor, a generalized linear mixed model was conducted to examine main and interactive effects of treatment and the candidate variable on outcomes. RESULTS: Adolescents with higher family conflict, more extensive self-harm histories, and more externalizing problems produced on average more reduction on SH frequency from baseline to post-treatment. Adolescents meeting BPD diagnosis were more likely to have high SH frequency at post-treatment. Analyses indicated significant moderation effects for emotion dysregulation on NSSI and SH. DBT was associated with better rates of improvement compared to IGST for adolescents with higher baseline emotion dysregulation and those whose parents reported greater psychopathology and emotion dysregulation. A significant moderation effect for ethnicity on SA over the treatment period was observed, where DBT produced better rate of improvement compared to IGST for Hispanic/Latino individuals. CONCLUSIONS: These findings may help to inform salient treatment targets and guide treatment planning. Adolescents that have high levels of family conflict, externalizing problems, and increased level of severity markers demonstrated the most change in self-harm behaviors over the course of treatment and benefitted from both treatment interventions. Those with higher levels of emotion dysregulation and parent psychopathology may benefit more from the DBT.

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.

Reducing Health Risk Behaviors and Improving Depression in Adolescents: A Randomized Controlled Trial in Primary Care Clinics.

Objective: Primary care (PC) is a major service delivery setting that can provide preventive behavioral health care to youths. To explore the hypothesis that reducing health risk behaviors (HRBs) would lower depressive symptoms, and that health risk and depression can be efficiently targeted together in PC, this study (1) evaluates an intervention designed to reduce HRBs among adolescent PC patients with depressive symptoms and (2) examines prospective links between HRBs and depressive symptoms. Method: A Randomized controlled trial was conducted comparing a behavioral health intervention with enhanced Usual PC (UC+). Participants were 187 adolescents (ages 13-18 years) with past-year depression, assessed at baseline, 6 months, and 12 months. Primary outcome was the Health Risk Behavior Index (HRBI), a composite score indexing smoking, substance use, unsafe sex, and obesity risk. Secondary/exploratory outcomes were an index of the first three most correlated behaviors (HRBI-S), each HRB, depressive symptoms, and satisfaction with mental health care. Results: Outcomes were similar at 6 and 12 months, with no significant between-group differences. HRBI, HRBI-S, and depressive symptoms decreased, and satisfaction with mental health care increased across time in both groups. HRBI, HRBI-S, and smoking predicted later severe depression. Conversely, severe depression predicted later HRBI-S and substance use. Conclusions: UC+ and the behavioral health intervention yielded similar benefits in reducing HRBs and depressive symptoms. Findings underscore the bidirectional links between depression and HRBs, supporting the importance of monitoring for HRBs and depression in PC to allow for effective intervention in both areas.