Emergency department staff experiences of working with people who self-harm: A qualitative examination of barriers to optimal care.

For people who seek help for self-harm, emergency departments (ED) are often the first point of contact, making them a suitable setting for intervention. In Australia, base rates of self-harm presentations to ED are increasing, while the quality of care these people receive is often considered sub-optimal. This study used qualitative interviews to explore potential barriers ED staff face in delivering best possible self-harm care. Seventeen staff across two EDs in the state of Victoria, Australia, were interviewed regarding their perceptions of barriers to providing optimal self-harm care and suggestions for improvement. Three themes were identified: (1) system-related challenges when managing self-harm in ED, including the shortage of hospital resources, challenges of ED as a physical environment, and insufficient education, training and guidelines about self-harm care for staff; (2) human-related challenges regarding management of self-harm in ED, which encompassed the nature of a person's circumstances and presentation, and staff attitudes towards self-harm; and (3) staff suggestions for improving self-harm care in ED. Specific recommendations that were proposed based on these findings included introducing a separate ED area for mental health-related presentations, provision of specialised education and training about self-harm care to staff, better implementation of guidelines on treating self-harm in ED, and employing mental health educators to provide on-the-floor mentoring to nurses. The relevance of these barriers and recommendations to the wider healthcare sector is also discussed. Together, these findings may inform improvements to the quality of care provided to those who engage in self-harm.

Global prevalence of psychosocial assessment following hospital-treated self-harm: systematic review and meta-analysis.

BACKGROUND: Hospital-treated self-harm is common, costly and associated with repeated self-harm and suicide. Providing a comprehensive psychosocial assessment following self-harm is recommended by professional bodies and may improve outcomes. AIMS: To review the provision of psychosocial assessments after hospital-presenting self-harm and the extent to which macro-level factors indicative of service provision explain variability in these estimates. METHOD: We searched five electronic databases to 3 January 2023 for studies reporting data on the proportion of patients and/or events that were provided a psychosocial assessment. Pooled weighted prevalence estimates were calculated with the random-effects model. Random-effects meta-regression was used to investigate between-study variability. RESULTS: 119 publications (69 unique samples) were included. Across ages, two-thirds of patients had a psychosocial assessment (0.67, 95% CI 0.58-0.76). The proportion was higher for young people and older adults (0.75, 95% CI 0.36-0.99 and 0.83, 95% CI 0.48-1.00, respectively) compared with adults (0.64, 95% CI 0.54-0.73). For events, around half of all presentations had these assessments across the age range. No macro-level factor explained between-study heterogeneity. CONCLUSIONS: There is room for improvement in the universal provision of psychosocial assessments for self-harm. This represents a missed opportunity to review and tailor aftercare supports for those at risk. Given the marked unexplained heterogeneity between studies, the person- and system-level factors that influence provision of psychosocial assessments after self-harm should be studied further.

Does adolescent depression modify the association between psychosocial job stressors and mental health in emergent adulthood?

BACKGROUND: Job stressors can be particularly harmful to the mental health of disadvantaged groups through differential exposure, differential sensitivity to the effects of exposure, or both. In this paper, we assess the extent to which emergent adult workers with an adolescent history of high depression symptoms may be differentially sensitive to the effect of job stressors on mental health. METHODS: We conducted a secondary analysis of three waves of the Australian arm of the International Youth Development Study (n = 1262). We used multivariable linear regression to assess whether self-reported measures of high depression symptoms at one or two time points in adolescence (ages 11-16 years) modified the cross-sectional association between four self-reported job stressors (job demands, job control, job strain, and incivility at work) and psychological distress (Kessler-10 scores) in emergent adulthood (ages 23-27 years). RESULTS: For all four job stressors, there was a consistent pattern of approximately a doubling in the magnitude of association for participants with a history of high depression symptoms at two points in adolescence compared with those with no history of depression. However, results of effect modification analysisfor only job demands and job strain excluded chance as a potential explanation. CONCLUSIONS: Findings showed partial support for the hypothesis that a history of high depression symptoms in adolescence predicts stronger associations between job stressor exposures and psychological distress among those employed in emergent adulthood. The limitations of this secondary analysis suggest a need for purpose-designed studies to answer this important research question more definitively.

Global prevalence of psychiatric in- and out-patient treatment following hospital-presenting self-harm: a systematic review and meta-analysis.

Background: Hospital-treated self-harm is common, costly, and strongly associated with suicide. Whilst effective psychosocial interventions exist, little is known about what key factors might modify the clinical decision to refer an individual to psychiatric in- and/or out-patient treatment following an episode of hospital-treated self-harm. Methods: We searched five electronic databases (CENTRAL, CDSR, MEDLINE, Embase, and PsycINFO) until 3 January 2023 for studies reporting data on either the proportion of patients and/or events that receive a referral and/or discharge to psychiatric in- and/or outpatient treatment after an episode of hospital-treated self-harm. Pooled weighted prevalence estimates were calculated using the random effects model with the Freedman-Tukey double arcsine adjustment in R, version 4.0.5. We also investigated whether several study-level and macro-level factors explained variability for these outcomes using random-effects meta-regression. The protocol of this review was pre-registered with PROSPERO (CRD42021261531). Findings: 189 publications, representing 131 unique studies, which reported data on 243,953 individual participants who had engaged in a total of 174,359 episodes of self-harm were included. Samples were drawn from 44 different countries. According to World Bank classifications, most (83.7%) samples were from high income countries. Across the age range, one-quarter of persons were referred for inpatient psychiatric care and, of these, around one-fifth received treatment. Just over one-third were referred to outpatient psychiatric care, whilst around half of those referred received at least one treatment session across the age range. Event rate estimates were generally of a lower magnitude. Subgroup analyses found that older adults (mean sample age: ≥60 years) may be less likely than young people (mean sample age: ≤25 years) and adults (mean sample age: >25 years to <60 years) to be referred for outpatient psychiatric care following self-harm. More recent studies were associated with a small increase in the proportion of presentations (events) that were referred to, and received, psychiatric outpatient treatment. No macro-level factor explained between-study heterogeneity. Interpretation: There is considerable scope for improvement in the allocation and provision of both in- and out-patient psychiatric care following hospital-presenting self-harm, particularly considering that the period after discharge from general hospitals represents the peak risk period for repeat self-harm and suicide. Given the marked between-study heterogeneity, the basis for allocation of aftercare treatment is therefore not yet known and should be further studied. Funding: There was no specific funding for this review.

Which programmes and policies across health and community settings will generate the most significant impacts for youth suicide prevention in Australia and the UK? Protocol for a systems modelling and simulation study.

INTRODUCTION: Suicide is a leading cause of mortality among young people aged 15-24 globally. Despite the deployment of comprehensive suicide prevention strategies, we still do not know which interventions, for which groups of young people, for how long and with what intensity could generate the most significant reductions in suicide rates. System dynamics modelling has the potential to address these gaps. SEYMOUR (System Dynamics Modelling for Suicide Prevention) will develop and evaluate a system dynamics model that will indicate which suicide prevention interventions could generate the most significant reductions in rates of suicide and attempted suicide among young people aged 12-25 in Australia and the UK. METHODS AND ANALYSIS: A comparative case study design, applying participatory system dynamics modelling in North-West Melbourne (Australia) and Birmingham (UK). A computer simulation model of mental health service pathways and suicidal behaviour among young people in North-West Melbourne will be developed through three workshops with expert stakeholder groups (young people with lived experience, carers, clinicians, policy makers, commissioners). The model will be calibrated and validated using national, state and local datasets (inputs). The simulation model will test a series of interventions identified in the workshops for inclusion. Primary model outputs include suicide deaths, self-harm hospitalisations and self-harm presentations to emergency departments. An implementation strategy for the sustainable embedding of promising suicide prevention interventions will be developed. This will be followed by model customisation, re-parameterisation, and validation in Birmingham and adaptation of the implementation strategy. ETHICS AND DISSEMINATION: The project has received approval from the University of Melbourne Human Research Ethics Committee (2022-22885-25971-4), the University of Birmingham Science, Technology, Engineering and Mathematics Ethics Review Committee (ERN_21-02385) and the UK HRA (22/HRA/3826). SEYMOUR's dissemination strategy includes open-access academic publications, conference presentations, accessible findings coproduced with young people, e-briefs to policy makers, webinars for service providers and commissioners.

Interventions for youth suicide and suicide-related behaviour: An update to a systematic review.

OBJECTIVE: To update our 2018 review with the latest evidence from randomised controlled trials (RCTs) on the effectiveness of interventions to prevent youth suicide and suicide-related behaviour. METHOD: In keeping with our 2018 review, Embase, PsycInfo, and Medline were searched using relevant key words. Included trials were RCTs evaluating the impact of an intervention or approach designed to prevent or reduce youth suicide and suicide-related behaviour. Key data were extracted, and results synthesised narratively. RESULTS: Thirty RCTs were included across clinical (n = 13), educational (n = 8), and community settings (n = 9). No trials were conducted in workplace or primary care settings, or with indigenous populations, and few trials involved partnerships with young people. There were some concerns or a high risk of bias for most trials. CONCLUSION: While a relatively large number of RCTs have been published in recent years, knowledge gaps remain. Further high-quality RCTs are needed, including those focussing on vulnerable population groups. Meaningful consumer involvement and a stronger emphasis on implementation are also recommended.

Predictors of suicidal ideation severity among treatment-seeking young people with major depressive disorder: The role of state and trait anxiety.

OBJECTIVE: Depression and suicidal ideation are closely intertwined. Yet, among young people with depression, the specific factors that contribute to changes in suicidal ideation over time are uncertain. Factors other than depressive symptom severity, such as comorbid psychopathology and personality traits, might be important contributors. Our aim was to identify contributors to fluctuations in suicidal ideation severity over a 12-week period in young people with major depressive disorder receiving cognitive behavioural therapy. METHODS: Data were drawn from two 12-week randomised, placebo-controlled treatment trials. Participants (N = 283) were 15-25 years old, with moderate to severe major depressive disorder. The primary outcome measure was the Suicidal Ideation Questionnaire, administered at baseline and weeks 4, 8 and 12. A series of linear mixed models was conducted to examine the relationship between Suicidal Ideation Questionnaire score and demographic characteristics, comorbid psychopathology, personality traits and alcohol use. RESULTS: Depression and anxiety symptom severity, and trait anxiety, independently predicted higher suicidal ideation, after adjusting for the effects of time, demographics, affective instability, non-suicidal self-injury and alcohol use. CONCLUSIONS: Both state and trait anxiety are important longitudinal correlates of suicidal ideation in depressed young people receiving cognitive behavioural therapy, independent of depression severity. Reducing acute psychological distress, through reducing depression and anxiety symptom severity, is important, but interventions aimed at treating trait anxiety could also potentially be an effective intervention approach for suicidal ideation in young people with depression.

Characteristics of self-harm presentations to the emergency department of the Royal Melbourne Hospital, 2012-2019: Data from the Self-Harm Monitoring System for Victoria.

BACKGROUND: Rates of self-harm and suicide are increasing world-wide, particularly in young females. Emergency departments (EDs) are a common first point-of-contact for young people who self-harm. We examined age- and sex-related differences in: (1) rates of self-harm over an eight-year period; (2) changes in demographic, presentation, and treatment characteristics over this period, and; (3) rates of, and time to, self-harm re-presentation. METHODS: This was a retrospective observational study of all self-harm presentations in persons aged nine years and older to the Royal Melbourne Hospital ED over an eight-year period, 1 January 2012-31 December 2019. The Royal Melbourne Hospital is one of the largest and busiest public EDs in Melbourne, Australia and serves a primary catchment area of approximately 1.5 million people. RESULTS: There were 551,692 presentations to the Royal Melbourne Hospital ED over this period (57.6 % by females). Of these, 7736 (1.4 %) were self-harm related. These self-harm presentations involved 5428 individuals (54.8 % female), giving an overall repetition event-rate of 11.2 %. Self-harm related presentations increased by 5 % per year (Incidence Rate Ratio [IRR 1.05, 95 % CI 1.02-1.08); a 44 % increase over the eight-year period (IRR 1.44, 95 % CI 1.15-1.80). This increase was more pronounced for young people aged< 25 years. The most common method was self-poisoning, primarily by anxiolytics or analgesics. The proportion of presentations involving self-poisoning alone declined modestly over time, whilst the proportion involving self-injury alone increased. For just over half of all presentations the person was seen by ED mental health staff. The median time to first re-presentation was 4.5 months (Inter-Quartile Range [IQR] 0.7-13.2 months). CONCLUSIONS: Rates of hospital presenting self-harm may be increasing, particularly amongst young people, whilst most self-harm presentations occurred outside office hours; so appropriate ED staffing, training and clinical care models are needed. Around half of those with a repeat episode of self-harm repeated within three months of their index (i.e., first recorded) presentation. Efforts to establish appropriate aftercare services, including alternatives to ED services with service availability 24 h a day 7 days a week, aimed at reducing repetition rates, should be prioritised.

COVID-19 related innovation in Aotearoa/New Zealand mental health helplines and telehealth providers - mapping solutions and discussing sustainability from the perspective of service providers.

Background: The coronavirus disease 2019 (COVID-19) pandemic and associated interventions resulted in changes in both the demand and supply of mental health services and necessitated agile adaptation and innovation from service providers. Aims: The aim of this study was to explore what innovative solutions were adopted in response to COVID-19 and the pandemic control measures, what opportunities and challenges were associated with these innovations, as well as to critically reflect on the longer-term sustainability of the innovations in the context of Aotearoa/New Zealand mental healthcare. Materials and methods: We used thematic analysis to analyse the data from the 23 in-depth interviews with helpline employees and general practitioners from 18 service providers that regularly engage in mental healthcare. Results: Two key themes related to COVID-19 and the pandemic control measures were identified from respondents' accounts. These were "Technological innovations" and "Process innovations" where providers noted types of innovative solutions, and opportunities and challenges associated with those. The themes culminated in a meta theme "Sustainability of changes to service delivery" that appeared consistently in each theme and asks to consider how sustainable these innovative solutions might be in the long-term. Namely, sustainability of innovation was questioned in respect to the (a) innovative solutions being the emergency solutions with little or no impact analysis, (b) "returning back to normal" due to limited future funding and innovation as a sunk cost, and (c) sporadic and inconsistent innovation between service providers that does not contribute to quality and continuity of care from the systems perspective. Conclusion: COVID-19 and the measures of pandemic control were associated with an increase in innovative solutions from service providers. There were both opportunities and challenges associated with these innovative efforts and the sustainability of innovation was questioned. Future research about COVID-19 related innovation of service provision should focus on service user experiences and empirically measure the innovation safety and efficacy.

Suicidal Behaviour, including Ideation and Self-Harm, in Young Migrants: A Systematic Review.

Young people experience high rates of suicidal ideation, self-harm, suicide attempt and death due to suicide. As a result of increasing globalisation, young people are increasingly mobile and can migrate from one country to another seeking educational and employment opportunities. With a growing number of young migrants, it is important to understand the prevalence of suicidal behaviour among this population group. We systematically searched Medline, Embase, and PsycINFO from inception until 31 March 2022. Eligible studies were those providing data on suicidal ideation, self-harm, suicide attempt, and death due to suicide. Seventeen studies were included in the review, some of which provided data on multiple outcomes of interest. Twelve studies provided data on suicidal ideation, five provided data on self-harm, eight provided data on suicide attempt, and one study had data on suicide death among young migrants. The quality of the included studies was varied and limited. The studies included in this review commonly reported that young migrants experience higher rates of self-harm and suicide attempt, but no major differences in suicidal ideation and suicide death compared to non-migrant young people. However, the limited number of studies focused on suicidal behaviour among young migrants highlights the need for further high-quality studies to capture accurate information. This will enable the development of policies and interventions that reduce the risk of suicidal behaviour among young migrants.

Acute alcohol use and suicide deaths: an analysis of New Zealand coronial data from 2007-2020.

AIMS: Acute alcohol use is a proximal risk factor for suicide. However, the proportion of suicide deaths involving acute alcohol use has not been quantified in New Zealand. We sought to quantify and characterise the association between acute alcohol use and suicide. METHODS: Data for all suicides (≥15 years) between July 2007 and December 2020 were drawn from the National Coronial Information System. Acute alcohol use was defined as blood alcohol concentration (BAC) >50mg/100mL. Logistic regression was used to compare characteristics between suicide deaths with and without acute alcohol use. RESULTS: Twenty-six point six percent of suicide deaths involved acute alcohol use. No difference in the association was found by sex (male AOR: 0.87 (95%CI: 0.74,1.02)). Ethnicity differences were identified (Maori AOR: 1.20 (95%CI: 1.01,1.42), Pacific AOR: 1.46 (95%CI: 1.10,2.00)). Those aged 15-54 years had similar risks of suicide involving acute alcohol use, with a lower association in older age groups. CONCLUSIONS: Acute alcohol use was identified in approximately one quarter of suicides, with stronger associations in those of Maori and Pasifika ethnicity, and those aged <55 years. Acute alcohol use is a significant but modifiable risk factor for suicide in New Zealand.

Detection of self-harm and suicidal ideation in emergency department triage notes.

OBJECTIVE: Accurate identification of self-harm presentations to Emergency Departments (ED) can lead to more timely mental health support, aid in understanding the burden of suicidal intent in a population, and support impact evaluation of public health initiatives related to suicide prevention. Given lack of manual self-harm reporting in ED, we aim to develop an automated system for the detection of self-harm presentations directly from ED triage notes. MATERIALS AND METHODS: We frame this as supervised classification using natural language processing (NLP), utilizing a large data set of 477 627 free-text triage notes from ED presentations in 2012-2018 to The Royal Melbourne Hospital, Australia. The data were highly imbalanced, with only 1.4% of triage notes relating to self-harm. We explored various preprocessing techniques, including spelling correction, negation detection, bigram replacement, and clinical concept recognition, and several machine learning methods. RESULTS: Our results show that machine learning methods dramatically outperform keyword-based methods. We achieved the best results with a calibrated Gradient Boosting model, showing 90% Precision and 90% Recall (PR-AUC 0.87) on blind test data. Prospective validation of the model achieves similar results (88% Precision; 89% Recall). DISCUSSION: ED notes are noisy texts, and simple token-based models work best. Negation detection and concept recognition did not change the results while bigram replacement significantly impaired model performance. CONCLUSION: This first NLP-based classifier for self-harm in ED notes has practical value for identifying patients who would benefit from mental health follow-up in ED, and for supporting surveillance of self-harm and suicide prevention efforts in the population.

The association between alcohol use disorder and suicidal ideation in a New Zealand birth cohort.

BACKGROUND: Alcohol use disorder is associated with increased suicide risk; however, both alcohol use disorder and suicide share risk factors which must be accounted for in order to understand this relationship. This study aimed to explore the longitudinal relationship between alcohol use disorder and suicidal ideation in adulthood, while accounting for both child background and adult covariate factors. METHOD: Data were collected from the Christchurch Health and Development Study, a birth cohort of 1265 children born in Christchurch (New Zealand) in mid-1977. Alcohol use disorder (operationalised as alcohol abuse and alcohol dependence) was quantified between age 18 and 40 in five data waves. The outcome measure suicidal ideation was reported over the same time periods. Childhood confounding variables were controlled for, as well as time-dynamic covariates collected in adulthood, including internalising disorders, distress due to relationship dissolutions and other substance use disorders. RESULTS: The association between alcohol abuse and suicidal ideation was not statistically significant before or after adjusting for childhood confounding and adulthood covariate factors, when compared to no alcohol disorder. However, the association between alcohol dependence and suicidal ideation was significant both before and after adjustment (unadjusted odds ratio = 2.89, 95% confidence interval = [2.09, 3.99]; adjusted odds ratio = 1.52, 95% confidence interval = [1.04, 2.23]), when compared to no alcohol disorder. Furthermore, alcohol dependence remained significant when compared to alcohol abuse (unadjusted odds ratio = 2.33, 95% confidence interval = [1.61, 3.37]; adjusted odds ratio = 1.54, 95% confidence interval = [1.00, 2.37]). CONCLUSION: This analysis found an association between alcohol dependence and suicidal ideation within a New Zealand birth cohort, which persists even after adjustment for childhood confounding and adulthood covariate factors. Given the high rates of suicide and heavy drinking within the New Zealand population, any comprehensive national or regional suicide prevention plan should seek to reduce risky alcohol consumption at an individual and population level, as this represents a modifiable risk factor for suicide.

Effect of alcohol interventions on suicidal ideation and behaviour: A systematic review and meta-analysis.

BACKGROUND: Alcohol consumption is related to both suicidal ideation and behaviour, but evidence regarding the effect of psychological interventions to reduce alcohol use on self-harm, suicidal behaviour and ideation is limited. Therefore, the aim of the current study was to conduct a systematic literature review and meta-analysis of the effect of alcohol-related psychological interventions on these outcomes at the individual level. METHODS: We searched the Cochrane CENTRAL, Cochrane DARE, EMBASE, Medline, ProQuest, PsycINFO, PubMed, SCOPUS, and Web of Science electronic databases to 5 January 2021. We included all English-language papers worldwide utilising psychological interventions with a focus on harmful alcohol use and suicidal ideation, self-harm, and/or suicidal behaviour. RESULTS: We identified 11 studies, nine provided sufficient numerical data for meta-analysis. Although the methods and effect sizes varied substantially in the studies, reducing alcohol may led to a reduction in self-harm and suicide attempt by the final follow-up assessment (Odds ratio [OR] 0.57, 95% confidence interval [CI] 0.33 to 0.97, 6 studies, 491 participants, I2 = 0%). However, there was no apparent effect for these interventions on suicidal ideation or suicide deaths. There was no significant difference in effect by therapeutic approach. Neither intervention dose (in hours) nor duration (in months) significantly explained differences in treatment effectiveness. CONCLUSIONS: Interventions targeting harmful alcohol consumption may contribute towards a reduction in self-harm at the individual level. However, there was no apparent effect of these interventions on suicidal ideation (measured either continuously or dichotomously) or suicide deaths.

Psychosocial work exposures and health outcomes: a meta-review of 72 literature reviews with meta-analysis.

OBJECTIVE: This meta-review aimed to present all available quantitative pooled estimates for the associations between psychosocial work exposures and health outcomes using a systematic literature review of literature reviews with meta-analysis. METHODS: A systematic review of the literature from 2000 to 2020 was conducted using PubMed, Web of Science, Scopus, and PsycINFO databases following the PRISMA guidelines. All literature reviews and Individual-Participant Data (IPD)-Work consortium studies exploring an association between psychosocial work exposures and health outcomes and providing pooled estimates using meta-analysis were included. All types of psychosocial work exposures and health outcomes were studied. The quality of each included review was assessed. RESULTS: A total of 72 reviews and IPD-Work consortium studies were included. These mainly focused on job strain as exposure and cardiovascular diseases and mental disorders as outcomes. The associations between psychosocial work factors and cardiovascular diseases and mental disorders were in general significant, and the magnitude of these associations was stronger for mental disorders than for cardiovascular diseases. Based on high-quality reviews, significant associations were found between job/high strain and long working hours as exposures and coronary heart diseases, (ischemic) stroke, and depression as outcomes. A few additional significant associations involved other exposures and health outcomes. CONCLUSIONS: The included reviews brought convincing findings on the associations of some psychosocial work factors with mental disorders and cardiovascular diseases. More research may be needed to explain these associations, explore other exposures and outcomes, and make progress towards determining the causality of the associations.

Psychosocial interventions for self-harm in adults.

BACKGROUND: Self-harm (SH; intentional self-poisoning or self-injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most counties, often repeated, and associated with suicide. There has been a substantial increase in both the number of trials and therapeutic approaches of psychosocial interventions for SH in adults. This review therefore updates a previous Cochrane Review (last published in 2016) on the role of psychosocial interventions in the treatment of SH in adults. OBJECTIVES: To assess the effects of psychosocial interventions for self-harm (SH) compared to comparison types of care (e.g. treatment-as-usual, routine psychiatric care, enhanced usual care, active comparator) for adults (aged 18 years or older) who engage in SH. SEARCH METHODS: We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020). SELECTION CRITERIA: We included all randomised controlled trials (RCTs) comparing interventions of specific psychosocial treatments versus treatment-as-usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, or a combination of these, in the treatment of adults with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow-up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide. DATA COLLECTION AND ANALYSIS: We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratio (ORs) and their 95% confidence intervals (CIs). For continuous outcomes, we calculated mean differences (MDs) or standardised mean differences (SMDs) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post-intervention) was appraised for each intervention using the GRADE approach. MAIN RESULTS: We included data from 76 trials with a total of 21,414 participants. Participants in these trials were predominately female (61.9%) with a mean age of 31.8 years (standard deviation [SD] 11.7 years). On the basis of data from four trials, individual cognitive behavioural therapy (CBT)-based psychotherapy may reduce repetition of SH as compared to TAU or another comparator by the end of the intervention (OR 0.35, 95% CI 0.12 to 1.02; N = 238; k = 4; GRADE: low certainty evidence), although there was imprecision in the effect estimate. At longer follow-up time points (e.g., 6- and 12-months) there was some evidence that individual CBT-based psychotherapy may reduce SH repetition. Whilst there may be a slightly lower rate of SH repetition for dialectical behaviour therapy (DBT) (66.0%) as compared to TAU or alternative psychotherapy (68.2%), the evidence remains uncertain as to whether DBT reduces absolute repetition of SH by the post-intervention assessment. On the basis of data from a single trial, mentalisation-based therapy (MBT) reduces repetition of SH and frequency of SH by the post-intervention assessment (OR 0.35, 95% CI 0.17 to 0.73; N = 134; k = 1; GRADE: high-certainty evidence). A group-based emotion-regulation psychotherapy may also reduce repetition of SH by the post-intervention assessment based on evidence from two trials by the same author group (OR 0.34, 95% CI 0.13 to 0.88; N = 83; k = 2; moderate-certainty evidence). There is probably little to no effect for different variants of DBT on absolute repetition of SH, including DBT group-based skills training, DBT individual skills training, or an experimental form of DBT in which participants were given significantly longer cognitive exposure to stressful events. The evidence remains uncertain as to whether provision of information and support, based on the Suicide Trends in At-Risk Territories (START) and the SUicide-PREvention Multisite Intervention Study on Suicidal behaviors (SUPRE-MISS) models, have any effect on repetition of SH by the post-intervention assessment. There was no evidence of a difference for psychodynamic psychotherapy, case management, general practitioner (GP) management, remote contact interventions, and other multimodal interventions, or a variety of brief emergency department-based interventions. AUTHORS' CONCLUSIONS: Overall, there were significant methodological limitations across the trials included in this review. Given the moderate or very low quality of the available evidence, there is only uncertain evidence regarding a number of psychosocial interventions for adults who engage in SH. Psychosocial therapy based on CBT approaches may result in fewer individuals repeating SH at longer follow-up time points, although no such effect was found at the post-intervention assessment and the quality of evidence, according to the GRADE criteria, was low. Given findings in single trials, or trials by the same author group, both MBT and group-based emotion regulation therapy should be further developed and evaluated in adults. DBT may also lead to a reduction in frequency of SH. Other interventions were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to the use of these interventions is inconclusive at present.

Educational and Employment Outcomes among Young Australians with a History of Depressive Symptoms: A Prospective Cohort Study.

The aim of this study was to investigate whether depressive symptoms reported during adolescence are associated with subsequent educational and employment outcomes, including whether experiences of depressive symptoms in adolescence are associated with higher exposures to adverse psychosocial job stressors among those who were employed in emerging adulthood. We used data from the Victorian arm of the International Youth Development Study (IYDS). Multiple logistic regression analyses were used to model the association of depressive symptoms reported in 2002 (wave one) and/or 2003 (wave two) and self-reported completion of compulsory secondary schooling, employment status, and exposure to a number of psychosocial job stressors roughly a decade later (i.e., at wave three in 2014). In fully adjusted models, reporting high depressive symptoms at waves one or two (odds ratio (OR) 0.71, 95% confidence interval (CI) 0.55 to 0.92), as well as at both waves (OR 0.55, 95% CI 0.41 to 0.75) were associated with a reduced likelihood of completing secondary schooling by wave three. High depressive symptoms reported at multiple waves were also associated with a reduced likelihood of employment (OR 0.49, 95% CI 0.36 to 0.66). Amongst those employed at wave three (n = 2091; 72.5%), adolescent depressive symptoms were associated only with workplace incivility. Psychosocial job stressor exposures should be considered in the design and selection of jobs for young workers with a history of depressive symptoms in order to increase employment participation and sustainability for young people experiencing symptoms of depression.

Interventions for self-harm in children and adolescents.

BACKGROUND: Self-harm (SH; intentional self-poisoning or self-injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most countries, often repeated, and associated with suicide. Evidence assessing the effectiveness of interventions in the treatment of SH in children and adolescents is lacking, especially when compared with the evidence for psychosocial interventions in adults. This review therefore updates a previous Cochrane Review (last published in 2015) on the role of interventions for SH in children and adolescents. OBJECTIVES: To assess the effects of psychosocial interventions or pharmacological agents or natural products for SH compared to comparison types of care (e.g. treatment-as-usual, routine psychiatric care, enhanced usual care, active comparator, placebo, alternative pharmacological treatment, or a combination of these) for children and adolescents (up to 18 years of age) who engage in SH. SEARCH METHODS: We searched the Cochrane Common Mental Disorders Specialized Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic Reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020). SELECTION CRITERIA: We included all randomised controlled trials (RCTs) comparing specific psychosocial interventions or pharmacological agents or natural products with treatment-as-usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, placebo, alternative pharmacological treatment, or a combination of these, in children and adolescents with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow-up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide. DATA COLLECTION AND ANALYSIS: We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence internals (CIs). For continuous outcomes, we calculated the mean difference (MD) or standardised mean difference (SMD) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post-intervention) was appraised for each intervention using the GRADE approach. MAIN RESULTS: We included data from 17 trials with a total of 2280 participants. Participants in these trials were predominately female (87.6%) with a mean age of 14.7 years (standard deviation (SD) 1.5 years). The trials included in this review investigated the effectiveness of various forms of psychosocial interventions. None of the included trials evaluated the effectiveness of pharmacological agents in this clinical population. There was a lower rate of SH repetition for DBT-A (30%) as compared to TAU, EUC, or alternative psychotherapy (43%) on repetition of SH at post-intervention in four trials (OR 0.46, 95% CI 0.26 to 0.82; N = 270; k = 4; high-certainty evidence). There may be no evidence of a difference for individual cognitive behavioural therapy (CBT)-based psychotherapy and TAU for repetition of SH at post-intervention (OR 0.93, 95% CI 0.12 to 7.24; N = 51; k = 2; low-certainty evidence). We are uncertain whether mentalisation based therapy for adolescents (MBT-A) reduces repetition of SH at post-intervention as compared to TAU (OR 0.70, 95% CI 0.06 to 8.46; N = 85; k = 2; very low-certainty evidence). Heterogeneity for this outcome was substantial ( I² = 68%). There is probably no evidence of a difference between family therapy and either TAU or EUC on repetition of SH at post-intervention (OR 1.00, 95% CI 0.49 to 2.07; N = 191; k = 2; moderate-certainty evidence). However, there was no evidence of a difference for compliance enhancement approaches on repetition of SH by the six-month follow-up assessment, for group-based psychotherapy at the six- or 12-month follow-up assessments, for a remote contact intervention (emergency cards) at the 12-month assessment, or for therapeutic assessment at the 12- or 24-month follow-up assessments. AUTHORS' CONCLUSIONS: Given the moderate or very low quality of the available evidence, and the small number of trials identified, there is only uncertain evidence regarding a number of psychosocial interventions in children and adolescents who engage in SH. Further evaluation of DBT-A is warranted. Given the evidence for its benefit in adults who engage in SH, individual CBT-based psychotherapy should also be further developed and evaluated in children and adolescents.

Trajectories of change in depression symptoms and suicidal ideation over the course of evidence-based treatment for depression: Secondary analysis of a randomised controlled trial of cognitive behavioural therapy plus fluoxetine in young people.

OBJECTIVES: Effective treatment of depression is a key target for suicide prevention strategies. However, only around one-third of young people with suicide risk respond to evidence-based treatments. Understanding the trajectory of suicidal ideation, as a marker of suicide risk, over the course of evidence-based treatment for depression might provide insight into more targeted and effective treatments. METHODS: This is a secondary analysis of data from the multicentre Youth Depression Alleviation-Combined Treatment trial. A total of 153 young people aged 15-25 years diagnosed with major depressive disorder were randomly assigned in this double-blind, placebo-controlled trial to either cognitive behavioural therapy plus fluoxetine or cognitive behavioural therapy plus placebo. Participants were assessed for depression and suicidal ideation at baseline and at weeks 4, 8 and 12. RESULTS: Using group-based trajectory modelling, we identified two distinct depression trajectories. The first (Improving; 54.9%; n = 83) comprised those who experienced a consistent decline in depression symptoms. The second (Persisting; 45.1%; n = 70) comprised those who, despite treatment, still had clinically significant levels of depression by the end of treatment. For suicidal ideation, we identified four distinct trajectories: Non-clinical (15.5%; n = 20), Low Improving (47.1%; n = 75), High Improving (24.8%; n = 38) and High Persisting (12.7%; n = 20). Treatment allocation was not significantly associated with trajectory membership for either depression or suicidal ideation. CONCLUSION: Understanding the course of depression and suicidal ideation during treatment has important implications for managing suicide risk. The findings suggest that there is an identifiable group of young people for whom enhanced psychological and/or pharmacological intervention might be required to ensure a better treatment response. Specific interventions for those with suicidal ideation may also be prudent from the outset. CLINICAL TRIAL REGISTRATION: The Youth Depression Alleviation-Combined Treatment trial was prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12612001281886).